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on October 20, 1998
Is Electrical Stimulation
A Form Of Behavioral Therapy?
An Essay by John D. Perry, PhD, BCIA-C
The following discussion first appeared on IncontiPro email list in October, 1998.
Sections:
Jump to AHCPR Guideline
Jump to THE GHOST IN THE BOX
Jump to What is Behavioral
Therapy
Jump to Helpers and Healers
Note: This discussion was later revised, shortened, and
published as
"Is Electrical Stimulation A Drug?" in Biofeedback,
March, 2000 (28)1
Marta Krissovich, chairperson of the 2000 Multi-Specialty Nursing Conference on Incontinence, asked a deceptively simple and extremely important question:
John
Please share your opinion. Is
electrical stimulation therapy
a type of behavioral therapy?Marta
As I was getting ready to respond, a physical therapist suggested that e-stim could be considered behavioral therapy because it was a form of biofeedback, (which everyone agrees is a form of behavioral therapy).
So now we have really TWO questions:
1. Is e-stim a behavioral therapy? and 2. Is e-stim a form of biofeedback?
Let me address the second one first. When the therapist describes e-stim as "biofeedback", she is using the term "biofeedback" in a sometimes popular, but not scientifically accurate, sense.
And while my opinions might be interesting, I think that I should refer you to the really BIG experts in the field of biofeedback to answer the question.
1. Most people in the field of biofeedback consider the 908-paged volume, "Biofeedback: A Practitioner's Guide", by Mark S. Schwartz and Associates (The Guilford Press, New York, Copyright 1995 by The Mayo Foundation, second edition) to be the most authoritative book on biofeedback. The second edition is an update of a previous edition that was considered the "bible" of the field for nearly a decade.
So, do Schwartz and his Mayo Clinic (and other) authors consider Electrical Stimulation to be a form of biofeedback? I can tell you this; it is not even mentioned in the index, not a single time.
And Electrical Stimulation is not included in the Table of Contents, either. While I haven't read all 38 thick chapters, I don't believe there is a single reference to e-stim anywhere in the book.
Schwartz' definition of "biofeedback" is quoted in a paper that I presented in 1989 to show that Arnold Kegel was the real "founder" of biofeedback http://www.incontinet/articles/art_urin/20yearbf.htm.
2. Another authoritative source would be the Biofeedback Certification Institute of America ("BCIA"), which sets the national standards for, and provides formal Certification in, Biofeedback.
People who are Certified in Biofeedback are allowed to put "BCIA-C" after their names. Some well-known Certified people are Joan Coxe, RN and Barbara Woolner, RN.
Certification requires completion of 80 hours of continuing education in specific topics of biofeedback [for initial certification]. Content includes everything from "anatomy of thoracic, lumbar and sacral spine" to "research on EEG biofeedback, including alpha and theta motor rhythm, and other frequency ranges for the control of epilepsy" and "how to perform a continuity check on electrodes and cables." There are progressive requirements; after 17 years, an additional 320 CEUs is required for "Senior Fellow", (which I will be when I send in my application next month).
The Certification process is based on a four-page fine-print document called the "Blueprint Knowledge Statements". These are the "facts" that one has to know to pass the national exam. In addition, an internship is virtually required, and there is a "hands-on" assessment (practical test using real instruments on real people).
I participated in writing the original "blueprint", and I have been a BCIA "assessor". I can tell you that electrical stimulation has no place in either the knowledge blueprint or the practical examination. Zippo! It just isn't considered a part of biofeedback.
I could cite other authorities, but I think I've made the point; people in the biofeedback field do not consider electrical stimulation to be a form of biofeedback. And, for good reason.
3. People who don't actually DO biofeedback do not usually realize that it involves highly technical and precise instruments. For the past decade almost all such devices have been computerized, which allows even greater precision, accuracy, and most-important, self-evident and highly compelling visual displays. It is generally believed that the enormous amount of timely (instantaneous) information conveyed by the feedback display is a major source of the efficacy of biofeedback therapies.
It is, of course, possible to use very primitive forms of "biofeedback" to provide "feedback" and thus facilitate learning. Biofeedback Guru Erik Pepper once described the use of two bathroom scales to teach "balance" to patients. In the 1960s, that was progress.
Today "balance" is being taught by highly sophisticated electronic instruments and complex load-bearing platforms.
