Case Studies

Chronic Illness

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Introduction

Evidence indicates that for many forms of chronic illness, the general dysregulation and drain of the illness experience can be reflected in decreased coherence. In addition, many individuals with chronic illness experience various forms of stress related to the chronic illness experience (academic, job, financial, social, physical) which can further amplify either core symptoms or related feelings of fatigue, malaise, etc. Feeling hopeless and or ineffective, these patients are also at risk of developing negative emotions which may further complicate things by promoting unhelpful neurohormal and immune events that can interfere with recovery.

There is new evidence that HRV training, breath control and engaging positive emotions may impact specific conditions such as airway reactivity in asthma, glycemic control in diabetes, blood flow in sickle cell anemia, and effect positive changes that promote immune function in conditions such as cancer and atopic dermatitis. It has long been acknowledged that although negative emotions and stress don’t cause inflammatory bowel disease, they likely play a role in exacerbation and maintenance of symptoms for many. The emWave PC/Mac Stress Relief System has been used successfully with patients have the following conditions:

  1. Asthma
  2. Cystic Fibrosis
  3. Fibromyalgia
  4. Cancer
  5. Atopic Dermatitis
  6. Type II DM
  7. DM I
  8. Sickle Cell Anemia
  9. Immune System dysfunction
  10. Crohns and Ulcerative Colitis

Children and adults with a variety of chronic illnesses often share the feeling of a sense of loss of control as part of the ongoing chronic illness experience. One of the benefits of using the FFISL and the Quick Coherence technique is that these approaches give back some measure of control over the chronic illness and that alone has important therapeutic impact. Many patients greatly appreciate the ability to master a technique that allows for some self-management of symptoms commonly associated with chronic illness such as pain, stress and insomnia. In addition, because often times these patients are on multiple medications, adding an effective tool that is safe and non-pharmacological is particularly welcome.

Chronic Illness case Study I: Asthma with vocal cord dysfunction

Author's Commentary: Over the past several years a number of studies have reviewed the pivotal role that emotional regulation (or lack thereof) can have on the clinical course of asthma and the frequency of exacerbations and need for hospitalizations. Mind/body techniques can be very helpful in modifying the course of asthma and in providing tools for individuals with asthma to better manage long-term health as well as acute events; in some cases reducing or eliminating the need for bronchodilating agents. Some children and teens with asthma develop other complicated breathing problems such as paradoxical vocal cord adduction, where the vocal cords inadvertently close during inspiration creating an uncomfortable feeling of tightness or shortness of breath which is not medication responsive. For most children who experience this, there is a psychophysiological state of inter-related phenomena that seem to bring this on, including stress as a common mediating factor.

Janelle was a 16 year old competitive figure skater referred by the pulmonology group with a diagnosis of asthma complicated recently by paradoxical vocal cord adduction (also called vocal cord dysfunction or VCD). Janelle was finding her daily practice and also performance at skating competitions was being affected by her experience of shortness of breath that was related to VCD and therefore not responsive to her usual asthma medications. This resulted in decreased stamina and had an impact on her ability to finish a full routine without becoming fatigued and short of breath. She felt “driven" to do well in figure skating, admitted to stress secondary to her strict schedule and was finding it less “fun” at times. Her goal was to compete successfully at a national level. She was also a straight “A” student in high school.

In reviewing the etiology of VCD we reviewed the basic sequence we think happens to most individuals that we see. First of all, increased levels of recurrent stress may lead to more thoracic breathing patterns and a tendency to “brace” or tighten the muscles in the upper body-shoulders, neck and even face. With these muscles being tighter, particularly at times of increased aerobic activity where you are breathing harder, a basic “dys-coordination” occurs whereby the tightened neck muscles and thoracic breathing contribute to a situation where the vocal cords inappropriately close (adduct) partially during inhalation causing resistance to air flow. This is experienced as tightness and shortness of breath. This feeling in turn may increase anxiety even “panic” feelings which can drive the cycle further in the wrong direction. This is commonly at first attributed to the underlying asthma which can be exacerbated by exercise. However, in the case of VCD, it is not medication responsive and requires an undoing of this habituated pattern of stress, muscle tightness, thoracic breathing and negative expectation and emotional “dysregulation” with symptoms of anxiety.

