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  1. 1. Mediational Models in Psychophysiological Disorders Richard Gevirtz, Ph.D. CSPP at Alliant International U.-San Diego [email_address] Website: WWW.Alliant.edu/faculty/gevirtz 12/19/09 Gevirtz
  2. 2. Outline I <ul><li>I. Epidemiology </li></ul><ul><li>II. Mediational model : </li></ul><ul><ul><li>Psychophysiological disorders Disorders with central mediation </li></ul></ul><ul><li>III. Mediators </li></ul><ul><ul><li>A. Respiration </li></ul></ul><ul><ul><li>B. Limbic or RAS </li></ul></ul><ul><ul><li>B. Sympathetic n.s. </li></ul></ul><ul><ul><li>C. Parasympathetic n.s. </li></ul></ul><ul><ul><ul><li>1. Vagal mechanisms </li></ul></ul></ul><ul><ul><ul><li>2. Porges Polyvagal Theory </li></ul></ul></ul><ul><ul><ul><li>3. Neurovisceral Integration </li></ul></ul></ul>12/19/09 Gevirtz
  3. 3. Outline II <ul><li>IV. HRV-I: Underlying Physiology </li></ul><ul><ul><li>A. Sources of variance </li></ul></ul><ul><ul><ul><li>1. respiration </li></ul></ul></ul><ul><ul><ul><li>2.blood pressure/baroreceptors </li></ul></ul></ul><ul><ul><ul><li>3. sympatheic vascular tone? </li></ul></ul></ul><ul><ul><li>B. Spectral analysis </li></ul></ul><ul><li>VI. HRV-II: Measurement </li></ul><ul><li>VII. HRV-III: Feedback </li></ul><ul><ul><li>A. Effect on spectral </li></ul></ul><ul><ul><li>B. Resonance </li></ul></ul><ul><li>VIII. Treatment Protocol </li></ul>12/19/09 Gevirtz
  4. 4. Outline III <ul><li>IX. Applications </li></ul><ul><ul><li>A. Autonomic mediators </li></ul></ul><ul><ul><ul><li>Hypertension/hypotension </li></ul></ul></ul><ul><ul><ul><li>Chronic muscle pain </li></ul></ul></ul><ul><ul><ul><li>Dysreflexia </li></ul></ul></ul><ul><ul><ul><li>IBS/RAP </li></ul></ul></ul><ul><ul><ul><li>Asthma </li></ul></ul></ul><ul><ul><li>B. Respiration </li></ul></ul><ul><ul><ul><li>COPD </li></ul></ul></ul><ul><ul><ul><li>Asthma </li></ul></ul></ul><ul><ul><ul><li>Panic </li></ul></ul></ul><ul><ul><li>C. Inflammation </li></ul></ul><ul><ul><ul><li>Asthma </li></ul></ul></ul><ul><ul><li>D. CNS </li></ul></ul><ul><ul><ul><li>FM </li></ul></ul></ul><ul><ul><ul><li>CRPS </li></ul></ul></ul>12/19/09 Gevirtz
  5. 5. Evidence of efficacy, HRV Biofeedback <ul><li>Asthma-Lehrer et al., Chest, 2004 </li></ul><ul><li>COPD- Giardino et al., APB, 2004 </li></ul><ul><li>CAD- Del Pozo et al. (AHJ, 2004), van Dixhoorn et al. </li></ul><ul><li>Performance- Strack et al., Gruzelier’s group (APB, 2005) </li></ul><ul><li>Stress, performance, etc., McCraty et al (Har. Bus Rev, 2003; Physio Beh Sci, 1999; numerous HeartMath reports) </li></ul><ul><li>IBS/RAP- Humphreys & Gevirtz (JPGN, 2000) Sowder, Gevirtz,et al. (2007) </li></ul><ul><li>FM- Hasset et al. APB,(2007) </li></ul><ul><li>Altitude sickness-Bernardi (2001& in press) </li></ul><ul><li>MDD, Karavadis et al., APB, (2007), Zucker et al.(2007), Rene et al.(2007) </li></ul><ul><li>Congestive Heart Failure-(Bernardi, 2002, Circulation) Swanson, Gevirtz, et al. (2007) </li></ul><ul><li>Hypertension- (Schein et al, 2001, J. Human Hypertension; Herbs & Gevirtz, 1994, Abstract, APB; Lehrer et al.,( 2004) Reinke, Gevirtz, et al. (2007) </li></ul><ul><li>PTSD Zucker et al., White et al.,(2008) </li></ul><ul><li>GAD Murphy, Hoffmann et al. (2008) </li></ul>
  6. 6. Estimates of Primary Care Visits 12/19/09 Gevirtz
  7. 7. 12/19/09 Gevirtz
  8. 8. Alternative Medicine in the U.S. 12/19/09 Gevirtz JAMA, 1998 The $21.2 billion is up 45% since 1990
  9. 9. Alternative Medicine: Out-of-Pocket Expenditures <ul><li>$12.2 billion out-of-pocket </li></ul><ul><li>This exceeds 1997 out-of-pocket expenditures for all hospitalizations in the U.S. </li></ul>12/19/09 Gevirtz
  10. 10. Most Common Reasons for Seeking Alternative Medicine Therapies <ul><li>Headaches 32% </li></ul><ul><li>Arthritis 27% </li></ul><ul><li>Fatigue 27% </li></ul><ul><li>Allergies 17% </li></ul><ul><li>Back Pain 49% </li></ul>12/19/09 Gevirtz Therapy Used Relax,Chiro Relax, Chiro Relax, Message Herbal, Relax Chiro, Massage About 40% of patients inform their physician of alternative therapies.
  11. 11. Percentage of Americans Using Alternative Therapy 12/19/09 Gevirtz
  12. 12. Stigma of Pain <ul><li>Mental health disorders are so stigmatized in our culture that disorders that may only partially involve psychological/emotional factors are considered just as shameful as mental disorders. </li></ul><ul><li>“ Physicians in particular need to be sensitized to the fact that people with pain generally expect to experience stigmatizing attitudes among health care practitioners, especially regarding the use of pain medication.” Zelman, 2004 </li></ul>12/19/09 Gevirtz
  13. 13. Mediational Model of Psychophysiological Disorders 12/19/09 Gevirtz Physical Symptoms Physiological Systems Cognitive/Emotional Factors Early Developmental Factors Genetics Social & Cultural Factors “hysteria”
  14. 14. Respiratory System 12/19/09 Gevirtz
  15. 18. Downloaded from: StudentConsult (on 14 August 2006 08:36 PM) © 2005 Elsevier
  16. 19. 12/19/09 Gevirtz
  17. 20. 12/19/09 Gevirtz
  18. 22. Normal lung Emphysema
  19. 23. Respiratory Tasks in Normal Breathing <ul><li>Adequate saturation of blood with oxygen </li></ul><ul><li>Adequate saturation of blood with CO 2- dissolved as carbonic acid </li></ul><ul><li>Alkaline buffer-bicarbonate </li></ul><ul><li>Maintain pH of blood at 7.4 </li></ul><ul><li>removal and retention of alkaline and acidic products by the kidneys </li></ul><ul><li>maintain breathing drive at optimal levels </li></ul>12/19/09 Gevirtz
  20. 24. Blood pH: A critical tight band <ul><li>7.4 (+or-.5) blood pH - since scale is log, a .2 difference means a doubling of the hydrogen ions present </li></ul><ul><li>pH controlled primarily by CO 2 </li></ul><ul><ul><li>CO 2 is end product of cell metabolism </li></ul></ul><ul><ul><li>is analogous to ash or smoke </li></ul></ul><ul><ul><li>in pure form, deadly </li></ul></ul><ul><ul><li>converted to carbonic acid to protect tissue </li></ul></ul><ul><ul><li>builds quickly with exercise, but so does oxygen demand </li></ul></ul>12/19/09 Gevirtz
  21. 25. <ul><li>Breathing volume than controls these parameters: </li></ul><ul><ul><li>“ Therefore changes in breathing volume relative to CO 2 production regulate the moment to moment concentration of pH in the bloodstream…There is a tight interaction between the breathing volume, the amount of CO 2 , production, the partial pressure of CO 2 in the arterial blood ( indicated as Pa CO 2 ), and the blood pH. Note that concentration of CO 2 in the blood, not the amount of oxygen, is the major regulator of breathing drive” </li></ul></ul><ul><ul><li>Gilbert (in press) in Multidisciplinary Approaches to Breathing </li></ul></ul>12/19/09 Gevirtz
  22. 26. 12/19/09 Gevirtz
  23. 27. 12/19/09 Gevirtz The Bohr Effect
