clinical and educational efficacy of a university-based .../67531/metadc... · biofeedback therapy...
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CLINICAL AND EDUCATIONAL EFFICACY OF A UNIVERSITY-BASED
BIOFEEDBACK THERAPY CLINIC
Shwu-Huey Shiau, M.S., M.Ed.
Dissertation Prepared for the Degree of
DOCTOR OF PHILOSOPHY
UNIVERSUTY OF NORTH TEXAS
December 2003
APPROVED:
Cynthia K. Chandler, Major Professor Carolyn W. Kern, Committee Member Douglas Norton, Committee Member Jan Holden, Program Coordinator for Counseling Michael Altekruse, Chair of the Department of
Counseling, Development, and Higher Education
M. Jean Keller, Dean of the College of Education Sandra L. Terrell, Interim Dean of the Robert B. Toulouse School of Graduate Studies
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Shiau, Shwu-Huey, Clinical and educational efficacy of a university-based
biofeedback therapy clinic. Doctor of Philosophy (Counseling), December 2003, 125
pp., 26 tables, 13 figures, references, 59 titles.
This study is a qualitative analysis and a quantitative analysis of all peripheral
biofeedback client data files of the University of North Texas Biofeedback Research and
Training Laboratory since its establishment in 1991 and through the year of 2002. The
purpose of this study is to evaluate the clinical and educational efficacy of the BRTL.
Clients’ electromyography and temperature measures, self-report of homework
relaxation exercises and progress, and the pre- and post-Stress Signal Checklist were
reviewed and analyzed.
In regard to clinical efficacy, results indicate statistically significant changes in
both temperature training and muscle tension training as a whole group. When divided
into subtypes based on the clients’ primary presenting problem, findings indicate
statistical significance in chronic pain, tension headache, and temporomandibular jaw
pain on temperature training, and show statistical significance in chronic pain, tension
headache, hypertension, migraine headache, stress, and temporomandibular jaw pain
on muscle tension training.
When analyzing the Stress Signal Checklist, only 31.5% of clients with 4 or more
treatment sessions had complete information on both pre- and post-Stress Signal
Checklist. For these 31.5%, 87.5% reported symptoms decreased. When reviewing the
clients' self-reported progress in therapist's session notes, there is no procedure for
computing a treatment success-to-failure ratio due to the inconsistency of therapists in
recording clients' statements.
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This study also identifies three basic biofeedback learning curves that show how
people learn self-regulation skills in biofeedback therapy: 1) steady state and trainable
(low variability), 2) phasic state and trainable (high variability), and 3) phasic state and
low trainable (high variability).
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Copyright 2003
by
Shwu-Huey Shiau
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ACKNOWLEDGEMENTS
Profound, heartfelt thanks to Dr. Cynthia Chandler for her confidence in me, her
ongoing support, guidance, and encouragement, and her commitment to my
professional development.
I am very grateful for the support from my committee, Dr. Carolyn Kern and Dr.
Douglas Norton.
I thank Dr. Richard Herrington for his consultation on the statistical techniques
and procedures for this research.
Finally, special thanks and deep appreciation to I-Hui, whose love, friendship,
and support sustain me throughout the whole process.
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TABLE OF CONTENTS Page
ACKNOWLEDGMENTS iii
LIST OF TABLES v
LIST OF FIGURES vii
CHAPTER I
Introduction 1 Statement of Problem 3 Review of Literature 5
CHAPTER II
Purpose of Study 14 Research Questions 14 Research Assumptions 15 Methods and Procedures 15
Data Analysis 17 Limitation 19
CHAPTER III
Results and Discussion 21 Educational Efficacy of the Biofeedback Research and Training Laboratory 21 Clinical Efficacy of the Biofeedback Research and Training Laboratory 30 Discussion 73
APPENDIX A 82
APPENDIX B 87
APPENDIX C 111
REFERENCES 118
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LIST OF TABLES
Table Page
1. Sample recorded client’s statements of reported symptom decrease in other than the primary presenting problem 46 2.1 Frequency and percent of clients with 3 or less treatment session
based on primary presenting problem 52 2.2 Frequency and percent of clients with 3 or less treatment sessions
based on year 52 3.1 Frequency and percent of clients with 4 or more treatment sessions
based on year 53 3.2 Frequency and percent of clients with 4 or more treatment sessions
based on gender 53 3.3 Frequency and percent of clients with 4 or more treatment sessions
based on primary presenting problem 54 4.1 Mean, standard deviation, and standard error mean for 6 points
temperature slope 57 4.2 One-sample t-test for 6 points temperature slope as a whole group 57 4.3 Mean, standard deviation, and standard error mean for 6 points temperature slope sorted by primary presenting problem 58 4.4 One-sample t-test for 6 points temperature slope sorted by primary
presenting problem 59 4.5 Mean, standard deviation, and standard error mean for 6 points temperature slope sorted by gender 60 4.6 One-sample t-test for 6 points temperature slope sorted by gender 60 4.7 Mean, standard deviation, and standard error mean for 6 points temperature slope sorted by age 61 4.8 One-sample t-test for 6 points temperature slope sorted by age 61
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Table Page 4.9 Mean, standard deviation, and standard error mean for 6 points temperature slope sorted by number of sessions 62 4.10 One sample t-test for 6 points temperature slope sorted by number of sessions 63 5.1 Mean, standard deviation, and standard error mean for 6 points EMG slope 64 5.2 One-sample t-test for 6 points EMG slope as a whole group 64 5.3 Mean, standard deviation, and standard error mean for 6 points
EMG slope sorted by primary presenting problem 65 5.4 One-sample t-test for 6 points EMG slope sorted by primary
presenting problem 66 5.5 Mean, standard deviation, and standard error mean for 6 points EMG slope sorted by gender 67 5.6 One-sample t-test for 6 points EMG slope sorted by gender 67 5.7 Mean, standard deviation, and standard error mean for 6 points EMG slope sorted by age 68 5.8 One-sample t-test for 6 points EMG slope sorted by age 68 5.9 Mean, standard deviation, and standard error mean for 6 points EMG slope sorted by number of sessions 69 5.10 One sample t-test for 6 points EMG slope sorted by number of sessions 70
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LIST OF FIGURES
Figure Page
1. Biofeedback Research and Training Laboratory Responsibility Hierarchy 29 2.1 Number of clients treated based on year and gender 31 2.2 Number of clients treated based on ethnicity 31 2.3 Number of clients treated based on age 32 2.4 Number of clients treated based on primary presenting problem 33 2.5 Number of neurofeedback therapy clients treated based on year 34 3.1 Number of clients who reported primary presenting problem decreased 36 3.2 Number of clients who reported other types of progress 44 3.3 Number of clients who reported increased awareness 49 4.1 Number of clients with 4 or more treatment sessions based on age 55 4.2 Number of clients with 4 or more treatment sessions based on number
of sessions 55 5.1 Three basic biofeedback learning curves for training temperature increases 72 5.2 Three basic biofeedback learning curves for training muscle tension
reductions 73
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CHAPTER 1
Introduction
Biofeedback is the use of electronic equipment to teach a person physical
awareness, to increase a feeling of relaxation, to self-regulate the body’s systems, and
furthermore to reduce unwanted stress-related symptoms (Schwartz, 1995). A ten-year
review of literature suggests that biofeedback therapy is an effective treatment for a
number of psychophysiological concerns that include pediatric headache (Hermann &
Blanchard, 1997; Holden, Deichmann & Levy, 1999; Arndorfer & Allen, 2000), tension
headache (Arena, Bruno, Hannah, & Meador, 1995; Blanchard, Taylor, & Dentinger,
1992), essential hypertension (McGrady, 1994, Jurek, Higgins, & McGrady, 1992),
fecal/urinary incontinence (Tries & Brubaker, 1996; McDowell, Engberg, Sereika,
Donovan, Jubeck, Weber, & Engberg, 1999), irritable bowel syndrome (Blanchard,
Greene, Scjarff, & Schwarz-McMorris, 1993; Blanchard, Schwarz, Suls, Gerardi, Scharff,
Greene, Taylor, Berremen, & Malamood, 1992; Schwarz & Blanchard, 1991), diabetes
(McGrady, Graham, & Bailey, 1996; Sauders, Cox, Teates, & Pohl, 1994; Needham &
Eldridge, 1993), asthma (Kern-Buell, McGrady, Cornran, & Nelson, 2000; Peper &
Tibbetts, 1992), temporomandibular disorder (TMD) (Flor & Birbaumer, 1993; Mishra,
Gathel, & Gardea, 2000), phantom limb pain (Belleggia & Birbaumer, 2001), and
chronic pain (Newton-Jone, Spence, & Schotte, 1995; Flor & Birbaumer, 1993).
For treating both children and adults’ migraine headache and tension headache,
biofeedback therapy was effective in reducing headache activities (including duration,
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intensity, and frequency) and medication consumption (Blanchard, Peters, Hermann,
Turner, Bukley, Barton, & Dentinger, 1997; Grazzi & Bussone, 1993; Blanchard, Taylor,
& Dentinger, 1992). One study showed that children had greater improvement in
headache activity reductions than adults did with biofeedback therapy (Sarafino &
Goehring, 2000).
Research showed that biofeedback therapy was effective in reducing artery blood
pressure for about 5mm Hg (McGrady, 1994). Using a combination of biofeedback
relaxation and medication treatment with individuals with essential hypertension was
more effective in lowering blood pressure than using medicine alone (Jurek, Higgins, &
McGrady, 1992).
A study showed a decrease in blood glucose after thermal feedback treatment
with patients with insulin-dependent diabetes (McGrady, Graham, Bailey, 1996).
Thermal biofeedback successfully helped a diabetes patient decrease attacks of
intermittent claudication to zero (Sauders, et al., 1993). In addition, the physiological
results of thermal biofeedback promoted a sense of self-control in a patient with
diabetes and double amputation which increased his self-esteem, and furthermore,
decreased his depression symptoms (Needham & Elkdridge, 1993).
Biofeedback-assisted pelvic floor muscle training significantly decreased the
urinary accident episodes and the average number of accidents per day for older adults
(aged 60 or older) (McDowell, 1999; Burn, Pranikoff, Nochajski, Hadley, Levy, & Ory,
1993). Biofeedback training significantly improved irritable bowel syndrome (IBS)
symptoms such as abdominal pain, diarrhea, constipation, flatulence, belching, and
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nausea with a proximately 50% successful rate (Blanchard, et al., 1993; Blanchard, et
al., 1992).
Studies showed that electromyography (EMG) biofeedback was effective in
treating chronic pain and temporomandibular disorder (TMD). Patients demonstrated
significant reductions in pain frequency, duration, and intensity after biofeedback
treatment (Edwards, et al., 2000; Newton-John, Spence, & Schotte, 1995; Flor &
Birbaumer, 1993).
Statement of Problem
Since the Biofeedback Research and Training Laboratory was established in the
later part of the year 1991, the BRTL has provided educational training to hundreds of
students and delivered treatment service to numerous university students, staff and
faculty, and community citizens. On the surface, the BRTL presents as a useful, typical
service to the community. However, no objective analysis of the client services has
been performed.
Definition of Biofeedback
There are various definitions of biofeedback. For the purpose of this study,
biofeedback is defined as:
A group of therapeutic procedures that utilizes electronic or electromechanical
instruments to accurately measure, process and ‘feed back’ to persons
information with reinforcing properties about their neuro-muscular and
autonomic activity, both normal and abnormal, in the form of analogue or binary,
auditory and/or visual feedback signals. Best achieved with a competent
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biofeedback professional, the objectives are to help persons develop greater
awareness and voluntary control over their physiological process that are
otherwise outside awareness and/or under less voluntary control, by first
controlling the external signal, and then with internal psychophysiological cues
(Schwartz, 1995, p.29).
Biofeedback includes peripheral biofeedback (i.e., thermal biofeedback and
electromyography biofeedback) and central nervous system biofeedback (i.e.,
electroencephalography biofeedback). Thermal biofeedback is the use of a temperature
probe, which is made of small pieces of heat-sensitive electrical material, to measure
changing skin temperature. Electromyography is the use of an electronic instrument to
measure the electrical activities of skeletal muscles. Electroencephalography
biofeedback (neurofeedback) is the measurement of electric activity of the brain such
as frequency, amplitude, or duration of activity of delta, theta, alpha, or beta brainwave
from certain scalp or brain locations (Schwartz, 1995).
For the purpose of this study, the research would only examine the efficacy of
thermal biofeedback and electromyography biofeedback at the BRTL and excluded
electroencephalography (EEG) biofeedback because EEG has evolved into its own
independent field and has its own construct that deserves a separate and focused
investigation. However, the researcher would count the total number of EEG clients
treated in Biofeedback Research and Training Laboratory.
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Review of Literature
Migraine Headache/Vascular Headache
In Grazzi and Bussone’s (1993) study on EMG biofeedback treatment (adjunctive
with breathing exercise) on migraine, results showed significant decreases in migraine
episodes and improved in the Pain Total Index in most patients although their mean
muscle activity did not change significantly in the treatment sessions. In addition,
patients maintained their reductions of migraine episodes at the 12-month follow-up.
According to Hermann, Blanchard, and Flor (1997), home-based biofeedback
treatment significantly reduced headache activity (included frequency, duration, and
intensity) of children with migraine. Results also suggested that the child’s age,
externalizing behavior tendencies, and initial level of psychosomatic complain were
three prediction factors of treatment outcome.
After reviewing 31 studies of behavior treatments of recurrent pediatric
headache, Holden, Deichmann, and Levy (1999) concluded that thermal biofeedback
alone was probably an efficient treatment for pediatric headache.
One study compared 4 treatment conditions: thermal biofeedback (TBF) for hand
warming, thermal biofeedback for hand cooling, thermal feedback for stabilization for
hand temperature, and biofeedback to suppress alpha in the EEG, to determine if
thermal feedback for hand warming was the best biofeedback treatment for vascular
headache (Blanchard et al., 1997). Findings indicated that patients in three conditions
(TBF-warming, TBF-cooling, EEG alpha-suppress) showed significant headache activity
reductions, and reductions of medication consumption was found in both TBF-warming
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and TBF-cooling groups. However, no evidence supported the patients received TBF-
warming had greater headache reductions.
Tension Headache
Blanchard, Taylor, and Dentinger (1992) studied using a comprehensive
treatment, which included drug withdrawal, progressive muscle relaxation, and 8
sessions of thermal feedback, with patients with high-medication-consumption
headache. They found 6 of 10 subjects demonstrated clinically significant reduction of
headache activity and analgesic consumption. In the 11-month follow-up, subjects were
able to uphold these reductions as documented by their headache diary.
In a comparison study on three treatments: frontal EMG biofeedback, trapezius
EMG biofeedback and progressive muscle relaxation therapy in the treatment of tension
headache, results indicated clinically significant decreases in headache activities in all
three treatment groups. Trapezius EMG biofeedback group had the highest percentage
improvement (74%) and frontal EMG group and progressive relaxation group had
43.8% and 33.9% improvement respectively (Arena, Burno, Hannah, & Meador, 2000).
Sarafino and Goehring (2000) reviewed the archival data from 56 studies to
evaluate if there was an age difference in acquiring biofeedback control and success in
treating headache. Findings suggested both thermal biofeedback and EMG biofeedback
substantially reduced subjects’ (both children and adults) headache activities and
children demonstrated greater improvement than adults did. In thermal biofeedback,
children had 62.27% decreases in their headache activities and adults had 33.8%
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decreases. In EMG biofeedback, children and adults showed 80.78% and 47.98%
decrease in headache activities respectively.
In Arnodorfer and Allen’s (2001) study on using thermal biofeedback treatment
package with children with recurrent tension headache, they found all five children
showed a significant decrease in headache frequency, duration, and intensity. At the 6-
month follow-up, 4 of 5 children were free from headaches.
Hypertension
McGrady (1994) studied patients with essential hypertension treated with group
relaxation training and thermal biofeedback. Forty-nine percent of the subjects in the
experimental group demonstrated a decrease in mean blood pressure of 5mm Hg.
Findings also indicated reductions of forehead muscle tension (from 2.9 microvolts to
1.8 microvolts), increases in finger temperature (from 87.7 °F to 90.2 °F), and
decreases in state anxiety (from scores 42.3 to 35.2) and trait anxiety (from scores 43.3
to 37.1). At the 10-month follow-up, only succeeders in the experimental group, who
continued practicing relaxation exercises at home, showed the long-term maintenance
of decreased blood pressure.
In Jurek, Higgins, and McGrady’s (1992) research on comparison of combination
of biofeedback-assisted relaxation and diuretic with diuretic alone to treat essential
hypertension, they found the combination treatment (diuretic combined with 16
sessions of biofeedback) had higher success to lower patients’ blood pressure (11 out of
20 patients) then diuretic alone (1 out of 10 patients).
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Diabetes
According to Saunders et al. (1994), thermal biofeedback (5 sessions for hand
and 16 sessions for foot) adjunctive with autogenic training homework exercises
successfully decreased attacks of intermittent claudication to zero by the 12th session
and increased walking distance to about a mile per day for a patient with non-insulin-
dependent diabetes mellitius. The patient was free of intermittent claudication and his
walking distance increased to 4.5 miles per day at the 12- and 48-month follow-up.
Needham and Eldridge (1993) studied the efficacy of using thermal biofeedback
to treat a 39-year-old man, who was diabetic, blind, and had double amputation, and to
reduce his depression and pains. The subject responded to the treatment immediately
and was able to raise his temperature up to 3.9 degrees Fahrenheit. In addition,
thermal biofeedback promoted a sense of self-control for the subject that in turn
facilitated the reductions of the subject’s depression.
Findings of a study suggested patients with insulin-dependent diabetes mellitus
reduced their average blood glucose (from 200mg/dl to 158 mg/dl) and percentage of
values above 200 mg/dl (from 43% to 22%) after 12, 30-minute weekly sessions of
biofeedback treatment (McGrady, Graham, & Bailey, 1996).
Incontinence
In McDowell’s et al. (1999) research of biofeedback-assisted pelvic floor muscle
training on 105 older adults (aged 60 years or older) with urinary incontinence, data
indicated a median 75.0% of reductions in urinary accidents in the treatment group
compared to a median 6.4% of reductions in the control group. Subjects, who
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completed treatment, decreased the average number of accidents per day from 4.0 pre-
treatment to 1.7 post-treatment.
In comparison study of effectiveness of paravaginal EMG biofeedback and pelvic
muscle exercise treatment in treating older women with urinary incontinence (UI),
results indicated that 61% reductions of UI episodes and 23% cures in the biofeedback
group and 54% reductions of UI episodes and 16% cures in the pelvic floor muscle
exercise group (Burn, Pranikoff, Nochajski, Hadley, Levy, & Ory, 1993).
Irritable Bowel Syndrome (IBS)
In one control study, eight IBS patients received 10 sessions of progressive
relaxation training with home practice. Results indicated that 50% of subjects were
significantly improved in their symptoms such as abdominal pain, diarrhea, constipation,
flatulence, belching, and nausea than subjects in the control group (Blanchard, et al.,
1993).
