Treatment of Post-Traumatic Stress Disorder 
with EMG Biofeedback and the Treatment of 
Post-Traumatic-Stress Headache with EMG and 
Thermal Biofeedback.


Jean E. Horn


Humboldt State University


			 
    According to DiMatto (1991) Biofeedback, which measures muscle tension, is 
called EMG (electromyographic) feedback.  The EMG (electromyograph) measures the 
amount of electrical charge in the muscle (contractions), which the individual 
realizes as muscle tension.  Biofeedback, which measures temperature and blood 
flow, is called Thermal Biofeedback.  Thermal biofeedback measures the body 
temperature in Fahrenheit degrees, which is an indirect measure of peripheral 
vasoconstrictions of the blood vessels (Schwartz, 1995).  The therapist may use 
EMG biofeedback and Thermal biofeedback in the same session.  EMG biofeedback 
for clients who suffer from muscle tension, and Thermal biofeedback if the 
client suffers from tension headaches.
    EMG (electromyographic) biofeedback is used in the treatment of Post-
Traumatic-Stress Disorder (PTSD). Clients who suffer from Post-Traumatic-Stress 
Disorder may also suffer from Post-Traumatic Headache (PT-HA), which is treated 
with Thermal biofeedback.
     The DSM-IV (TR) lists Post-Traumatic Stress Disorder as an anxiety disorder 
that is caused by some trauma to the person.  The person expresses the anxiety 
as intense fear, helplessness, or horror.  Acute symptoms of PTSD should appear 
at least one to three months after the trauma.  If Post-Traumatic-Stress 
Disorder lasts longer than three months the symptoms are considered chronic.  
The DSM-IV (TR) states that trauma may be the result of physical or sexual child 
abuse, rape, natural disasters (earthquakes, floods, or tornadoes), robberies, 
terrorist attacks, vehicle accidents, and trauma experienced during combat in 
war.
    The study conducted by Peniston (1986) included 16 Viet Nam Veterans (10 
inpatients and 6 outpatients) with a seven-year history of chronic Post-
Traumatic-Stress Disorder.  The participant's ages ranged from 29 to 49 years.  
Participants were randomly assigned to the EMG biofeedback induced 
desensitization procedure (EMG-D) or the NO Treatment control (NT) procedure.  
Participants in the (EMG-D) procedure were seen for three pre-training sessions 
comprised of visualization/imagery and progressive relaxation training 
(Peniston, 1986).  The NO Treatment control (NT) was given pre-and post-EMG 
measures (Peniston, 1986).  Stress was recorded for both groups through the 
measurement of the participant's forehead muscle tension.  Peniston (1986) found 
that participants in the (EMG-D) procedure had significantly reduced their 
muscle tension and showed continued improved functioning over a twenty-four 
month follow up period.  The no Treatment control (NT) did not see a reduction 
of EMG forehead tension. 
	The twenty-four month follow-up was conducted through telephone contacts 
with the 8 participants in the (EMG-D) and NT groups.  Peniston (1986) found 
that the (EMG-D) group Vietnam combat veterans self-reported less anxiety.  
Fewer flashbacks and nightmares were reported by the (EMG-D) group during this 
24 month period.  Peniston (1986) reports of several instances where the 
veterans reported the occurrence of 2 to 4 flashbacks, but in each instance the 
(EMG-D) group reported that they were able to cope with the anxious feelings.  
	The NT group reported greater anxiety with more frequent re-occurrences of 
nightmares and flashbacks.  Peniston (1986) reports that the NT group had more 
hospital readmissions than the (EMG-D) group (5 out of 8) during the twenty-four 
month follow-up period.
    This study shows the effectiveness of EMG biofeedback and imagery relaxation 
as a useful method in the reduction of client's muscle tension.
    Hickling, Sison, and Vanderploeg (1986) study included six participants who 
were referred for treatment in a biofeedback clinic in a Veterans Administration 
medical center.  The participant's ages ranged from 33 to 66 years.  Hickling 
(1986) stated that the treatment goal for all of the participants included the 
reduction of physical arousal and subjective tension/stress as well as 
increasing the participant's ability to deal effectively with stress.  Two 
participant's treatment goals included the reduction of tension headache 
intensity and frequency.
    The biofeedback equipment (Hickling, 1986) used was a Cyborg Processor 
Integrator.  For the Thermal biofeedback the researchers used a Cyborg 142 
temperature unit.
    The researchers stated that all of the treatment sessions were conducted by 
a female psychology aide, certified in biofeedback therapy.  Hickling (1986) 
stated the initial two or three sessions consisted of audiotaped progressive 
muscle relaxation (PMR) training, based largely on procedures outlined by 
Bernstein and Borkovec (1978).  The researchers used Electromyographic 
biofeedback (EMG), simultaneously with both auditory and visual feedback from a 
frontalis muscle electrode placement.  Participants received between 7 and 14 
relaxation/EMG training sessions over a period of 8 to 16 weeks, as well as 
group therapy and individual therapy.  Sessions following the PMR Training 
involved the use of autogenic phrases as used by (Schultz & Luthe, 1969).  The 
researchers encouraged the participants to practice relaxation on a daily bases.  
Two of the participants were given additional training in Thermal biofeedback 
following the relaxation/EMG training in an effort to relieve complaints of 
vascular headaches (Hickling, 1986).  The researchers had the participant's rate 
their subjective feelings of tension at the beginning and end of each session 
(0= no tension, 10 = worst imaginable tension).  Each of the participants were 
asked to rate their progress, a seven point Likert scale was used (-3 = markedly 
worse, -2 = moderately worse, -1 = slightly worse, 0 = no change, + 1 = slight 
improvement, +2 = moderate improvement, +3 = markedly improved).  