One such device, used in both research and clinical practice at the University of Oregon Health Sciences School, is able to show Multiple Sclerosis patients not only how well they are doing (learning) but also scores their progress or deterioration; it prints a "scattergram" and can even tell which muscles are being used (appropriately or inappropriately) to "maintain" balance. Obviously, this represents a major technological improvement over using two bathroom scales to teach balance.
But less obviously, any physician who told an MS patient today that bathroom scales were "sufficient", or "the best we can offer", would be guilty of malpractice.
Many readers will have discerned where this discussion was headed. Recently some people (sales people, actually) have put forth the claim that "vaginal weights" are a form of "biofeedback". They say that learning to retain a vaginal weight provides "biofeedback" about vaginal muscles.
At the superficial level, on a par with using bathroom scales for MS, that is "true". But it is dishonest to imply that weights are the best that we can offer our patients in 1998. We have much better tools at our disposal, and the patient deserves to know that.
If you have only read the sales literature, you might not be aware that "cones" are no better than "verbal instruction alone" in the results they provide patients. For a detailed discussion, see http://www.incontinet.com/comparison.htm. In short, "cones" provide the most help for those who need the least help.
Reimbursement issues are quite a separate matter. Support the efforts of the Continence Coalition to get Medicare reimbursement!
But it remains true that, for those who are actually spending money on adult products, it will be cheaper in one year or less to buy genuine, up-to-date biofeedback than to have half-dry results from cones, plus the on-going expenditure for non-reimbursed adult products.
4. A superficial analysis of electrical stimulation, and especially of the devices, makes it easy to confuse them with biofeedback devices.
BOTH devices may consist of "little black boxes" with a 9-volt battery inside and wires that are attached to a vaginal or rectal sensor. (The situation is complicated by the fact that at least one manufacturer actually sell devices that incorporate BOTH e-stim and biofeedback circuitry. But they are separate devices in the same box.)
But despite the superficial resemblance, there is a fundamental difference. In e-stim, the electricity flow FROM the device, INTO the patient. In biofeedback, electricity (much smaller amounts, by the way) flow FROM the patient INTO the box. It is like a divided highway. One road goes into the city, another road comes out. They just happen to be side-by-side.
But don't try to cross the median! If you don't think the direction of current flow is important, try driving the wrong way on a California Freeway!
So electrical stimulation devices put something into the patient; biofeedback devices do not. That is a rather fundamental difference, both in theory and in practice.
5. The argument is sometimes made that electrical stimulation "helps patients identify the right muscle", or "shows patients what it feels like to have the right muscle contract".
For starters, I have tried both myself, and it is my personal opinion that the sensations produced by an e-stim are NOTHING LIKE the sensations that are produced when I contract my own pelvic muscles! [Try it yourself and see if you don't agree.]
The "identification" argument carries a little more weight, especially for patients who don't know their "blank" from their "blank". I once had a patient who was making poor progress with EMG biofeedback, and I asked her what she thought she was trying to do. She explained that she was trying to "contract the muscle that is where my uterus used to be".
After I picked myself up off the floor (not visible to her), I explained that, actually, I was thinking of a muscle a little closer to the vaginal entrance. She thought about it, and with the improved mental image, quickly started contracting the right muscles.
With modern computerized EMG biofeedback instruments, which are extremely sensitive, it is possible to detect and display a contraction "below trace level"; i.e., one that is so weak the muscle does not move perceptibly. As soon as you do that, the patient has identified the muscle correctly.
So I have never needed to use e-stim to help a patient discover the right muscle; my biofeedback instrument does that for me.
Whether the use of e-stim for the limited purpose of "identification" actually helps or not is an empirical, not an opinion, question. To date there is absolutely NO research that shows that e-stim used this way contributes to better or sooner results. It MAY BE, but there's no research.
There is an interesting question, does the very different sensation produced by the stimulation device DETRACT from learning to do it right? I can imagine a patient saying "when I do it, it certainly doesn't FEEL like the stimulator; I must be doing something wrong", when in fact she was not.
6. Last but not least, there is the claim that electrical stimulation should be considered "like" biofeedback, because it produces results "like" biofeedback.
This one gets a little tricky, because our best and closest source, the AHCPR Guideline, is terribly confused on this issue, and drastically misrepresented the research. The full discussion is presented in papers mentioned below, but for now let me explain in summary terms.
