Biofeedback and Self-Regulation, Vol. 7, No. 1, 1982
A Study of Physician Attitude on Biofeedback Maxine L. Weinman, i Roy J. Mathew, and James L. Claghorn TexasResearch Instituteof Mental Sciences A study of physician attitudes on biofeedback was conducted among members o f the Harris County Medical Society, Harris County, Texas. The sample was drawn to match the proportionate representation in the society by speciality. Findings indicated that over 62% of the respondents had little knowledge o f biofeedback, over 86% did not use biofeedback in their practice, 21.7% referred patients for biofeedback, and 47.1% were undecided whether insurance coverage should be provided. For specific disorders, adjunct treatment was the most recommended category for migraine and muscle contraction headaches, relaxation training for anxiety and tension, pain management, and essential hypertension. Responses were also analyzed by speciality category.
Biofeedback is a process aimed at producing voluntary control over involuntary physiological functions by providing the individual with augmented auditory or visual signals of those functions. Feedback may be provided via amplification and logical processing of subtle variations in skeletal and autonomic responses such as brain wave activity, peripheral skin temperature, galvanic skin response, heart rate, blood pressure, and muscle tension. Therapeutic application of biofeedback has been directed toward a variety of disorders: neuromuscular rehabilitation, tension headaches, migraine headaches, asthma, anxiety, epilepsy, gastrointestinal ailments, and hypertension (Miller, 1978). 'Address all correspondenceto Dr. Maxine L. Weinman, PsychosomaticResearch Section, Texas ResearchInstituteof MentalSciences, 1300Moursund,Houston,Texas77030. 89 0363-3586/82/0300-0089503.00/0
© 1982 Plenum Publishing Corporation
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The widespread interest in the clinical and research applications of biofeedback techniques has been reflected in the establishment of two national biofeedback societies (Biofeedback Society of America and American Society of Biofeedback Clinicians) and numerous state societies, as well as two journals (Biofeedback and Self-Regulation and the American Journal of Clinical Biofeedback). The Task Force Report of the Biofeedback Society of America has recommended the use of biofeedback in six major areas: vascular headache (Diamond, Diamond-Falk, DeVeno, 1978), muscle contraction headache (Budzynski, 1978), vasoconstrictive disorders (i.e., primary Raynaud's disease, Taub & Stroebel, 1978), psychophysiological disorders (Fotopoulos & Sunderland, 1978), gastrointestinal disorders (Whitehead, 1978), and physical medicine and rehabilitation (Fernando & Basmajian, 1978). Additionally, the proliferation of books written for the lay public has enhanced the appeal of biofeedback. Many issues regarding biofeedback are unresolved or controversial. Uncertainties exist regarding the ethics of treatment provision and the appropriate application of insurance coverage. Some insurance companies provide coverage for biofeedback therapy as part of a routine professional visit, some cover it only as a psychiatric service, and others may limit eligibility of service providers or only reimburse for specific conditions. A related issue concerns the medical community's acceptance of biofeedback as a treatment modality, specifically for those disorders recommended by the Biofeedback Society of America. Physicians' attitudes and knowledge are important aspects of promoting qualified biofeedback therapists. The purpose of this study was to survey attitudes and knowledge about biofeedback among physicians in the Harris County Medical Society. In order to detect patterns of response and avoid bias, the sample was stratified according to the proportionate representation by speciality in the total population. Based on this stratification, questionnaires were mailed to a random sample of members of the Harris County Medical Society.
METHOD
Subjects and Procedure A 10°70 proportionate sample of Harris County physicians was desired for this study. Certain physician specialities were not included in the research because they lacked relevancy to the subject matter, for example, anesthesiology, emergency medicine, and general preventive medicine. As of 1978 a total of 4,175 physicians were listed in the Harris County Medical
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Society roster. Those eligible for the study totaled 3,373. In order to achieve a 10% response, questionnaires were mailed to 1,181 physicians, a 35% random sample that was stratified according to proportionate representation by specialty. The sampling by speciality was based on 19 categories; certain specialities were combined when individual numbers were small or when groupings were appropriate. Subsequent to the selection process, the questionnaire and a letter of explanation were mailed to the 1181 physicians. All responses were coded by a speciality number to guarantee anonymity. The return rate was 465 questionnaires, which represented 38.6% of the total 1,181 sample and 13.5% of the population total, 3,373. The specialists in the total population, their proportion to the total population, their proportionate number in survey sample, and the response rate by specialty are presented in Table I.