  24. 28. 12/19/09 Gevirtz From, Chaitow, Bradley, & Gilbert (2002), Multidisciplinary Approaches to Breathing Pattern Disorders
  25. 29. 12/19/09 Gevirtz “ As a consequence of hyperventilation, the decrease in PCO 2 will reduce the caliber of the arteries and thereby impede the flow of blood to body tissue (ischemia), and the increase in blood pH will reduce the amount of oxygen that hemoglobin can release to the body tissue (hypoxia). Therefore, the heart must pump more frequently and with greater vigor in order to compensate for the decrease in pCO 2 and increase in pH.” { Ley, 1987, p.309}
  26. 30. 12/19/09 Gevirtz
  27. 31. 12/19/09 Gevirtz 40 torr 30 torr
  28. 32. 12/19/09 Gevirtz This is your brain on normal breathing. This is your brain on hyperventilation. Low blood flow High blood flow
  29. 33. Mechanics of Breathing <ul><li>Diaphragm </li></ul><ul><li>Chest wall muscles – intercostal muscles </li></ul><ul><li>Accessory muscles – scalene muscles </li></ul><ul><li>Retraction of abdominal muscles is sign of distress </li></ul>
  30. 34. 12/19/09 Gevirtz
  31. 35. Diaphragmatic and Pursed Lip Breathing <ul><li>Many sources available to incorporate these techniques </li></ul><ul><ul><li>Freid (1987,1993) </li></ul></ul><ul><ul><li>Chaitow, Bradley, & Gilbert(2002) </li></ul></ul><ul><ul><li>Gevirtz in Schwartz and Andrasik (2003) </li></ul></ul><ul><ul><li>Bradley( 1998) </li></ul></ul><ul><ul><li>Clifton-Smith (1999) </li></ul></ul>12/19/09 Gevirtz
  32. 36. Autonomic Nervous System (ANS) <ul><li>The ANS is divided into three divisions: the parasympathetic, with cranial and sacral connections, the Sympathetic, with central nervous connections in the thoracic and lumbar segments of the spinal cord, and the enteric nervous system which occupies the digestive tract(MacArthur Research Network) </li></ul>12/19/09 Gevirtz
  33. 37. 12/19/09 Gevirtz
  34. 38. Sympathetic Nervous System 12/19/09 Gevirtz
  35. 39. Muscle spindle increased intrafusal firing
  36. 40. 12/19/09 Gevirtz
  37. 41. 12/19/09 Gevirtz
  38. 42. 12/19/09 Gevirtz
  39. 43. <ul><li>“…compared with our ancestors, modern lifestyles have all but eliminated the danger of predatory aggression, and we rarely engage the central autonomic networks developed by evolutionary pressure to cope with the most stressful challenges to homeostasis.” (p.683) </li></ul>
  40. 44. Parasympathetic Nervous System
  41. 45. Overall Models <ul><li>Balance Model vs. Regulatory Model </li></ul>PNS Activation SNS Activation Co-Activation model Reciprocal or Balance
  42. 46. Cardiac Vagal Tone <ul><li>Context dependent </li></ul><ul><li>Reflects input from vagal afferent nerve fibers as well as brain structures (cardiorespiratory center, amygdala, and hypothalamus) </li></ul>
  43. 47. Neuroanatomy <ul><li>Complex </li></ul><ul><ul><li>Pre and post ganglionic fibers </li></ul></ul><ul><ul><li>Efferent and afferent components </li></ul></ul><ul><li>Efferents </li></ul><ul><ul><li>CNS to target organs </li></ul></ul><ul><ul><li>Two components </li></ul></ul><ul><ul><ul><li>Brachial motor-voluntary muscles of the pharynx, larynx, and part of tongue </li></ul></ul></ul><ul><ul><ul><li>Visceral motor- glands and smooth muscle of the pharynx, larynx, and thoracic abdominal organs ( heart, lungs, liver, pancreas, and gut </li></ul></ul></ul><ul><li>Afferents </li></ul><ul><ul><li>Target organs to CNS </li></ul></ul><ul><ul><li>Three components </li></ul></ul><ul><ul><ul><li>Visceral sensory-info from larynx, esophagus, trachea, visceral organs. Also chemoreceptors and stretch receptors in aorta </li></ul></ul></ul><ul><ul><ul><li>General sensory- pharynx, tympanic membrane, and external auditory meatus </li></ul></ul></ul><ul><ul><li>Special Sensory- taste sensation in epiglottis </li></ul></ul>
  44. 48. CNS Cell Bodies <ul><li>Medullary Structures </li></ul><ul><ul><li>Brachial motor neurons </li></ul></ul><ul><ul><ul><li>Nucleus Ambiguus (NA) </li></ul></ul></ul><ul><ul><li>Visceral motor neurons </li></ul></ul><ul><ul><ul><li>Dorsal motor nucleus (DMNX) </li></ul></ul></ul><ul><li>Afferents just outside of CNS- Superior and inferior ganglia </li></ul><ul><ul><li>Transmit from receptors in target organs to the nucleus of the Solitary Tract (also in the medulla) from there info (gut distention, blood pressure, etc) is sent to hypothalamus and NA, regulating vagal and sympathetic efferents (baroreflex). </li></ul></ul>
  45. 49. Age <ul><li>Both sympathetic and parasympathetic influence on the SA node of the heart decline with age (Craft and Schwartz, 1995) </li></ul>
  46. 50. RSA and Glucose Metabolism I <ul><li>Many studies have found that diminished glucose regulation is associated with decreased RSA. Cause or effect? </li></ul><ul><li>Pancreas and liver have vagal input, but poorly understood. </li></ul><ul><li>Falling plasma glucose activates the sympathetic system leading to release of epinephrine from the adrenal medulla. This stimulates hepatic and renal glucose production and gluconeogenisis. It also stimulates skelatal muscle to uptake glucose. </li></ul>
  47. 51. RSA and Glucose Metabolism II <ul><li>Stimulation of the vagal efferent nerve fibers results in insulin release by pancreatic β -cells, while liver efferents increases glucogen formation. </li></ul><ul><li>Hypoglycemia->sympathetic activation-increased glucose production. </li></ul><ul><li>Hyperglycemia parasympathetic activation decreased glucose production and increased storage. </li></ul>
  48. 52. Parasympathetic Insufficiency <ul><li>“ Impaired parasympathetic regulation of glucose is therefore a risk factor for hyperglycemia and hyperinsulinemia-precursors of Type II diabetes.” (Masi et al., 2007) </li></ul><ul><li>Vagal function early sign of insulin dysregulation or could long term vagal dysfunction be a risk for the development of insulin reistence and diabetes. </li></ul>
  49. 53. Parasympathetic (PSNS) Activity <ul><li>Parasympathetic activity: </li></ul><ul><ul><li>Decreases heart rate, polarizes cells. </li></ul></ul><ul><ul><li>Acts through acetylcholine, high turnover in cells means beat-to-beat regulation. </li></ul></ul><ul><ul><li>Acts to stabilize the cardiac membrane and re-establish homeostasis. </li></ul></ul><ul><ul><li>Usually exceeds SNS activity. </li></ul></ul>12/19/09 Gevirtz
  50. 54. Polyvagal Theory of Stephen Porges 12/19/09 Gevirtz
  51. 55. 12/19/09 Gevirtz Stage ANS Component Behavioral Component III Myelinated vagus (ventral vagal complex) Social communication, self-soothing and calming, inhibit symp-adrenal-influences II Sympathetic-adrenal-system (sympathetic nervous system) Mobilization, fight/flight, active avoidance I Unmyelinated vagus (dorsal vagal complex) Immobilization, death feigning, passive avoidance, shutdown.