For Janelle, training in progressive muscle relaxation (with special attention being given to the shoulders, neck and face muscles) was combined with training in quick coherence/freeze framer HRV techniques and resulted in an excellent impovement over a 12 week time frame. She was taught to practice diaphragmatic "heart focussed" breathing first in resting, sitting and standing positions, and then taught to breathe more comforatbly and fully with positive expectations while engaging in increasingly higher levels of aerobic demand (skating slowly at first and then gradually with more intensity). She was gradually able to breathe much more comfortably again while skating with increased confidence and improved performance. Daily use of the Quick Coherence technique and related stress management approaches were also suggested as a way to manage day-to-day background stress which was also felt to be a contributing factor.

Chronic Illness Case Study II: Dealing with the Long-term Sequellae of Cancer

Author's Commentary: Children, teens and adults with chronic illness experience significant emotional distress both in the acute phase but also in long term followup. Experience suggests that mind/body approaches can be very helpful as symptom management adjuncts for cancer patients with stress, pain, insomnia and nausea as well as emotional coping and indirectly promoting immune function through positive affect.

From a mental health perspective, cancer survivors may experience significant stressors as late sequellae of treatment and have a higher incidence of PTSD symptoms. In our practice, we have found that survivors of childhood cancer can struggle with PTSD, mood problems, survivor guilt, and chronic stress. Mind/body skills approaches which include emotional regulation and stress management are key tools for these individuals and provide a foundation for enhanced health and wellness as they move forward. This case nicely illustrates a number of these issues.

Steve is a 19-year-old first year college student who is a long-term cancer survivor. Steve has long term sequellae from his cancer which include depression, bedwetting, and insomnia, as well as experiences of multiple stresses from financial strains and interpersonal difficulties with family and peers. He began working with both a behavioral pediatrician and a pediatric psychologist 2 years ago with a goal of enhancing overall functioning and improving stress management and overall coping skills. Steve found that anxiety and stress issues were contributing to ongoing problems with symptoms such as insomnia and emotional lability.

Early on in the course of treatment he was introduced to the emWave PC/Mac Stress Relief System as well as the Quick Coherence technique. He then used the emWave PC/Mac Stress Relief System at home for a period of six weeks. He utilized the emWave PC/Mac Stress Relief System on his laptop computer every day for that period of time and developed an excellent ability to achieve a state of high coherence quickly and consistently. Despite ongoing stressors he found that using emotional self-regulation techniques he experienced a much greater ability to handle stress, was less moody and had better control of maintaining a positive affect. His problems with insomnia improved as well as his overall health status during this time. He also experienced improvements in his interpersonal relationships secondary to his enhanced ability to manage frustration and stress. He continues to use these strategies on a daily basis at college.

 

Emotional/Behavioral Disorders

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Introduction

Certain negative emotional states such as anxiety, anger and panic, include a component of over­arousal thereby triggering the “fight or flight” repertoire of physiological responses. Some of these existing emotional tendencies are additionally amplified by stress. When in an undesirable emotional state, many individuals then experience unwanted cognitive and behavioral phenomena that can lead to impaired performance and undesirable behavioral choices. If shifted to a more positive, balanced emotional state, many find that performance and behavioral control improves. The emWave PC/Mac Stress Relief System has been used successfully with clients having emotional/behaviorial conditions, such as:

  1. Anxiety Disorders
  2. Depression
  3. Anger Management
  4. Emotional Lability
  5. Asperger’s Syndrome
  6. Performance Anxiety
  7. Peak Performance Training
  8. ADHD

Emotional/Behavioral Disorders Case Study I: Clinical Psychology

The following information is provided by a licensed clinical social worker in private practice in Atlanta, Georgia.

I have a private psychotherapy practice in the Martin Luther King, Jr. National Historic Site in downtown Atlanta, Georgia. I also spend a day each week in an urban low cost clinic. I work with adults ranging in age from their early 20’s into their 70’s. In both practice settings most of my patients are city dwellers. They present with a spectrum of diagnoses ranging Generalized Anxiety Disorder to Complex PostTraumatic Stress Disorder. Some seek to resolve creative blocks limiting their art and others are seeking freedom from lives interrupted by intrusive recollections of a painful childhood. I introduce each of them to the emWave PC/Mac Stress Relief System regardless of their presenting problem.