To examine the long-term improvement of biofeedback-assisted relaxation
treatment on IBS, Schwarz et al. (1990) conducted a 4- year follow-up study, 19 of
original 27 IBS patients participated in the follow-up. Seventeen of these 19 subjects
(89.5%) reported more than 50% improvement. Fifty percent of patients who
submitted symptom monitoring diaries showed at least a 50% reduction of IBS
symptoms such as pain, tenderness, diarrhea, nausea, and flatulence.
Blanchard, et al. (1992) conducted two studies to determine if a multicomponent
psychological treatment, which included progressive muscle relaxation, thermal
biofeedback, and cognitive therapy, was superior to other treatment. They found that a
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multicomponent psychological treatment was not superior to an attention-placebo
control (pseudo-medication and EEG alpha suppression biofeedback) and a symptom-
monitoring control when used to treat IBS. However, subjects, who were in the
multicomponent treatment group, attention-placebo group, and treatment of symptom
monitoring group, show reductions in all GI symptoms: abdominal pain, diarrhea,
constipation, belching, flatulence, nausea, and bloating. Subjects in the symptom-
monitoring group only demonstrated decreases in diarrhea and nausea.
Chronic Pain/Temporomandibular Disorder (TMD)
Mishra, Gatchel, and Gardea (2000) conducted a study to evaluate the relative
efficacy of three cognitive-behavior treatment conditions: a cognitive-behavioral skills
training (CBST) treatment group, a biofeedback treatment group, and a combination of
biofeedback and CBST treatment group, on patients with TMD. Although all three
treatment groups reported significant decreases in their Characteristic Pain Intensity
score compared to the no-treatment group, the biofeedback group showed the greatest
reductions relative to the no-treatment group.
In a case study on using electromyography feedback in the comprehensive
treatment of central pain and tremor after the subject had her initial cerebral accident 7
years ago, the 70-year-old female reported a significant decrease in duration, intensity,
and frequency of pain, a significant increase in efficacy of managing her daily pain, and
a significant increase in efficiency of sleep (Edwards, et al., 2000).
Flor and Birbaumer (1993) studied three types of treatment (cognitive-behavior
therapy, EMG biofeedback, and conservative medical treatment) for patients with
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chronic musculoskeletal pain (TMD and back pain). They found that the biofeedback
group showed the most substantial changes in Multidimensional Pain Inventory (MPI)
Pain Severity score. At the 6-month follow-up, 40% of subjects in the biofeedback
group sustained the reductions in pain severity, affective distress, catastrophizing scale,
and number of doctor visits compared with 17% in the CBT group and 8% in the
medical group. At the 24-month follow-up, the values of percentage change to 30% for
the biofeedback group, 18% for the CBT group, and 17% for the medical group.
Newton-John, Spence, and Schotte (1995) compared cognitive-behavior therapy
with EMG biofeedback in treating patients with low back pain. Findings indicated
significant improvement on the score of Pain Diary, Pain Disability Index, Pain Belief
Questionnaire, Beck Depression Inventory, and State-Trait Anxiety Inventory for
patients in both treatment groups but not in the control group. At 6-month follow-up,
patients maintained reductions of pain index, pain belief, and depression. However, no
significant differences were found between cognitive-behavior therapy and EMG
biofeedback on outcome measure.
Asthma
Kern-Buell et al. (2000) studied biofeedback-assisted relaxation for young, non-
steroid-dependent asthmatics. Findings showed 68% decreases in asthma symptoms
and 46% decreases in inhaler use in the experimental group and compared to 42%
decrease in asthma symptoms and 1.8% decrease in inhaler use in the control group.
Subjects in the experimental group demonstrated decreases in inflammation as
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demonstrated by the differences of the numbers of neutrophils and basophils in their
blood.
In a fifteen-month follow-up study by Pepper and Tibbetts (1992), results
indicated that subjects reduced their asthma symptoms, medical uses, breathless
episodes, and emergency visits after they had 16 weekly group EMG and incentive
inspirometer biofeedback sessions in combination with diaphragmatic breathing
training, guided imagery, prolonged exhalation, and desensitization strategies.
Anxiety Disorder
Watson, Tuorilla, Vickers, Gearhart, and Mendez (1997) studied 90 Vietnam War
veterans with posttraumatic stress disorder (PTSD) who were divided into three
treatment groups: relaxation instruction, relaxation instruction with deep breathing, and
relaxation instruction with deep breathing and thermal biofeedback. Although subjects’
temperature increased and EMG decreased in the 10 treatment sessions, only 4 of 21
PTSD symptoms and physiological dependent variables, which were flashbacks,
avoidance of thoughts, hyperalertness, and exaggerated startle, showed improvement.
Results suggested treatments were mildly effective.
Pediatric Constipation/Encopresis
In a control group study on pediatric constipation and encopresis, children in the
experimental group, who were treated with external anal sphincter (EAS)
electromyographic biofeedback plus Standard Medical Care (SMC), showed elimination
of EAS paradoxical constriction. At the 16-month follow-up, 75% of parents, whose
children were in the experimental group, reported complete elimination of constipation
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compared to 47% parents in the control group (only SMC). Seventy-nine percent of
experimental group parents and 49% of control group parents reported complete
elimination of soiling (Cox, Sutphen, Borowitz, Dickens, & Singles, 1994).
Hand Dsytonia (Writer’s Cramp)
In Deepak and Behari’s (1999) study on using brachioradialis EMG audio
biofeedback for hand dystonia, findings indicated 9 of 10 subjects had significant
improvement in hand writing from 37% to 93% and showed significant reductions of
pain and discomfort. At the 2-month and 6-month follow-up, percentage improvement
was from 20% to 82.6% and from 23.3% to 93.3% respectively.
Phantom Limb Pain
A case study found that a treatment of combined 6 sessions of EMG and 6
sessions of thermal biofeedback successfully eliminated a 69-year-old man’s phantom
limb pain after his amputation 3 years ago (Belleggia & Birbaumer, 2001). The
participant’s skin temperature in the stump increased and EMG level decreased during
treatment sessions. At the 12-month follow-up, the participant maintained complete
elimination of phantom limb pain.
In summary, biofeedback therapy has been shown to be effective in treating
migraine headache (Grazzi & Bussone, 1993), tension headache (Sarafino & Goehring,
2000), hypertension (McGrady, 1994), diabetes (Saunders, et al., 1994), incontinence
(McDowell, 1999), irritable bowel syndrome (Blanchard, et al. 1993), chronic pain
(Mishra, Gatchel, & Gardea, 2000), asthma (Kern-Buell et al. 2000), anxiety disorder
(Watson, et al., 2000), and pediatric constipation (Cox et al., 1994).
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Chapter II
Purpose of the Study
This study performed a qualitative when appropriate a quantitative analysis of all
client data files with the exception of neurofeedback since the establishment of the
Biofeedback Research and Training Laboratory in 1991 through the year 2002 for the
purpose of determining the clinical and educational efficacy of this service. The
researcher:
1. determined the variety of presenting concerns treated;
2. compared concerns treated with what the literature suggest biofeedback is
effective in treating;
3. determined the efficacy of such treatment at the Biofeedback Research and
Training Laboratory of a variety of disorders; and
4. determined if the Biofeedback Research and Training Laboratory provides a
useful service to the community.
Research Questions
This study was designed to answer the following questions:
1. Does the Biofeedback Research and Training Laboratory treat a variety of
concerns and disorders?
2. Does the Biofeedback Research and Training Laboratory treat concerns related to
what the literature suggests biofeedback is effective in treating?
3. Is the treatment for a variety of disorders provided at the Biofeedback Research
and Training Laboratory clinically effective?
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4. Does the Biofeedback Research and Training Laboratory provide useful services
to the community of clients and students?
Research Assumptions
The research assumptions were:
1. The Biofeedback Research and Training Laboratory treats most concerns
suggested for treatment by the literature.
2. The Biofeedback Research and Training Laboratory provides useful services to
the community of clients.
a. The Biofeedback Research and Training Laboratory treats a variety of
concerns and disorders.
b. The treatment provided at the Biofeedback Research and Training Laboratory
is effective in reducing or eliminating symptoms.
c. The Biofeedback Research and Training Laboratory provides treatment at low
cost.
3. The Biofeedback Research and Training Laboratory provides useful services to
the community of students (i.e., therapists in training).
Methods and Procedures
Data collection methods included in-depth interviews with the Director of BRTL
and an unobtrusive method of reviewing archival data client files. Client data files
included therapist’s session notes, client’s physiological measures, and the Stress Signal
Checklist. The Stress Signal Checklist is a list of 50 items commonly associated with
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stress with a 0-5 Likert response format. No research validity or reliability data is
available on the Stress Signal Checklist.
The researcher performed a qualitative analysis and a quantitative analysis of the
archival data of all clients’ files from 1992 to 2002. The client’s data files were divided
into two categories: clients who completed three or less treatment sessions (N = 88)
and clients who completed four or more treatment sessions (N = 321). For the clients
who completed four or more treatment sessions, the researcher examined and analyzed
each element of the data files that included:
1. number of clients treated with thermal biofeedback and/or electromyography
biofeedback by year, by gender, and by primary presenting problem,
2. the pre- and post- Stress Signal Checklist,
3. pre-, middle-, and post- electromyography and temperature measures, and
4. client’s self-report of homework relaxation exercises and progress (i.e.,
therapist’s session notes).
For pre-, middle-, and post- electromyography and temperature measures, the
researcher collected every client’s beginning and ending temperature and/or
electromyography in the first, middle, and last training session. This resulted in six
temperature measures and/or six electromyography measures for each client. These six
physiological measures (either temperature or electromyography measures) were used
to generate a slope for each client. Then the slope of each client’s growth trajectory
was used as the dependent variable to perform a one-sample t-test (Kraemer &
Thiemann, 1989; Maxwell, 1998; & Willett, 1994, Willett, 1989). The use of each
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individual’s slope as the dependent measure (i.e., intense design) can increase
statistical power (Maxwell, 1998).
For the clients who completed three or less treatment sessions, the researcher
only examined the number of clients treated with thermal biofeedback and/or
electromyography biofeedback by year, by gender, and by primary presenting problem.
The researcher counted the total number of EEG neurofeedback clients by year
although the measure of efficacy of EEG neurofeedback was not included in this study.
The unique complexities of EEG deserve an independent inquiry.
Role of the Researcher
In this study, the researcher functioned as an outside consultant and an inside
advocate. As an outside consultant, the researcher’s main goal was to evaluate the
efficacy and effectiveness of the treatment program in the BRTL. The evaluator wanted
to understand if the program has been effective, to what degree, and under what
conditions. As an inside advocate, the researcher promoted that the BRTL has provided
a quality program that has benefited university students, staff and faculty, and
community citizens.
Data Analysis
The procedure of data analysis included organizing the data, generating
categories, themes, and patterns, coding the data, testing emergent understandings,
searching for alternative explanation, and writing the report (Marshall & Rossman,
1999).
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In quantitative analysis, the data were organized and categorized by year, by
gender, by age, by ethnicity, and by primary presenting problem for all clients. The
researcher calculated the total number and percentage of clients based on year,
gender, age, and primary presenting problem. The researcher examined the data of the
pre- and post- Stress Signal Checklist and calculated the percentage of clients whose
symptoms decreased. One-sample t-test and factor analysis were used for statistical
analysis on physiological measures (both temperature and electromyography
measures). Effect sizes were computed by using Pearson’s r to determine the clinical
significance (Rosenthal, 1991). S-techniques were used to perform factor analysis. S-
technique factors individuals across occasions (Minke, 1997). In this study, occasions
refer to the six time points (beginning and ending measures of the first, middle, and
last session) where temperature and muscle tension measures were collected.
According to Budzynski (1989), the criteria for EMG training is to decrease frontal
EMG level to less than 2.5 microvolts in the cases of tension headache or 4.0 microvolts
in cases of migraine. Stoyva (1989) stated that the criterion on the autogenic training
and biofeedback combined was for clients to learn to keep EMG level at 3.5 microvolts
or less. For temperature training, the goal was that clients learned to produce hand
temperature greater than 90 degrees Fahrenheit (Budzynski, 1989) or greater than 89
degrees Fahrenheit for the nonfeedback average (Stoyva, 1989). Therefore, to avoid
the ceiling effect and floor effect on the physiological measures, the researcher
excluded clients whose beginning temperatures were over 90 degrees Fahrenheit
and/or whose beginning electromyography reading was below or equal 2.5 microvolts
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on both one-sample t-test and factor analysis (see Appendix A-collection of fitted
individual growth trajectories)
In the qualitative analysis, the research examined and analyzed therapist’s
session notes that were based on clients’ self-report of symptom reductions and
homework relaxation exercises, and therapists’ observations of client’s progress to find
and generate the themes and patterns of treatment progress. Therapist’s session notes
were categorized into four areas: 1) decreased primary presenting problem, 2) report of
other types of progress other than primary presenting problem, 3) increased
awareness, and 4) negative experiences reported by clients.
After examining each element of client data files (both quantitative and
qualitative data), the researcher formulated hypothesis and tested emergent
understanding and searched for alternative explanations to answer some questions that
have not been answered. For example, why clients terminated treatment prematurely
(i.e., having three or less sessions), what factors contributed to symptom reliefs, and
how clients learned to increase temperature and/or decrease muscle tension in
treatment sessions.
Limitation
Qualitative research is inherent with researcher’s bias (Mashall & Rossman,
1999). In addition, the researcher works as a teaching assistant in the BRTL and the
Director of BRTL is also the major professor of the researcher. Under these conditions,
bias is likely to happen. However, the researcher strived to maintain objectivity and had
been encouraged to remain in a neutral position by the major professor.
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This study examined archival data so no names from the data files were revealed
in order to protect clients’ privacy. The Stress Signal Checklist, which has not yet been
published, was used with permission of Dr. Barbara Peavey, practitioner of Grapevine,
Texas. No reliability and validity research has been performed with this instrument.
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CHAPTER III
Results and Discussion
Educational Efficacy of the Biofeedback Research and Training Laboratory
The Biofeedback Research and Training Laboratory (BRTL) was established the
latter part of the year 1991 at the University of North Texas (UNT) by the Director, Dr.
Cynthia K. Chandler. Dr. Chandler is a full-time professor in the Counseling Program of
the College of Education, a national certified biofeedback therapist (BCIA-C), a national
certified neurofeedback provider (BCIA-EEG), a licensed professional counselor (LPC)
and a licensed marriage and family therapist (LMFT) in the state of Texas.
The mission of the Biofeedback Research and Training Laboratory is “to provide
a teaching, learning, and research environment for training, provision of services and
advancement of knowledge in the area of biofeedback” (Chandler, 1999, p.1). Since
1992, the BRTL has provided quality, but affordable, biofeedback therapy for an
abundance of clients. The clientele include university students, faculty and staff, and
community citizens from a large metropolitan area.
Goals of the Biofeedback Research and Training Laboratory
There are three main goals for the BRTL: 1) to provide training in the field of
biofeedback, 2) to conduct faculty-directed research, and 3) to offer quality, but
affordable, biofeedback therapy and other services to the University and DFW
metroplex community.
The BRTL is utilized to provide training in the field of biofeedback therapy on a
full-time basis by the following graduate classes: Introduction of Biofeedback,
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Biofeedback Practicum, Advanced Practicum in Biofeedback, and Advanced Clinical
Training in Biofeedback and Neurofeedback. Introduction of Biofeedback is offered in
the Summer I semester. In this class, graduate students (masters and doctoral
students) learn the knowledge and techniques for performing biofeedback and
neurofeedback therapy. Biofeedback Practicum is offered in the Summer II semester.
Students use the laboratory equipment to provide biofeedback therapy for clients with
different conditions. Advanced Practicum in Biofeedback is offered in the Fall semester.
Students use biofeedback and neurofeedback therapeutic techniques with clients. In
addition, students can enroll in Advanced Clinical Training in Biofeedback and
Neurofeedback, to gain more clinical experience during any semester.
From 1992 to 2002, there have been 183 graduate students who have enrolled
in Introduction of Biofeedback and 118 students who have enrolled in Biofeedback
Practicum. Eighty students have enrolled in Advanced Practicum in Biofeedback from
1995 to 2002. Fifty-six students have enrolled in Advanced Clinical Training in
Biofeedback and Neurofeedback from 1993 to 2002 (UNT Student Information
Management System, 2002). The average per semester enrollment is approximately 17
graduate students enrolled in the introductory course, 11 students enrolled in the
practicum course, 8 students enrolled in the advanced practicum courses, and 11
students enrolled in the clinical course. In addition, 3 to 5 masters’ and post-masters’
students work in the BRTL as interns to gain experience and hours for their license as
professional counselors every semester (C. K. Chandler, personal communication, April,
2002).
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To offer quality, but affordable, biofeedback therapy, the BRTL charges the small
fee of $25.00 per session for community clients, $10.00 per session for staff and faculty
members of the University of North Texas, and $5.00 per session for UNT students. All
treatment services are provided by graduate students and interns under faculty
supervision.
In 1999, the BRTL created a website, www.coe.unt.edu/edhe/Biofeedback1.htm,
to serve as an educational resource. Community citizens can use this website to find
biofeedback-related information and resources such as resources for referral and
information on biofeedback therapy and certification.
Facility
The BRTL is part of the University of North Texas’s Counseling and Human
Development Center (CHDC). The CHDC consists of a secretary’s office, a waiting room,
a staffing room, a control room, a conference room, a library, a biofeedback office, two
restrooms, 3 group counseling rooms, 3 play therapy rooms, 4 biofeedback therapy
rooms that can double as individual counseling rooms when needed, and 5 individual
counseling rooms (Holden & Kern, 1996). Prior to the year of 2002 there were 15 TV-
VCR stations in the control room, from which professors and/or supervisors can view,
videotape, or both for ongoing sessions. In 2002, the CHDC purchased new electronic
equipment that included 10 DVD video recorders, 2 CD writers, and 17 computers.
Currently, there are 10 DVD-TV-VCR stations (7 stations are in the intern room and 3
stations are in the control room) and 17 computers, which are in the control room and
hook up to each counseling room to record counseling sessions automatically (L. Steen,
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Personal Communication, May, 2003). Each biofeedback room contains swivel chairs, a
reclining chair, a computer, a wooden computer cabinet, a printer, a cassette-CD
player, and biofeedback equipment.
The BRTL shares the facility such as the video control room, receptionists,
waiting room, and library with the CHDC. However, the BRTL functions independently in
terms of having its own budget account, client waiting list, telephone line and answer
machine, filing system, recruitment of clients, and scheduling of clients.