For many years (well, 1983-87) Kathy Burgio, (a PhD psychologist) presented biofeedback research results in terms of the (overall) "percent reduction in symptoms (leaks)". If a group of 10 patients collectively had 100 leaks per week before treatment, and a TOTAL of 20 leaks per week after biofeedback treatment, they had a 80% "symptom reduction rate" [i.e., 100-20=80, and 80/100=80%]. This proved to be a very valuable way to compare research results.
Then, when certain manufacturers commissioned electrical stimulation research, they got MUCH lower "reduction rates", so they coined a new statistic, the "(number of people who got) symptom improvement (of 50% or more)". They hoped, we can assume, that people would not notice that they were now counting people, NOT counting their leaks!
If 10 patients leaked 10 times each in the week before therapy [i.e., 100 leaks], and eight of them reduced their leaks to 4 leaks each in the week after therapy, with two patients still at 6 leaks per week, they could report that there was a "80% cured or improved" rate -- just like Burgio's biofeedback, right?
Wrong. The e-stim patients still had 8 times 4 is 32 plus 12 is 44 leaks; 100 minus 44 is 56, and 56 divided by 100 is a 56% "symptom reduction rate", vastly inferior to Burgio's 80% for biofeedback.
Generally, it seems, the true "symptom reduction rate" [like Burgio] is about 100 minus DOUBLE the non-improvement rate.
In this example, with 80% of patients "improved", we have 20% who didn't meet that criteria. Double 20% is 40%, subtracted from 100% is 60% -- which is close to the calculated symptom reduction rate of 56%. Try it with another set of numbers; I've tried several with similar results.
So a "patient" improvement rate is dramatically less than the corresponding "symptom" improvement rate. When you see an e-stim article claiming an 80% patient "cured or improved" rate, understand that could be only a 56% symptom reduction rate!
Now, go back and read the AHCPR guidelines on biofeedback and on electrical stimulation. You will find that the AHCPR authors did NOT understand or recognize this very serious difference. If they had understood the research, they wouldn't have give as high marks to e-stim as they did.
Worse yet, in a couple of sections they used the "patient" and "symptom" terms interchangeably, leading to very confused results. See the papers listed below for the precise citations of this very embarrassing error.
Finally, compare the results of well-known e-stim studies with biofeedback results, as I have done at http://www.incontinet.com/comparison.htm, and you will see that we are talking "apples and walnuts".
E-stim is simply not in the same class as biofeedback, when it comes to treating incontinence.
So what can we say about electrical stimulation as a form of biofeedback? Well, to paraphrase Hertz, there's "biofeedback" and "not exactly". I'm trying to be polite.
For a more detailed analysis of the discussion of e-stim in the AHCPR Guideline, see: http://www.incontinet.com/estim.htm. A Critique of the biofeedback section of the AHCPR Guideline is found at : http://www.incontinet.com/ahcprbfb.htm. For contemporary understandings of the nature of biofeedback, see The Ghost in the Box at http://www.incontinet.com/ghost.htm.
Even if e-stim isn't biofeedback,
is it a form of behavioral therapy?
(1) Many people who treat incontinence have been led by the Public Health Service's AHCPR "Guideline" on incontinence into thinking that it is.
(a) Interestingly, the 1992 version of the Guideline does NOT explicitly claim that e-stim is behavioral therapy. But it does muddy the waters by fuzzy thinking.
Chapter 3, "Treatment of Urinary Incontinence", begins by stating that "The three major categories of treatment are * behavioral, * pharmacologic and * surgical (p. 27).
Why are there (only) "three" major categories? We can only speculate that it must have been convenient to separate "drugs" and "surgery", the two "traditional" treatments, and then lump together everything else into a third category, loosely called "behavioral" treatments. But does that make it true? What if, in reality, there are "four" major categories? Would that be a sin against nature? Let's look more closely at their argument.
The Guideline says that "Behavioral techniques include: bladder training, habit training, prompted voiding, and pelvic muscle exercise."
Then, this: "Additional techniques that may be used in conjunction with these behavioral methods include: biofeedback, vaginal cone retention, and electrical stimulation" (p. 27).
Notice that they haven't really claimed that the last three ARE behavioral methods; they are just described as "additional techniques" that can be used WITH behavioral methods.
But when we get to details, the Guideline describes the four "behavioral techniques", and then "cones, biofeedback, and electrical stimulation" all with bold sub-headings. Only biofeedback gets a highlighted box. And there is, tacked on, another major paragraph, about behavioral techniques in nursing homes.