I usually present the emWave PC/Mac Stress Relief System in this manner. I tell my patients that change, while sometimes desirable (and always inevitable) is nonetheless often contrary to the habitual nature of humans. I explain that psychotherapy will often stir up memories and emotions and that part of their therapy will involve my teaching them some basic skills. These skills, in emotional self-regulating as practiced with the emWave PC/Mac Stress Relief System, will help them to understand and manage these “periods” so they might make the best therapeutic use of them.


I want to teach my patients how to “soothe” and “ground” themselves. I help them learn that they can change their minds about a problem by using the emWave PC/Mac Stress Relief System. They discover new ways to manage their emotions rather than feeling controlled by them.

The emWave PC/Mac Stress Relief System quickly and easily shows them the power of their own thoughts and the immediate effect they can have on their body. One goal of therapy, stated or not, is always to heal the past in the present and thereby free the future for new possibilities. The emWave PC/Mac Stress Relief System is a valuable tool that helps my patients learn that they can change their minds.

I use the emWave PC/Mac Stress Relief System in conjunction with these psychotherapeutic techniques:

  1. Psychodynamic / Insight Oriented (talk) Therapy
  2. Eye Movement Desensitization and Reprocessing (EMDR) (I believe the emWave PC/Mac Stress Relief System has many elements similar to EMDR. One primary similarity being the attention paid to multiple stimuli. Similarly, I think of the emWave PC/Mac Stress Relief System as helping the user to “reprocess or rethink” ideas that may have gotten “stuck” due to strong emotion or dysfunctionally stored information. I suspect the emWave PC/Mac Stress Relief System might have a similar effect on sub-clinical problems that professionally administered EMDR has on more florid clinical issues.
  3. Peak Performance Enhancement

Emotional/Behavioral Disorders Case Study II: Anxiety in the Context of Burn Pain

Here is a case study from a recreation therapist at University of North Carolina hospital in Chapel Hill, NC, who points out that consistent practice, and helping patients move along the continuum from education to application, can result in burn patients learning to reduce stress and anxiety, expand coping skills, and improve autonomic nervous system functioning.

Author's Commentary: Burn injuries result in sequellae of events, often with profound physical, psychological, and emotional ramifications. Concomitant trauma on a psychological level frequently accompanies the physical trauma of the burn injury. Aside from the very significant pain issues, burn survivors often suffer from anxiety, PTSD, and/or depression. HeartMath techniques, and the emWave PC/Mac Stress Relief System, offer patients a means for reducing the distress associated with post burn psychopathology and a method for influencing the pathophysiology.

In the burn population, researchers are interested in the psychopathological responses to burn injury. Psychological distress has been shown to affect the physical recovery process. Clearly, interventions designed to improve coping with the myriad of post burn issues are of significant interest. The HeartMath techniques offer a user-friendly format for integrating emotional aspects of coping with cognitive processing. For example, the emWave PC/Mac Stress Relief System and Quick Coherence technique can be useful for engaging the patient in dialogue around trauma-associated distress while providing an appropriate avenue for focusing efforts to reduce the distress.

Two cornerstone HeartMath emotions, appreciation and gratitude, are effective building blocks for developing the much-needed coping skills. Burn patients often gravitate to this perspective naturally, and the attentive healthcare worker will often hear an expression of gratitude. This affords the opportunity to introduce a framework for skill development, such as the Quick Coherence technique. For example, patients often make a remark of gratitude, such as “I am thankful my burn wasn’t worse” or in reference to spared body parts, survival, family support, etc. Depending upon the location of the burn, those with an available digit can benefit from the concrete learning opportunities associated with the emWave PC/Mac Stress Relief System.

