AAPB White Paper
Biofeedback Treatment of Primary Raynaud´s in Baltimore, MD
Keith Sedlacek, M.D.

Raynaud's is a spasm of the arterioles of the fingers, toes or other extremities (ears, nose). It is approximately five times more common in women than men. The symptoms usually consists of a blanching (white, then blue and/or red) with numbness and pain, usually on both sets of fingers. In about 0.5 % of the cases it can progress to amputation. Primary Raynaud's is also called Raynaud's disease. This was described in 1862 by the French physician Raynaud.

The most common stress that triggers the spasm and change in color (from a healthy pink to a white, blue or red color) is cold or emotional stress. When air temperature falls below about 50 - 60'F. it may trigger spasms in the fingers or toes (with or without pain).Thus, going out on a cold day, grabbing a cold steering wheel, or reaching in and getting frozen food out of a freezer can trigger an attack. A cool or cold swimming pool or ocean can also trigger an attack. Most commonly, both cold stresses and/or emotional stresses trigger the spasms. If people are excited, frightened or exhausted this may trigger an attack. People may have as few as one or two attacks per day or have as many as five to twenty. Although warm weather does help, people even have attacks in tropical climates.

Secondary Raynaud's (also called Raynaud's Phenomenon) is secondary to another disease or disorder and can be caused by diseases such as arteriosclerosis, reaction to toxic chemicals, trauma or blockage in the artery (or arterioles). Some diseases that cause secondary Raynaud's are scleroderma, lupus, rheumatoid arthritis, leukemia and myeloma. Approximately 3 to 9 % of primary Raynaud's patients will go on to develop connective tissue disease (secondary Raynaud's).

Diagnosis of Raynaud's should include an examination by a physician and a complete history as well as laboratory tests including complete blood chemistries, urinalysis and antinuclear antibodies.

The most common treatment in the past has been the suggestion to move to a warmer climate or to use specific drugs (vasodilators) that open the arteries. These drugs often have upsetting and negative side effects. Generally they are used for a very short period of time such as for cold exposure (Alaska) or if the physician feels the negative side effects are outweighed by the benefits of chemically opening the arteries. Patients also need to stop smoking. Nicotine tightens down the arteries (vasoconstricts) and worsens Raynaud's. Smoking also increases blood viscosity and can make the blood flow less smoothly which also can trigger some attacks. Also caffeine should be avoided since it initially opens up the arteries; however, arteries and arterioles then tighten down and can trigger an attack.

Over the last decade, behavioral treatments have begun to be clinically available and have proven to be helpful for 80 to 92 % of Raynaud's patients. Biofeedback treatment can train the arteries and arterioles to open up, thus warming the fingers and toes. Clinical and double blind control studies published by Freedman showed a 92% reduction in symptoms with 20 treatment sessions. This reduction continue to be shown at one and three year follow up. Clinical reports and studies by Sedlacek, Taub and Stroebel have also shown temperature biofeedback as an effective treatment. What is important is that the patients practice regularly once or twice a day to obtain a skill in raising the skin temperature. Raynaud's patients can show normal skin temperature. In a 72 to 74 degree room, skin temperature should be above 86 ° for women and above 87' for men. With biofeedack treatment, skin temperature should be trained to increase above 93 to 94 degrees (some believe that 95 ° produces even better results). Patients also need to develop a skill in warming quickly. That is at least one or two degrees within one to two minutes, so as to keep the arteries and arterioles from closing. This skill can reduce or stop the painful attack and spasm. Most patients require twice a day practice sessions from 10 to 20 minutes with home equipment. Home practice need to be continued from 12 to 18 months to get maximum results. This means patients must practice through the following winter. Patients below 30 years of age can often be treated in from 10 to 20 treatments depending on the number of digits involved and the number of additional diseases or disorders. The older the patient, the more digits involved, and the greater the number of diseases and disorders, the longer the treatment for a successful result. If the patient is middle aged (35 to 60) or older and has several digits involved, it can require up to 20 to 35 treatment sessions. Some biofeedback clinicians start with two to four treatments with electromyography (EMG) for muscle relaxation, followed by 8 to 30 treatments with temperature feedback.

Biofeedback is helpful in secondary Raynaud's by reducing some of the symptoms of secondary Raynaud's through increasing peripheral blood flow. Between 15 and 35 sessions are usually required depending on the age of the patient and the severity of symptoms, and how many other diseases or disorders are present.

The crucial points of biofeedback treatment are 1) the biofeedback equipment and training, 2) the acquisition of handwarming skills, 3) use of home equipment and 4) the transfer of the handwarming skills into everyday life to reduce or stop the attacks.

Primary Raynaud's is treated successfully in 80 to 90% of cases with 10-30 biofeedback treatments. The treatment "package" should include home practice with home equipment so that handwarming skill can be developed and transferred into daily life. Up to a 92% reduction of symptoms can be produced, healing of skin ulceration occurs more rapidly and patients develop new mental and physical skills which help them in their daily life.

Freedman, R.R., Ianni, P., & Wenig, P. (1983). Behavioral treatment of Raynaud's disease. Journal of Consulting and Clinical Psychology, 51(4), 539-549.

Freedman, R.R., Ianni, P., & Wenig, P. (1985). Behavioral treatment of Raynaud's disease: Long term follow-up. Journal of Consulting and Clinical Psychology, 53(1), 136.

Freedman, R.R., Lynn, S.J., lanni, P., & Hale, P.A. (1981). Biofeedback treatment of Raynaud's disease and phenomenon. Biofeedback and Self-Regulation, 6(3), 355-365.

Freedman, R.R.(1987). Long-term effectiveness of behavioral treatments of Raynaud's disease.Behavior Therapy, 18, 387-399.

Yocum, D.E., Hodes, R., Sundstrom, W.R., & Cleeland, C.S. (1985). Use of biofeedback training in treatment of Raynaud's disease and phenomenon. The Journal of Rheumatology, 12(1), 90-93.