Although the "outline" of the chapter is somewhat fuzzy, it roughly follows the initial summary, and includes the three "additional techniques" after (but not quite 'under') the section on pelvic muscle exercise. [In 1992 the "additional" techniques have the same "outline" status as the three major forms of behavioral therapy.]
Cones are described as "an adjunct to pelvic muscle training", and electrical stimulation gets (in 1992) a very guarded "cautious use of this technique" is recommended.
Also curious, the summary statement about "behavioral treatments" appears at the END of the section on biofeedback, BEFORE the discussion of e-stim! They state: "The results of these studies indicate that behavioral treatments in outpatients appear to be effective in significantly reducing, if not curing, UI." Then there is the strange and NOT very enthusiastic discussion of e-stim.
(b) In the 1996 "update", chapter (3) on Treatment begins with the same "The three major categories of treatment are behavioral, pharmacological, and surgical" (p. 31).
The effects of political pressure on the Guideline committee are immediately evident in the first full paragraph. It begins by making a strong statement of the "least invasive first" principle, and says that for most forms of UI, behavioral techniques meet that criteria.
Then comes a curious disclaimer, "However, an informed patient's preference must be respected", and "a combination" of surgery, drugs and behavioral interventions may be "appropriate". Obviously this non-sequitor was inserted at the last minute to satisfy one or another power group, since only an UN-informed patient would reject the "least invasive first" principle.
In the 1996 version, "behavioral techniques" are "ranked" in the order of "active participation" required.
This time, there are again three "major" categories of therapy: Toileting Assistance (scheduled toileting and prompted voiding), Bladder Training (Bladder retraining and scheduled voiding), and Pelvic Muscle Rehabilitation.
Under the third category (PMR), there are now FOUR sub-categories. (1) "Pelvic Muscle Exercise", a.k.a. "verbal instruction alone". It is said that this requires "repeated guidance over an extended period of time" (p. 38). [Interestingly, it is noted that Kegel himself recommended that patients be seen weekly, but it fails to mention that they were to be seen weekly FOR BIOFEEDBACK!]
(2) The second section is entitled "PME and Bladder inhibition Augmented by Biofeedback Therapy", and b/f receives the highest possible ("A") rating.
[A detailed critique of this section is available at http://www.incontinet.com/ahcprbfb.htm.]
(3) The third section is "Pelvic Muscle Exercise Augmented with Vaginal Weight Training". ["cones"].
(4) The fourth section is entitled "Pelvic Floor Electrical Stimulation", not "PME augmented by..." as were the other two sections. The lack of parallelism is appropriate and noteworthy; the Guidelines do NOT suggest that e-stim is a means of "augmenting" PME. In fact, they suggest exactly the opposite!
[For a detailed critique of this section, see my review at: http://www.incontinet.com/estim.htm]
They say that "pelvic floor electrical stimulation ... MAY be effective when augmented by other pelvic muscle rehabilitation therapies" p.43)!
Excuse me? The "other PMR therapies" are already effective when used by themselves; so why would anyone want to use e-stim, which needs to be augmented by them? Unfortunately, there is no answer in the Guideline.
In Summary, The AHCPR Guideline on Incontinence leads one to believe the e-stim IS a form of behavioral therapy, even if the justification is less than clear. But is that really true?
Or is e-stim simply "lumped" in with behavioral therapy because that seemed, to the AHCPR panel, to be the "closest" fit?
(2) So, what is "behavioral therapy"? According to Mark Schwartz et al:
Behavioral therapy developed in the 1950s. It was an alternative to insight-oriented psychodynamic theories and therapies for mental disorders. ... The roots ... include the notion that one learns maladaptive behaviors. Thus, in most cases, one can unlearn them. The model is largely educational rather than medical as such.
So, strictly speaking, "behavioral therapy" applies to a wide range of disorders where "learning" plays a major role. A more specific term in wide use is "behavioral medicine", which emerged in the 1970s.
Behavioral medicine ... focuses on the application of learning theories to medical disorders and other health-related topics. ...
Behavioral medicine places much emphasis on the patient's role in prevention and recovery from organic diseases and conditions. The same emphases are clear in ... biofeedback. (6)
In the field of incontinence, this means teaching a patient how to contract and relax the pelvic muscles, either to (1) make them stronger, (2) keep them strong, (in Stress UI), or (3) to inhibit premature bladder contractions (in Urge Inc.).
It would have been more accurate if the Guideline referred to "behavioral medicine" instead of "behavioral therapy" (which includes mental dysfunctions).