RESULTS
Knowledge of Biofeedback The first question addressed to the physicians concerned their overall knowledge about biofeedback. A scale from 1 to 5 was used, with 1 = no knowledge and 5 = very knowledgeable. The overall response is presented in Table II. Sixty-two percent of the respondents checked category 1 or 2, indicating relatively little knowledge, while 11.6% were in the most knowledgeable categories, 4 and 5. Twenty-three percent checked the middle category, 3. Examining these responses by specialty of physicians showed that neurologists, psychiatrists, and allergists had the majority of their responses in categories 3 through 5. Looking at the other extreme, category 1, 11 speciality groups checked this category more frequently than any other: aerospace medicine, general practice, internal medicine, obstetrics and gynecology, neoplastic disease, oncology, occupational/physical medicine, opthomalogy, otorhinolaryngology, pediatrics, and surgery.
The Use of Biofeedback The second question concerned the actual use of biofeedback in practice. As illustrated in Table II, 86.2°70 of the physicians did not use biofeedback. Of the 7.7% who responded "yes," 8 of the 35 users were psychiatrists, 7 were surgeons, 5 were occupational/physical medicine specialists, and 4 were general practitioners. The rest were composed of
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Physician Attitude on Biofeedback Table 11. Physician Response to Biofeedback Questionnaire
"How knowledgeable are you about biofeedback?" Not at all t
070 33.8
2
N (154)
3
070 28.7
N (131)
% 23.9
4
N (109)
070 9.6
N (44)
Very
No response
5
4
070 2.0
N (9)
070 2.0
N (9)
"Do you use biofeedback in your practice?" Yes % 7.7
N (35)
No 070 86.2
N (99)
No 070 72.1
N (393)
No response o70 N 6.1 (28)
"Do you refer patients for biofeedback?" Yes % 21.7
N (329)
No response 070 N 6.1 (28)
"Do you support insurance coverage for biofeedback treatment?" Yes o70 27.6
N (126)
No 070 16.9
N (77)
Undecided 070 N 47.1 (215)
No response o70 N 8.3 (38)
internists (3), opthomologists (2), neurologists (2), and obstetricians (2), with 1 endocrinologist and 1 otorhinolaryngologist.
Referral of Patients The third question addressed the physicians' willingness to refer patients for biofeedback treatment. As seen in Table II, 21.7°70 responded "yes." Speciality responses showed that psychiatrists, neurologists, and pulmonary disease specialities were the only majority "yes" responders. The "yes" response was generally represented across the various specialities, with the exceptions of aerospace medicine, cardiovascular disease, neoplastic disease, and oncology.
Insurance Coverage The fourth item canvassed attitudes concerning health insurance coverage for biofeedback. As seen in Table II, the largest response category was "undecided" (47.1°70). Twenty-seven percent responded "yes," with dermatologists, psychiatrists, and neurologists having their majority re-
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Weinman, Mathew, and Claghorn
sponse in this category. The "no" response (16.9%) was not represented by any speciality majority.
Specific Application of Biofeedback The next series of questions dealt specifically with indications for the use of biofeedback in the treatment of nine disorders. Physicians were asked to check either "primary" or "adjunct treatment" or "not indicated" for each disorder; a "don't know/no opinion" and "not sure" category was also created. The physicians' responses are presented in Table III. Overall, the "primary treatment" response and the "not indicated" categories did not receive a majority response for any of the named disorders. "Adjunct treatment" and "don't know" received the largest overall responses. "Adjunct treatment" was selected more frequently than any other response for migraine (49%) and muscle contraction headaches (41070), relaxation training for anxiety and tension (36%), pain management (51%), and essential hypertension (42%). The "don't know/no opinion" category was selected most frequently for Raynaud's disease (idiopathic) (41%), fecal incontinence (42%), neuromuscular rehabilitation (40%) and epilepsy (42070). Consistently, between 3307o and 43% of all responses were in the "don't know" category.