  52. 56. Porges’ Evolutionary Theory of Emotion <ul><ul><li>Porges, S. (1997) Emotion: An Evoutionary By-Product of the Neural Regulation of the Autonomic Nervous System in C.S. Carter, I. Lederhendler, B. Kirkpatrick (eds.) The integrative neurobiology of affiliation. Annals of the New York Academy of Sciences, 807. </li></ul></ul><ul><ul><li>Porges, S. (1995) Orienting in a defensive world: Mammalian modifications of our evolutionary heritage. A Polyvagal theory. Psychophysiology:32 ,301-318. </li></ul></ul>12/19/09 Gevirtz
  53. 57. <ul><li>Porges, S. (2001) The polyvagal theory: phylogenetic substrates of a social nervous system. Intl J. Psychophysiology, 42 , 29-52. </li></ul><ul><li>Love: an emergent property of the Mammalian autonomic nervous system. Psychoneuroendocrinology, 23 ,:837-61 </li></ul>12/19/09 Gevirtz
  54. 58. Autonomic Nervous System Components 12/19/09 Gevirtz
  55. 59. Phylogenetic Hierarchy in Cardiovascular Response to Stress 12/19/09 Gevirtz *Allows rapid regulation of metabolic output:useful in social regulation DMNX=dorsal motor nucleus SNS=sympathetic nervous system NA= nucleus ambiguous
  56. 60. Polyvagal Theory Proposes: <ul><li>Three global evolutionary phases: </li></ul><ul><ul><li>“… primitive unmyelinated visceral vagus that fosters digestion and responds to threat by depressing metabolic activity.”-immobilization </li></ul></ul><ul><ul><li>“… sympathetic nervous system that is capable of increasing metabolic output and inhibiting the visceral vagus to foster mobilization for ‘fight or flight’.” </li></ul></ul><ul><ul><li>The third stage, unique to mammals, is characterized by a myelinated vagus that can rapidly regulate cardiac output to foster engagement and disengagement with the environment”-linked to cranial nerves and facial muscles </li></ul></ul>12/19/09 Gevirtz
  57. 61. Social Engagement and the PNS Porges (In Press) Annals of the NY Acad of Sciences <ul><li>There are well defined neural circuits to support social engagement behaviors and the defensive strategies of fight, flight, and freeze. </li></ul><ul><li>These neural circuits form a phylogenetically organized hierarchy. </li></ul><ul><li>Without being dependent on conscious awareness the nervous system evaluates risk in dangerous, or life threatening environments. </li></ul><ul><li>Social engagement behaviors and the benefits of the physiological states associated with social support require a neuroception of safety. </li></ul><ul><li>Social behaviors associated with nursing, reproduction, and the formation of strong pair bonds require immobilization without fear </li></ul><ul><li>Immobilization without fear is mediated by the co-opting of the neural circuit regulating defensive freezing behaviors through the involvement of oxytocin, a neuropeptide in mammals involved in the formation of social bonds. </li></ul>12/19/09 Gevirtz
  58. 62. 12/19/09 Gevirtz Cortex Brainstem Cranial Nerves V, VII, IX, X, XI Bronchi Heart Head turning Pharyanx Larynx Facial muscles Middle Ear muscles Muscles of mastication Environment
  59. 63. 12/19/09 Gevirtz
  60. 64. Example of RSA <ul><li>Notice how heart rate increases with inhale. Heart rate decreases with exhale. This pattern shows high vagal tone (high PSNS activity) and a high amount of heart rate variability. </li></ul>12/19/09 Gevirtz Peak/valley differences = vagal tone when resp is in normal range Respiration Heart Rate Inhale Exhale
  61. 65. Vagal Withdrawal: An alternative to Sympathetic Activation <ul><li>. : Neurosci Biobehav Rev. 1995 Summer;19(2):225-33. </li></ul><ul><ul><li>Cardiac vagal tone: a physiological index of stress. Porges SW. Institute for Child Study, University of Maryland, College Park 20742, USA. Cardiac vagal tone is proposed as a novel index of stress and stress vulnerability in mammals. A model is described that emphasizes the role of the parasympathetic nervous system and particularly the vagus nerve in defining stress. The model details the importance of a branch of the vagus originating in the nucleus ambiguus. In mammals the nucleus ambiguus not only coordinates sucking, swallowing, and breathing, but it also regulates heart rate and vocalizations in response to stressors. In mammals it is possible, by quantifying the amplitude of respiratory sinus arrhythmia, to assess the tonic and phasic regulation of the vagal pathways originating in the nucleus ambiguus. Measurement of this component of vagal tone is proposed as a method to assess, on an individual basis, both stress and the vulnerability to stress. </li></ul></ul>12/19/09 Gevirtz
  62. 66. 12/19/09 Gevirtz
  63. 67. 12/19/09 Gevirtz Worrying about being late for an appointment. See FFT B Driving. See FFT A 13 Br/Min 33 Br/min
  64. 68. 12/19/09 Gevirtz Anxiety attack while driving home
  65. 69. Vagal modulation of responses to stress in PTSD Sahar, Shalev, and Porges (2001) Biol. Psychiatry, 49,637-43 <ul><li>29 trauma survivors </li></ul><ul><ul><li>14 with PTSD (PTSD active) </li></ul></ul><ul><ul><li>15 w/o (Non PTSD) </li></ul></ul><ul><li>Stress profile focus on PNS measures </li></ul><ul><li>PTSD showed blunted RSA during MA </li></ul><ul><li>Coupling of RSA/IBI only in the Non-PTSD group (r=.75) </li></ul><ul><li>Responses to challenge may be dominated by the SNS in PTSD </li></ul>12/19/09 Gevirtz
  66. 70. Levine’s Approach to Trauma Treatment 12/19/09 Gevirtz
  67. 71. 12/19/09 Gevirtz “ Rather, Levine looks to the process of what happens when we experience trauma. He sees recovery as getting past a series of mental vortexes that can block our ability to continue traveling down life's stream. As we travel down the stream, our relationship with the traumas changes, just as our relationship with a loved one who has died changes as we continue to live, and they do not. When we get caught in the vortexes created by our traumatic histories we become struck, and whirling within the vortexes, we can relive the traumas - through flashbacks, anxiety, or actual repetitions of particular aspects of the trauma. Levine doesn't minimize the importance of our memories, but emphasizes the primacy of our feelings, of our body states, and of our body's need to physically remove the traumas in order to heal. In this sense, he reminds me of Stan Grof's work on healing the body through breathwork. But the methods proposed here are considerably gentler.”
  68. 72. Bessel van der Kolk 12/19/09 Gevirtz Abnormal psychophysiological responses in PTSD have been demonstrated on two different levels: 1) in response to specific reminders of the trauma and 2) in response to intense, but neutral stimuli, such as acoustic startle. The first paradigm implies heightened physiological arousal to sounds, images, and thoughts related to specific traumatic incidents. A large number of studies have confirmed that traumatized individuals respond to such stimuli with significant conditioned autonomic reactions, such as heart rate, skin conductance and blood pressure (20,21,22,23, 24,25). The highly elevated physiological responses that accompany the recall of traumatic experiences that happened years, and sometimes decades before, illustrate the intensity and timelessness with which traumatic memories continue to affect current experience (3,16). This phenomenon has generally been understood in the light of Peter Lang's work (26) which shows that emotionally laden imagery correlates with measurable autonomic responses. Lang has proposed that emotional memories are stored as &quot;associative networks&quot;, that are activated when a person is confronted with situations that stimulate a sufficient number of elements that make up these networks. One significant measure of treatment outcome that has become widely accepted in recent years is a decrease in physiological arousal in response to imagery related to the trauma (27). However, Shalev et al (28) have shown that desensitization to specific trauma-related mental images does not necessarily generalize to recollections of other traumatic events, as well.
  69. 73. 12/19/09 Gevirtz Stephen Porges started off the day with a lecture on his research: &quot;Application of Polyvagal Theory to Clinical Treatment&quot;. Most of it was in understandable English, because Porges is a U of Illinois professor and knows how to teach. According to the conference bio, &quot;his polyvagal Theory of Emotion led to the discovery of an integrated neural system that regulates social engagement behaviors.&quot; His lecture today focused on the need for face-to-face interactions for bonding to occur. When there’s a violation of the interaction—someone doesn’t make eye contact, when a supposed intimate is speaking, the speaker experiences distress: anger/shame/alienation. Safety creates proximity creates contact creates bonding. There might be more bonding in sleeping together than in sex. Porges commented on the dysfunction in the Seinfeld rule, &quot;No sleepovers!“ (We know that those people were all attachment disordered!) I can’t recount the whole lecture, but I can give you tidbits: Facial muscles go down to the heart. Talking, listening, and smiling calm us down. Two vagal nerve systems. The old one, from lizard days, shuts us down completely. It’s the one from which we can swoon, be literally scared shitless, or become selectively mute, when distressed. The new vagus is linked to face and is protective of mobilization systems.
  70. 74. 12/19/09 Gevirtz It works socially. Our nervous system can relax us through the meyelinated vagus, if we are experiencing safety; mobilize us, through the sympathetic and adrenal system, if we sense dangere, or completely immobilize us, through the old, lizard unmeyelinated vagus, if we think our life is in danger, feigning death like a mouse fooling a cat. (Doug, out birding during the day, caught and pet a horned lizard, who didn’t move at all. It was in the immobilization vagal phase.) Social behavior enables us to function better. Social engagement systems: prosody (tone and music of our voices), gaze, facial expressivity, posture during social engagement, mood, affect, and behavioral state regulation.
  71. 75. 12/19/09 Gevirtz Environment can be interpreted, based on our state. Borderline cutters, in a study, lost vagal control of their hearts while watching emotional videos. Controls, did fine. Very autistic kids attend to low (more frightening) tones. They stay scared and &quot;mobilized&quot; most of the time and try to soothe by doing weird stuff, not be connecting with others. If you play them music with all the low tones filtered out, over time, they will become socially engaged, like normal kids. I saw the video, it was way cool.