Types of Biofeedback Treatment
The Biofeedback Research and Training Laboratory provides six types of
biofeedback treatments:
1. Thermal biofeedback: this modality is used to train persons to increase their
finger or toe temperature,
2. Electromyography (EMG) feedback: this modality is used to help persons to
reduce their muscle tension or to gain motor control,
3. Electroencephalography (EEG) feedback: this modality is used to train to
either increase or decrease a person’s brainwave rhythms,
4. Electrodermal response (EDR): this modality is used to train to reduce sweat-
gland activity,
5. Pulse: this modality is used to train regular heartbeat, and
6. Breathing rate: this modality is used to train diaphragmatic breathing.
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In addition to the above modalities, treatment protocols include autogenic
relaxation training, progressive muscle relaxation techniques, diaphragmatic breathing,
guided imagery, systematic desensitization, and cognitive restructuring.
Typical Treatment Procedure
First session.
At the first visit, a client fills out paperwork with the therapist that includes the
biofeedback intake form, the Stress Signal Checklist, a body map for discomforts, and
an informed consent. The biofeedback therapist also gives an oral description of what
fight-or-flight response is, how people react to stressful situations, and what and how
biofeedback therapy can help deal with stress. The attempt of this introduction is to
educate clients and to inform them of what they can expect in the treatment sessions.
Next, the therapist briefly explains the biofeedback equipment to the client while
attaching sensors to him or her and then conducts a standard psychophysiological
assessment (PPA) to gain baseline information in order to formulate a treatment plan.
Treatment sessions.
In the second session, the therapist presents a treatment plan to a client to sign
and also explains type of treatment (for example, thermal biofeedback, or EMG
biofeedback), goals of treatment, and an estimated target date for completion of
treatment, and the rationale for treatment that a client is receiving. A therapist also
explains to the client how the audio feedback is used on the biofeedback equipment to
train him or her to increase skin temperature or decrease muscle tension for treatment
of a particular condition.
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All treatment sessions have some similarities in format: a 5 minutes baseline
phase, a 15-20 minutes training phase (i.e., a therapist reads a training script and
coaches a client), and another 5 minutes baseline phase. Clients receive audio feedback
throughout the whole process. In thermal biofeedback sessions, the therapist typically
uses an autogenic script (Schultz, 1969) to facilitate feelings of relaxation, heaviness,
and warmth. A client is instructed to raise the external skin temperature as measured
on a finger thermister. In EMG training, a progressive muscle relaxation script (Wolpe,
1973) is used to assist in relaxing different muscle groups. A client is instructed to relax
a muscle group as it is measured by an EMG sensor on the surface of the skin that near
the muscle group.
In the beginning of every session, a therapist asks about progress of homework
relaxation exercises and answers any questions or concerns a client might have. At the
end of each session, the therapist discusses the session with the client and elicits
feedback about his or her experience in the session. Then a new homework exercise is
assigned and the client is encouraged to practice at home. Typical homework includes
instructions for listening to a 15 minute relaxation tape (provided by the therapist)
daily, or at least 3-5 times per week, and record practice sessions on a homework log.
Termination session.
At the end of the final treatment session, the client completes another Stress
Signal Checklist and a counselor evaluation form. Furthermore, therapist and client
review experiences and progress that the client has made and reiterates how to
generalize self-regulation skills to daily living.
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Treatment goals
1. To increase finger temperature.
2. To decrease muscle tension.
3. To reduce or eliminate symptoms.
Equipment in the Training Setting
The BRTL has a variety of equipment that includes 2 sets of portable battery
operated equipment not integrated with a computer: two Autogenics AT-42s for skin
temperature training and two AT-33s Autogenic for muscle tension training; and 4 sets
of computerized equipments: two Pro-Comp with Biograph software from Thought
Technology, and two Focused Technology F-1000s.
1. AT-42 Autogenic Single Channel Temperature Trainer is a portable, single-
channel temperature training instrument with rechargeable batteries. It has a
built-in microprocessor to collect and analyze session data and present
temperature information.
2. AT-33 Autogenic EMG is a portable, single channel EMG training instrument and
has rechargeable batteries, a LED digital meter, and a LED light bar displays that
are activated by pressing a panel button. The AT-33 also has a 3 variations of
audio feedback played through the internal speaker or optional earphones.
3. Focused Technology F-1000 computerized system has two channels for
temperature training, two channels for EMG and EEG training, one channel for
skin conductance training, two channels for respiration training, and one channel
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for heart rate. It has a built-in sound synthesizer, analog, digital and FFT filter,
and versatile data logging and presentation (www.focused-technology.com).
4. Pro-Comp from Thought Technology with Biograph software computerized
system has 8 channels of any combination of modalities, including EEG, skin
conductance, heart rate, blood volume pulse, temperature, and respiration
(www.bio-medical.com).
Of the three primary goals of the BRTL mentioned earlier the two goals that
receive the greatest attention are 1) to provide and support training and education in
biofeedback therapy to students, and 2) to service the community by providing
biofeedback therapy. The third primary goal of the BRTL, to provide faculty-directed
research in biofeedback, is the least attended to area of the BRTL. Since the inception
of the BRTL and through the year 2002, four articles have been published as a result of
the BRTL research, two national and two state (Chandler, Bodenhamer-Davis, Holden,
Evenson, & Bratton, 2001; Bodenhamer-Davis & Chandler, 1998; Chandler, 1996;
Chandler & Sanders, 1994). In addition, the BRTL research has resulted in two
international and three national professional presentations as well as six state
presentations (Chandler & Brew, 2001; Chandler, Lawson, Molenaar, DeSalme, Pinzon,
Pope-Cody, Linebarger, & Lang, 1999; Lawson, Chandler, Molenaar, Pinzon, Pope-Cody,
Linebarger, & Lang, 1998; Chandler & Mosse, 1996; Chandler & Sanders, 1993;
Chandler & Brew, 1999; Chandler, Lawson, Molenaar, DeSalme, Pinzon, Pope-Cody,
Linebarger, & Lang, 1998; Chandler, 1998; Chandler, Holden, Bodenhamer-Davis, &
Evenson, 1997; Chandler & Mosse. 1996; Chandler, 1992).
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Biofeedback students are active in ongoing biofeedback research and
presentations and over the years have received 9 state research scholarship awards (7
from the Biofeedback Society of Texas and 2 from the Texas Association for Counselor
Education and Supervision) and 2 national research/scholarship award from the
Association for Applied Psychophysiology and Biofeedback.
Client fees received for biofeedback services are utilized to support the
maintenance of the BRTL, provide for research support, and award an annual $1000
student scholarship in biofeedback study.
Biofeedback Research and Training Laboratory Responsibility Hierarchy (see Figure 1)
Figure 1. Biofeedback Research and Training Laboratory Responsibility Hierarchy
The BRTL teaching fellow and students enrolled in the biofeedback courses
↓ reports to
Director of the Biofeedback Research and Training Laboratory
↓ reports to
Chair of the Department of Counseling, Development, and Higher Education
↓ reports to
Dean of the College of Education
↓ reports to
President of the University of North Texas
Job Descriptions.
The Director of the BRTL is a full-time graduate faculty Professor in a counseling
program and is nationally certified in biofeedback and neurofeedback through the
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national organization the Biofeedback Certification Institute of America
(hppt://www.bcia.org). She is also a licensed professional counselor and a licensed
marriage and family therapist. As part of her faculty duties, the Director of the BRTL
supervises all students and interns performing biofeedback therapy, teaches all of the
biofeedback related courses and oversees the administration of the biofeedback
laboratory including the supervision of the teaching fellow of the BRTL.
The BRTL teaching fellow is a doctoral student in a counseling program who
specializes in biofeedback therapy and/or research. The teaching fellow performs the
daily administrative tasks required to run the BRTL. These include: returning phone
calls, maintaining the biofeedback equipment and supplies, maintaining the client
waiting list, maintaining administrative files, supervising the organization and
completion of client files, assisting in the instruction of biofeedback in the didactic
biofeedback course, assisting in the supervision of students during biofeedback clinical
courses.
Clinical Efficacy of the Biofeedback Research and Training Laboratory
From 1992 to 2002, the Biofeedback Research and Training Laboratory provided
peripheral biofeedback therapy for 409 clients. Figure 2.1 shows the number of male
and female clients treated in the BRTL each year. Three hundred and twelve clients
were female and 97 clients were male. Among these 409 clients, 270 clients had
information regarding their ethnicity. For these 270 clients, 90% were Caucasian, 4.1%
were Hispanic, 3% were Africa American, 2.2% were Asian, 0.7% were others (see
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Figure 2.2). Clients’ ages ranged from 15 to 76 years old. Seventy-eight percent were
between 25 to 55 years old (see Figure 2.3).
Figure 2.1. Number of clients treated based on year and gender.
1
9
22
61
53
3036
4235
16
71
7 7
17 16
812 13 10
2 4
0
10
20
30
40
50
60
70
1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002
Year
Num
ber o
f Clie
nts
FemaleMale
Figure 2.2. Number of clients treated based on ethnicity.
8 6
243
11 20
50
100
150
200
250
300
AfriicaAmerican
Asian Caucasian Hispanic Others
Ethnicity
Num
ber o
f Clie
nts
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32
Figure 2.3. Number of clients treated based on age.
4
57
131
104
84
29
0
20
40
60
80
100
120
140
15-17 18-24 25-35 36-45 46-55 56-76
Age
Num
ber
of C
lient
s
This data does not include an estimated 1,000 client contact hours or over 100
clients in which students provided biofeedback therapy for fellow students to meet the
certification requirement that all biofeedback therapists must have 10 hours as a client
as part of their biofeedback training. Most of these trainees did not have a significant
presenting concern. The data also does not include 2 client contact hours every doctoral
student in the counseling program is required to do for the observation/participation
requirement for the doctoral program. The Director of the BRTL was on research
sabbatical in 2002 and thus client activity of the BRTL was minimal. Activity picked back
up to normal in 2003.
Figure 2.4 demonstrates the number of clients and the number of variety of
concerns and symptoms treated in the BRTL that included anxiety, chronic pain,
fibromyalgia, gastrointestinal problems, migraine headache, hypertension, performance
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anxiety, Raynaud’s, sleep problem, stress, tension headache, test anxiety,
temporomandibular joint pain, and others. Symptoms that were included as
gastrointestinal problems were irritable bowel syndrome, gastritis, stomach cramp/pain,
ulcer, colitis, and spastic colon. Symptoms that are under the others category are nail
biting, mood swing, smoking cessation, caffeine addiction, blepharospasm, Bell’s palsy,
concentration problem, asthma, vocal cords problem, blushing, and eating disorder.
Chronic pain, stress, anxiety, and tension headache, which composed 62.3% of
all 409 clients, were the top four primary presenting problems that the BRTL treated.
Figure 2.4. Number of clients treated based on primary presenting problem.
49
87
919
44
22 2012
713
75
17 17 18
0102030405060708090
100
Anx
iety
Chr
onic
Pai
n
Fibr
omya
lgia
Gas
troin
test
inal
Pro
blem
Tens
ion
Hea
dach
e
Hyp
erte
nsio
n
Mig
rain
eHea
dach
ePer
form
ance
Anx
iety
Ray
naud
's
Sle
ep P
robl
em
Stre
ss
Test
Anx
iety
TMJ
Oth
ers
Primary Presenting Problem
Num
ber o
f Clie
nts
The BRTL also provided neurofeedback therapy for clients with Attention Deficit
Disorder/Attention Deficit Hyperactivity Disorder. From 1994 to 2002, 98 clients that
were not part of 409 peripheral biofeedback clients received neurofeedback therapy in
the BRTL. Figure 2.5 represents the number of neurofeedback clients treated based on
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34
year. Number of neurofeedback clients treated depends on the availability of the
student therapists with that particular interest area.
Figure 2.5. Number of neurofeedback therapy clients treated based on year.
13
33
26
10
6 5
13
10
5
10
15
20
25
30
35
1994 1995 1996 1997 1998 1999 2000 2001 2002
Year
Num
ber
of C
lient
s
Results of Clients’ Self-Reported Progress
Clients’ self-reported progress included the pre- and post- Stress Signal Checklist
and therapist’s session notes which included: 1) clients’ report of practice of homework
exercises, and 2) clients’ self-reported progress and therapists’ observations. Clients’
self-reported progresses were only examined for the 321 clients who completed 4 or
more treatment sessions.
Stress Signal Checklist
For the 321 clients, only 101 clients (31.5%) had completed information on both
pre- and post- Stress Signal Checklist. Of these 101 clients, 88 clients (87.1%) reported
symptom decrease, 4 clients (4%) reported remaining the same, and 9 clients (8.9%)
reported symptom increase.
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Therapist’s Session Notes: Clients’ report of practice of homework exercises
Eighty percent of the 321 clients with 4 or more treatment sessions reported
doing their relaxation homework exercise. However, there was no specific information
regarding number of homework exercises that clients practiced per week.
Therapist’s session notes: Clients’ self-reported progress and therapist’s observations
Therapists’ session notes that included clients’ self-reported progress and
therapist’s observations were categorized into four areas: 1) decreased primary
presenting problem, 2) report of other types of progress other than primary presenting
problem, 3) increased awareness of primary presenting problem and/or other areas,
and 4) negative experience.
There is no procedure for computing a treatment success to failure ratio using
therapist’s session notes due to the inconsistency of therapists in recording clients’
statements. For 321 the clients who had 4 or more treatment sessions, only 218 clients
(68%) had self-reported progress recorded in files by their therapists.
Decrease in primary presenting problem.
Decrease in primary presenting problem was defined as decrease in severity and
frequency of symptoms. The following findings are based on clients with 4 or more
treatment sessions who had self-reported progress recorded in their files by therapists
(i.e. 218 client files). For those 218 clients, 101 clients (46.3%) reported primary
presenting symptoms decreased. Figure 3.1 summarizes the number of clients who
reported primary presenting problem decreased. The following paragraphs are detailed
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qualitative results from therapist’s session notes classified by each primary presenting
problem.
Figure 3.1. Number of clients reported primary presenting problem decreased.
24
45
511
2418
15
4 2 4
34
8 10 913 15
25
148 9
2 14
15
3 4 6
05
101520253035404550
Anxi
ety
Chr
onic
Pai
n
Fibr
omya
lgia
Gas
troin
test
inal
Pro
blem
Tens
ion
Hea
dach
e
Hyp
erte
nsio
nM
igra
ine
Hea
dach
ePe
rform
ance
Anx
iety
Ray
anud
's
Slee
p P
robl
em
Stre
ss
Test
Anx
iety
TMJ
Oth
ers
Primary Presenting Problem
Num
ber o
f Clie
nts
Clients had self-reportedinformationClients reported primarypresenting problem decreased
Anxiety.
There were 36 clients with 4 or more treatment sessions who had anxiety as
their primary presenting problem. Only 24 of the 36 clients with anxiety as primary
presenting problem had self-reported information recorded by their therapists and 13 of
these 24 clients (54.2%) reported that anxiety level and symptoms decreased and they
felt calmer and more relaxed in general. One client with a panic attack stated that she
was able to relax in stressful situations and use deep breathing to help gain emotional
stability. Another client reported not having panic attacks for 2 weeks. She stated she
was able to talk herself out of a panic attack. One client stated she noticed
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37
improvement in her overall feelings of well-being and felt more confident and less
anxious. One client who had a phobia of flying reported her symptoms decreased
significantly when flying.
Chronic pain.
There were 67 clients with 4 or more treatment sessions who had chronic pain
as their primary presenting problem. Only 45 of the 67 clients with chronic pain as
primary presenting problem had self-reported information recorded by their therapists
and 15 of these 45 clients (33.3%) reported severity and frequency of pain decreased
or eliminated. Clients reported being able to recognize tension location and able to
reduce and alleviate muscle tension and pain. One client with shoulder pain stated his
shoulders were not as tense as before and felt like a weight was lifted. In addition, he
stated he was able to mentally pull himself out of high stress situations. Another client
reported being able to achieve relaxation even in midst of pain and distress. He stated
pain had become more a disconcerting certainty rather than a dreadful consuming
suffering.
Fibromyalgia.
There were 6 clients with 4 or more treatment sessions who had fibromyalgia as
their primary presenting problem. Five of the 6 clients with fibromyalgia as primary
presenting problem had self-reported information recorded by their therapists and 2 of
these 5 clients (40%) reported symptoms decreased. One client reported having no
shoulder and back pain for over a week and feeling much better overall. Another client
stated she realized there was no need for her to hold tension in her body and she was
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38
able to let go more. In addition, the intensity of her headache and muscle tension
decreased.
Gastrointestinal problem.
There were 17 clients with 4 or more treatment sessions who expressed
gastrointestinal problem as their primary presenting problem. Only 11 of the 17 clients
with gastrointestinal problem as primary presenting problem had self-reported
information recorded by their therapists and 5 of these 11 clients (45.5%) reported
gastrointestinal symptoms decreased. One client with spastic colon stated she had less
stress attacks of colon. One client with irritable bowel syndrome stated she was able to
use relaxation techniques in situations that had previously been very stressful. In
addition, she began to go out to public to eat which she had previously avoided.
Hypertension.
There were 21 clients with 4 or more treatment sessions who had hypertension
as their primary presenting problem. Eighteen of the 21 clients with hypertension as
primary presenting problem had self-reported information recorded by their therapists
and 8 of these 18 clients (44.4%) reported blood pressure decreased. Five clients had
blood pressure measured before and after each treatment session. One client
decreased his systolic blood pressure an average of 7 mmHg and diastolic blood
pressure an average of 5 mmHg. Another client reduced blood pressure an average of
11 mmHg for her systolic blood pressure and 2.5 mmHg for her diastolic blood pressure
after the biofeedback session. One client reduced an average of 5.8 mmHg and 0.4
mmHg respectively for systolic and diastolic blood pressure. The last one reduced an
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39
average of 6 mmHg for systolic blood pressure and 2 mmHg for diastolic blood
pressure. One client’s physician cut down his hypertension medication to half and his
kidney function was returning to normal at the end of his treatment. One client
reported her blood pressure decreased significantly.
Migraine headache.
There were 18 clients with 4 or more treatment sessions who expressed migraine
headache as their primary presenting problem. Fifteen of the 18 clients with migraine
headache as primary presenting problem had self-reported information recorded by
their therapists and 9 of these 15 clients (60%) reported decreases in frequency and
severity of migraine and being able to use relaxation skills to better deal with migraine.
One client reported being able to work through her migraine a little better and feeling
more relaxed. Another client stated she felt like her everyday life had been affected
positively and her migraine had alleviated. One client stated she was able to use
breathing to fight off what felt like an on coming migraine and she was much more
attentive to her physical self.
Performance anxiety.
There were 9 clients with 4 or more treatment sessions who had performance
anxiety as their primary presenting problem. Only 4 of the 9 clients with performance
anxiety as primary presenting problem had self-reported information recorded by their
therapists and 2 of these 4 clients (50%) reported decreases in frequency of anxiety.
One client stated her two speaking engagement went better. Another client reported
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using breathing to calm herself when she was anxious and she was happier and more
confident.
Raynaud’s disease.
There were 6 clients with 4 or more treatment sessions who had Raynaud’s
disease as their primary presenting problem. Only 2 of the 6 clients with Raynaud’s
disease as primary presenting problem had self-reported information recorded by their
therapists and 1 of these 2 clients (50%) reported her symptoms decreased. She stated
she was able to warm her hands and used relaxation skills to reduce tension. Her
energy level increased that enabled her to spend time with her friends after work which
she was not able to do before. She was more alert and focused. In addition, she was
able to let go more and not worried too much.
