We have just returned from the 14th annual meeting of The American Academy of Pain Management. It was held in Denver at the Adam’s Mark Hotel, where the AAPB had its meeting two years ago. The organization is relatively young. It is reminiscent of the biofeedback community in several ways: It has a multi-disciplinary membership and attendance. It favors a multi-disciplinary approach to its subject. It also feels itself on the outside of the mainstream. Pain has not been taken seriously as a discipline within medicine for very long. And many of the conditions treated—such as fibromyalgia, chronic fatigue syndrome, and multiple chemical sensitivity—themselves have an equivocal status within medicine. Hence there is a sense of second-class citizenship just as we suffer in biofeedback. There is the wish to be recognized within the larger medical community, of a message not being heard, and of the message being preached to the choir. The exhibit area was flooded with gadgetry from various sources, and here Chinese herbal remedies were to be found shoulder to shoulder with ionic detoxifying baths and infrared healing wands. It was quite the bazaar for the gadgeteer.

The differences between the AAPM and the AAPB were just as pronounced, however. Attendees were mostly MDs, and clearly these were the ones who were willing to think independent thoughts. They were predominantly clinicians from the trenches rather than researchers from academia. In other words, they had all been humbled by the intractability of chronic pain in their own practice, and of the inadequacy of any simple models. Another significant point of difference was that the nametags did not show pedigree, so you could not tell who was an MD and who was not. That meant everyone had to treat everyone else respectfully, both in the lecture halls and in the exhibit area.

Psychology was the only discipline represented here that proscribed certain courses as being unsuitable for CEs for psychologists. What was good enough for the MDs was not necessarily good enough for the psychologists. Not only that, but the psychologists were the only ones who had to have the lecturer certify their attendance personally at every session. This meant that at the end of the lectures, the speakers would be besieged by a horde of psychologists who needed the initials on their individual record sheets. This looked worse than high-schoolish.

Jeff Cram had set up a track on biofeedback as one of four offerings on Saturday. Sue had been invited to talk about neurofeedback. Marjorie Toomim contributed a talk on SMEG work with fibromyalgia; Jeff Cram talked on his SEMG work; Frank Andrasik talked about migraine research with conventional biofeedback; and Rollin McCraty talked about Heart Rate Variability training.

Sue may have had as many as 200 in attendance at her lecture, which was quite well received. Most pain clinics offer conventional biofeedback, but it clearly plays somewhat of a marginal role in most of them. Even more people give biofeedback lip service. But most are also prepared to hear that neurofeedback deserves their further attention. Several commented to Sue afterwards that hers was the most outstanding presentation that they had yet heard at the conference. Another attendee told Sue of her relief in hearing the lecture. As a long-term biofeedback practitioner she had just taken up neurofeedback, and found herself denounced by her biofeedback colleagues as an apostate. Is this still possible in this day and age? The field of biofeedback is sometimes its own worst enemy.

We are going to post Sue’s presentation on the Bulletin Board, although most of it won’t be news to this list. You may want to scavenge the introductory material for your own use in presentations, and then there is Sue’s take on the current state of our work with migraines, Reflex Sympathetic Dystrophy, etc.

At this conference I got a good update and exposure to current work in Cortical Electrical Stimulation. The presentation was by Daniel L. Kirsch, PhD, who is chairman of Electromedical Products International, Inc., of Mineral Wells, Texas, and Hong Kong, PRC. He is the author of “The Science Behind Cranial Electrotherapy Stimulation,” 2nd ed. 2002. Kirsch is another one of the pioneers whose battles prepared the ground for our current successes, such as they are. He fought the battle with the FDA over his device, the Alpha-Stim, eventually having to take the FDA to court to gain approval. His challenge was a bit greater than ours, since the technique hardly qualifies as non-invasive. Kirsch now refers to the FDA as the Faster Death Agency.

Kirsch has an interesting take on the matter of negative effects, which can also occur with CES. He says simply that the technique cannot be judged by its first session—that he cannot necessarily predict what the response might be to the first session. On the other hand, he is confident that he can predict the outcome of the twentieth, and that negative effects will then no longer be the issue. The treatment must be judged as a whole. We can take a leaf out of his book in that regard.

A related talk on the use of CES with psychiatric conditions was given by Rosemary Pitt, a psychiatrist. She had muttered something about snake oil while passing Kirsch’s exhibit hall display at a prior conference, and Kirsch challenged her to try the technique. As it turns out, she was bearing her own burdens with regard to insomnia and fatigue. Her husband remained skeptical. The next day, when it came time for her appointed session at the booth, her husband had taken her slot. He had seen more change in his wife than she herself had observed….

One year hence, and she has some 150 of her active patients on the Alpha-Stim, and she was here to talk about it. She talked about a patient with schizoaffective disorder, with whom she had tried all the anti-psychotics. Within five minutes of the first application of CES, the man’s tremors stopped, and his legs stopped shaking. With more extended treatment, he came off all his neuroleptics. He was once again able to leave the house, to which his prior fears had bound him. The technique, however, had no impact whatsoever on his insomnia.