  72. 76. HRV 12/19/09 Gevirtz
  73. 77. What Is Heart Rate Variability? <ul><li>HRV is the spontaneous change in HR. </li></ul><ul><li>HRV is related to interaction between sympathetic and parasympathetic influences at sinoatrial node in the heart. </li></ul><ul><li>HRV interacts with respiratory and blood pressure regulation. </li></ul>12/19/09 Gevirtz
  74. 78. 12/19/09 Gevirtz
  75. 79. 12/19/09 Gevirtz
  76. 80. Measurement of R-Wave <ul><li>The time between R-wave peaks is interbeat interval or heart period. It is also called “NN” (normal to normal) interval. </li></ul>12/19/09 Gevirtz Measured in ms i.e.1000ms=60 BPM R-Wave Interbeat Interval
  77. 81. HRV Defined (MacArthur Network) <ul><li>Heart rate variability (HRV) refers to the beat-to-beat alterations in heart rate. Under resting conditions, the ECG of healthy individuals exhibits periodic variation in R-R intervals. This rhythmic phenomenon, known as respiratory sinus arrhythmia (RSA), fluctuates with the phase of respiration -- cardio-acceleration during inspiration, and cardio-deceleration during expiration. RSA is predominantly mediated by respiratory gating of parasymphathetic efferent activity to the heart: vagal efferent traffic to the sinus node occurs primarily in phase with expiration and is absent or attenuated during inspiration. Atropine abolishes RSA. </li></ul><ul><li>Reduced HRV has thus been used as a marker of reduced vagal activity. However, because HRV is a cardiac measure derived from the ECG, it is not possible to distinguish reduced central vagal activity (in the vagal centers of the brain) from reduced peripheral activity (the contribution of the target organ -- the sinus node -- or the afferent/efferent pathways conducting the neural impulses to/from the brain). </li></ul>12/19/09 Gevirtz
  78. 82. Respiratory Influences <ul><li>HR changes related to respiration are called respiratory sinus arrhythmia (RSA). </li></ul><ul><li>HR increases with inhalation. HR decreases with exhalation. </li></ul><ul><li>Amount of HR change with breathing is used as an index of vagal “tone”. </li></ul>12/19/09 Gevirtz
  79. 83. R e spiratory Activity Continually Perturbs Cardiovascular hemodynamics 12/19/09 Gevirtz <ul><li>“ In the brain stem, respiration modulates the activity of most sympathetic and vagal efferents both through direct coupling between the respiratory and autonomic centers and through modulation of central sensitivity to baroreceptor and other afferent inputs. The autonomic efferents in turn modulate heart rate (HR) and peripheral vascular resistance with respiratory periodicities.” </li></ul><ul><ul><li>Saul JP at. Al.Transfer function analysis of the circulation: unique insights into cardiovascular regulation. Am J Physiol. 1991 Oct;261(4 Pt 2):H1231-45 </li></ul></ul>
  80. 84. Allostatic Load and HRV <ul><li>What aspect of allostasis does HRV potentially measure? </li></ul><ul><li>Although our understanding of the meaning of HRV is far from complete, it seems to be a marker of both dynamic and cumulative load. As a dynamic marker of load, HRV appears to be sensitive and responsive to acute stress. Under laboratory conditions, mental load -- including making complex decisions, and public speech tasks -- have been shown to lower HRV. As a marker of cumulative wear and tear, HRV has also been shown to decline with the aging process. Although resting heart rate does not change significantly with advancing age, there is a decline in HRV, which has been attributed to a decrease in efferent vagal tone and reduced beta-adrenergic responsiveness. By contrast, regular physical activity (which slows down the aging process) has been shown to raise HRV, presumably by increasing vagal tone. </li></ul><ul><li>In short, HRV appears to be a marker of two processes, relevant to the conceptualization of allostatic load: (1) frequent activation (short term dips in HRV in response to acute stress); and (b) inadequate response (long-term vagal withdrawal, resulting in the over-activity of the counter-regulatory system -- in this case, the sympathetic control of cardiac rhythm). </li></ul>12/19/09 Gevirtz
  81. 85. <ul><li>More from McEwen Allostatic load </li></ul>
  82. 86. <ul><li>How is HRV measured? </li></ul><ul><li>Originally, HRV was assessed manually from calculation of the mean R-R interval and its standard deviation measured on short-term (e.g., 5 minute) electrocardiograms. The smaller the standard deviation in R-R intervals, the lower is the HRV. To date, over 26 different types of arithmetic manipulations of R-R intervals have been used in the literature to represent HRV. Examples include: the standard deviations of the normal mean R-R interval obtained from successive 5-minute periods over 24-hour Holter recordings (called the SDANN index); the number of instances per hour in which two consecutive R-R intervals differ by more than 50 msec over 24-hours (called the pNN50 index); the root-mean square of the difference of successive R-R intervals (the rMSSD index); the difference between the shortest R-R interval during inspiration and the longest during expiration (called the MAX-MIN, or peak-valley quantification of HRV); and the base of the triangular area under the main peak of the R-R interval frequency distribution diagram obtained from 24-hour recording; and so on. So far, experimental and simulation data appear to indicate that the various methods of expressing HRV are largely equivalent, and there is no evidence that any one method is superior to another, provided measurement windows are 5 minutes or longer. </li></ul>12/19/09 Gevirtz
  83. 87. 12/19/09 Gevirtz
  84. 88. What contributes to the variability in sequential R-waves <ul><li>Underlying physiology of HRV </li></ul><ul><ul><li>Sympathetic </li></ul></ul><ul><ul><li>Parasympathetic </li></ul></ul><ul><ul><li>Baroreceptors </li></ul></ul><ul><ul><li>Peripheral vascular influences </li></ul></ul>12/19/09 Gevirtz
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  91. 95. Baroreflex Sensitivity (BRS) <ul><li>Sensitive prognostic indicator of cardiovascular health (Osterzeil et al., 1995, Br. Heart J, 73, 517-522) </li></ul><ul><li>Can be reliably estimated with .1 Hz paced breathing (Davies et al., 2002, Am. Heart J, 143,441-7) </li></ul><ul><li>Measure IBI (in msec) from valley to peak during .1 Hz paced breathing </li></ul><ul><li>Correlates r=.81 with finipres methods </li></ul><ul><li>Superior to: Bolus phenylephrine, alpha index, and sequence method (Davies et al., 1999, Clinical Science, 97, 515-522) </li></ul>12/19/09 Gevirtz
  92. 96. <ul><li>The baroreceptor vagal reflex is an important part of the cardiovascular control system. It may be defined as the biological neural control system responsible for short-term blood pressure regulation. </li></ul><ul><li>The schematic of the baroreceptor vagal reflex is shown in Fig. 1. Baroreceptors (first-order cells) located in the great arteries provide sensory information to second-order barosensitive neurons located in the nucleus tractus solitaire (NTS) in the lower brainstem. Via a number of intermediate medullary neural networks, the second-order NTS neurons effect motor neurons which in turn control heart rate and total peripheral resistance and thus blood pressure. </li></ul>12/19/09 Gevirtz
  93. 97. Baroreceptor Sensitivity <ul><li>A rise in BP stimulates the baroreceptor to signal to the SA node through the PNS to brake the HR </li></ul><ul><li>A drop in BP stimulates the baroreceptor to increase HR through the SNS </li></ul><ul><li>The ability of BP to regulate HR is called “Baroreceptor Sensitivity” (BRS) </li></ul>12/19/09 Gevirtz
  94. 98. Chemoreceptors: Control of Respiratory Drive <ul><li>Peripheral Chemoreceptors </li></ul><ul><ul><li>Located primarily in the carotid and aortic bodies(in humans mostly carotid) </li></ul></ul><ul><ul><li>Increase firing rapidly primarily in response to hypoxia, but also to hypercapnia </li></ul></ul><ul><ul><li>Control ventilation </li></ul></ul><ul><li>Central Chemoreceptors </li></ul><ul><ul><li>Sensitive to pH of cerebral spinal fluid </li></ul></ul><ul><li>Also have important effects on cardiovascular system </li></ul>12/19/09 Gevirtz