Sleep problem.
There were 7 clients with 4 or more treatment sessions who had sleep problem
as their primary presenting problem. Only 4 of the 7 clients with sleep problem as
primary presenting problem had self-reported information recorded by their therapists
and all of these 4 clients (100%) reported quality of sleep improved that included easier
to fall asleep, sleep longer, no frequent awakenings during the night, no too-early
awakenings in the morning, and/or reduced use of sleep aides.
Stress.
There were 60 clients with 4 or more treatment sessions who had stress as their
primary presenting problem. Only 34 of the 60 clients with anxiety as primary
presenting problem had self-reported information recorded by their therapists and 15 of
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these 34 clients (44.1%) reported reducing general stress level and feeling better
overall. One client reported having quicker recovery from stress. Another client stated
she was able to recognize stressors and developed coping strategies for coping with
work and family stress. Six clients reported being able to identify stressful situations
and using relaxation techniques such as deep breathing to stay calm and control stress.
One pregnant woman reported she had less headache and nausea after biofeedback
training.
Tension headache.
There were 35 clients with 4 or more treatment sessions who had tension
headache as their primary presenting problem. Only 24 of the 35 clients with tension
headache as primary presenting problem had self-reported information recorded by
their therapists and 14 of these 24 clients (58.3%) reported decreasing in frequency
and severity of headache and having learned how to deal with or prevent headaches.
One client reported being able to stop her headaches by using the autogenic relaxation
tape. In addition, she had changed her attitude about relaxation. Another client stated
life overall was still stressful but she learned how to better handle it. One client stated
she went on an entire day with no discomfort or pain from tension; furthermore, she
was much more positive and calm and felt physically less stressed.
Test anxiety.
There were 11 clients with 4 or more treatment sessions who had test anxiety as
their primary presenting problem. Eight of the 11 clients with test anxiety as primary
presenting problem had self-reported information recorded by their therapists and 3 of
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these 8 clients (37.5%) reported their test anxiety level reduced. One client stated she
was able to sleep better, retained more of what she studied, and remembered and
recalled more. Another client with test anxiety stated he felt less restless in the situation
where he had to sit for prolonged period of time and more relaxed during tests.
Temporomandibular joint pain.
There were 14 clients with 4 or more treatment sessions who had TMJ as their
primary presenting problem. Only 10 of the 14 clients with TMJ as primary presenting
problem had self-reported information recorded by their therapists and 4 of these 10
clients (40%) reported symptoms decreased and experiencing no or less pain. One
client stated she was able to alleviate her jaw pains by being aware how and where she
held the tension and leaving some space between her teeth. Another one reported no
headaches and jaw pains for 2 weeks. In addition, she said, “I wish more people would
learn what I did instead of turning to drugs or alcohol.”
Others.
There were 14 clients with 4 or more treatment sessions whose primary
presenting problem was under the others category. Only 9 of the 14 clients whose
primary presenting problem was under others category had self-reported information
recorded by their therapists and 6 of these 9 clients (66.7%) reported symptoms
decreased. One client with nail biting problem reported having less nail biting behavior
because she was more aware when she engaged in nail biting and then she was able to
stop it. One client with vocal cords problem stated having some improvement in his
voice quality. One woman with eating disorder reported she ate healthier and was not
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thinking about a laxative. She used relaxation for stress reduction, not a laxative and
she was happier. One client with blepharospasm stated her twitches did not occur and
she felt she was able to control it. In addition, relaxation exercises helped her fall
asleep.
One client who had a blushing problem stated that he was less tense and had
less blushing. His increased ability to relax and let go helped him feel more comfortable
when he was lecturing in class. One client with chronic fatigue syndrome reported
feeling more present and relaxed despite the pain. She was aware of her tiredness and
learned how to respect her body’s needs. Another client with concentration problems
reported being able to concentrate better and using deep breathing when she was
stressed.
Report of other types of progress other than primary presenting problem.
For 218 clients (64.7%) who had self-reported statements recorded by their
therapists, 141 clients (64.7) reported having positive gains or progress in one or more
areas not directly related to their primary presenting symptom. Figure 3.2 shows the
number of clients reported other types of progress other than their primary presenting
problem based on primary presenting problem.
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Figure 3.2. Number of clients who reported other types of progress other than primary
presenting problem based on primary presenting problem.
24
45
511
2418 15
4 2 4
34
8 10 9
1825
4 7
1814 12
1 1 2
22
6 7 4
05
101520253035404550
Anx
iety
Chr
onic
Pai
nFi
brom
yalg
iaG
astro
inte
stin
al P
robl
emTe
nsio
n H
eada
che
Hyp
erte
nsio
nM
igra
ine
Head
ache
Per
form
ance
Anx
iety
Ray
anud
'sSl
eep
Pro
blem
Stre
ssTe
st A
nxie
ty
TMJ
Oth
ers
Primary Presenting Problem
Num
ber o
f Clie
nts
Clients had self-reportedinformation
Clients reported other typesof progress
Seventy-five percent of clients with anxiety as primary presenting problem
reported other types of progress. Four out of five clients (80%) with fibromyalgia as
primary presenting problem reported other types of benefits form the biofeedback
training. Eighty percent of clients with TMJ as their primary presenting problem
reported other types of benefits and gain from the biofeedback training sessions. Six
out of 8 clients (75%) with test anxiety as their primary presenting problem and 18 out
of 24 clients (75%) with tension headache as their primary presenting problem reported
having other types of progress. Eighty percent of clients with migraine headache as
primary presenting problem reported other benefits from the biofeedback training.
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Following is a list of examples of client’s statements recorded by therapists that
reported positive progress that clients made in the sessions that was not directly related
to their primary presenting problem.
1. Decreases in the other related symptoms for clients who had multiple
symptomatology (see Table 1);
2. Having a more positive attitude and positive feelings such as feeling happier,
calmer, rested, energetic, secured, more alive, more relaxed, and more
confident;
3. Having less negative feelings such as feeling less irritable, rushed, anxious,
restless, guarded, and nervous;
4. Improving quality of sleep such as easier to fall asleep and/or being able to sleep
through the night;
5. Incorporating deep breathing into daily life to deal with difficult times at work or
at home;
6. Being able to use deep breathing and/or relaxation techniques to calm
themselves in a stressful situation;
7. Having a quick recovery from stress;
8. Being able to use relaxation techniques to prevent symptoms occurring such as
headache, jaw pain;
9. Increases in self-care behaviors such as decreasing caffeine and/or nicotine
intake, exercising more, and taking time for pleasurable activity;
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10. Participating in activities that had not been done for a while such as going out to
eat for irritable bowel syndrome clients and talking to a stranger for social
anxiety clients;
11. Increasing productivity at work;
12. Increasing concentration;
13. Increasing a sense of control over tension, anger, racing thought, and obsessive
thought,
14. Increasing tolerance for frustration;
15. Increasing the ability of letting go;
16. More in touch with oneself and feelings;
17. Being able to recognize negative thought patterns such as taking responsibility
for others’ action; and
18. Having spiritual experiences such as “out of body” experience and “oneness”
experience.
Table 1. Sample recorded clients’ statement of reported symptom decrease in other
than the primary presenting problem.
Client’s primary presenting problem Area of improvement
Anxiety Decreased stiffness in back and neck
Blushing Decreased performance anxiety
Chronic Pain: Decreased frequency of headache
Better prepared for examination
Fibromyalgia Decreased frequency of headache
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Table 1. (continued) Hypertension:
Decreased frequency of migraine and neck pain
Decreased performance anxiety
Less stress in public speaking
Stabilized blood sugar
Irritable bowel syndrome Decreased use of inhaler for asthma
Migraine:
Decreased stomach distress
Decreased blood pressure and stomach stress
Panic attack Decreased muscle tension
Raynaud’s Decreased frequency of headache
Sleep problem Mood swing improved
Stress:
No more chest pain
Decreased frequency of headache
Decreased neck pain
Tension headache:
Fewer episodes of insomnia
Decreased test anxiety
Decreased asthma attack
Backache diminished
Blood pressure decreased
TMJ Decreased frequency of headache
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One anxiety client stated that biofeedback had made a great difference in his life
in the way that he reacted to situations and people. He was able to think before he got
upset and most of the time he decided it was not worth it. His wife also noticed a big
change in him. For one client with migraine, her physician indicated that her blood
pressure had decreased to a point of there being a possibility of eliminating medication
for it.
Increased awareness of primary presenting problem and/or other areas.
One hundred and twenty-one clients (55.5%) out of 218 clients who had
statements recorded by their therapists reported increasing awareness in one or more
areas. Figure 3.3 summaries the number of clients who reported increased awareness
of primary presenting problem and/or other areas based on primary presenting
problem. Two out of 2 clients (100%) with Raynaud’s as their primary presenting
problem reported increased awareness of physiological responses. Seventy-five percent
of clients with performance anxiety as primary presenting problem reported increased
awareness of different stressors and their responses to a stressful situation.
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Figure 3.3. Number of clients who reported increased awareness based on primary
presenting problem.
24
45
511
2418 15
4 2 4
34
8 10 914
29
3 4
139 8
3 2 2
16
5 58
05
101520253035404550
Anx
iety
Chro
nic
Pai
nFi
brom
yalg
iaG
astro
inte
stin
al P
robl
emTe
nsio
n H
eada
che
Hype
rtens
ion
Mig
rain
e He
adac
heP
erfo
rman
ce A
nxie
tyRa
yanu
d's
Sle
ep P
robl
em
Stre
ssTe
st A
nxie
ty
TMJ
Oth
ers
Primary Presenting Problem
Num
ber o
f Clie
nts
Clients had self-reportedinformationClients reported increasedawareness
Following are examples of reported increased awareness regarding the primary
presenting problem and/or other areas.
1. Increased awareness of physiological responses such as breathing, muscle
tension, temperature, sweat, and heart rate in the sessions;
2. Increased awareness and sensitivity of physiological responses (i.e.,
temperature, muscle tension, sweat, heart rate, breathing) before, while, and
after a stressor presented;
3. Increased awareness of different stressors (i.e., work, school, relationship
problem, caffeine, nicotine, traffic, noises, . . . etc.) in life and how these
stressors impact them;
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4. Increased awareness of how they respond to stressful situations; and
5. Increased awareness of the mind-body connection (i.e., how their thinking affect
physiological responses).
Negative experiences reported by clients.
Seven clients whose statements (3.2%) were recorded by therapists reported
negative experiences related to biofeedback therapy. Following is a list of recorded
negative thoughts or feelings that clients had as a result of biofeedback therapy:
1. having difficulty letting go and being afraid of what might come up and the
emotions stuck in her neck, chest, and stomach, and feeling like drowning when
breathing deeply and wanting to fight relaxation because it was so different,
2. having a need to do something instead of just relaxing,
3. feeling tired after relaxation,
4. unpleasant images came up during relaxed state,
5. increased frequency of headache,
6. perceived audio feedback as a punishment, and
7. having irrational thought such as “I am fine as long as I am having success. As
soon as I cannot figure one out, it makes me a failure.”
Two clients reported having both positive and negative experiences from the
treatment. One client reported feeling less stress but unable to relax without feeling
guilty for not working on something. Another reported being able to relax longer and
feeling much calmer but feeling guilty when she was too relaxed and she was afraid of
losing control.
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Results of Quantitative Analysis of Physiological Measures
For all clients that were treated in the BRTL since 1992 to 2002, 321 clients
completed four or more treatment sessions and 88 clients had three or less treatment
sessions. The following findings present the simple quantitative analysis such as
percentage and frequency for both groups. However, only clients with 4 or more
treatment sessions were compared using a one-sample t-test and factor analysis.
Clients with 3 or less treatment sessions
From 1992 to 2002, 88 clients completed 3 or less treatment sessions. Three or
less treatment sessions is considered to be too few sessions to positively impact
therapeutic progress in biofeedback therapy. For these 88 clients, 78.4% were female
and 22.6% were male. Thirty-six clients had only one treatment session. Thirty-two
clients had 2 treatment sessions, and 20 clients had three treatment sessions. Tables
2.1 and 2.2 show the frequency and percent of clients treated in the BRTL based on
primary presenting problem and year for clients with 3 or less treatment sessions.
The top three primary presenting problems in this group were chronic pain,
anxiety, and stress. Symptoms that included as gastrointestinal problems were irritable
bowel syndrome and colitis. Symptoms that included in others category included
concentration problem, blepharospasm, Bell’s Palsy, and ADHD.
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Table 2.1. Frequency and percent of clients with 3 or less treatment sessions based on
primary presenting problem.
Presenting Problem Frequency Percent Anxiety 13 14.8 Chronic Pain 20 22.8 Fibromyalgia 3 3.4 Gastrointestinal Problem 2 2.3 Migraine Headache 2 2.3 Hypertension 1 1.1 Performance Anxiety 3 3.4 Raynaud’s 1 1.1 Sleep Problem 6 6.8 Stress 15 17.1 Tension Headache 9 10.2 Test Anxiety 6 6.8 TMJ 3 3.4 Others 4 4.5 Total 88 100
Table 2.2. Frequency and percent of clients with 3 or less treatment sessions based on
year.
Year Frequency Percent 1992 2 2.3 1993 1 1.1 1994 14 15.9 1995 11 12.5 1996 11 12.5 1997 10 11.4 1998 6 6.8 1999 14 15.9 2000 14 15.9 2001 3 3.4 2002 2 2.3 Total 88 100
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Clients with 4 or more treatment sessions
Three hundred and twenty-one clients completed 4 or more treatment sessions
from 1993 to 2002. Tables 3.1, 3.2, and 3.3 show the frequency and percent of clients
treated based on year, gender, and primary presenting problem. Years of 1995, 1996,
1998, and 1999 composed almost 55% of the 321 clients. The female to male client
ratio was about 3 to 1.
Table 3.1. Frequency and percent of clients with 4 or more treatment sessions based on
year.
Year Frequency Percent 1993 15 4.7 1994 15 4.7 1995 67 20.9 1996 58 18.1 1997 28 8.7 1998 42 13.1 1999 41 12.8 2000 31 9.7 2001 15 4.7 2002 9 2.8 Total 321 100.0
Table 3.2. Frequency and percent of clients with 4 or more treatment sessions based on
gender.
Gender Frequency Percent Female 243 75.7 Male 78 24.3 Total 321 100.0
Symptoms that were included as gastrointestinal problems were irritable bowel
syndrome, gastritis, stomach cramp/pain, ulcer, and spastic colon. Symptoms that were
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under the others category were nail biting, mood swing, smoking cessation, caffeine
addiction, attention deficiency disorder, asthma, vocal cords problem, blushing, and
eating disorder.
Four most common presenting problems the BRTL treated were chronic pain,
stress, anxiety, and tension headache.
Table 3.3. Frequency and percent of clients with 4 or more treatment sessions based on
primary presenting problem.
Primary Presenting Problem Frequency Percent Anxiety 36 11.2 Chronic Pain 67 20.9 Fibromyalgia 6 1.9 Gastrointestinal Problem 17 5.3 Hypertension 21 6.5 Migraine Headache 18 5.6 Performance Anxiety 9 2.8 Raynauld's 6 1.9 Sleep Problem 7 2.2 Stress 60 18.7 Tension Headache 35 10.9 Test Anxiety 11 3.4 TMJ 14 4.4 Others 14 4.4 Total 321 100.0
Figures 4.1 and 4.2 demonstrate the frequency and percent of clients treated in
the BRTL based on age and number of sessions. Most people received biofeedback
therapy in the BRTL was between 25 to 55 years old that made up to 78.5% of all 321
clients. About 69% of clients had 4 to 10 treatment sessions. Only 4.7% of clients had
more than 20 treatment sessions.
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Figure 4.1. Number of clients with 4 or more treatment sessions based on age.
4
41
101
7972
24
0
20
40
60
80
100
120
15-17 18-24 25-35 36-45 46-55 56-76
Age
Num
ber
of C
lient
s
Figure 4.2. Number of clients with 4 or more treatment sessions based on number of
sessions.
85
136
56
2915
0
20
40
60
80
100
120
140
160
4-5 6-10 11-15 16-20 20+
Number of Sessions
Num
ber o
f Clie
nts
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Results of one-sample t-test—temperature training.
This study adopted a longitudinal approach and an individual growth model
(Willett, 1994) for data analysis. The linear individual growth model is used as the basis
for the statistical analysis. Individual growth trajectory provided more information such
as individual growth and individual differences in growth when compared to measuring
individual change with observation at two time point (i.e. pre- and post- test) (Willett,
1989; Maxwell, 1998).
The researcher collected six temperature data points for clients who had
temperature training. These six temperature data points are beginning and ending
temperature of the first, middle, and last treatment session. Each client’s six
temperature data points were used to plot a slope that represented each client’s
personal growth trajectory for temperature training. Then, all temperature slopes were
combined to perform a one-sample t-test to determine its statistical significance. The
basic assumption for this model is that if there is no change occurred due to
temperature training; the t value will be zero. Effect sizes were computed by using
Pearson’s r (Rosenthal, 1991).
Findings of one sample t-test on temperature training are summarized in tables
4.1, 4.2, 4.3, 4.4, 4.5, 4.6, 4.7, 4.8, 4.9, and 4.10. Clients whose beginning
temperature was greater than 90 degrees Fahrenheit were excluded to avoid the ceiling
effect (see Appendix A for collection of fitted individual growth trajectories, Table A1
and A2). Total subject number is 104. Results show statistical significance in
temperature training as a whole group (Tables 4.1 & 4.2), t = 4.672, df = 103, p =
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.000 (two-tailed), with a small effect size (r2 = .21). When divided into subtypes based
on primary presenting problem (Tables 4.3 & 4.4), results indicate statistical
significance in chronic pain (t = 3.163, df = 17, p = .006 (2-tailed), r2 = .56), tension
headache (t = 2.723, df = 15, p = .016 (2 tailed), r2 = .46), and TMJ (t = 3.040, df =
6, p = .023 (2-tailed), r2 = 1.32). All three of these symptom categories have moderate
to large effect sizes.
Table 4.1. Mean, standard deviation, and standard error mean for 6 points temperature slope.
N Mean Std. Deviation Std. Error Mean slope 6 points
temp 104 .7598 1.65847 .16263
Table 4.2. One-sample t-test for 6 points temperature slope as a whole group.