Biofeedback works by (1) showing a patient what to do [indicating on the screen when a contraction is made], and (2) rewarding a patient for doing it [the graph goes up and the therapist says "That's it, keep it up!"] By repetition, the patient LEARNS how to make pelvic muscle contractions stronger, and better.
In sharp contrast, electrical stimulation does NOT show the patient what to do, and does not reward the patient for learning anything. In fact, while being stimulated, the patient doesn't know what the patient is doing (just what the stimulator is doing to the patient).
This may explain why the results with e-stim are so much inferior to those of biofeedback. Some manufacturers encourage patient non-activity by "boasting" that "no patient effort" is necessary.
But the most effective e-stim studies have been those in which the patient ALSO does PME, when signaled to do so by the stimulator. But that means that we cannot separate the effects of the stimulator from the effects of the patient's own PME efforts. [Thus, the Guideline statement that e-stim MAY be effective when it is augmented by other methods.]
The pivotal study by Lamhut, Jackson and Wall, 1992, in which cognitively impaired patients used e-stim without significant improvement, proves that the patient must LEARN to do the exercises in order to improve. [And 1/4 of their impaired patients actually got WORSE with e-stim!]
In other words, most --if not all -- of the effect of e-stim lies in signaling the patient when to make a contraction. A $2.00 timer could do as well as a vaginal stimulator device. [And that's a hypothesis that should be put to the test!]
A major advance in the past decade of biofeedback has been the contribution of the monograph "The Ghost in the Box" [Available in a shareware version at http://www.incontinet.com/ghost.htm.]
The principle theme of "Ghost" is that there is NO AGENT, no active force or influence, inside the biofeedback box, that does *anything* TO the patient. The biofeedback box functions like a mirror, to show the patient what she is doing in a very precise way, so she can do it better and easier.
EXACTLY the opposite claim is made for electrical stimulation boxes. THEY claim that the electrical impulses sent from their box to the patient do make changes in the patient (or the patient's muscles, to be exact), quite apart from anything that the patient may be doing or thinking.
In this respect, e-stim more closely resembles pharmacological therapies, where precisely the same claim is made. In drug therapy, certain chemicals are introduced into the body, which chemicals have their effect regardless of whether the patient "believes in" the drug or not. Drugs do NOT change the patient's learned behavior. Drugs directly change the way specific body organs work. But they do not change the way bodily SYSTEMS work; i.e., there is no change in the mind-body connection, no "learning" of new behavior, as there is in biofeedback and other behavioral therapies.
A much stronger case can be made for classifying e-stim among the pharmacologic agents. By injecting electrons into the muscle, they cause chemical reactions (polarization) to take place there, and the muscle contracts. But the patient does not "learn" anything, any more than the patient "learns" from ingesting oxybutynin. The electro-chemical effect takes place without regard to learning, and thus e-stim cannot be considered a form of behavioral therapy or behavioral medicine.
In this regard, it is worth noting that the section on e-stim actually forms a (literary) "bridge" between the "behavioral therapy" section and the "pharmacologic treatment" section in the Guideline (1996, p. 43). That is a step in the right direction. Hopefully in the next update it will be put squarely in the pharmaceuticals, where it belongs.
An interesting and potentially illuminating side-discussion is the self-concept of the therapist involved. Some therapists view themselves as "healers"; they possess some sort of special skill or magical touch, which they use to "heal" the patient. Sometimes the magic is in the therapist's hands, sometimes in little bottles, sometimes in little black boxes the therapist has. The critical part is that the therapist "does something to" the patient, which results in improvement or "healing". The patient is essentially passive. Electrical stimulation devices are favorite tools of "healers".
At the other extreme, some therapists view themselves as "helpers"; they are primarily teachers, who help their patients to heal themselves. They do not "make people better", they lead their patients into healthier habits and directions so that they can make themselves better. They try to help by changing the patient's perceptions, assumptions, or bodily responses. Biofeedback devices are a major teaching aid for "helpers".
Most of us are actually part-helper, part-healer, although there is a wide spread and major differences in style between us. I tend towards being a "helper", professionally, but when my back hurts, I run to the nearest Myofascial- release trained "healer" to fix it.
But the distinction DOES hold up in the case of biofeedback devices (no agent!) and electrical stimulation devices (100% "agent"). Confusion can result from not keeping this difference clear. When people refer to biofeedback as a "treatment", (instead of "training"), the distinction is already getting blurred.
Thanks to Marta for stimulating this discussion.
John
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