A few days ago, I received a chain letter from a friend. There wasn't any money involved. All you had to do was send some words of greeting to five of your friends along with copies of the letters those who were links in the "chain" before you had sent to their five friends, and in return you would experience a stroke of good luck within 4 days. One of the letters in the chain was from Tip O'Neill. His words of greeting were, "This is a bunch of bull!" Nevertheless, our former Speaker of the House of Representatives didn't break the chain. Neither did I.
I must confess that after I read the articles Dr Karen Olness, guest editor for this Issue of Pediatrie Annals on Biofeedback Therapy, had sent to me, my initial feelings echoed those of Mr O'Neill. However, before sending Dr Olness and her authors1 words along to you, for fear of experiencing bad luck in not doing so, I decided to find out all I could about the subject in the short period of time an editor has between receiving articles and having to pass them on to the publisher. My basic understanding of biofeedback and cyberphysiologic therapy, including its components - hypnosis, self-hypnosis, hypnoanalgesia, hypnoanesthesia, relaxation training, and mental imagery - was at best rudimentary.
First, I reviewed the indexes of five major pediatrie textbooks published within the past 4 years.1-5 Only two listed any of these subjects. One addressed biofeedback and relaxation therapy for the treatment of migraine headaches, and the other, hypnosis in treating enuresis and applying relaxation skills during labor and delivery to reduce the amount of anesthetic agents required. Incidentally, acupuncture, a method used for centuries to produce analgesia and anesthesia, was not listed in the index of any of the five.
Second, 1 read several of the scientific papers referenced by the authors of the articles appearing in this issue of Pediatrie Annals. While some regarding the validity of the efficacy of biofeedback therapy in controlling pain and other symptoms were convincing, most consisted of anecdotal reports or of clinical interventions using small patient samples with no control groups and did not address confounding variables such as the patient's age, diagnosis, psychological profile, and support systems.
Third, I asked my colleagues at the University of Rochester if they used biofeedback therapy in children. Their reports ranged from using none (the Pain Treatment Center), to using cognitive orientation and distraction techniques for painful procedures (Pediatrie Oncology Division and Pediatrie Emergency Department), to using galvanic skin-resistance relaxation techniques (Behavioral Pediatrie Clinic), and to using rectal balloons that transmit internal pressures for biofeedback signals to control fecal incontinence (Spina Bifida Center). One of our former house officers, now in private practice, has taken biofeedback and hypnosis training workshops sponsored by the Society for Behavioral Pediatrics and Society for Clinical and Experimental Hypnosis. She uses biofeedback therapy, hypnosis, and self-hypnosis every day to manage migraine headaches, encopresi, school phobia, and anxiety reactions, among other clinical problems.
Finally, I viewed the videotape "No Fears, No Tears: Children With Cancer Coping With Pain," produced by Leora Kuttner, PhD, (author of the second article in this issue of Pediatrie Annals) and available, along with an instruction manual, from the Canadian Cancer Society, 955 West Broadway, Vancouver, British Columbia, V52 3X8, Canada. "No Fears, No Tears" demonstrates how children being treated for cancer at the Children's Hospital of Vancouver respond to anxiety- reducing and painelimination techniques such as preparation (practicing) for painful procedures, distraction methods used during the procedure, relaxation breathing (blowing), use of a "magic glove" to create anesthesia, and the invoking of "switches" in the brain to turn off pain anywhere in the body. Children are pictured during venipunctures, bone marrow aspirations, lumbar punctures, and even cranial taps lying quietly in proper procedural positions talking to their parent or other "coach" and showing no evidence of pain or discomfort. If 1 had any doubts that biofeedback therapy works, I have none now.
How do biofeedback therapies, cyperphysiologic strategies, and hypnosis apply to primary care pediatrie practice? The following maladies are encountered in practice and are responsive to these treatments, as described by our authors:
Attention deficit disorder
Bruxism (teeth grinding)
Chronic pain syndrome
Headaches (tension and migraine)
Irritable bowel syndrome
Minor surgical procedures
Parasomnias (eg, sleep walking, night terrors)
Reflex sympathetic dystrophy
Sickle cell disease
Tics (eg, eye blinking, grimacing, twitching)
Vocalizations (eg, throat clearing, habit coughs)
Certainly at least one of these diagnoses is encountered every day in practice. Whether primary care pediatricians are willing to take the time to learn hiofeedback therapy, to master it, and to apply it is questionable. It does take a great deal of time, and it may not be applicable in everyone's practice. If one does not wish to apply these techniques, referring to biofeedback therapists or hiring one to work in one's own office are alternatives. At the very least, practitioners should be aware of the wide range of uses for biofeedback therapy and should keep an open mind to its applicability in practice while learning more about it.
If you are wondering whether my keeping the chain letter going brought me a stroke of good luck, it sute did. The Giants won the Super Bowl!
1. Avery ME, First LR. Pediatric Medicine. Baltimore, Md: Williams and Wilkins; 1989.
2. Behrman RE, Vaughan VC. Nelson Textbook of Pediatrics. 13th ed. Philadelphia, Pa: Harcourt Brace Jovanovich Inc; 1987.
3. Hockelman RA, Blatman S, Friedman SB, Nelson NM, Seidel HM. Primary Pediatrics Care. 2nd ed. St Louis, Mo: CV Mushy Co; 1987.
4. Oski FA, DeAngelis CD; Feigin RD, Warshaw JB. Principles and Practice of Padiatrics Philadelphia, Pa: JB Lippincott Co; 1990.
5. Rudolph AM, Hoffman JIE. Pediatrics. 18th ed. Norwalk, Conn: Appleton and Lange; 1987.