She talked about a violent, bipolar kid, for whom none of the drugs worked. He was often placed in restraints while in treatment. Within five minutes of application of CES, a violent episode was aborted. With extended treatment, he came off all meds. Pitt also reported the case of an autistic child, who with extended treatment went from having a vocabulary of some 150 isolated words went to speaking in full sentences, and no longer required one-on-one attendance at all functions. Finally, there was the case of the patient who had undergone multiple surgeries. With CES, he came off $2000 per month in pain medications and went back to work.

“I am happy to be losing patients left, right, and center,” said Dr. Pitt. As for insurance coverage, Pitt said that at CIGNA “someone is trying to get it approved through the committee.” She now rents the units out for $75 per month, and if usage extends to as much as eight months, the patient owns the unit.

After the lecture I asked an obvious question. “Have you ever used CES with someone whom you or your colleagues would consider to be a candidate for ECT, with someone in agitated depression, or with someone undergoing a suicidal episode?” Dr. Pitt said that she was very reluctant to order ECT, and that in fact she had used CES to abort a nocturnal suicidal event. The patient had the unit available, so she was obviously doing CES on an ongoing basis. The prior exposure had not been sufficient to forestall the suicidal episode, but it was sufficient to abort it.

CES needs to be administered and supervised by a licensed health professional. The Alpha-Stim unit needs to be purchased with the authorization of such a professional. The FDA rules restrict the sales of these devices to those individuals who can see, diagnose, and treat the condition for which the product is marketed. This includes non-physician and even non-medical personnel.

Steve Mann reported at the conference that he obtained explicit authorization from his psychology board in Vermont to use CES in his practice years ago. New Jersey followed suit in 1998. The technique has now been in use for some twenty-two years, and there have been no reports of adverse incidents to the FDA over that timeframe, after an estimated 12 million users.

From Steven Mann:
ASPPB Guidelines III A3
“Adding new services and techniques.” The psychologist, when developing competency in a service or technique that is either new to the psychologist or new to the profession, shall engage in ongoing consultation with other psychologists or relevant professionals and shall seek appropriate education and training in the new area. The psychologist shall inform clients of the innovative nature and the known risks associated with the services so that the client can exercise freedom of choice concerning such services.

The overlap with what we do well with neurofeedback is obvious from the above. There is also similarity with respect to the need for some continuing level of exposure in many severe cases. Hence the case for home use. I find myself thinking that CES may be a good kick-start for many of our clients. Likely there would be no problem in using it in conjunction with neurofeedback. Also, some might find home use easier and more affordable with CES than with neurofeedback. So if CES is found to be helpful, it could be installed as the home use component of a continuing program in clinical neurofeedback.

One should perhaps not judge CES any more than neurofeedback by the isolated case report of miraculous outcomes. But since we have difficulty predicting the outcome of early sessions with our most difficult clients, having something else in the arsenal to draw upon for stabilization seems like a good idea. The advantage with the CES is that there is virtually no clinical decision to be made. The device operates either at 0.5 Hz or at 100 Hz, and on general principles (i.e., given what we know about trauma encoding at low frequency) I would avoid the low frequency mode altogether.

One does have to decide on current level, and in this regard, it is perhaps wise to start with current values below 100uA, which are not sensed by the client. One can become adventuresome later. Then there is the issue of duration of training, and again it might be advisable to start with brief exposures such as could readily be fitted into a neurofeedback session. Ultimately it may be possible simply to combine the techniques, so that there is a level of stimulation while the person is undergoing neurofeedback training.

In our clinic, and in our philosophical musings, we have always preferred the training model and have stayed away from anything that could be considered invasive, or from anything that looks like a “procedure” delivered to the client passively. There is a clear case to be made for staying consistently in the mode of treatment that is evocative of the person’s own capacities through a purely training model. We also believe that our particular mission is to stay close to the training model. For those similarly inclined, there is the possibility of partnering with another professional who would supervise the CES.

There is at least one circumstance where a passive procedure is devoutly to be wished, and that is in the case of autism, where we often have a challenge during the first few sessions with tolerating the electrodes, etc. The CES, by contrast, can be administered during sleep, and thus could potentially prepare the ground for neurofeedback

With the above as a background, I chatted with Caroline Grierson about her use of the Alpha-Stim technique. She offers the unit to her pain patients to try out, and if it benefits them, they can purchase it or have the insurance company cover it for them. Of those who have chosen to pursue the Alpha-Stim beyond that initial trial period, some 16 of 20 have found some continuing benefit. Some use it to extend the benefit of neurofeedback beyond the period where it would usually fade. Some use it as an aid in going to sleep. Some use it for activation, others for calming. Some report that it allows them to tolerate their pain better. Over-use can cause difficulties with sleep onset in some cases. All these reports sound familiar to those working with neurofeedback. Yet none of the patients see the Alpha-Stim as a replacement for neurofeedback. The effect is apparently not the same, and the technique lacks the learning component of neurofeedback that leads to cumulative improvement over time

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