  95. 99. Chemoreceptors (Cont) <ul><li>Respiratory and Cardiovascular systems highly intertwined </li></ul><ul><li>“ Chemoreceptor stimulation causes a marked increase in ventilation and sympathetic nerve activity, while baroreceptor activation causes a mild decrease in ventilation and a sharp reduction in sympathetic nerve activity.” </li></ul><ul><li>“ Baroreceptor activation…has a particularly potent inhibitory effect on the sensitivity to peripheral chemorecptor stimulation, with little (if any) inhibitory effect on the sensitivity to central chemoreceptor firing.” </li></ul><ul><li>“ Increases in ventilation cause a complex cascade of pulminary and cardiovascular effects, including activation of the stretch receptors and an elevation in arterial blood pressure: these make it difficult to isolate the direct cardiovascular effects of chemostimuli in a spontaneously breathing subject.” </li></ul>12/19/09 Gevirtz
  96. 100. Chemorecptors (cont) <ul><li>“ Nevertheless, despite their complexity, these relationships appear to form a stable network, which in normals allows each subsystem to be adequately regulated , while allowing appropiate cross-talk between systems. In the disease states, such as chronic heart failure, there is breakdown of the normal magnitude (and in some cases direction) of the cardiorespiratory reflexes, which can lead to potentially maladaptive feedback loops.” ( Francis, Coats, & Ponikowski, 2002) </li></ul>12/19/09 Gevirtz
  97. 101. 12/19/09 Gevirtz Synthesis of interactions among some of the important reflexes of the cardiovascular and respiratory systems (Francis et al. 2002) Baroreceptors Increased BP Increased Sympathetic nerve activity Cardiovascular integration center Ventilatory integration center Lung Stretch Lower pCO 2 Higher PO 2 Peripheral Chemoreceptors Central Chemoreceptors Increased Ventilation + + + + - - - - - Cardiovascular system Respiratory system
  98. 102. <ul><li>Frequency Domain Measures </li></ul><ul><li>The power spectrum </li></ul>12/19/09 Gevirtz
  99. 103. 12/19/09 Gevirtz 1 4 15 12 10 6 20 25 Breaths per minute
  100. 104. Hertz to Breaths per minute <ul><li>Hz B/min </li></ul><ul><li>.5 30 </li></ul><ul><li>.25 15 </li></ul><ul><li>.2 12 </li></ul><ul><li>.18 11 </li></ul><ul><li>.16 10 </li></ul><ul><li>.15 9 </li></ul><ul><li>.13 8 </li></ul><ul><li>.12 7 </li></ul><ul><li>.10 6 </li></ul><ul><li>.08 5 </li></ul><ul><li>.06 4 </li></ul><ul><li>.05 3 </li></ul><ul><li>.03 2 </li></ul><ul><li>.02 1 </li></ul><ul><li>B/min/60=Hz </li></ul><ul><li>Hz x 60 = B/min </li></ul>12/19/09 Gevirtz
  101. 105. Temperature Rhythms 12/19/09 Gevirtz
  102. 106. Hertz to Breaths per minute <ul><li>Hz B/min </li></ul><ul><li>.5 30 </li></ul><ul><li>.25 15 </li></ul><ul><li>.2 12 </li></ul><ul><li>.18 11 </li></ul><ul><li>.16 10 </li></ul><ul><li>.15 9 </li></ul><ul><li>.13 8 </li></ul><ul><li>.12 7 </li></ul><ul><li>.10 6 </li></ul><ul><li>.08 5 </li></ul><ul><li>.06 4 </li></ul><ul><li>.05 3 </li></ul><ul><li>.03 2 </li></ul><ul><li>.02 1 </li></ul><ul><li>B/min/60=Hz </li></ul><ul><li>Hz x 60 = B/min </li></ul>12/19/09 Gevirtz
  103. 107. Temperature Spectrum 12/19/09 Gevirtz
  104. 108. Hertz to Breaths per minute <ul><li>Hz B/min </li></ul><ul><li>.5 30 </li></ul><ul><li>.25 15 </li></ul><ul><li>.2 12 </li></ul><ul><li>.18 11 </li></ul><ul><li>.16 10 </li></ul><ul><li>.15 9 </li></ul><ul><li>.13 8 </li></ul><ul><li>.12 7 </li></ul><ul><li>.10 6 </li></ul><ul><li>.08 5 </li></ul><ul><li>.06 4 </li></ul><ul><li>.05 3 </li></ul><ul><li>.03 2 </li></ul><ul><li>.02 1 </li></ul><ul><li>B/min/60=Hz </li></ul><ul><li>Hz x 60 = B/min </li></ul>12/19/09 Gevirtz
  105. 109. Heart Rate Rhythms 12/19/09 Gevirtz
  106. 110. Hertz to Breaths per minute <ul><li>Hz B/min </li></ul><ul><li>.5 30 </li></ul><ul><li>.25 15 </li></ul><ul><li>.2 12 </li></ul><ul><li>.18 11 </li></ul><ul><li>.16 10 </li></ul><ul><li>.15 9 </li></ul><ul><li>.13 8 </li></ul><ul><li>.12 7 </li></ul><ul><li>.10 6 </li></ul><ul><li>.08 5 </li></ul><ul><li>.06 4 </li></ul><ul><li>.05 3 </li></ul><ul><li>.03 2 </li></ul><ul><li>.02 1 </li></ul><ul><li>B/min/60=Hz </li></ul><ul><li>Hz x 60 = B/min </li></ul>12/19/09 Gevirtz
  107. 111. Heart Rate Spectrum 12/19/09 Gevirtz
  108. 112. Hertz to Breaths per minute <ul><li>Hz B/min </li></ul><ul><li>.5 30 </li></ul><ul><li>.25 15 </li></ul><ul><li>.2 12 </li></ul><ul><li>.18 11 </li></ul><ul><li>.16 10 </li></ul><ul><li>.15 9 </li></ul><ul><li>.13 8 </li></ul><ul><li>.12 7 </li></ul><ul><li>.10 6 </li></ul><ul><li>.08 5 </li></ul><ul><li>.06 4 </li></ul><ul><li>.05 3 </li></ul><ul><li>.03 2 </li></ul><ul><li>.02 1 </li></ul><ul><li>B/min/60=Hz </li></ul><ul><li>Hz x 60 = B/min </li></ul>12/19/09 Gevirtz
  109. 113. 12/19/09 Gevirtz
  110. 114. Hertz to Breaths per minute <ul><li>Hz B/min </li></ul><ul><li>.5 30 </li></ul><ul><li>.25 15 </li></ul><ul><li>.2 12 </li></ul><ul><li>.18 11 </li></ul><ul><li>.16 10 </li></ul><ul><li>.15 9 </li></ul><ul><li>.13 8 </li></ul><ul><li>.12 7 </li></ul><ul><li>.10 6 </li></ul><ul><li>.08 5 </li></ul><ul><li>.06 4 </li></ul><ul><li>.05 3 </li></ul><ul><li>.03 2 </li></ul><ul><li>.02 1 </li></ul><ul><li>B/min/60=Hz </li></ul><ul><li>Hz x 60 = B/min </li></ul>12/19/09 Gevirtz
  111. 115. Respiration Spectrum at Normal Breathing Pace 12/19/09 Gevirtz
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  126. 130. LF/HF Ratio <ul><li>Often cited as a measure of “sympathovagal balance” with high scores indicating sympathetic dominance </li></ul><ul><li>Still controversial (see Eckberg et al.) </li></ul><ul><li>Does correlate (r=.97) with a fractal measure of entropy </li></ul>12/19/09 Gevirtz
  127. 131. 12/19/09 Gevirtz
  128. 132. 12/19/09 Gevirtz Relationship between In(LF/HF) ratio and alpha 1 , a detrended fluctuation measure,( a fractal measure).
  129. 133. 12/19/09 Gevirtz Severise, Gevirtz et al., 2008
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  137. 141. 12/19/09 Gevirtz Determinants of Heart Rate (IBI) Intrinsic Pacemaker 1-2 Hz (110-120 b/m) Sympathetic Influences on the Sino-Atrial Node A paced accelerator Parasympathetic Influences on the Sino-Atrial Node A paced brake Baroreceptor Feedback System IBI Medullary Influences Vascular Influences
  138. 142. 12/19/09 Gevirtz Based on an interview with Laceys in 1977
  139. 143. 12/19/09 Gevirtz
  140. 144. Cardiac Parasympathetic Afferent System <ul><li>Vagal afferent pathways from the heart to the brain exceed brain to heart </li></ul><ul><li>These can affect: </li></ul><ul><ul><li>cortical function </li></ul></ul><ul><ul><li>EEG </li></ul></ul><ul><ul><li>Emotional memory system </li></ul></ul>12/19/09 Gevirtz
  141. 145. Heart as a Separate Nervous System <ul><li>Neural Cardiology </li></ul><ul><li>Elaborate neural plexus </li></ul><ul><li>Sensory neurites </li></ul><ul><li>Afferents can effect cortical functioning and performance </li></ul>12/19/09 Gevirtz
  142. 146. Heart as Endocrine “Gland” <ul><li>Heart produces: </li></ul><ul><ul><li>Atrial peptides </li></ul></ul><ul><ul><li>Oxytocin </li></ul></ul><ul><ul><li>Dopamine </li></ul></ul><ul><ul><li>Epinephrine </li></ul></ul><ul><ul><li>Norepineprine </li></ul></ul><ul><li>Pulsing of impulses greatly affect communications in the Endocrine System </li></ul>12/19/09 Gevirtz
  143. 147. <ul><li>Fascinating Rhythms </li></ul>12/19/09 Gevirtz
  144. 148. Role of Oscillations <ul><li>In healthy individuals, a degree of interaction between activity of SNS and PSNS allows more effective responses to demands. This interaction occurs as oscillations of SNS and PSNS activity. </li></ul><ul><li>This interaction produces variability in HR. Oscillations in HR interact with other systems (hormones, blood pressure, respiration, emotion, etc). </li></ul>12/19/09 Gevirtz