Although use of HeartMath technology is necessarily tailored to an individual’s specific circumstance, common elements of progressive training can be identified. Following an introduction to HeartMath techniques, with an emphasis on the impact of both positive and negative emotions, specific skill development may continue. The point at which the technology of the emWave PC/Mac Stress Relief System is introduced may vary. For those patients who are technologically inclined, or who may be drawn to the “game-like” nature of the program, it can be effectively introduced during the initial session. The immediate reduction in pain or anxiety that patients frequently report after use of the emWave PC/Mac Stress Relief System is reinforcing, as patients often integrate the perception that they can teach themselves to feel better. Since many patients experiencing pain or anxiety also exhibit disordered breathing patterns, attention to breathing can aid patients in achieving coherence.

Patients who understandably become very focused on the situations surrounding their injury may require coaching to identify events in their life evocative of positive emotional experiences. Empowering patients to influence their physiology and sense of well being through use of the emWave PC/Mac Stress Relief System is most effective when followed up with identifying potential situations for applying the new skill.

Application of HeartMath techniques can be useful during specific burn related events that typically increase pain or anxiety, such as wound-care, surgical interventions, or emotionally charged issues like facing family, friends, or classmates after a disfiguring burn injury. The following are a few examples of specific situational applications of the emWave PC/Mac Stress Relief System.

A. Jen, a middle age woman with burns on over 40% of her body, was highly motivated to use the emWave PC/Mac Stress Relief System program on a daily basis. She noticed that she “felt better” after spending time in a coherent state. This was significant, given her history of substance abuse, depression, and anxiety. During her 7-minute practice session, with the hot air balloon game, the soaring balloon dropped precipitously, then resumed it’s previous height. In processing this event afterwards, the patient relayed flashing back to the events surrounding the fire, and being able to recover from the anxiety by focusing on the gratitude she felt for having saved a child’s life before the fire ravaged the house.

B. Freddy, a teenager was extremely nervous prior to surgery, and was open to trying the emWave PC/Mac Stress Relief System program during Recreational Therapy. The immediate success was evident, as his first request after returning to his room post-op was to use the emWave PC/Mac Stress Relief System again because he wanted to feel better.

C. Scott, a 50 year old man, frustrated with many perceived annoyances of being hospitalized, applied the Quick Coherence® technique, and used the emWave PC/Mac Stress Relief System to change his perspective about many of his stressors. In one instance, after becoming frustrated with the phone “ringing off the hook,” the patient was able to apply his heart intelligence to observe that “they don’t know what’s going on up here, they are just being concerned friends. I can let them know when a good time to call would be.”

 

Psychophysiologic Disorders

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Introduction

Disorders that by definition include both a mind and body component are increasingly identified in primary care. Most commonly, the “mind” component includes stress and negative emotional experiences resulting in ANS imbalances which in turn mediate a plethora of “body” symptoms including pain, trouble sleeping, appetite changes, fatigue, dizziness and nausea to name a few. In many cases, excess, chronic, sympathetic nervous system over-arousal is particularly problematic and for certain conditions such as Irritable Bowel Syndrome and Tourette’s, and can lead to flare ups of these conditions. Some of the more common psychophysiological disorders seen everyday in primary care offices include:

  1. Insomnia
  2. Cardiovascular rehab
  3. Functional GI disorders including irritable bowel syndrome
  4. Somatization/Somataform/Conversion Disorders (often manifest as somatic complaints such as abdominal pain, headache, etc.)
  5. Habits/Tics/Tourette’s
  6. Hypertension

Psychophysiological Disorders Case Studies

Here are some case studies from a nurse at Allegheny Hospital in Pittsburgh, PA.

Author's Commentary: The following cases illustrate the use of the emWave PC/Mac Stress Relief System and HeartMath techniques in patients with complex mind/body issues

A. Jill, a 34 year old female with Multiple Sclerosis, Irritable Bowel Syndrome, and Hypertension of unknown etiology. Jill came to our center for symptom management of her Irritable Bowel Syndrome and associated stress and anxiety related to her declining health. Using the emWave PC/Mac Stress Relief System, she became much more open and communicative. It was as though she was opening her heart for the first time. Her IBS symptoms became less bothersome, blood pressure decreased from 180/90 to 126/70. Having experienced these welcomed improvements, she recognized the self-healing ability that she possessed and recommitted to living her life to the fullest.