Test Value = 0 T df Sig. (2-
tailed) Mean
Difference 95% Confidence Interval of the
Difference Lower Upper
slope 6 points temp
4.672 103 .000** .7598 .4372 1.0823
** p < .01
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Table 4.3. Mean, standard deviation, and standard error mean of 6 points temperature slope sorted by primary presenting problem. Primary Presenting Problem
N Mean Std. Deviation
Std. Error Mean
Anxiety 9 .7521 1.28075 .42692 Chronic pain 18 1.3637 1.82902 .43110 Fibromyalgia 1 .3257 . . Gastrointestinal Problem 7 1.1571 1.93744 .73228 Tension Headache 16 1.0996 1.61537 .40384 Hypertension 7 .8824 1.11242 .42045 Migraine Headache 5 -.4617 2.17901 .97448 Performance Anxiety 3 -.4648 1.23117 .71082 Raynaud’s 6 1.1362 2.90800 1.18719 Sleep Problem 3 .1743 2.60588 1.50451 Stress 14 .4008 1.28154 .34251 Test Anxiety 3 1.0114 .74286 .42889 TMJ 7 .5298 .46107 .17427 Others 5 -.0971 1.79730 .80378 a t cannot be computed because the sum of case weights is less than or equal 1.
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Table 4.4. One-sample t-test for 6 points temperature slope sorted by primary presenting problem.
Test Value = 0 Primary Presenting Problem
t df Sig. (2-
tailed) Mean
Difference 95% Confidence Interval of the
Difference Lower Upper
Anxiety slope 6 points temp
1.762 8 .116 .7521 -.2324 1.7365
Chronic Pain slope 6 points temp
3.163 17 .006** 1.3637 .4541 2.2732
Gastrointestinal Problem
slope 6 points temp
1.580 6 .165 1.1571 -.6347 2.9490
Tension Headache
slope 6 points temp
2.723 15 .016** 1.0996 .2389 1.9604
Hypertension slope 6 points temp
2.099 6 .081 .8824 -.1464 1.9113
Migraine Headache
slope 6 points temp
-.474 4 .660 -.4617 -3.1673 2.2439
Performance Anxiety
slope 6 points temp
-.654 2 .580 -.4648 -3.5232 2.5936
Raynaud's slope 6 points temp
.957 5 .382 1.1362 -1.9156 4.1880
Sleep Problem slope 6 points temp
.116 2 .918 .1743 -6.2991 6.6477
Stress slope 6 points temp
1.170 13 .263 .4008 -.3391 1.1408
Test Anxiety slope 6 points temp
2.358 2 .142 1.0114 -.8339 2.8568
TMJ slope 6 points temp
3.040 6 .023** .5298 .1034 .9562
Others slope 6 points temp
-.121 4 .910 -.0971 -2.3288 2.1345
a No statistics are computed for one or more split files * p < .05 ** p < .01
Tables 4.5 and 4.6 illustrate findings of a one-sample t-test based on gender
subtypes. Both male clients and female clients show a statistically significant increase in
their finger temperature (male, t = 2.408, df = 18, p = .027 (2-tailed), and female, t =
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4.035, df = 84, p = .000 (2-tailed)). Females have a small effect size (r2 = .19) and
males have a moderate effect size (r2 = .30).
Table 4.5. Mean, standard deviation, and standard error mean of 6 points temperature slope sorted by gender. GENDER N Mean Std. Deviation Std. Error Mean Female slope 6 points
temp 85 .7432 1.69787 .18416
Male slope 6 points temp
19 .8341 1.50965 .34634
Table 4.6. One-sample t-test for 6 points temperature slope sorted by gender.
Test Value = 0 GENDER
t df Sig. (2-
tailed) Mean
Difference 95% Confidence Interval of the
Difference Lower Upper
Female slope 6 points temp
4.035 84 .000** .7432 .3769 1.1094
Male slope 6 points temp
2.408 18 .027** .8341 .1065 1.5618
* p < .05 ** p < .01 When divided into age subtypes (Table 4.7 & 4.8), for the age groups of 18-24
years old, 25-35 years old, 46-55 years old, and 56-76 years old, findings shows
statistical significance at p < .05. Results of clients based on age subtypes are: age
range 18-24, t = 2.485, df = 16, p = .024 (2-tailed); age range 25-35, t = 2.325, df =
31, p = .027 (2-tailed); age range 46-55, t = 2.231, df = 20, p = .037 (2-tailed); and
age range 56-76, t = 7.305, df = 2, p = .018 (2-tailed). Age range18-24 group has a
moderate effect size (r2 = .36) and age range 56-76 group has a large effect size (r2 =
17.7). The other two age groups have small effect sizes: 25-35 (r2 = .17) and 46-55 (r2
= .23).
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Table 4.7. Mean, standard deviation, and standard error mean of 6 points temperature slope sorted by age. Age N Mean Std. Deviation Std. Error Mean 15-17 slope 6 points
temp 3 1.0448 .64709 .37360
18-24 slope 6 points temp
17 1.2274 2.03641 .49390
25-35 slope 6 points temp
32 .7121 1.73251 .30627
36-45 slope 6 points temp
28 .3404 1.21672 .22994
46-55 slope 6 points temp
21 .9309 1.91240 .41732
56-76 slope 6 points temp
3 1.0495 .24884 .14367
Table 4.8. One-sample t-test for 6 points temperature slope sorted by age.
Test Value = 0 Age
t df Sig. (2-
tailed) Mean
Difference 95% Confidence Interval of the
Difference Lower Upper
15-17 slope 6 points temp
2.796 2 .108 1.0448 -.5627 2.6522
18-24 slope 6 points temp
2.485 16 .024** 1.2274 .1804 2.2744
25-35 slope 6 points temp
2.325 31 .027** .7121 .0875 1.3368
36-45 slope 6 points temp
1.480 27 .150 .3404 -.1314 .8122
46-55 slope 6 points temp
2.231 20 .037** .9309 .0604 1.8014
55-76 slope 6 points temp
7.305 2 .018** 1.0495 .4314 1.6677
* p < .05 ** p < .01
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Tables 4.9 and 4.10 show the results based on number of sessions that clients
had. Clients with treatment sessions between 6 to 10 sessions and 11 to 15 sessions
show statistically significant increases in finger temperature: 6 to 10 sessions, t =
2.745, df = 35, p = .009 (2-tailed), and 11 to 15 sessions, t = 4.670, df = 24, p = .000
(2-tailed). Clients with 6 to 10 treatment sessions have a small effect size (r2 = .21) and
clients with11 to 15 sessions have a large effect size (r2 = .87).
Table 4.9. Mean, standard deviation, and standard error mean of 6 points temperature slope sorted by number of sessions. Number of Sessions
N Mean Std. Deviation
Std. Error Mean
4-5 slope 6 points temp
30 .4810 1.66442 .30388
6-10 slope 6 points temp
36 .8398 1.82940 .30490
11-15 slope 6 points temp
25 1.2278 1.31449 .26290
16-20 slope 6 points temp
10 .2063 1.40533 .44441
20+ slope 6 points temp
3 .5333 2.76874 1.59853
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Table 4. 10. One-sample t-test for 6 points temperature slope sorted by number of session.
Test Value = 0 Number of
Sessions
t df Sig. (2-tailed)
Mean Difference
95% Confidence Interval of the
Difference Lower Upper
4-5 slope 6 points temp
1.583 29 .124 .4810 -.1406 1.1025
6-10 slope 6 points temp
2.754 35 .009** .8398 .2208 1.4587
11-15 slope 6 points temp
4.670 24 .000** 1.2278 .6852 1.7704
16-20 slope 6 points temp
.464 9 .654 .2063 -.7990 1.2116
20+ slope 6 points temp
.334 2 .770 .5333 -6.3446 7.4113
** p < .01
Muscle tension training
The researcher collected six electromyography data points for clients who had
muscle tension training. These six electromyography data points are beginning and
ending muscle tension of the first, middle, and last treatment session. Each client’s six
muscle tension data points were used to plot a slope that represented each client’s
personal growth trajectory for muscle tension training. Then, all muscle tension slopes
were combined to perform a one-sample t-test to determine its statistical significance.
The basic assumption for this model is that if there is no change occurred due to
muscle tension training, the t value will be zero. Effect sizes were computed by using
Pearson’s r.
Findings of one-sample t-test for muscle tension training are summarized in
tables 5.1, 5.2, 5.3, 5.4, 5.5, 5.6, 5.7, 5.8, 5.9, and 5.10. Clients whose beginning
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muscle tension were below or equal to 2.5 microvolt were excluded to avoid the floor
effect (see Appendix A for collection of fitted individual growth trajectories, Tables A3
and A4). Overall subject number is 163. Tables 5.1 and 5.2 show a statistically
significant change in muscle tension training as a whole group, t = -8.489, df = 162, p
= .000 (2-tailed), with a moderate effect size (r2 = .44).
Table 5.1. Mean, standard deviation, and standard error mean for 6 points EMG slope.
N Mean Std. Deviation Std. Error Mean
slope 6 points emg
163 -.2719 .40897 .03203
Table 5.2. One-sample t-test for 6 points EMG slope as a whole group. Test Value = 0 t df Sig. (2-
tailed) Mean
Difference95% Confidence Interval
of the Difference Lower Upper
slope 6 points emg
-8.489 162 .000** -.2719 -.3352 -.2087
* p < .05 ** p < .01
When divided into subtypes based on clients’ primary presenting problem (Table 5.3
& 5.4), results indicate statistical significance in the following symptoms:
1. chronic pain, t = -3.947, df = 27, p = .001 (2-tailed), with a large effect size (r2
= .56),
2. tension headache, t = -2.469, df = 21, p = .022 (2 tailed), with a moderate
effect size (r2 = .28),
3. hypertension, t = -2.953, df = 11, p = .013 (2-tailed), with a large effect size (r2
= .73),
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4. migraine headache, t = -3.335, df = 10, p = .008 (2-tailed), with a large effect
size (r2 = 1.01),
5. stress, t = -4.705, df = 30, p = .000 (2-tailed), with a large effect size (r2 = .71),
and
6. TMJ, t = -2.878, df = 6, p = .028 (2-tailed), with a large effect size (r2 = 1.18).
Table 5.3. Mean, standard deviation, and standard error mean of 6 points EMG slope sorted by primary presenting problem. Primary Presenting Problem
N Mean Std. Deviation
Std. Error Mean
Anxiety slope 6 points emg 18 -.2275 .47337 .11157 Chronic Pain slope 6 points emg 28 -.2094 .28071 .05305 Fibromyalgia slope 6 points emg 4 -.1979 .27296 .13648 Gastrointestinal Problem
slope 6 points emg 8 -.2025 .36988 .13077
Tension Headache slope 6 points emg 22 -.2960 .56219 .11986 Hypertension slope 6 points emg 12 -.2345 .27509 .07941 Migraine Headache slope 6 points emg 11 -.3101 .30841 .09299 Performance Anxiety slope 6 points emg 5 -.2463 .32063 .14339 Raynaud's slope 6 points emg 2 -.0614 .22425 .15857 Sleep Problem slope 6 points emg 4 -.5293 1.00629 .50315 Stress slope 6 points emg 31 -.3339 .39515 .07097 Test Anxiety slope 6 points emg 5 -.4286 .52807 .23616 TMJ slope 6 points emg 7 -.3110 .28587 .10805 Others slope 6 points emg 6 -.1795 .41351 .16882
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Table 5.4. One-sample t-test for 6 points EMG slope sorted by primary presenting problem.
Test Value = 0 Primary Presenting Problem
t df Sig. (2-tailed)
Mean Differenc
e
95% Confidence Interval of the
Difference Lower Upper
Anxiety slope 6 points emg
-2.039 17 .057 -.2275 -.4629 .0079
Chronic Pain slope 6 points emg
-3.947 27 .001** -.2094 -.3182 -.1005
Fibromyalgia slope 6 points emg
-1.450 3 .243 -.1979 -.6322 .2365
Gastrointestinal Problem
slope 6 points emg
-1.549 7 .165 -.2025 -.5117 .1067
Tension Headache
slope 6 points emg
-2.469 21 .022* -.2960 -.5452 -.0467
Hypertension slope 6 points emg
-2.953 11 .013* -.2345 -.4093 -.0597
Migraine Headache
slope 6 points emg
-3.335 10 .008** -.3101 -.5173 -.1029
Performance Anxiety
slope 6 points emg
-1.718 4 .161 -.2463 -.6444 .1518
Raynaud's slope 6 points emg
-.387 1 .765 -.0614 -2.0763 1.9534
Sleep Problem slope 6 points emg
-1.052 3 .370 -.5293 -2.1305 1.0719
Stress slope 6 points emg
-4.705 30 .000** -.3339 -.4789 -.1890
Test Anxiety slope 6 points emg
-1.815 4 .144 -.4286 -1.0843 .2271
TMJ slope 6 points emg
-2.878 6 .028* -.3110 -.5754 -.0466
Others slope 6 points emg
-1.063 5 .336 -.1795 -.6135 .2544
* p < .05 ** p < .01
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Tables 5.5 and 5.6 indicate statistical significance in muscle tension training with
both genders: female, t = -7.799, df = 134, p = .000, with moderate effect size (r2 =
.45) and male, t = -3.385, df = 27, p = .002, with a moderate effect size (r2 = .41).
Table 5.5. Mean, standard deviation, and standard error mean of 6 points EMG slope sorted by gender. GENDER N Mean Std.
Deviation Std. Error Mean
Female slope 6 points emg 135 -.2647 .39431 .03394 Male slope 6 points emg 28 -.3070 .47994 .09070 Table 5.6. One-sample t-test for 6 points EMG slope sorted by gender.
Test Value = 0 GENDER
t df Sig. (2-
tailed) Mean
Difference
95% Confidence Interval of the
Difference Lower Upper
Female slope 6 points emg
-7.799 134 .000** -.2647 -.3318 -.1975
Male slope 6 points emg
-3.385 27 .002** -.3070 -.4931 -.1209
* p < .05 ** p < .01
When divided into age subtypes, findings (Tables 5.7 & 5.8) indicate all age group
are statistically significant except age range 15-17 years old. Results of clients based on
age subtypes are:
1. age range 18-24, t = -3.633, df = 17, p = .002 (2-tailed), with a large effect size
(r2 = .73),
2. age range 25-35, t = -3.565, df = 52, p = .001 (2-tailed), with a small effect size
(r2 = .24),
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3. age range 36-45, t = -3.741, df = 41, p = .001 (2-tailed), with a moderate effect
size (r2 = .33),
4. age range 46-55, t = -4.623, df = 29, p = .000 (2-tailed), with a large effect size
(r2 = .71), and
5. age range 56-76, t = -4.369, df = 17, p = .000 (2-tailed), with a large effect size
(r2 = 1.06).
Table 5.7. Mean, standard deviation, and standard error mean of 6 points EMG slope sorted by age. Age N Mean Std. Deviation Std. Error Mean 15-17 slope 6 points emg 2 -.3943 .45255 .32000 18-24 slope 6 points emg 18 -.4421 .51622 .12167 25-35 slope 6 points emg 53 -.2043 .41711 .05730 36-45 slope 6 points emg 42 -.2452 .42472 .06554 46-55 slope 6 points emg 30 -.2666 .31580 .05766 56-76 slope 6 points emg 18 -.3589 .34847 .08214 Table 5.8. One-sample t-test for 6 points EMG slope sorted by age.
Test Value = 0 Age
t df Sig. (2-
tailed) Mean
Difference 95% Confidence Interval of the
Difference Lower Upper
15-17 slope 6 points emg -1.232 1 .434 -.3943 -4.4603 3.6717 18-24 slope 6 points emg -3.633 17 .002** -.4421 -.6988 -.1854 25-35 slope 6 points emg -3.565 52 .001** -.2043 -.3192 -.0893 36-45 slope 6 points emg -3.741 41 .001** -.2452 -.3775 -.1128 46-55 slope 6 points emg -4.623 29 .000** -.2666 -.3845 -.1486 56-76 slope 6 points emg -4.369 17 .000** -.3589 -.5322 -.1856 * p < .05 ** p < .01
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Tables 5.9 and 5.10 indicate a statistically significant change in muscle tension
training no matter how many treatment session clients had at p < .01. The following
are the results of the number of session subtypes:
1. 4 to 5 sessions, t = -2.905, df = 39, p = .006 (2-tailed), with a small effect size
(r2 = .21),
2. 6 to 10 sessions, t = -5.683, df = 72, p = .000 (2-tailed), with a moderate effect
size (r2 = .44),
3. 11 to 15 sessions, t = -5.114, df = 24, p = .000 (2-tailed), with a large effect
size (r2 = 1.05),
4. 16 to 20 sessions, t = -3.605, df = 13, p = .003 (2-tailed), with a large effects
size (r2 = .93), and
5. 20+ sessions, t = -5.612, df = 10, p = .000, with a large effect size (r2 = 2.86).
Table 5.9. Mean, standard deviation, and standard error mean of 6 points EMG slope sorted by number of sessions. Number of Sessions
N Mean Std. Deviation
Std. Error Mean
4-5 slope 6 points emg
40 -.2287 .49795 .07873
6-10 slope 6 points emg
73 -.2995 .45018 .05269
10-15 slope 6 points emg
25 -.2425 .23710 .04742
16-20 slope 6 points emg
14 -.2369 .24595 .06573
20+ slope 6 points emg
11 -.3579 .21153 .06378
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Table 5.10. One-sample t-test for 6 points EMG slope sorted by number of sessions.
Test Value = 0 Number of Sessions
t df Sig. (2-
tailed) Mean
Difference 95% Confidence Interval of the
Difference Lower Upper
4-5 slope 6 points emg
-2.905 39 .006** -.2287 -.3880 -.0695
6-10 slope 6 points emg
-5.683 72 .000** -.2995 -.4045 -.1944
11-15 slope 6 points emg
-5.114 24 .000** -.2425 -.3404 -.1446
16-20 slope 6 points emg
-3.605 13 .003** -.2369 -.3789 -.0949
20+ slope 6 points emg
-5.612 10 .000** -.3579 -.5000 -.2158
* p < .05 ** p < .01
Results of factor analysis – temperature training.
The researcher collected 6 temperature data points for clients who had
temperature training and 6 muscle tension data points for clients who had muscle
tension training. Six temperature data points are beginning and ending temperature of
the first, middle, and last treatment session and six muscle tension data points are
beginning and ending muscle tension of first, middle, and last treatment session. Each
client’s six temperature data points were used to plot an individual temperature learning
curve that represents how a client learned or did not learn to increase finger
temperature in temperature training sessions (see Appendix C for examples of
individual temperature learning curve). Each client’s six muscle tension data points were
used to plot an individual EMG learning curve that represent how a client learned or did
not learn to reduce muscle tension in muscle tension training sessions (see Appendix C
for examples of individual EMG learning curve). Factor analysis is a mathematical tool
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and is used to classify the regularity in the data into its separate patterns (Rummel,
1967).
Figure 5.1 shows the three basic biofeedback learning curves for training
temperature increases that are composed of 84% of 104 clients (see Appendix B for
detailed print-out of factor analysis for temperature training, Table B1, B2, and B3). The
following illustrate these three basic biofeedback learning curves for training
temperature increases presented by the data:
1. steady state and trainable (low variability), composed of 40.2% of 104 clients,
shown in solid line,
2. phasic state and low trainable (high variability), composed of 27.7% of all 104
clients, shown in large dotted line, and
3. phasic state and trainable (high variability), composed of 16.2% of all 104
clients, shown in small dotted line.