  145. 149. More on Oscillations <ul><li>Oscillations help bring the physiology back to equilibrium after stressors and contribute to stability of the system. </li></ul><ul><li>Oscillations allow for a timed sequence of events to occur (e.g., firing of all sets of cells necessary to contract the ventricles) and for the repetition of those events. </li></ul>12/19/09 Gevirtz
  146. 150. More on Oscillations <ul><li>Oscillations help predict daily events, e.g., circadian changes in HRV. </li></ul><ul><li>Pathology arises when these oscillations are disturbed, leading to a LOSS of variability and a decrease in ability to adapt. </li></ul>12/19/09 Gevirtz
  147. 151. Heart Rate Variability (HRV) and Health <ul><li>>150,000 Medline ciataions (2000) </li></ul><ul><li>“ Importantly, decreased HRV is almost uniformly associated with adverse outcome.” (Kleiger et al., 1992 Cardiology Clinician) </li></ul><ul><li>Predictor of mortality(all causes) </li></ul><ul><li>Especially sudden death </li></ul><ul><li>Hundreds of citations on methodology,( see the Task Force Report, 1996) </li></ul>12/19/09 Gevirtz
  148. 152. HRV in Health <ul><li>Changes in the amount of HRV are related to change in autonomic activity in: </li></ul><ul><ul><li>Aging: decreases vagal tone. </li></ul></ul><ul><ul><li>Exercise: improves HRV. </li></ul></ul><ul><ul><li>Stress: HRV decreases with SNS arousal. </li></ul></ul><ul><ul><li>Circadian rhythms: HRV changes with time of day. </li></ul></ul>12/19/09 Gevirtz
  149. 153. HRV as a Risk Factor <ul><li>HRV has been widely reported to be a risk factor for CHD, for all cause mortality, and even cancer mortality. </li></ul><ul><li>< 50 ms vs > 50 ms Ors often 3-4 </li></ul><ul><ul><li>This means that a shift SDNN (standard deviation of R-R on ECG) from low to moderate decreases risk of mortality by 4 to 1 </li></ul></ul><ul><ul><li>Kleiger et al. 1987, Am J. Cardio. </li></ul></ul>12/19/09 Gevirtz
  150. 154. HRV as an Outcome Measure <ul><li>Since HRV: </li></ul><ul><ul><li>is not changed by placebo (Kleiger et al., 1991, Vybrial et al, 1993, De Ferrari et al., 1993, Casadei et al., 1996, Venkatesh et al., 1996) </li></ul></ul><ul><ul><li>is stable ( Kleiger et al., 1991, Bigger et al., 1992, Stein et al., 1995) </li></ul></ul><ul><li>It is an excellent candidate for an outcome measure for txs of anxiety, depression,etc. (Pignotti & Steinberg, 2000) </li></ul>12/19/09 Gevirtz
  151. 155. HRV may be a sensitive marker of changes in depression <ul><li>Nahshoni et al (2001) Am J Geriatric Psychiatry, 255-60 </li></ul><ul><ul><li>Cardiac vagal activity increased after ECT in 11 elderly depressed patients compared to controls. </li></ul></ul><ul><ul><li>Similar to many medication studies </li></ul></ul>12/19/09 Gevirtz
  152. 156. Power-law Relationship of Heart Rate Variability as a predictor of Mortality in the Elderly <ul><li>“ Power-law relationship of 24-hour HR variability is a more powerful predictor of death than the traditional risk markers in elderly subjects”(Huikuri et al., 1998, American Heart Journal ) </li></ul><ul><li>Cerebro-vascular adjusted relative risk= 2.84 </li></ul><ul><li>Cardiac mortality adjusted relative risk= 2.05 </li></ul>12/19/09 Gevirtz
  153. 157. Criteria for Sampling <ul><li>R-wave (and ECG) needs to be sampled at at least 256 samples/second </li></ul><ul><li>Need a sharp peak for r-wave detection </li></ul><ul><li>PPG reading may not always be satisfactory due to lack of sharp peak </li></ul>12/19/09 Gevirtz
  154. 158. 12/19/09 Gevirtz Leah 1 HF(.15-.4Hz) LF(.08-.14Hz) VLF(.001-.07Hz)
  155. 159. Fig.1. Here is an example of the various frequencies displayed in a spectral format. Note the bottom graphic shows activity in the bands (the x axis) of VLF (0-.04Hz), LF (.05-.11Hz), & HF (.12-.4 Hz). The Y axis is power or amplitude, and the z axis represents 32 sec time epochs 12/19/09 Gevirtz <ul><li>HF </li></ul><ul><li>LF </li></ul><ul><li>VLF </li></ul>
  156. 160. Fig. 2. Note the high level of VLF activity accompanying rumination, worry or performance anxiety. 12/19/09 Gevirtz
  157. 161. Fig.3. The “meditators peak” in the .08-.11 range. Note that the patient has learned to both “quiet her mind” while breathing slowly and diapragmatically. 12/19/09 Gevirtz
  158. 162. Early stages of Resonant Frequency Acquisition 12/19/09 Gevirtz
  159. 163. RFT Continued 12/19/09 Gevirtz
  160. 164. Achievement of “meditators peak” through Resonant Frequency Training 12/19/09 Gevirtz
  161. 165. The “meditators peak” 12/19/09 Gevirtz
  162. 166. Patient after 10 minutes of RFT 12/19/09 Gevirtz
  163. 167. Evidence of efficacy, HRV Biofeedback <ul><li>Asthma-Lehrer et al., Chest, 2004 </li></ul><ul><li>COPD- Giardino et al., APB, 2004 </li></ul><ul><li>CAD- Del Pozo et al. (AHJ, 2004), van Dixhoorn et al. </li></ul><ul><li>Performance- Strack et al., Gruzelier’s group (APB, 2005) </li></ul><ul><li>Stress, performance, etc., McCraty et al (Har. Bus Rev, 2003; Physio Beh Sci, 1999; numerous HeartMath reports) </li></ul><ul><li>IBS/RAP- Humphreys & Gevirtz (JPGN, 2000) Sowder, Gevirtz,et al. (2007) </li></ul><ul><li>FM- Hasset et al. APB,(2007) </li></ul><ul><li>Altitude sickness-Bernardi (2001& in press) </li></ul><ul><li>MDD, Karavadis et al., APB, (2007), Zucker et al.(2007), Rene et al.(2007) </li></ul><ul><li>Congestive Heart Failure-(Bernardi, 2002, Circulation) Swanson, Gevirtz, et al. (2007) </li></ul><ul><li>Hypertension- (Schein et al, 2001, J. Human Hypertension; Herbs & Gevirtz, 1994, Abstract, APB; Lehrer et al.,( 2004) Reinke, Gevirtz, et al. (2007) </li></ul><ul><li>PTSD Zucker et al., White et al.,(2008) </li></ul><ul><li>GAD Murphy, Hoffmann et al. (2008) </li></ul>
  164. 168. Heart Rate Variabilty Biofeedback “ Increasing RSA” 12/19/09 Gevirtz
  165. 169. 12/19/09 Gevirtz Ordinary Breathing produces three HR frequencies, HF,LF,&VLF Progression to approx. 6 BPM, (Diaphragmatically) in experienced breathers produces single summated peak at about .1hz: RESONANT FREQUENCY Daily practice in this state increases homeostatic reflexes Vaschillo’s Resonant Frequency Theory
  166. 170. 12/19/09 Gevirtz Leah 1 HF LF VLF
  167. 171. 12/19/09 Gevirtz RFT : Notice trend from three waves to a dominant .1 Hz Wave
  168. 172. 12/19/09 Gevirtz
  169. 173. Resonance <ul><li>Dictionary Definition: </li></ul><ul><ul><li>The increase of amplitude of oscillations of an electric or mechanical system due to a periodic force whose frequency is equal or very close to the natural undamped frequency of the system </li></ul></ul><ul><li>Transfer functions, phase angles, and such </li></ul><ul><li>Resonance Frequency Biofeedback Training </li></ul>12/19/09 Gevirtz
  170. 174. 12/19/09 Gevirtz EFFECTS OF HRV BIOFEEDBACK ON HEART RATE
  171. 175. 12/19/09 Gevirtz
  172. 176. Resonance and Effects of HRV Biofeedback <ul><li>Paul Lehrer, Ph.D. </li></ul><ul><li>UMDNJ Dept of Psychiatry </li></ul><ul><li>Piscataway, N.J. </li></ul>12/19/09 Gevirtz
  173. 177. 12/19/09 Gevirtz Resonance in Physiological Systems Resonance is a property of an oscillating system in which perturbations at specific frequencies produce large increases in oscillation amplitudes. A system has resonance properties if two processes (functions) of the system interplay against each other in a feedback relationship. Resonce system
  174. 178. Reaction of Aperiodic and Resonance Systems to Perturbation Stimuli 12/19/09 Gevirtz Aperiodic system Resonance system Perturbation Stimuli Output Function (Response to stimuli) Time Time Time Time T[s] Resonance frequency : F[Hz] = I/T[s]
  175. 179. Pendulum as a Resonance System <ul><li>The pendulum may oscillate because kinetic and potential energies of mass are linked with each other by feedback. The process of kinetic energy change elicits a process of potential energy change and vice versa . </li></ul>12/19/09 Gevirtz Stimuli
  176. 180. The Human Body Consists of Many Resonant Systems 12/19/09 Gevirtz To understand why human beings are more sensitive to some frequencies than to others, it is useful to consider the human body as having sub-systems, where each sub-system has its own resonant frequency.