B. Karen, a 38 year old female with a long standing history of depression, anxiety and panic disorder. She was being seen for management of symptoms due to Irritable Bowel Syndrome. Karen was extremely receptive to learning to use the emWave PC/Mac Stress Relief System and optimistic that it would be a useful tool. On the fourth session, she had made significant gains in her level of coherence. Karen’s had finally achieved a modest gain of 4 percent of high coherence. Karen became tearful then sobbing uncontrollably then shared that she was overmedicating herself and she had suicidal ideations. She acknowledged for the first time that her life did have meaning and achieving this level of coherence was so cathartic for her. Following a hospitalization, Karen began to slowly engage with her family, care for her children, and integrate back into society.

C. Brent, a 45 year old male for anger management and anxiety. After 15 sessions with the emWave PC/Mac Stress Relief System, he successfully achieved a medium level (eight percent) of entrainment. This provided confidence to Brent and he began to use the Quick Coherence technique whenever feelings of anger or anxiety arose. He accepted the suggestion to use the technique twice daily during times when there were no anger or anxiety. Upon his last visit Brent achieved a 30 percent high level of coherence. Several months later, he wrote a note expressing how calm and peaceful his life had become. He verbalized deep appreciation for all the blessings in his life.

   

Pain

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Introduction

Acute chronic and recurrent pain is a significant problem worldwide for children and adults and one of the leading reasons that people seek medical (conventional or complementary) treatment. Negative emotional states such as anxiety and fear go hand in hand with pain experiences and are often as important as the pain stimulus itself in the patient’s experience of distress. In addition, patient perceptions of control or lack thereof over their pain, can contribute to poor coping with pain. Excess sympathetic nervous system arousal may contribute to or mediate pain intensity in certain conditions. Therefore, the emWave PC/Mac Stress Relief System and its techniques that promote stress reduction, reframing of emotional states and offer active control, are very helpful.

Pain Case Study I: Chronic Lower Back Pain

Here is a case from a pain specialist at a hospital in California that gives a good sense of how the emWave PC/Mac Stress Relief System can be used in a chronic pain situation:

Author's Commentary: Patients come into our inpatient chronic pain management program having tried unsuccessfully with surgery, medication, single outpatient treatment modalities and talk therapy to deal with their chronic pain condition. With repeated failure they frequently report feeling utterly helpless to modify their pain or function in a meaningful way. Their attempt to cope is often maladaptive such as muscular bracing and guarding, lying down or sitting throughout most of the day, and social isolation, which itself becomes part of the problem of chronic pain.

Tom had worked in construction for many years prior to his back injury and subsequent 2 back surgeries. He had been a very active person and someone who loved organizing social events with co-workers. He described himself as the person others sought out when they had problems or needed advice or support. Now he was unable to work, had limited tolerance for activity as he experienced increased pain with exertion and rarely got together with anyone other than family. He had turned increasingly to narcotic medication to cope with his unremitting back pain and now experienced negative side effects from the medication, and still had debilitating pain. Tom came into the chronic pain program to slowly wean off his narcotic medication while simultaneously increasing his strength and endurance, learning proper body mechanics and pacing during activities and developing coping skills from our interdisciplinary team.

He said he used to be “high on life” and his biggest goal was to somehow “get back to being the person he used to be”. He reacted negatively to his pain as if the pain sensations were triggers reminding him of what he feared he had lost forever. At first he was angry to hear he would be learning to manage his pain, not get rid of it.

As a biofeedback specialist I may use a number of modalities, depending on the problem. I began with EMG biofeedback training to bring Tom’s awareness to the excessive muscle tension in his neck and shoulder area (his “solution” to keep pressure off his back) and a likely source of his aching shoulders and frequent headaches. I also trained him in Autogenic Relaxation and gave him my relaxation tape to use in learning what relaxation is and developing “intentional” self-quieting skills. After he learned to breathe deeply without fear that his back would spasm, I introduced the Quick Coherence technique and the emWave PC/Mac Stress Relief System. I knew he needed to change his relationship to his pain and asked him if he would react angrily to his child if he were injured. Of course he said he would give him his love, support, and do everything he could to comfort him. I suggested that he consider offering his injured back the same love and concern as he would his child; that his pain merely signified injured tissue. As he practiced with the emWave PC/Mac Stress Relief System and began to open his heart, he changed his perception and shifted away from his emotional battle with his pain. Frequently he reported his pain sensation decreased following training. A wonderful moment came after a session when he exclaimed that he experienced for the first time in years the “high on life” feelings he had longed to feel again. With training he said that even when he had a pain flare, he was able to maintain peace in his heart and use that feeling “as a shield from the pain over his pure self”.