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Figure 5.1. Three basic biofeedback learning curves for training temperature increases.
Standard scores
PERIOD
654321
1.5
1.0
.5
0.0
-.5
-1.0
-1.5
-2.0
REGR factor score
1 for analysis 1
REGR factor score
2 for analysis 1
REGR factor score
3 for analysis 1
Results of factor analysis – muscle tension training.
Figure 5.2 shows the three basic biofeedback learning curves for training muscle
tension reduction that are composed of 82.2% of 163 clients (see Appendix B for
detailed print-out of factor analysis for muscle tension training, Table B4, B5, and B6).
The following illustrate three basic biofeedback learning curves for training muscle
tension reduction presented by the data:
1. steady state and trainable (low variability), composed of 38.4% of 163 clients,
shown in solid line,
2. phasic state and low trainable (high variability), composed of 24.1% of all 163
clients, shown in large dotted line, and
4. phasic state and trainable (high variability), composed of 19.6% of all 163
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clients, shown in small dotted line.
Figure 5.2. Three basic biofeedback learning curves for training muscle tension reduction. Standard Scores
PERIOD
654321
2.0
1.5
1.0
.5
0.0
-.5
-1.0
-1.5
-2.0
REGR factor score
1 for analysis 1
REGR factor score
2 for analysis 1
REGR factor score
3 for analysis 1
Discussion
When reviewing client files, there were a large number of clients that did not
have sufficient information in their files such as lacking the pre- and/or post- Stress
Signal Checklist, no information on clients’ ethnicity, no session notes regarding clients’
self-reported progress and therapist’s observations. Only 25.4% of clients had
completed information on both pre- and post- Stress Signal Checklist. Two main
reasons for lacking this information could be: (a) clients decided to terminate treatment
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and did not come in for the termination session, and (2) therapists failed to give the
Stress Signal Checklist to clients in the first or last session.
There were a small number of clients having information regarding reasons for
early termination. Followings are a list of reasons:
1. Clients had a scheduling problem;
2. It was the end of the semester;
3. Therapists finished their training;
4. Clients can not get a release from their physician for biofeedback treatment;
5. Clients did not have time to commit themselves to the training;
6. Clients (pregnant women) had their baby early or lost their baby;
7. Clients participated in other therapy; and
8. Clients moved to another state.
There were 180 client files (44%) out of 409 client files that did not have
information written down on their session notes except clients’ physiological measures
(i.e. temperature and muscle tension reading). When considering the client files that did
have client status and progress information written in the therapist session notes a
majority of these clients did report good progress. Approximately 80% of clients who
had self-reported information in their files reported some types of progress such as
primary presenting problem decreased, other symptom decreased when clients had
multiple symptomology, and/or other types of progress when excluding the 180 client
files that did not have clients’ self-reported information and/or therapists’ observations.
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Therefore, it is difficult to determine efficacy of biofeedback therapy when there is
incomplete information.
Possible reasons for the lack of clients’ self-reported progress and therapist’s
observations on session notes could be:
1. Clients did not experience any progress;
2. Clients did experience some progress such as symptom decrease, increased
awareness, or other benefits but did not share these progress with therapists in
sessions;
3. Clients reported progress but therapists did not record on session notes;
4. Therapists failed to ask about clients’ progress or did not know what and how to
ask due to inexperience in biofeedback therapy; and
5. Therapists did not keep a proper case note.
This finding indicates the importance of keeping proper therapist’s session notes
so efficacy of treatment can be accurately measured through therapists’ session notes.
Implications for the BRTL are to provide greater structure and instruction regarding
keeping session notes for biofeedback students and to provide closer supervision to
insure completion of session notes for the purpose of evaluating treatment efficacy and
providing better research data in the future.
From 1992 to 2002, the BRTL provided biofeedback therapy for 409 clients.
There are some years such as 1995, 1996, 1998, 1999, and 2000 that had more clients
than the other years. Reasons for having more clients in these years are: (a) during
these years, there were more students taking biofeedback classes, and (b) there were
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master and/or doctoral students who specialized in biofeedback therapy and did their
internship in the BRTL. The year 2002 had a low frequency of biofeedback therapy
because Dr. Chandler, the Director of the BRTL, was on a research sabbatical. The
following year, 2003 data not included in this study, the biofeedback therapy frequency
rose to another high level due to large enrollment in the biofeedback courses (i.e. 22
students enrolled in Introduction of Biofeedback, 18 students enrolled in Biofeedback
Practicum, and 12 students enrolled in Advanced Practicum in Biofeedback).
The BRTL has provided biofeedback therapy for a variety of symptoms. When
compared with what the literature suggests biofeedback therapy is effective in treating,
the BRTL has provided service for clients with migraine headache, tension headache,
hypertension, irritable bowel syndrome, chronic pain, TMJ, asthma, and anxiety but did
not treat clients with diabetes, incontinence, pediatric constipation, hand dsytonia, and
phantom limb pain as primary presenting problems. Since the BRTL is a university-
based clinic, the BRTL also treated clients (mainly university students) with test anxiety
and performance anxiety.
This study shows that through temperature biofeedback training and EMG
biofeedback training clients were able to increase finger temperature and to decrease
forehead muscle tension. In temperature training, as a whole group, results indicate a
statistically significant increase in finger temperature. However, when divided into
subtypes based on primary presenting problem, only three primary presenting
problems, chronic pain, tension headache, and TMJ, show statistically significant
changes. Both chronic pain and TMJ have large clinical effect sizes and tension
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headache have a moderate clinical effect size. The fact that the other primary
presenting problems do not have statistically significant results could possibly be due to
small sample sizes. For example, performance anxiety, test anxiety, and sleep problem
only have 3 subjects each; migraine headache has 5 subjects and Raynauld’s has 6
subjects. In conclusion, in this type of treatment environment, temperature training
seems very helpful to clients with chronic pain and TMJ and moderately helpful for
tension headaches.
In muscle tension training, findings indicate statistically significant decreases in
muscle tension as a whole group. When divided into subtypes based on primary
presenting problem, six primary presenting problems, chronic pain, tension headache,
hypertension, migraine headache, stress, and TMJ, show statistically significant results.
Five of these presenting problems except tension headache showed large clinical effect
sizes. Small sample sizes could possibly contribute to the no statistically significant
results for other presenting problems. Most of them have less than 10 subjects except
anxiety, which has 18 subjects. In conclusion, in this type of treatment environment,
findings suggest that clients with chronic pain, tension headache, hypertension,
migraine headache, stress, and TMJ are able to benefit from muscle tension training.
From 1992 to 2002, the BRTL provided biofeedback therapy for 409 clients that
included 97 male clients and 312 female clients. The male and female client ratio is
approximately 1 to 3. This finding indicates that from 1992 to 2002 the majority of
clientele of BRTL was females (78.5%). For 409 clients, 270 clients had information
regarding their ethnicity and 243 out of these 270 clients were Caucasian (90%). This
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finding shows that there was not a lot of ethnic minority such as African American,
Asian, Hispanic, and Native American sought help from the BRTL from 1992 to 2002.
Therefore, these results indicate there is a need for the BRTL to reach males and ethnic
minority as potential clients in the future.
Findings indicate that both male and female clients have statistically significant
changes in temperature training and muscle tension training. In temperature training,
male clients have a moderate clinical effect size and female clients only have a small
clinical effect size. In muscle tension training, both genders have moderate effect sizes.
Results suggest that both genders do equally well on muscle tension training; however,
male clients might learn better in temperature training than female clients.
Results on age group subtypes demonstrate that 4 out of 6 age groups are
statistically significant in temperature training and 5 out of 6 age groups are statistically
significant in muscle tension training. Results on age group demonstrate that group 15
to 17 years are not statistically significant on both training modalities which might be
due to the small sample sizes (3 subjects for temperature training and 2 subjects for
muscle tension training). Clients with ages between 18 to 24 years old, traditional
college students’ age, have a moderate clinical effect size in temperature training and a
large clinical effect size in muscle tension training. Results on clients’ ages between 25
to 45 years old have small clinical effect sizes on both temperature and muscle tension
training. A possible explanation could be that clients in this age group tended to juggle
work, family, and possible school responsibilities that added an extra stress in their lives
and at the same time were not compliant with treatment. Results of clients with ages
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between 46 to 55 years old indicated a small clinical effect size on temperature training
and a large clinical effect size on muscle tension training. Clients with ages between 56
to 76 years old are the only group that has large clinical effect sizes on both
temperature and muscle tension training. Possible explanations could be that older
clients were probably more mature and settled and were more concerned about their
physical health; therefore, they put more efforts in the training which can contribute to
the success in the sessions.
The number of treatment sessions seemed to make a difference regarding
treatment efficacy on temperature training. Clients with 6 to 15 sessions show
statistically significant increases in their temperature. However, clients with 11 to 15
treatment sessions show a large clinical effect size and clients with 6 to 10 treatment
sessions only have a small clinical effect size. Results suggest clients need to have at
least 6 sessions to learn to increase their finger temperature but they need 11 to 15
sessions to really get the benefit from training. According to this study, more then 15
treatment sessions do not help with treatment efficacy. However, no statistically
significant results on more than 15 sessions could also be due to small sample sizes.
Number of sessions did not seem to impact much on muscle tension training.
Results indicate statistically significant reductions in clients’ muscle tension no matter
how many sessions they had. However, only clients with more than 10 sessions show a
large clinical effect size. Therefore, findings suggest clients are able to reduce their
forehead muscle tension after 4 treatment sessions but they need to at least 11
treatment sessions to obtain a great clinical benefit from the training.
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Three basic biofeedback learning curves are identified in this study: steady state
and trainable (low variability), phasic state and low trainable (high variability), and
phasic state and trainable (high variability). Both temperature training and muscle
tension training are categorized into these three patterns. The first pattern of
biofeedback learning curve, steady state and trainable (low variability), shows that
clients are able to learn to increase temperature and/or decrease muscle tension by the
end of training. In addition, clients’ learning remained at a fairly stable level with little
to no fluctuations. The second pattern of biofeedback learning curve, phasic state and
low trainable (high variability), demonstrates clients are not able to learn to increase
temperature and/or decrease muscle tension by the end of treatment, although clients
seem to be able to increase temperature and/or decrease muscle tension during
sessions. There is no indication that learning of these skills occurred by the end of
training. The last pattern of biofeedback learning curve, phasic state and trainable (high
variability), shows that clients are able to learn to increase temperature and reduce
muscle tension by the end of their training although temperature and/or muscle tension
fluctuated a lot during the period of treatment.
This study identifies three basic patterns of biofeedback therapy learning curve.
Future research might focus on what factors contribute to certain learning curves.
Possible factors are personality, age, locus of control, situational stressors, severity of
symptoms, practice effect (homework relaxation exercise), treatment atmosphere,
and/or therapeutic relationship. Furthermore, when the connection between learning
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curve and contributing factors is made, this information might be used to predict
treatment outcomes for certain types of client.
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APPENDIX A
Collection of Fitted Individual Growth Trajectories
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Table A1. Collection of fitted individual growth trajectory for clients with beginning temperature < = 90 degree Fahrenheit (x = period, y = temperature).
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
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84
Table A2. Collection of fitted individual growth trajectory for clients with beginning temperature > 90 degree Fahrenheit (x = period, y = temperature)
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
1 2 3 4 5 6
x
7075
8085
9095
y
![Page 94: Clinical and educational efficacy of a university-based .../67531/metadc... · biofeedback therapy clinic. Doctor of Philosophy (Counseling), December 2003, 125 pp., 26 tables, 13](https://reader033.vdocuments.mx/reader033/viewer/2022060316/5f0c038c7e708231d4335433/html5/thumbnails/94.jpg)
85
Table A3. Collection of fitted individual growth trajectory for clients with beginning EMG > 2.5 microvolt (x = period, y = microvolt)
x
y
1 2 3 4 5 6
02
46
8
x
y
1 2 3 4 5 6
02
46
8
x
y
1 2 3 4 5 6
02
46
8
x
y
1 2 3 4 5 6
02
46
8
x
y
1 2 3 4 5 6
02
46
8
x
y
1 2 3 4 5 6
02
46
8
x
y
1 2 3 4 5 6
02
46
8
x
y
1 2 3 4 5 6
02
46
8
x
y
1 2 3 4 5 6
02
46
8
x
y
1 2 3 4 5 6
02
46
8
x
y
1 2 3 4 5 6
02
46
8
x
y
1 2 3 4 5 6
02
46
8
x
y
1 2 3 4 5 6
02
46
8
x
y
1 2 3 4 5 6
02
46
8
x
y
1 2 3 4 5 6
02
46
8
x
y
1 2 3 4 5 6
02
46
8
x
y
1 2 3 4 5 6
02
46
8
x
y
1 2 3 4 5 6
02
46
8
x
y
1 2 3 4 5 6
02
46
8
x
y
1 2 3 4 5 6
02
46
8
x
y
1 2 3 4 5 6
02
46
8
x
y
1 2 3 4 5 6
02
46
8
x
y
1 2 3 4 5 6
02
46
8
x
y
1 2 3 4 5 6
02
46
8
x
y
1 2 3 4 5 6
02
46
8
x
y
1 2 3 4 5 6
02
46
8
x
y
1 2 3 4 5 6
02
46
8
x
y
1 2 3 4 5 6
02
46
8
x
y
1 2 3 4 5 6
02
46
8
x
y
1 2 3 4 5 6
02
46
8
x
y
1 2 3 4 5 6
02
46
8
x
y
1 2 3 4 5 6
02
46
8
x
y
1 2 3 4 5 6
02
46
8
x
y
1 2 3 4 5 6
02
46
8
x
y
1 2 3 4 5 6
02
46
8
x
y
1 2 3 4 5 6
02
46
8
x
y
1 2 3 4 5 6
02
46
8
x
y
1 2 3 4 5 6
02
46
8
x
y
1 2 3 4 5 6
02
46
8
x
y
1 2 3 4 5 6
02
46
8
x
y
1 2 3 4 5 6
02
46
8
x
y
1 2 3 4 5 6
02
46
8
x
y
1 2 3 4 5 6
02
46
8
x
y
1 2 3 4 5 6
02
46
8
x
y
1 2 3 4 5 6
02
46
8
x
y
1 2 3 4 5 6
02
46
8
x
y
1 2 3 4 5 6
02
46
8
x
y
1 2 3 4 5 6
02
46
8
x
y
1 2 3 4 5 6
02
46
8
x
y
1 2 3 4 5 6
02
46
8
x
y
1 2 3 4 5 6
02
46
8
x
y
1 2 3 4 5 6
02
46
8
x
y
1 2 3 4 5 6
02
46
8
x
y
1 2 3 4 5 6
02
46
8
x
y
1 2 3 4 5 6
02
46
8
x
y
1 2 3 4 5 6
02
46
8
x
y
1 2 3 4 5 6
02
46
8
x
y
1 2 3 4 5 6
02
46
8
x
y
1 2 3 4 5 6
02
46
8
x
y
1 2 3 4 5 6
02
46
8
x
y
1 2 3 4 5 6
02
46
8
x
y
1 2 3 4 5 6
02
46
8
x
y
1 2 3 4 5 6
02
46
8
x
y
1 2 3 4 5 6
02
46
8
x
y
1 2 3 4 5 6
02
46
8
x
y
1 2 3 4 5 6
02
46
8
x
y
1 2 3 4 5 6
02
46
8
x
y
1 2 3 4 5 6
02
46
8
x
y
1 2 3 4 5 6
02
46
8
x
y
1 2 3 4 5 6
02
46
8
x
y
1 2 3 4 5 6
02
46
8
x
y
1 2 3 4 5 6
02
46
8
x
y
1 2 3 4 5 6
02
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8
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1 2 3 4 5 6
02
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1 2 3 4 5 6
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1 2 3 4 5 6
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1 2 3 4 5 6
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1 2 3 4 5 6
02
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1 2 3 4 5 6
02
46
8
x
y
1 2 3 4 5 6
02
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8
x
y
1 2 3 4 5 6
02
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8
x
y
1 2 3 4 5 6
02
46
8
x
y
1 2 3 4 5 6
02
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8
x
y
1 2 3 4 5 6
02
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8
x
y
1 2 3 4 5 6
02
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8
x
y
1 2 3 4 5 6
02
46
8
x
y
1 2 3 4 5 6
02
46
8
x
y
1 2 3 4 5 6
02
46
8
x
y
1 2 3 4 5 6
02
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8
x
y
1 2 3 4 5 6
02
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x
y
1 2 3 4 5 6
02
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x
y
1 2 3 4 5 6
02
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x
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1 2 3 4 5 6
02
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x
y
1 2 3 4 5 6
02
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1 2 3 4 5 6
02
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x
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1 2 3 4 5 6
02
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x
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1 2 3 4 5 6
02
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x
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1 2 3 4 5 6
02
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1 2 3 4 5 6
02
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x
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1 2 3 4 5 6
02
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x
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1 2 3 4 5 6
02
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x
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1 2 3 4 5 6
02
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x
y
1 2 3 4 5 6
02
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x
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1 2 3 4 5 6
02
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x
y
1 2 3 4 5 6
02
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x
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1 2 3 4 5 6
02
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x
y
1 2 3 4 5 6
02
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x
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1 2 3 4 5 6
02
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x
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1 2 3 4 5 6
02
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x
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1 2 3 4 5 6
02
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1 2 3 4 5 6
02
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1 2 3 4 5 6
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1 2 3 4 5 6
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1 2 3 4 5 6
02
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x
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1 2 3 4 5 6
02
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x
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1 2 3 4 5 6
02
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x
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1 2 3 4 5 6
02
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x
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1 2 3 4 5 6
02
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x
y
1 2 3 4 5 6
02
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x
y
1 2 3 4 5 6
02
46
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x
y
1 2 3 4 5 6
02
46
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x
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1 2 3 4 5 6
02
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x
y
1 2 3 4 5 6
02
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x
y
1 2 3 4 5 6
02
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x
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1 2 3 4 5 6
02
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x
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1 2 3 4 5 6
02
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x