Analysis of Biofeedback Usage by Physician Speciality Migraine Headache. No speciality group selected "primary treatment" or "not indicated" for the majority response for migraine headache. "Adjunct treatment," the largest response category for migraine, was represented by all speciality groups with the exceptions of aerospace medicine and pulmonary disease. Twelve of 19 Specialists chose "adjunct treatment" for the majority response. They were allergists, pulmonary disease specialists, dermatologists, psychiatrists, gastroenterologists, oncologists, internists, general practioners, occupational medicine specialists, obstetricians/ gynecologists, pediatricians, and endocrinologists. Neurologists had no majority preference, with 30% in the "adjunct treatment" category and 30% in the "not indicated" category. Muscle Contraction Headache. The "primary treatment" category received the majority response from dermatologists and endocrinologists for muscle contraction headaches. "Adjunct treatment," the largest response category, was represented by all speciality groups with the exceptions of aerospace medicine and neoplastic disease. Eight of the 19 spe-
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cialists chose "adjunct treatment" for the majority response. They were allergists, psychiatrists, neurologists, occupational medicine, pulmonary disease, internists, general practitioners, and gastroenterologists. The "not indicated" category did not receive a majority response from any speciality group. Raynaud's Disease. For Raynaud's disease (idiopathic), "primary treatment" did not receive any specialist majority. The largest overall response category was "don't know," representing majority response from 14 speciality groups. The "not indicated" category showed representation from all speciality groups, with the exceptions of aerospace medicine, cardiovascular disease, and dermatology. Two speciality groups, gastroenterologists and neurologists, had the majority response in this category. The "adjunct treatment" response was selected by all specialists with the exception of aerospace medicine, allergy, neoplastic disease, and otorhinolaryngology. A majority of dermatologists and psychiatrists chose the "adjunct treatment" category. Fecal Incontinence. The "primary treatment" did not receive any specialist majority for fecal incontinence. The largest overall response was "don't know," representing majority response from 14 speciality groups. The "not indicated" category was represented by all speciality groups with the exception of aerospace medicine, endocrinology, and oncology. A majority of neurologists, gastroenterologists, and psychiatrists felt that biofeedback was not indicated in treatment of fecal incontinence. "Adjunct treatment" was represented by all speciality groups with the exceptions of aerospace medicine, neoplastic disease, oncology, and otorhinolaryngology. Allergists and dermatologists provided the majority response in this category. Neuromuscular Rehabilitation. No speciality group selected "primary treatment" or "not indicated" as a majority response for neuromuscular rehabilitation. The largest overall response was "don't know," representing majority response from 9 speciality groups. "Adjunct treatment" was chosen by all speciality groups with the exception of aerospace medicine. Six of 19 specialists selected "adjunct treatment" as a majority response. They were dermatologists, psychiatrists, occupational medicine, neurologists, internists, and gastroenterologists. Epilepsy. For epilepsy, the "primary treatment" response did not receive any specialist majority. "Adjunct treatment" received majority response from dermatologists and psychiatrists. The largest overall response was "don't know," representing majority response from 12 specialities. The "not indicated" category was selected by all specialists with the exception of aerospace medicine and dermatology. Neurologists, gastroenterologists, oncologists, and internists had the majority of their responses in thie category.