  177. 181. 12/19/09 Gevirtz EACH BODY SUB-SYSTEM HAS A RESONANCE FREQUENCY BAND Mechanical Resonance
  178. 182. Resonance <ul><li>We found that the human cardiovascular system has resonant features. </li></ul><ul><li>Each person has a specific resonant frequency in the range of .055 - .12 Hz. </li></ul><ul><li>Breathing at resonant frequency causes high amplitudes in both heart rate (HR) and blood pressure (BP) oscillations. </li></ul><ul><li>We have found that breathing at resonant frequency trains the reflexes of the cardiovascular system, in particular, the baroreflex. </li></ul>12/19/09 Gevirtz
  179. 183. The Cardiovascular System Has the Property of Resonance <ul><li>HR, BP, vascular tone, and other functions of the cardiovascular system continually change in healthy people. </li></ul><ul><li>These changes are as important for the autonomic nervous system as movements for the nervous-muscular system . </li></ul><ul><li>HR and BP variability reveal resonant properties of the cardiovascular system. </li></ul>12/19/09 Gevirtz
  180. 184. Biofeedback Is Based on Resonant Properties of the Cardiovascular System <ul><li>Resonant frequency HR variability biofeedback gives people the ability to increase HR variability at a specific resonant frequency. </li></ul><ul><li>The biofeedback procedure produces high- amplitude oscillations in cardiovascular functions. </li></ul>12/19/09 Gevirtz
  181. 185. The Baroreflex Provides The Cardiovascular System with Resonant Properties <ul><li>If BP changes, the baroreflex produces contingent changes in HR and vascular tone (VT). </li></ul><ul><li>The increases in BP produce decreases in HR and VT, and decreases in BP produce increases in HR and VT. </li></ul><ul><li>By mechanical action increases in HR and in VT produce increases in BP, while BR-induced decreases in HR and in VT produce decreases in BP. </li></ul>12/19/09 Gevirtz
  182. 186. 12/19/09 Gevirtz HR and BP Reactions to Stimuli if the Baroreflex Does Not Work Blood Pressure Heart Rate Delay~5 sec Stimuli Time Time Time
  183. 187. 12/19/09 Gevirtz Stimuli Heart Rate Blood Pressure Delay~ 5 sec HR and BP Reactions to Stimuli if the Baroreflex Works Time Time Time Functional Resonance Stimuli elicit HR changes which, after a delay, change BP. BP changes, in turn elicit, HR changes due to baroreflex activity.
  184. 188. 12/19/09 Gevirtz Respiration Heart Rate Blood Pressure Delay~ 5 sec Time Time Time HR and BP Oscillations Elicited by the Stimulus of Respiration
  185. 189. Two Closed-Loop Baroreflex Model 12/19/09 Gevirtz W(HR-target) Blood pressure (BP) control system Heart rate (HR) control system Baroreceptors Vascular tone (VT) control system Brain HR VT W(BP-HR) BP Closed loop of HR baroreflex VT HR BP
  186. 190. POSITIVE RESONANCE at 0.1 Hz <ul><li>(6/minute, or period of 10 sec) </li></ul><ul><ul><li>Heart rate oscillations are at their maximum </li></ul></ul><ul><ul><li>Heart rate and blood pressure oscillations are 180 o out of phase </li></ul></ul><ul><ul><li>Baroreflex causes HR to decrease/increase just as biofeedback also is causing it to decrease/increase </li></ul></ul><ul><ul><li>Note-- Blood pressure effects are at their minimum (perhaps because vascular tone baroreflex effects resonate negatively with biofeedback effects at this frequency) </li></ul></ul>12/19/09 Gevirtz
  187. 191. 12/19/09 Gevirtz The highest HR oscillations are at a target frequency of ~ 0.1 Hz The phase of HR and the stimulus (breathing?) at that frequency is ~ 0 o
  188. 192. 12/19/09 Gevirtz Transfer function: Respiration to HRV ( n = 6) Vaschillo et al, Chest , in press
  189. 193. 12/19/09 Gevirtz Transfer Functions of Blood Pressure with Regard to Heart Rate (Baroreflex Effect of BP) and HR with Regard to Stimulus Max HR Oscil is at ~0.1 Hz (180 o HR:BP Phase) Min HR Oscil is at ~0.03 Hz (0 o HR:BP Phase)
  190. 194. Therefore, HRV biofeedback stimulates the baroreflex <ul><li>Voluntary maximization of HRV requires people to breathe at their resonant frequency (~6/min) </li></ul><ul><li>180 o HR:BP phase relationship implies baroreflex (BR) stimulation </li></ul><ul><li>BR and HRV are maximized </li></ul><ul><li>BR is “exercised” and trained </li></ul><ul><li>Neuroplasticity of the BR is demonstrated </li></ul>12/19/09 Gevirtz
  191. 195. Effects of Biofeedback Instruction to Increase HRV <ul><li>Slows breathing to resonant HRV frequency </li></ul><ul><li>HRV and respiration are in phase </li></ul><ul><li>HRV and blood pressure are 180 o out of phase </li></ul><ul><li>Large increase in HRV at a single frequency </li></ul>12/19/09 Gevirtz
  192. 196. We have found that: <ul><li>The cardiovascular system has at least two resonant mechanisms. It is seems the baroreflex underlies these mechanisms. </li></ul><ul><li>HR resonance occurs in the frequency range (.075-.11 Hz) (4.5-6.6 times/min). </li></ul><ul><li>BP resonance occurs in frequency range (.02-.05 Hz) (1-3 times/min). </li></ul><ul><li>Every person has individual HR and BP resonant frequencies . </li></ul>12/19/09 Gevirtz
  193. 197. 12/19/09 Gevirtz Resonant Frequency Varies Across Individuals (cycles / min)
  194. 198. 12/19/09 Gevirtz Examples of Individual Resonant Frequencies
  195. 199. 12/19/09 Gevirtz Individual Resonant Frequency (breath/min)
  196. 200. 12/19/09 Gevirtz
  197. 201. 12/19/09 Gevirtz Regression of Height on Resonant Frequency
  198. 202. 12/19/09 Gevirtz Resonant Frequency Height Weight Age The correlation coefficients (r) between resonant frequency and age, height, and weight r=-0.6 P<.0001 r=0.01 P<0.9 r=0.02 P<0.82
  199. 203. 12/19/09 Gevirtz r = -.55
  200. 204. 12/19/09 Gevirtz
  201. 205. Conclusion <ul><li>1) Each person has a specific resonant frequency. </li></ul><ul><li>2) The resonance frequency range is between 4.5 to 6.5 (times/min). </li></ul><ul><li>3) Asthma does not affect the resonant frequency. </li></ul><ul><li>4) Asthma decreases the amplitude of HR oscillation at the resonant frequency. </li></ul>12/19/09 Gevirtz
  202. 206. HRV biofeedback stimulates the baroreflex <ul><li>Voluntary maximization of HRV requires people to breathe at their resonant frequency (~6/min) </li></ul><ul><li>180 o HR:BP phase relationship implies baroreflex (BR) stimulation </li></ul><ul><li>BR and HRV are maximized </li></ul><ul><li>BR is “exercised” and trained </li></ul><ul><li>Neuroplasticity of the BR is demonstrated </li></ul>12/19/09 Gevirtz
  203. 207. Implications <ul><li>Baroreflexes are systematically stimulated with each breath, producing very high amplitude output </li></ul><ul><li>Does exercise improve baroreflex function? </li></ul><ul><li>Voluntary increase in HRV (or BP variability?) requires breathing in phase with HR (BP) changes </li></ul><ul><li>Does phase with respiration improve breathing? </li></ul>12/19/09 Gevirtz
  204. 208. HRV Biofeedback Also Can Improve Respiratory Function 12/19/09 Gevirtz
  205. 209. Function of Respiratory Sinus Arrhythmia <ul><li>Yasuma & Hayano (2004): promotes respiratory efficiency </li></ul><ul><ul><li>HR increases during inhalation </li></ul></ul><ul><ul><li>More blood to alveoli when O 2 concentration is highest </li></ul></ul>12/19/09 Gevirtz
  206. 210. 12/19/09 Gevirtz HRV and Pulse Oxyimetry Biofeedback for COPD Giardino, et al, 2004, App Psychophysiology and Biofeedback, 29,121-133
  207. 211. HRV and Pulse Oxyimetry Biofeedback for COPD Giardino, et al, 2004, App Psychophysiology and Biofeedback, 29,121-133 12/19/09 Gevirtz RSA ms 2 /Hz Lower scores indicate higher function
  208. 212. BUT 0 o phase relationship in intact humans occurs only during resonant-frequency breathing 12/19/09 Gevirtz
  209. 213. Learning to Judge Resonant Frequency <ul><li>The correlation between resonant frequency and height was nonsignificant when examined only for the first session </li></ul><ul><li>Thus: </li></ul><ul><li>Subjects gradually learned to find their RF </li></ul><ul><li>Subjects gradually learned to breathe at a single sustained rate </li></ul>12/19/09 Gevirtz
  210. 214. Learning to Judge Resonant Frequency <ul><li>The correlation between resonant frequency and height was non-significant when examined only for the first session </li></ul><ul><li>Thus: </li></ul><ul><li>Subjects gradually learned to find their RF </li></ul><ul><li>Subjects gradually learned to breathe at a single sustained rate </li></ul>12/19/09 Gevirtz