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1 2 3 4 5 6
02
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x
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1 2 3 4 5 6
02
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1 2 3 4 5 6
02
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x
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1 2 3 4 5 6
02
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x
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1 2 3 4 5 6
02
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x
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1 2 3 4 5 6
02
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x
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1 2 3 4 5 6
02
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x
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1 2 3 4 5 6
02
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x
y
1 2 3 4 5 6
02
46
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x
y
1 2 3 4 5 6
02
46
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x
y
1 2 3 4 5 6
02
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x
y
1 2 3 4 5 6
02
46
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x
y
1 2 3 4 5 6
02
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x
y
1 2 3 4 5 6
02
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x
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1 2 3 4 5 6
02
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x
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1 2 3 4 5 6
02
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x
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1 2 3 4 5 6
02
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1 2 3 4 5 6
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1 2 3 4 5 6
02
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1 2 3 4 5 6
02
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1 2 3 4 5 6
02
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1 2 3 4 5 6
02
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x
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1 2 3 4 5 6
02
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1 2 3 4 5 6
02
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1 2 3 4 5 6
02
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1 2 3 4 5 6
02
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1 2 3 4 5 6
02
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1 2 3 4 5 6
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1 2 3 4 5 6
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1 2 3 4 5 6
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1 2 3 4 5 6
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1 2 3 4 5 6
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1 2 3 4 5 6
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1 2 3 4 5 6
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1 2 3 4 5 6
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1 2 3 4 5 6
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Table A4. Collection of fitted individual growth trajectory for clients with beginning EMG < = 2.5 microvolt (x = period, y = microvolt)
x
y
1 2 3 4 5 6
02
46
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y
1 2 3 4 5 6
02
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1 2 3 4 5 6
02
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1 2 3 4 5 6
02
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x
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1 2 3 4 5 6
02
46
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1 2 3 4 5 6
02
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x
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1 2 3 4 5 6
02
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1 2 3 4 5 6
02
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x
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1 2 3 4 5 6
02
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1 2 3 4 5 6
02
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1 2 3 4 5 6
02
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1 2 3 4 5 6
02
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1 2 3 4 5 6
02
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1 2 3 4 5 6
02
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1 2 3 4 5 6
02
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x
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1 2 3 4 5 6
02
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1 2 3 4 5 6
02
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1 2 3 4 5 6
02
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1 2 3 4 5 6
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1 2 3 4 5 6
02
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1 2 3 4 5 6
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1 2 3 4 5 6
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1 2 3 4 5 6
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1 2 3 4 5 6
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1 2 3 4 5 6
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1 2 3 4 5 6
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1 2 3 4 5 6
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1 2 3 4 5 6
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1 2 3 4 5 6
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1 2 3 4 5 6
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1 2 3 4 5 6
02
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1 2 3 4 5 6
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1 2 3 4 5 6
02
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1 2 3 4 5 6
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1 2 3 4 5 6
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1 2 3 4 5 6
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1 2 3 4 5 6
02
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1 2 3 4 5 6
02
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1 2 3 4 5 6
02
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1 2 3 4 5 6
02
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1 2 3 4 5 6
02
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1 2 3 4 5 6
02
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1 2 3 4 5 6
02
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1 2 3 4 5 6
02
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1 2 3 4 5 6
02
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1 2 3 4 5 6
02
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1 2 3 4 5 6
02
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1 2 3 4 5 6
02
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1 2 3 4 5 6
02
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1 2 3 4 5 6
02
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1 2 3 4 5 6
02
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1 2 3 4 5 6
02
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1 2 3 4 5 6
02
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1 2 3 4 5 6
02
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1 2 3 4 5 6
02
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1 2 3 4 5 6
02
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x
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1 2 3 4 5 6
02
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1 2 3 4 5 6
02
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1 2 3 4 5 6
02
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1 2 3 4 5 6
02
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1 2 3 4 5 6
02
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1 2 3 4 5 6
02
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1 2 3 4 5 6
02
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x
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1 2 3 4 5 6
02
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1 2 3 4 5 6
02
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1 2 3 4 5 6
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1 2 3 4 5 6
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1 2 3 4 5 6
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1 2 3 4 5 6
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1 2 3 4 5 6
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1 2 3 4 5 6
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1 2 3 4 5 6
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1 2 3 4 5 6
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1 2 3 4 5 6
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1 2 3 4 5 6
02
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1 2 3 4 5 6
02
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1 2 3 4 5 6
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1 2 3 4 5 6
02
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1 2 3 4 5 6
02
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1 2 3 4 5 6
02
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1 2 3 4 5 6
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1 2 3 4 5 6
02
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1 2 3 4 5 6
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1 2 3 4 5 6
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1 2 3 4 5 6
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1 2 3 4 5 6
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1 2 3 4 5 6
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1 2 3 4 5 6
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1 2 3 4 5 6
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1 2 3 4 5 6
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1 2 3 4 5 6
02
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1 2 3 4 5 6
02
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1 2 3 4 5 6
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1 2 3 4 5 6
02
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1 2 3 4 5 6
02
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1 2 3 4 5 6
02
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1 2 3 4 5 6
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APPENDIX B
Factor Analysis
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Table B1. Communalities—Temperature Training Initial Extraction V109 1.000 .903 V216 1.000 .981 V239 1.000 .890 V244 1.000 .734 V295 1.000 .477 V297 1.000 .687 V330 1.000 .860 V402 1.000 .964 V408 1.000 .966 V52 1.000 .980 V53 1.000 .807 V93 1.000 .927 V141 1.000 .894 V155 1.000 .588 V212 1.000 .915 V222 1.000 .854 V246 1.000 .829 V258 1.000 .999 V281 1.000 .891 V333 1.000 .281 V334 1.000 .653 V339 1.000 .708 V360 1.000 .878 V367 1.000 .880 V371 1.000 .821 V379 1.000 .903 V380 1.000 .846 V336 1.000 .987 V66 1.000 .981 V75 1.000 .925 V108 1.000 .983 V113 1.000 .937 V204 1.000 .957 V254 1.000 .824 V329 1.000 .995 V15 1.000 .943 V84 1.000 .973 V91 1.000 .976 V105 1.000 .991
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Table B1. (continued) Initial Extraction V174 1.000 .942 V179 1.000 .793 V181 1.000 .775 V227 1.000 .991 V233 1.000 .917 V235 1.000 .549 V238 1.000 .895 V265 1.000 .959 V268 1.000 .956 V277 1.000 .850 V291 1.000 .993 V362 1.000 .765 V111 1.000 .957 V147 1.000 .792 V190 1.000 .830 V255 1.000 .723 V314 1.000 .861 V327 1.000 .869 V409 1.000 .918 V20 1.000 .734 V58 1.000 .906 V194 1.000 .961 V219 1.000 .993 V253 1.000 .414 V42 1.000 .889 V47 1.000 .804 V87 1.000 .820 V353 1.000 .703 V365 1.000 .827 V223 1.000 .991 V224 1.000 .885 V407 1.000 .989 V12 1.000 .984 V104 1.000 .953 V121 1.000 .977 V149 1.000 .895 V346 1.000 .978 V347 1.000 .693 V218 1.000 .875
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Table B1. (continued) Initial Extraction V288 1.000 .379 V293 1.000 .913 V23 1.000 .971 V74 1.000 .956 V125 1.000 .888 V132 1.000 .702 V137 1.000 .935 V193 1.000 .736 V250 1.000 .588 V270 1.000 .968 V283 1.000 .640 V304 1.000 .854 V350 1.000 .975 V361 1.000 .738 V368 1.000 .818 V393 1.000 .963 V83 1.000 .832 V114 1.000 .931 V251 1.000 .995 V5 1.000 .671 V37 1.000 .709 V115 1.000 .309 V241 1.000 .718 V307 1.000 .905 V394 1.000 .342 V404 1.000 .821 Extraction Method: Principal Component Analysis.
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Table B2. Total Variance Explained—Temperature Training
Initial Eigenvalues Extraction Sums of Squared LoadingsComponent Total % of
Variance Cumulative
% Total % of
Variance Cumulative
% 1 41.782 40.175 40.175 41.782 40.175 40.175 2 28.854 27.744 67.919 28.854 27.744 67.919 3 16.818 16.171 84.090 16.818 16.171 84.090 4 10.335 9.937 94.027 5 6.212 5.973 100.000 6 1.042E-14 1.002E-14 100.000 7 6.750E-15 6.490E-15 100.000 8 5.666E-15 5.448E-15 100.000 9 3.119E-15 2.999E-15 100.000 10 1.810E-15 1.741E-15 100.000 11 1.014E-15 9.749E-16 100.000 12 9.199E-16 8.845E-16 100.000 13 8.653E-16 8.320E-16 100.000 14 8.510E-16 8.183E-16 100.000 15 8.166E-16 7.852E-16 100.000 16 8.056E-16 7.746E-16 100.000 17 7.778E-16 7.479E-16 100.000 18 7.480E-16 7.193E-16 100.000 19 7.218E-16 6.940E-16 100.000 20 6.927E-16 6.661E-16 100.000 21 6.675E-16 6.418E-16 100.000 22 6.444E-16 6.197E-16 100.000 23 6.180E-16 5.943E-16 100.000 24 5.940E-16 5.711E-16 100.000 25 5.727E-16 5.507E-16 100.000 26 5.520E-16 5.308E-16 100.000 27 5.033E-16 4.840E-16 100.000 28 4.982E-16 4.790E-16 100.000 29 4.833E-16 4.647E-16 100.000 30 4.544E-16 4.369E-16 100.000 31 4.313E-16 4.147E-16 100.000 32 4.099E-16 3.941E-16 100.000 33 3.891E-16 3.741E-16 100.000 34 3.684E-16 3.542E-16 100.000 35 3.428E-16 3.296E-16 100.000 36 3.261E-16 3.135E-16 100.000 37 3.178E-16 3.056E-16 100.000 38 2.965E-16 2.851E-16 100.000 39 2.753E-16 2.647E-16 100.000
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Table B2. (continued)
Initial Eigenvalues Extraction Sums of Squared LoadingsComponent Total % of
Variance Cumulative
% Total % of
Variance Cumulative
% 40 2.612E-16 2.512E-16 100.000 41 2.219E-16 2.134E-16 100.000 42 2.134E-16 2.052E-16 100.000 43 1.917E-16 1.843E-16 100.000 44 1.859E-16 1.787E-16 100.000 45 1.443E-16 1.387E-16 100.000 46 1.172E-16 1.127E-16 100.000 47 1.076E-16 1.035E-16 100.000 48 9.301E-17 8.943E-17 100.000 49 7.139E-17 6.864E-17 100.000 50 5.869E-17 5.643E-17 100.000 51 5.674E-17 5.455E-17 100.000 52 3.300E-17 3.173E-17 100.000 53 2.119E-17 2.038E-17 100.000 54 1.212E-17 1.165E-17 100.000 55 -1.425E-17 -1.371E-17 100.000 56 -2.648E-17 -2.547E-17 100.000 57 -4.732E-17 -4.550E-17 100.000 58 -6.693E-17 -6.436E-17 100.000 59 -9.695E-17 -9.322E-17 100.000 60 -1.102E-16 -1.060E-16 100.000 61 -1.123E-16 -1.080E-16 100.000 62 -1.490E-16 -1.432E-16 100.000 63 -1.546E-16 -1.487E-16 100.000 64 -1.641E-16 -1.578E-16 100.000 65 -1.799E-16 -1.730E-16 100.000 66 -2.008E-16 -1.931E-16 100.000 67 -2.208E-16 -2.123E-16 100.000 68 -2.395E-16 -2.303E-16 100.000 69 -2.572E-16 -2.473E-16 100.000 70 -2.610E-16 -2.510E-16 100.000 71 -3.013E-16 -2.897E-16 100.000 72 -3.211E-16 -3.087E-16 100.000 73 -3.376E-16 -3.246E-16 100.000 74 -3.549E-16 -3.412E-16 100.000 75 -3.954E-16 -3.802E-16 100.000 76 -4.161E-16 -4.001E-16 100.000 77 -4.239E-16 -4.076E-16 100.000 78 -4.475E-16 -4.303E-16 100.000
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Table B2. (continued)
Initial Eigenvalues Extraction Sums of Squared LoadingsComponent Total % of
Variance Cumulative
% Total % of
Variance Cumulative
% 79 -4.801E-16 -4.616E-16 100.000 80 -4.946E-16 -4.755E-16 100.000 81 -5.312E-16 -5.108E-16 100.000 82 -5.417E-16 -5.209E-16 100.000 83 -5.770E-16 -5.548E-16 100.000 84 -6.108E-16 -5.873E-16 100.000 85 -6.145E-16 -5.909E-16 100.000 86 -6.446E-16 -6.198E-16 100.000 87 -6.545E-16 -6.293E-16 100.000 88 -6.688E-16 -6.431E-16 100.000 89 -7.002E-16 -6.733E-16 100.000 90 -7.190E-16 -6.914E-16 100.000 91 -7.463E-16 -7.176E-16 100.000 92 -7.932E-16 -7.627E-16 100.000 93 -8.052E-16 -7.742E-16 100.000 94 -8.362E-16 -8.040E-16 100.000 95 -8.504E-16 -8.177E-16 100.000 96 -9.186E-16 -8.832E-16 100.000 97 -9.571E-16 -9.203E-16 100.000 98 -1.003E-15 -9.643E-16 100.000 99 -1.191E-15 -1.146E-15 100.000 100 -3.755E-15 -3.611E-15 100.000 101 -4.473E-15 -4.301E-15 100.000 102 -6.245E-15 -6.005E-15 100.000 103 -6.970E-15 -6.702E-15 100.000 104 -1.635E-14 -1.572E-14 100.000 Extraction Method: Principal Component Analysis.
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Table B3. Component Matrix—Temperature Training Component 1 2 3 V109 .898 .111 .291 V216 4.621E-02 .986 -8.467E-02 V239 4.502E-02 .417 .845 V244 5.900E-02 .210 .828 V295 .552 .362 -.205 V297 .416 .102 .709 V330 -.291 .376 .797 V402 .751 .333 -.537 V408 .645 .739 6.066E-02 V52 .981 -.114 6.728E-02 V53 .800 -.333 .235 V93 -.211 .865 .366 V141 .923 -1.117E-02 -.205 V155 .655 -.109 .384 V212 .687 -.405 .528 V222 5.645E-02 .560 .733 V246 .725 -.442 .328 V258 -.145 .984 .101 V281 .584 .515 -.534 V333 .230 -.284 .383 V334 .300 -.553 .507 V339 .458 -.618 .341 V360 .794 -.399 -.296 V367 -.933 -6.466E-02 6.847E-02 V371 .761 -.253 -.420 V379 .253 .403 .822 V380 .748 .195 .498 V336 .625 .735 -.236 V66 -.575 .721 .362 V75 .466 .716 -.442 V108 .754 -.546 -.342 V113 .777 .550 -.176 V204 .773 .535 .270 V254 .503 -.752 -7.934E-02 V329 .603 -.790 -8.731E-02 V15 .951 -.103 .167 V84 .764 .157 .604 V91 .553 -.202 -.793 V105 .988 7.892E-02 9.525E-02 V174 .932 .254 9.402E-02
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Table B3. (continued) Component 1 2 3 V179 .814 .220 .285 V181 .343 -.693 .421 V227 .967 -.171 -.165 V233 -3.541E-03 -.777 .560 V235 -.482 -.550 .123 V238 .405 -9.422E-02 -.849 V265 .511 .779 .302 V268 -.434 .690 -.540 V277 .619 .434 -.528 V291 .989 -.120 3.292E-02 V362 -.708 -.301 -.416 V111 .647 -.730 -6.793E-02 V147 .858 .182 .150 V190 -.873 .109 .237 V255 .621 -.567 .124 V314 -.354 -.818 -.258 V327 .310 .401 .782 V409 .426 -.833 -.207 V20 .618 -.589 -7.122E-02 V58 .449 .273 -.793 V194 .772 -3.671E-02 .603 V219 -.482 .870 5.718E-02 V253 -6.913E-04 .366 -.529 V42 -.931 -7.388E-03 -.151 V47 -.278 .804 -.284 V87 .882 -5.176E-02 .197 V353 .770 -.258 .210 V365 .787 -.451 5.959E-02 V223 4.430E-02 .995 -3.557E-04 V224 -.329 .644 .602 V407 .518 -.777 -.343 V12 -.554 -.764 .305 V104 .807 .454 .310 V121 .451 -.850 -.227 V149 -.869 -.335 -.166 V346 .962 -.209 9.915E-02 V347 .822 .127 9.827E-03 V218 -.898 3.796E-02 .259 V288 .444 .357 .234 V293 .925 -.237 -2.015E-02
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Table B3. (continued) Component 1 2 3 V23 -.393 -.898 9.740E-02 V74 .622 -.730 -.189 V125 -.468 -.815 6.675E-02 V132 .369 -.153 .736 V137 .921 -9.547E-02 -.279 V193 .351 -.543 .564 V250 .448 -.178 .596 V270 -.710 -9.926E-03 .681 V283 .373 .365 -.607 V304 .691 .558 .255 V350 .769 .377 -.492 V361 -.725 .327 .324 V368 .209 .878 6.490E-02 V393 .899 .353 -.175 V83 .524 .740 .100 V114 .901 4.180E-02 -.343 V251 -.184 -.968 -.155 V5 .560 .575 .165 V37 .345 V115 -.145 -.432 V241 .702 -.287 V307 8.832E-02 -.702 V394 .542 6.531E-02 V404 .598 .650
-5.513E-02 .317 .379 .635 -.211 -.201
Extraction Method: Principal Component Analysis. a 3 components extracted.
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Table B4. Communalities--EMG Initial Extraction V10 1.000 .986 V13 1.000 .860 V65 1.000 .968 V175 1.000 .478 V191 1.000 .807 V216 1.000 .962 V274 1.000 .664 V284 1.000 .992 V295 1.000 .900 V297 1.000 .598 V319 1.000 .794 V321 1.000 .963 V326 1.000 .944 V330 1.000 .943 V356 1.000 .873 V376 1.000 .978 V384 1.000 .890 V402 1.000 .991 V60 1.000 .607 V116 1.000 .772 V130 1.000 .854 V146 1.000 .918 V165 1.000 .842 V171 1.000 .897 V173 1.000 .849 V207 1.000 .625 V212 1.000 .966 V217 1.000 3.990E-02 V222 1.000 .890 V225 1.000 .269 V234 1.000 .987 V243 1.000 .995 V246 1.000 .793 V261 1.000 .969 V262 1.000 .805 V267 1.000 .950 V281 1.000 .861 V313 1.000 .986 V317 1.000 .452 V318 1.000 .844 V328 1.000 .977
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Table B4. (continued) Extraction Initial V333 1.000 .774 V338 1.000 .986 V345 1.000 .915 V360 1.000 .676 V375 1.000 .977 V119 1.000 .568 V143 1.000 .851 V211 1.000 .594 V336 1.000 .809 V113 1.000 .479 V135 1.000 .453 V196 1.000 .977 V254 1.000 .908 V272 1.000 .888 V273 1.000 .631 V329 1.000 .817 V331 1.000 .494 V15 1.000 .897 V43 1.000 .609 V72 1.000 .774 V84 1.000 8.336E-02 V91 1.000 .960 V181 1.000 .926 V227 1.000 .863 V233 1.000 .939 V235 1.000 .899 V238 1.000 .859 V260 1.000 .773 V265 1.000 .962 V266 1.000 .922 V268 1.000 .666 V275 1.000 .962 V277 1.000 .957 V291 1.000 .969 V320 1.000 .916 V324 1.000 .973 V362 1.000 .986 V387 1.000 .910 V397 1.000 .966 V157 1.000 .980 V184 1.000 .770
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Table B4. (continued) Extraction Initial V187 1.000 .977 V190 1.000 .902 V228 1.000 .988 V255 1.000 .550 V276 1.000 .847 V282 1.000 .976 V301 1.000 .710 V314 1.000 .973 V327 1.000 .535 V335 1.000 .975 V20 1.000 .358 V58 1.000 .869 V62 1.000 .994 V68 1.000 .790 V127 1.000 .624 V172 1.000 .987 V194 1.000 .835 V213 1.000 .660 V219 1.000 .830 V253 1.000 .867 V340 1.000 .946 V47 1.000 .622 V96 1.000 .828 V153 1.000 .983 V316 1.000 .981 V353 1.000 .635 V365 1.000 .945 V55 1.000 .923 V150 1.000 .898 V223 1.000 .962 V224 1.000 .988 V377 1.000 .766 V346 1.000 .962 V347 1.000 .919 V249 1.000 .977 V288 1.000 .987 V293 1.000 .662 V383 1.000 .709 V8 1.000 .976 V23 1.000 .933 V45 1.000 .902
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Table B4. (continued) Extraction Initial V49 1.000 .997 V98 1.000 .464 V123 1.000 .909 V125 1.000 .846 V126 1.000 .904 V132 1.000 .771 V133 1.000 .787 V137 1.000 .991 V140 1.000 .915 V195 1.000 .947 V221 1.000 .947 V229 1.000 .837 V240 1.000 .917 V252 1.000 .769 V270 1.000 .746 V283 1.000 .738 V292 1.000 .470 V294 1.000 .751 V300 1.000 .934 V311 1.000 .968 V312 1.000 .181 V343 1.000 .835 V350 1.000 .906 V374 1.000 .906 V381 1.000 .578 V385 1.000 .830 V399 1.000 .453 V401 1.000 .875 V83 1.000 .952 V176 1.000 .870 V230 1.000 .761 V251 1.000 .992 V364 1.000 .621 V64 1.000 .757 V90 1.000 .985 V131 1.000 .914 V189 1.000 .732 V307 1.000 .656 V394 1.000 .967 V404 1.000 .846 Extraction Method: Principal Component Analysis.