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Physician Attitude on Biofeedback
Relaxation Training for Anxiety and Tension. The "primary treatment" category for relaxation training for anxiety and tension received a majority response from oncologists. The "adjunct treatment" category, the largest response category, was selected by all speciality groups with the exception of aerospace medicine, neoplastic disease, and oncology. Seven of 19 specialists selected "adjunct treatment" as a majority response. They were allergists, dermatologists, gastroenterologists, internists, neurologists, psychiatrists, and pulmonary disease specialists. The "not indicated" category received no specialist majority. Pain management. For pain management, the "primary treatment" and the "not indicated" category received no specialist majorities. "Adjunct treatment," the largest response category, was represented by all specialities with the exception of aerospace medicine. Eleven of 19 speciality groups selected "adjunct treatment" for a majority response. They were dermatologists, endocrinologists, gastroenterologists, general practioners, internists, obstetrician/gynecologists, neurologists, occupational medicine, pediatricians, psychiatrists, and pulmonary disease. Surgeons were equally split between "adjunct treatment" and "don't know." Essential Hypertension. For the last disorder, essential hypertension, the "primary treatment" and the "not indicated" categories received no speciality majorities. "Adjunct treatment," the largest response category, was chosen by all speciality groups with the exception of aerospace medicine. Nine of 19 speciality groups selected "adjunct treatment" as a majority response. They were dermatologists, endocrinologists, general practitioners, internists, neurologists, oncologists, pediatricians, psychiatrists, and pulmonary disease specialists.
SUMMARY
The results of this study indicated that the majority of physicians surveyed had little or no knowledge of biofeedback, did not use biofeedback in their practice, and were undecided about insurance coverage. About one-fourth of all physicians referred patients for biofeedback treatment. Regarding the use of biofeedback for specific disorders, the most frequent response was either "adjunct treatment" or "don't know/no opinion." The "primary treatment" category or "not indicated" categories received no majority response for any disorder. Responses by physician speciality revealed that psychiatrists and neurologists were the most knowledgeable about biofeedback, with psychiatrists using referring and supporting insurance coverage more frequently than any other speciality group.
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Majority responses by physician speciality group on the use of biofeedback as a treatment for specific disorders were difficult to interpret due to the large percentage Of "don't knows". For those disorders, however, in which "adjunct treatment" or "not indicated" received a high percentage of responses, most speciality groups were represented. Consistently, psychiatrists dominated the majority response across all speciality groups in the "adjunct treatment" category for specific disorders. The only exception was for fecal incontinence, in which the "not indicated" category received the majority response. These findings suggest that biofeedback, like other types of behavioral therapies, is supported as an "adjunct treatment" for some psychosomatic disorders. While it is too early to ascertain the role of biofeedback in the mainstream of medical treatment, its acceptance by the medical field will have an impact on its regulation. It is preferable for physicians to refer their patients to qualified biofeedback therapists for conditions that are amenable to treatment rather than having the public select therapists from the mass media. For this reason, studies on community acceptability are important educational means for physicians and biofeedback therapists to communicate and interact. The results of this survey magnified the need for more information on the use of behavioral therapies by physicians; in their responses to this questionnaire many participants expressed their interest in learning more about biofeedback.
REFERENCES Budzynski, T. Biofeedback in the treatment of muscle contraction (tension) headache. Biofeedback and Self-Regulation, 1978, 3, 409-434. Diamond, S., Diamond-Falk, J., & DeVeno, T. Biofeedback in the treatment of vascular headache. Biofeedback and Self-Regulation, 1978, 3, 385-408. Fernando, C. K., & Basmajian, J. V. Biofeedback in physical medicine and rehabilitation. Biofeedback and Self-Regulation, 1978, 3, 435-455. Fotopoulos, S. S., & Sunderland, W. P. Biofeedback in the treatment of psychophysiologic disorders. Biofeedback and Self-Regulation, 1978, 3, 331-362. Miller, N. E. Biofeedback and visceral learning. Annual Review of Psychology, 1978, 29, 373-404. Taub, E., & Stroebel, C. F. Biofeedback in the treatment of vasoconstrictive syndromes. Biofeedback and Self-Regulation, 1978, 3, 363-374. Whitehead, W. E. Biofeedback in the treatment of gastrointestinal disorders. Biofeedback and Self-Regulation, 1978, 3, 375-384. (Revision received July 23, 1981)