    As a group, the researchers found that all of the participants reported 
lower tension ratings from the beginning to the end of the sessions.  The 
participants reported significantly less tension as treatment progressed, and 
all learned to lower their frontalis (muscle) readings.  The researchers 
believed that relaxation training and biofeedback might be particularly useful 
in the treatment of PTSD.  
    This study is an example of how biofeedback may be used along with other 
treatments to help clients relieve their muscle tension and tension headaches.
    Sadigh (1999) quotes Noriss (1992) as suggesting that traffic accidents were 
the most common cause of the experience of post-traumatic symptoms in the United 
States. 
    In a study conducted by (Hickling, Blanchard, Schwartz, and Silverman, 1992) 
twelve participants (11 females and 1 male, with a mean age of 31.1 years) were 
observed.  All of the participants were seeking treatment for Post-Traumatic 
Headache (PT-HA), following a motor vehicle accident, and were referred to 
Hickling (1992).  Ten participants were referred by neurologists form outpatient 
practices, a hospital-based psychiatrist referred one patient, and an attorney 
referred one.  According to the researchers none of the participants had a 
significant headache history before their motor vehicle accident.  Hickling 
(1992) reports that nine of the participants had suffered diagnosable head 
trauma, three had lost consciousness; nine were taking more than one medication 
each day for their headaches.  According to Hickling (1992) six of the twelve 
participants had tried physical therapy and one participant had seen a 
chiropractor before seeking psychological treatment for their headaches.
    Hickling (1992) states the participant's headaches were diagnosed using the 
guidelines put forth by the Headache Classification Committee of the 
International Headache Society (Olsen, 1988, 1990).  The researchers had the 
twelve participants evaluated by (DJS) a Board Certified Neurologist; 
evaluations were by personal examination, or by reviewing the participant's 
neurological/medical records.
    Following the Blanchard and Andrasik (1985) headache scale, the researchers 
had each of the participant's record their headaches into a daily headache 
diary.  Headaches were recorded by the participants for one week before 