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Table B5. Total Variance Explained--EMG
Initial Eigenvalues Extraction Sums of Squared LoadingsComponent Total % of
Variance Cumulative
% Total % of
Variance Cumulative
% 1 62.657 38.440 38.440 62.657 38.440 38.440 2 39.356 24.145 62.584 39.356 24.145 62.584 3 32.023 19.646 82.230 32.023 19.646 82.230 4 15.806 9.697 91.927 5 13.159 8.073 100.000 6 3.241E-14 1.988E-14 100.000 7 1.478E-14 9.065E-15 100.000 8 1.023E-14 6.277E-15 100.000 9 9.211E-15 5.651E-15 100.000 10 5.909E-15 3.625E-15 100.000 11 4.525E-15 2.776E-15 100.000 12 1.310E-15 8.036E-16 100.000 13 1.263E-15 7.746E-16 100.000 14 1.218E-15 7.470E-16 100.000 15 1.165E-15 7.145E-16 100.000 16 1.135E-15 6.966E-16 100.000 17 1.124E-15 6.899E-16 100.000 18 1.090E-15 6.685E-16 100.000 19 1.050E-15 6.441E-16 100.000 20 1.024E-15 6.281E-16 100.000 21 9.860E-16 6.049E-16 100.000 22 9.786E-16 6.003E-16 100.000 23 9.624E-16 5.904E-16 100.000 24 9.479E-16 5.815E-16 100.000 25 9.397E-16 5.765E-16 100.000 26 9.186E-16 5.635E-16 100.000 27 9.058E-16 5.557E-16 100.000 28 8.687E-16 5.330E-16 100.000 29 8.524E-16 5.230E-16 100.000 30 8.153E-16 5.002E-16 100.000 31 8.105E-16 4.973E-16 100.000 32 7.766E-16 4.764E-16 100.000 33 7.509E-16 4.607E-16 100.000 34 7.452E-16 4.572E-16 100.000 35 7.212E-16 4.424E-16 100.000 36 7.185E-16 4.408E-16 100.000 37 6.954E-16 4.266E-16 100.000 38 6.710E-16 4.117E-16 100.000 39 6.671E-16 4.093E-16 100.000
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Table B5. (continued)
Initial Eigenvalues Extraction Sums of Squared LoadingsComponent Total % of
Variance Cumulative
% Total % of
Variance Cumulative
% 40 6.518E-16 3.999E-16 100.000 41 6.378E-16 3.913E-16 100.000 42 6.151E-16 3.774E-16 100.000 43 6.088E-16 3.735E-16 100.000 44 5.875E-16 3.604E-16 100.000 45 5.770E-16 3.540E-16 100.000 46 5.589E-16 3.429E-16 100.000 47 5.508E-16 3.379E-16 100.000 48 5.282E-16 3.241E-16 100.000 49 5.127E-16 3.145E-16 100.000 50 5.071E-16 3.111E-16 100.000 51 4.915E-16 3.016E-16 100.000 52 4.689E-16 2.877E-16 100.000 53 4.506E-16 2.764E-16 100.000 54 4.444E-16 2.727E-16 100.000 55 4.287E-16 2.630E-16 100.000 56 4.075E-16 2.500E-16 100.000 57 4.031E-16 2.473E-16 100.000 58 3.963E-16 2.431E-16 100.000 59 3.750E-16 2.300E-16 100.000 60 3.534E-16 2.168E-16 100.000 61 3.461E-16 2.123E-16 100.000 62 3.314E-16 2.033E-16 100.000 63 3.163E-16 1.941E-16 100.000 64 3.058E-16 1.876E-16 100.000 65 2.933E-16 1.800E-16 100.000 66 2.790E-16 1.712E-16 100.000 67 2.713E-16 1.664E-16 100.000 68 2.537E-16 1.557E-16 100.000 69 2.339E-16 1.435E-16 100.000 70 2.253E-16 1.382E-16 100.000 71 2.058E-16 1.262E-16 100.000 72 2.008E-16 1.232E-16 100.000 73 1.836E-16 1.127E-16 100.000 74 1.624E-16 9.963E-17 100.000 75 1.594E-16 9.778E-17 100.000 76 1.533E-16 9.403E-17 100.000 77 1.309E-16 8.032E-17 100.000 78 1.217E-16 7.463E-17 100.000
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Table B5 (continued)
Initial Eigenvalues Extraction Sums of Squared LoadingsComponent Total % of
Variance Cumulative
% Total % of
Variance Cumulative
% 79 1.077E-16 6.606E-17 100.000 80 9.895E-17 6.070E-17 100.000 81 5.738E-17 3.520E-17 100.000 82 5.078E-17 3.115E-17 100.000 83 2.852E-17 1.750E-17 100.000 84 2.055E-17 1.261E-17 100.000 85 1.103E-17 6.767E-18 100.000 86 -3.590E-18 -2.203E-18 100.000 87 -1.889E-17 -1.159E-17 100.000 88 -2.539E-17 -1.558E-17 100.000 89 -3.927E-17 -2.409E-17 100.000 90 -6.203E-17 -3.806E-17 100.000 91 -7.105E-17 -4.359E-17 100.000 92 -8.454E-17 -5.187E-17 100.000 93 -1.018E-16 -6.244E-17 100.000 94 -1.161E-16 -7.121E-17 100.000 95 -1.295E-16 -7.948E-17 100.000 96 -1.307E-16 -8.017E-17 100.000 97 -1.467E-16 -9.003E-17 100.000 98 -1.679E-16 -1.030E-16 100.000 99 -1.896E-16 -1.163E-16 100.000 100 -2.081E-16 -1.276E-16 100.000 101 -2.168E-16 -1.330E-16 100.000 102 -2.197E-16 -1.348E-16 100.000 103 -2.296E-16 -1.409E-16 100.000 104 -2.466E-16 -1.513E-16 100.000 105 -2.706E-16 -1.660E-16 100.000 106 -2.727E-16 -1.673E-16 100.000 107 -2.870E-16 -1.761E-16 100.000 108 -3.088E-16 -1.895E-16 100.000 109 -3.210E-16 -1.970E-16 100.000 110 -3.301E-16 -2.025E-16 100.000 111 -3.358E-16 -2.060E-16 100.000 112 -3.487E-16 -2.139E-16 100.000 113 -3.522E-16 -2.161E-16 100.000 114 -3.647E-16 -2.237E-16 100.000 115 -3.923E-16 -2.407E-16 100.000 116 -4.141E-16 -2.540E-16 100.000 117 -4.211E-16 -2.584E-16 100.000
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Table B5. (continued)
Initial Eigenvalues Extraction Sums of Squared LoadingsComponent Total % of
Variance Cumulative
% Total % of
Variance Cumulative
% 118 -4.500E-16 -2.761E-16 100.000 119 -4.515E-16 -2.770E-16 100.000 120 -4.752E-16 -2.916E-16 100.000 121 -4.850E-16 -2.975E-16 100.000 122 -5.044E-16 -3.094E-16 100.000 123 -5.287E-16 -3.243E-16 100.000 124 -5.504E-16 -3.376E-16 100.000 125 -5.652E-16 -3.468E-16 100.000 126 -5.744E-16 -3.524E-16 100.000 127 -5.930E-16 -3.638E-16 100.000 128 -6.106E-16 -3.746E-16 100.000 129 -6.315E-16 -3.874E-16 100.000 130 -6.515E-16 -3.997E-16 100.000 131 -6.687E-16 -4.103E-16 100.000 132 -6.782E-16 -4.161E-16 100.000 133 -6.814E-16 -4.180E-16 100.000 134 -6.886E-16 -4.225E-16 100.000 135 -7.165E-16 -4.396E-16 100.000 136 -7.306E-16 -4.482E-16 100.000 137 -7.517E-16 -4.611E-16 100.000 138 -7.702E-16 -4.725E-16 100.000 139 -7.844E-16 -4.812E-16 100.000 140 -8.062E-16 -4.946E-16 100.000 141 -8.375E-16 -5.138E-16 100.000 142 -8.417E-16 -5.164E-16 100.000 143 -8.695E-16 -5.335E-16 100.000 144 -8.893E-16 -5.456E-16 100.000 145 -9.117E-16 -5.593E-16 100.000 146 -9.417E-16 -5.777E-16 100.000 147 -9.511E-16 -5.835E-16 100.000 148 -9.795E-16 -6.009E-16 100.000 149 -1.028E-15 -6.308E-16 100.000 150 -1.058E-15 -6.492E-16 100.000 151 -1.065E-15 -6.534E-16 100.000 152 -1.094E-15 -6.713E-16 100.000 153 -1.105E-15 -6.778E-16 100.000 154 -1.126E-15 -6.906E-16 100.000 155 -1.150E-15 -7.053E-16 100.000 156 -1.168E-15 -7.168E-16 100.000
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Table B5. (continued)
Initial Eigenvalues Extraction Sums of Squared LoadingsComponent Total % of
Variance Cumulative
% Total % of
Variance Cumulative
% 157 -1.218E-15 -7.473E-16 100.000 158 -1.283E-15 -7.873E-16 100.000 159 -4.435E-15 -2.721E-15 100.000 160 -8.767E-15 -5.379E-15 100.000 161 -1.228E-14 -7.531E-15 100.000 162 -1.281E-14 -7.858E-15 100.000 163 -1.436E-14 -8.807E-15 100.000 Extraction Method: Principal Component Analysis.
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Table B6. Component Matrix--EMG
Component 1 2 3 V338 .980 -.108 -.116 V376 .976 -.147 -5.176E-02 V311 .976 5.709E-02 .116 V216 .972 9.405E-02 9.329E-02 V275 .970 -2.525E-02 .139 V324 .970 .164 6.959E-02 V23 .964 1.851E-02 5.211E-02 V90 .959 -.254 -3.537E-02 V131 .954 6.096E-02 -2.530E-02 V350 .950 -5.390E-02 -2.011E-02 V15 .938 -.128 -1.871E-02 V157 .936 .322 -1.754E-04 V8 .933 -.314 7.878E-02 V83 .930 -.294 7.587E-03 V249 .929 -.336 -4.023E-02 V234 .926 -.355 -4.951E-02 V328 .925 -.348 -1.039E-02 V196 .923 .264 .237 V153 .916 .154 -.346 V224 .914 .371 .118 V397 .912 -.103 .351 V10 .910 -.174 -.357 V340 .897 -.340 -.164 V335 .892 .394 .153 V243 .889 -.355 .280 V125 .888 -.166 .175 V187 .881 -4.072E-02 -.447 V402 .877 -.388 -.265 V194 .871 .210 .181 V343 -.870 -.126 .250 V251 .870 -.308 -.375 V191 .862 -.211 -.141 V195 .853 -.420 -.209 V228 .850 -.342 -.386 V123 .839 -.142 .431 V300 .837 .386 .292 V49 .835 -.427 -.344 V404 .833 -.233 -.314 V230 .822 .286 5.417E-02 V143 .816 1.761E-02 -.430
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Table B6. (continued)
Component 1 2 3
V221 .815 -.276 -.455 V68 .801 -.385 1.448E-02 V227 .799 .311 -.358 V91 .788 -.171 -.556 V375 .777 .224 .569 V307 .763 .170 .215 V43 .714 .263 .169 V219 .714 .239 .513 V365 .706 -.454 .491 V55 .704 -.651 -6.731E-02 V262 .702 1.885E-02 -.558 V207 .698 .129 -.347 V381 .697 .168 .253 V326 .695 -7.237E-02 -.675 V336 .685 .570 .121 V282 -.684 .614 .361 V229 .673 -.397 -.476 V13 -.660 -.161 -.631 V374 .655 -.332 .605 V347 .647 .371 .602 V113 .645 -.248 -2.840E-02 V399 .642 -.144 -.143 V165 .641 .597 .274 V72 .640 .540 .271 V47 .623 .238 .421 V213 .616 .529 -2.152E-02 V212 .585 .548 .570 V294 .584 .583 -.263 V175 .580 .107 .362 V295 .558 -.527 .558 V333 -.550 .436 -.531 V327 .534 -.293 -.405 V225 .490 .124 .116 V20 .470 3.862E-02 .368 V292 -.451 .424 .295 V84 .266 -9.526E-02 6.062E-02 V223 -9.437E-02 .975 -4.135E-02 V314 -.160 -.972 -5.220E-02 V176 .116 .925 -4.229E-02 V345 -.132 -.905 -.279
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Table B6. (continued)
Component 1 2 3
V384 7.203E-02 -.901 .272 V62 -.105 -.883 .450 V171 .354 .871 .112 V254 -6.769E-02 .864 .395 V190 .335 .862 -.217 V362 .521 .838 -.107 V320 .435 .837 .161 V133 .232 .835 -.189 V356 .218 .835 -.359 V265 -.288 .822 .452 V281 -.389 .818 .201 V319 -.310 .818 -.171 V401 .213 -.812 -.413 V184 .254 .807 -.233 V270 9.143E-02 .805 .298 V246 -7.104E-02 .793 -.398 V172 .479 -.791 .364 V291 .599 -.777 7.622E-02 V274 -.247 -.776 -2.457E-02 V65 .623 .760 5.098E-02 V253 -.344 -.757 -.420 V235 .474 .744 .347 V233 .452 .737 -.437 V181 .435 .720 -.468 V150 .522 .715 .337 V211 .288 .713 5.759E-02 V267 .669 -.707 -5.056E-02 V316 -.226 .698 -.665 V268 -.419 .682 -.157 V261 .258 -.678 -.666 V116 .214 .676 .520 V301 .484 -.650 .232 V330 -.539 .648 .482 V96 .497 .642 -.410 V293 .501 -.638 -6.311E-02 V318 -.333 -.636 .574 V385 .365 -.628 .550 V321 .614 .624 -.444 V252 .564 .617 .265 V64 .611 -.617 5.586E-02
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Table B6. (continued)
Component 1 2 3
V383 .461 .612 .349 V272 .583 -.601 .433 V45 .574 .581 .484 V119 -.207 .553 .468 V317 .403 .428 -.325 V312 -.217 .266 -.251 V58 -5.496E-02 -.143 .920 V284 .285 -.303 .905 V266 .393 .198 -.853 V140 .376 .334 .813 V346 -.516 .229 .802 V240 .530 -3.745E-02 .797 V387 .507 .186 .786 V273 .138 5.186E-02 -.780 V189 -.321 .206 -.766 V394 .591 .190 -.763 V329 -.469 -.143 .760 V222 .429 -.374 .752 V130 .538 -6.973E-02 .748 V277 .502 -.385 -.746 V126 .538 .264 -.738 V146 .258 .584 -.714 V173 .569 .136 -.712 V276 .584 6.915E-03 .712 V288 -.184 .675 -.705 V283 .486 7.348E-02 -.704 V353 -.127 -.361 -.700 V238 .636 .115 .664 V313 .557 .486 -.663 V132 -.100 -.571 -.659 V331 .251 3.608E-02 -.655 V360 -5.963E-02 -.504 .647 V364 -.157 -.443 -.633 V297 .391 .222 .629 V137 .469 -.613 .628 V260 .505 -.362 -.622 V377 .405 .478 -.612 V60 -.476 .217 .577 V135 .376 5.099E-02 .556 V127 .467 .332 .544
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Table B6. (continued) Component 1 2 3 V255 .503 .187 -.512 V98 .433 -.235 .470 V217 -3.434E-02 3.693E-02 .193 Extraction Method: Principal Component Analysis. a 3 components extracted.
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APPENDIX C
Examples of Individual Biofeedback Learning Curve
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Example of Individual Temp Curves (x = period, y = temperature Fahrenheit) Steady State Trainable (Low variability)
x
y
1 2 3 4 5 6
7075
8085
9095
Phasic State Trainable (High variability)
x
y
1 2 3 4 5 6
7075
8085
9095
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Example of Individual Temp Curves (x = period, y = temperature Fahrenheit)
Phasic State Low Trainable (High variability)
x
y
1 2 3 4 5 6
7075
8085
9095
Example of Individual Temperature Curves (x = period, y = temperature Fahrenheit)
Steady State Trainable (Low variability)
x
y
1 2 3 4 5 6
7075
8085
9095
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Example of Individual Temperature Curves (x = period, y = temperature Fahrenheit)
Steady State Trainable (Low variability)
x
y
1 2 3 4 5 6
7075
8085
9095
Phasic State Trainable (High variability)
x
y
1 2 3 4 5 6
7075
8085
9095
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Example of Individual EMG Curves (x = period, y = EMG microvolt)
Phasic State Low Trainable (High variability)
x
y
1 2 3 4 5 6
01
23
45
Phasic State Trainable (High variability)
x
y
1 2 3 4 5 6
01
23
45
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Example of Individual EMG Curves (x = period, y = EMG microvolt)
Steady State Trainable (Low variability)
x
y
1 2 3 4 5 6
01
23
45
Examples of Individual EMG Curves (x = period, y = EMG microvolt)
Phasic State Trainable (High variability)
x
y
1 2 3 4 5 6
01
23
45
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Examples of Individual EMG Curves (x = period, y = EMG microvolt)
Steady State Trainable (Low variability)
x
y
1 2 3 4 5 6
01
23
45
Phasic State Trainable (High variability)
x
y
1 2 3 4 5 6
01
23
45
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