  211. 215. L. Bernardi’s research: 6/min breathing <ul><li>Increases tolerance to lower SaO 2 </li></ul><ul><li>Increases respiratory gas exchange efficiency </li></ul><ul><li>Decreases dyspnea </li></ul><ul><li>Greater resistance to hyperventilation </li></ul><ul><li>Lowers hypoxic ventilatory response </li></ul><ul><li>Increases baroreflex response in chronic heart failure </li></ul><ul><ul><li>Bernardi, L., et al Lancet, 351 ,1308-1311., 1998 </li></ul></ul><ul><ul><li>Bernardi L. et al, J Hypertens, 19 :2221-2229,2001 </li></ul></ul><ul><ul><li>Bernardi, L. et al, Circulation 105 143-145, 2002. </li></ul></ul>12/19/09 Gevirtz
  212. 216. Yogis and Sherpas breathe at this Rate and Tolerate Altitude <ul><ul><li>Low hypoxic ventilatory response in laboratory </li></ul></ul><ul><ul><li>Resist hyperventilation </li></ul></ul><ul><ul><li>Higher SaO 2 </li></ul></ul><ul><ul><li>Low hemoglobin </li></ul></ul><ul><ul><li>Low minute volume ventilation </li></ul></ul><ul><ul><li>No mountain sickness </li></ul></ul><ul><ul><li>High exercise tolerance </li></ul></ul>12/19/09 Gevirtz <ul><li>Spicuzza et al, Lancet 356 :1495-1496, 2000 </li></ul><ul><li>Keyl, C. et al. J Appl Physiol. ;94: 213-219, 2003 </li></ul>
  213. 217. Possible Reason?? <ul><li>In phase respiration and respiratory sinus arrhythmia at resonant frequency </li></ul><ul><li>More efficient ventilation </li></ul><ul><li>Higher baroreflex gain, stronger autonomic modulation </li></ul>12/19/09 Gevirtz
  214. 218. Controlled Study of 56 Healthy Subjects <ul><li>Increase RSA amplitude vs. Waiting List </li></ul><ul><li>10 20-min weekly sessions with home practice </li></ul><ul><li>Physiological assessment at sessions 1, 4, 7, 10 </li></ul>12/19/09 Gevirtz
  215. 219. 12/19/09 Gevirtz
  216. 220. Low Frequency RRI power 12/19/09 Gevirtz
  217. 221. High Frequency RRI power 12/19/09 Gevirtz
  218. 222. Mean R-R Interval 12/19/09 Gevirtz Tx x Task p < .02 Tx x Session p < .08 Tx x Task x Session p < .04
  219. 223. Total RRI power 12/19/09 Gevirtz
  220. 224. Mean Diastolic BP 12/19/09 Gevirtz
  221. 225. Mean Systolic BP 12/19/09 Gevirtz
  222. 226. R e spiratory Activity Continually Perturbs Cardiovascular hemodynamics 12/19/09 Gevirtz <ul><li>“ In the brain stem, respiration modulates the activity of most sympathetic and vagal efferents both through direct coupling between the respiratory and autonomic centers and through modulation of central sensitivity to baroreceptor and other afferent inputs. The autonomic efferents in turn modulate heart rate (HR) and peripheral vascular resistance with respiratory periodicities.” </li></ul><ul><ul><li>Saul JP at. Al.Transfer function analysis of the circulation: unique insights into cardiovascular regulation. Am J Physiol. 1991 Oct;261(4 Pt 2):H1231-45 </li></ul></ul>
  223. 227. There Are Many Types of Breathing Procedures to Contr o l Body Condition <ul><li>E astern m e dicine includes respiratory training. </li></ul><ul><li>Special respiratory training procedures are dev e loped (e.g., by Eric Peper, Buteiko, Strelnikova). </li></ul><ul><li>Heart rate variability biof ee dback includes respiratory training at resonance frequency of the cardiovascular system. In order to reach the highest therap eu tic effect, individual needs to breath at his/her own r e sonant frequency. </li></ul>12/19/09 Gevirtz
  224. 228. Heart Rate Variability Biofeedback Improves Autonomic Functions Regulation: <ul><li>- Increases baroreflex gain and peak e xpiratory flow; </li></ul><ul><li>Lehrer, P., at al. Heart rate variability biofeedback increases baroreflex gain and peak expiratory flow. Psychosom Med. 2003 65(5):796-805. </li></ul><ul><li>- Improves eff i ciency of p u lmonary gas exchange. </li></ul><ul><li>Giardino, N., at al. Respiratory sinus arrhythmia is associated with efficiency of pulmonary gas exchange in healthy humans. Am J Physiol Heart Circ Physiol. 2003 May;284(5):H1585-91. </li></ul>12/19/09 Gevirtz
  225. 229. 12/19/09 Gevirtz L 4, Paced Breathing
  226. 230. Forced Oscillation Pneumography 12/19/09 Gevirtz
  227. 231. RFT & Baroreflex Function Baroreflex Gain 12/19/09 Gevirtz
  228. 232. 12/19/09 Gevirtz
  229. 233. 12/19/09 Gevirtz
  230. 234. 12/19/09 Gevirtz
  231. 235. 12/19/09 Gevirtz Full Protocol HRV alone Placebo Waiting List
  232. 236. 12/19/09 Gevirtz
  233. 237. Heart Rate RSA Biofeedback Training: A Treatment Manual Resonant Frequency (RFT) Training Based on Lehrer, Vashillo, & Vashillo (2000) Applied Psychophysiology and Biofeedback, 25, 177-191 Richard Gevirtz, Ph.D. CSPP at AIU, San Diego, CA 12/19/09 Gevirtz
  234. 238. Assessment <ul><li>Using an EKG for the office procedure (Currently two are readily available: Thought Technology Infiniti or CardioPro and J& J Use 2, C-2 System), turn screen away from patient and allow at least 5 minutes of “free breathing”. It is useful to distract the patient by having them listen to an audio tape of neutral material (National Geographic, travelogs, etc) </li></ul><ul><li>RFT determination: </li></ul><ul><ul><li>Instructions: (Show screen such as Fig. 1 or 2) “On this screen you will see your breath wave, your heart rate updated every beat, and a breath pacer. Try and breath at the pace of the pacer, but keep it as effortless as possible.” </li></ul></ul><ul><ul><li>Set pacer at 7, 6.5, 6, 5.5, 5, 4.5 breaths per minute. Use 2-3 minutes for each interval. Observe 1) peak valley differences in B/M, and LF power or relative power. Write down maximum values. For example, 24 B/M and .4 ms. </li></ul></ul><ul><ul><li>If you have a capnometer, watch for signs of HV </li></ul></ul>12/19/09 Gevirtz
  235. 239. 12/19/09 Gevirtz Peak 78 Valley 65 LF Power Fig. 1. J&J Screen showing HR, Resp,temp, Skin Cond, and a spectral analysis. Peak valley differences are about 14 B/M (79-65), LF is .1. Breath Pacer
  236. 240. 12/19/09 Gevirtz Fig. 2.1. CardioPro screen for HR and Resp
  237. 241. 12/19/09 Gevirtz Fig. 2.2. CardioPro Training Screen Breath Pacer
  238. 242. Treatment I <ul><li>Once RF is determined, Use instructions such as the following: (from Lehrer, Vaschillo, and Vaschillo, p.184, italics mine) </li></ul><ul><li>Your heart goes up and down with your breathing. When you breathe in, your heart tends to go up. When you breathe out, your heart tends to go down. These changes in heart rate are called “Respiratory Sinus Arrhythmia” or RSA. RSA triggers very powerful reflexes in the body that help to control the whole autonomic nervous system (including your heart rate, blood pressure, and breathing). We will train you to increase the size of these heart rate changes. Increasing the size of these heart rate changes will exercise these important reflexes, and help them to control your body more efficiently. As`a part of this treatment we will give you information about the swings in your heart rate that accompany breathing. That will be the RSA biofeedback. You will use this information to teach yourself to increase your RSA. If you practice the technique regularly at home, you will strengthen the reflexes that regulate the autonomic nervous system. This should help you manage your health (or IBS, or Pain, etc) and ability to manage every day stress.” </li></ul>12/19/09 Gevirtz
  239. 243. 12/19/09 Gevirtz Leah 1 HF LF VLF
  240. 244. Treatment II <ul><li>Training procedes: </li></ul><ul><li>EZ Air (BFE.org)(click on support) </li></ul><ul><ul><li>Use pacer or Breathsounds (www.BreathSounds.com) at first, but let the patient take over the pace when ready. </li></ul></ul><ul><ul><li>Encourage home practice </li></ul></ul><ul><ul><ul><li>Biosvyaz, St. Peterberg, Russia (www.biosvyaz.com) </li></ul></ul></ul><ul><ul><ul><li>Heart Math Freeze Framer(www.heartmath.com) </li></ul></ul></ul><ul><ul><ul><li>Heart Tracker (BioCom Technologies, www.biocomtech.com) </li></ul></ul></ul><ul><ul><ul><li>Temp monitor (about $20) available from BMI ( or Future Health ( www.futurehealth.org ) </li></ul></ul></ul>12/19/09 Gevirtz
  241. 245. 12/19/09 Gevirtz
  242. 246. 12/19/09 Gevirtz
  243. 247. 12/19/09 Gevirtz
  244. 248. 12/19/09 Gevirtz Bio-Medical Instruments (www.bio-medical.com)
  245. 249. 12/19/09 Gevirtz
  246. 250. Treatment III <ul><li>Check for RF peak and pattern at the beginning of each session with the screen hidden from the patient. </li></ul><ul><li>Once evidence for a good RF is found, challenge the patient with stressors and then instruct them to resume training. </li></ul><ul><li>Watch for VLF elevations. They represent either chronic sympathetic activation or vagal withdrawal (as in chronic worry). </li></ul>12/19/09 Gevirtz

Notas del editor

  • * 07/16/96 * ##
  • * 07/16/96 * ##
  • * 07/16/96 * ## Fig. 1. J&amp;J Screen showing HR, Resp,temp, Skin Cond, and a spectral analysis. Peak valley differences are about 14 B/M (79-65), LF is .1.
  • * 07/16/96 * ##

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