treatment and for one week after the treatment.  Headaches were rated on a scale 
from "0" (no headache) to "5" (intense, incapacitating headache).
     Hickling (1992) stated treatment was individually tailored to address the 
needs of each participant.  All of the participants received cognitive/ 
behavioral therapy and relaxation training.  The researchers used biofeedback 
treatment when it was clinically determined that relaxation training and 
cognitive/ behavioral therapy failed to provide sufficient relief.  Of the 
twelve participants, seven participants received either Thermal or EMG 
biofeedback.  The researchers stated that the mean number of treatment sessions 
was 20 (range 8 to 50). 
    Hickling (1992) found that eight of the twelve participants (67%) met the 
generally accepted criteria (Blanchard and Schwartz, 1988) of clinically 
significant improvement.  The researchers found that headache daily diaries of 
more then one week might be a better estimate of headache activity.
    Eight of the participants in the Hickling (1992) study met the DSM-III-R 
criteria for PTSD.  Those participants who met the criteria for PTSD required 
significantly more treatment sessions (a mean of 24.6 sessions) than the non-
PTSD group (10.8 sessions).  The researchers found from their data that patients 
with PTSD required almost 2.5 times as much treatment as those who did not meet 
the criteria for PTSD.  The researchers say that the presence of PTSD 
complicates the treatment of headaches, and that the PTSD disorder must also be 
treated as well. 
    The study conducted by Hickling (1992) shows how cognitive/behavioral 
therapy, relaxation training, and EMG and Thermal biofeedback can be combined 
into one treatment program.
    Schwartz (1995) agrees with the Hickling (1986) study, he states that 
clients who are diagnosed with post-traumatic headache often experience the most 
time with pain each year.   Those clients who suffer from tension-type headaches 
and "mixed headaches" often experience less time     with pain than do those 
with Post-Traumatic headaches (Schwartz, 1995).  Schwartz (1995) also stated 
that clients with Post-Traumatic headache experience more time with pain than 
most patients with migraines.  
    I believe that EMG biofeedback is a useful therapy, which allows clients to 
take an active role in their own medical care.  EMG or Thermal biofeedback is 
cost efficient, relaxation or other biofeedback techniques may be learned in a 
very short period of time.  Through the training of relaxation techniques the 
client is able to have some control over their physiological processes.  That is 
the client with the aid from a biofeedback therapist learns to do relaxation 
techniques without the aid of an EMG or Thermal biofeedback machine.  Eventually 
the client is able to do the relaxation techniques without the aid from the 
biofeedback therapist.  The client may do their relaxation techniques they have 
learned, at home or at work, and without others knowing that they are doing 
relaxation techniques.  Helping the client to relieve muscle tension or tension 
headaches at anytime that they (the client) are in pain. 
    It is not known exactly how EMG or Thermal biofeedback works, some critics 
say that biofeedback has a placebo effect.  Never the less, if a client receives 
relief from their symptoms of muscle tension or tension headache then EMG and 
Thermal biofeedback are useful therapies.
    Post-Traumatic -Stress Disorder (PTSD) and Post-Traumatic Headache (PT-HA) 
are the most difficult illnesses to treat, with EMG or Thermal biofeedback 
therapy alone.  As Hickling (1992) suggests the Post-Traumatic-Stress Disorder 
should be treated along with biofeedback therapy.  Treating Post-Traumatic-
Stress Disorder with a combination of different therapies is more realistic, 
such therapies would include, cognitive/behavioral therapy, drug therapy, and 
biofeedback therapy. A holistic treatment plan would take the individual's 
physical and mental condition into consideration.

      






Reference

    DiMatteo, M.R. (1991).  The Psychology of Health, Illness, and Medical Care 
. . . An Individual Perspective.   Pacific Grove, California: Brooks/Cole 
Publishing Company.  173.

    Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, TR 
(2000).  Washington, DC: APA.  463, 464, and 465.

    Hickling, E.J., Sison, Jr., G.F., Vanderploeg, R.D. (1986).  Treatment of 
Posttraumatic Stress Disorder with Relaxation and Biofeedback Training.  
Biofeedback and Self-Regulation.  11, (2).  125-134.

    Hickling, E.J., Blanchard, E.B., Schwartz, S.P., and Silverman, D.J. (1992).  
Headaches and Motor Vehicle Accidents: Results of the Psychological treatment of 
Post-Traumatic Headache.  Headache Quarterly, Current Treatment and Research.  
3, (3).  285-289.


    Morgan, J. (2003).  Psychology 476 Class Lectures.  Spring 2003.

    Peniston, E. (1986).  EMG Biofeedback-Assisted Desensitization Treatment for 
Vietnam Combat Veterans Post-Traumatic - Stress Disorder.  Clinical Biofeedback 
and Health.  9, (1).  35-41.

    Sadigh, M.R. (1999).  The Treatment of Recalcitrant Posttraumatic Nightmares 
with Autogenic Training and Autogenic Abreaction: A Case Study.  Applied 
Psychophysiology and Biofeedback.  24, (3).  203-210.

    Schwartz, M.S. (1995).  Biofeedback A Practitioner's Guide, Second Edition.  
New York, New York: The Guildford Press.  340. 

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