During the 4-week program, Tom had tapered off all his narcotic medications and switched to non-opioid medication and as happens so often, his pain was often decreased. He stopped talking about pain, his sense of humor returned, he rarely used his cane, and he had several plans for fun activities after returning home. Tom “got his life back”, which is what most patients really want out of the program. HeartMath tools have become an indispensable treatment component for me to use with chronic pain patients to promote emotional wellness and perception change about themselves and their pain.

 

Pain Case Study II: Teenager with Abdominal Migraine

Author's Commentary: This case is an example of how the emWave PC/Mac Stress Relief System can help kids and teens with migraine and migraine variants. Studies clearly support the efficacy of a variety of relaxation/self­regulation techniques in the treatment of headache. This was extrapolated to an application with abdominal migraine with great success.

Elaine is a 13 year old female who had a history of periumbilical recurrent abdominal pain since a young age (several years) and who had completed extensive evaluations with specialists in neurology and gastroenterology with no specific findings. Evaluation at the integrative medicine clinic found her history to be consistent with a diagnosis of abdominal migraine. Results of laboratory and radiologic tests were all within normal limits and previous therapeutic interventions which included a food elimination diet and use a smooth muscle relaxant medication proved to be unhelpful. At the time of her visit, she reported (her parents concurred) having severe abdominal pain episodes several times per month, screaming and writhing in pain, necessitating several trips to the local emergency room which resulted in no definitive findings.

Occasionally Elaine described experiencing a headache before, during or after the abdominal pain but this symptom is not consistent. In addition to the abdominal pain, she will occasionally experience concurrent symptoms of nausea and vomiting.

Elaine had been missing school several days per year on average because of this ongoing pain and this had increased recently. In addition, her family felt that her pain was beginning to affect the entire family’s function. Pain episodes could last anywhere from a few hours to a few days at this point and nothing was providing Elaine with any consistent relief. Mental health screening was within normal limits. Past medical history was otherwise noncontributory except to note a strong paternal family history for migraine.

Initial recommendations were made for a multimodality treatment approach that included low-dose SSRI coverage which was not started initially, self-regulation skills training to facilitate a lowered state of sympathetic nervous system arousal and some basic nutritional supplementation

At her first follow up visit one week later, Elaine had reported 2 severe abdominal pain episodes during the prior week. In fact, one had occurred while the family was out of town and they all ended up coming home early because of Elaine’s pain symptoms. At this session, Elaine was taught to discriminate differences in relaxed versus aroused states of mind/body, and she was coached through basic progressive muscle relaxation and diaphragmatic breathing exercises and a practice plan was made.

At her second visit one week later, things were about the same. She was instructed in the relevance of peripheral temperature as a marker for stress and then the basics of mental imagery were reviewed.

At her third follow-up she noted the frequency and severity of events had slightly decreased. At that visit she was introduced to the emWave PC/Mac Stress Relief System and the Quick Coherence technique. The use of skills that she had previously been practicing and mastering was discussed, showing how those skill helped with getting into the “zone”. We reviewed home and school practice strategies.

By her fourth follow up things were continuing to improve and Elaine had only one severe episode in the previous 3 weeks. She was attending school every day which was a great improvement and was receiving A and B grades. She reported only one minor episode of pain in 4 weeks. Elaine described practicing 1-2 times each day for 5-10 minutes. We then worked on the idea of taking shorter more frequent “mini-breaks” for 1-2 minutes a time, several times each using the Quick Coherence technique.

At the fifth and sixth follow-ups each about 4 weeks apart she continued to do extremely well with minimal abdominal migraine episodes, regular school attendance and with her family also commenting about improvements noted in her mood. Elaine reports using the various self-regulation techniques on a regular basis and feeling quite confident in using them in both preventative and abortive modes. 

   

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