SZ: Did you participate in a competitive sport growing up?
Dr. Lagos: I did. As a high school athlete I was on the track team as well as the cross country team. In college at the University of Florida I rowed with the crew team.
SZ: Do you compete competitively now?
Dr. Lagos: I am an avid weekend warrior. I play golf, tennis, run and some dancing.
SZ: When did you become interested in biofeedback and the uses of biofeedback to help athletes?
Dr. Lagos: During graduate school at Rutgers University, I worked with Dr. Paul Lehrer who is well known for his work in heart rate variability biofeedback particularly to treat anxiety and health conditions related to anxiety. I approached him during graduate school because as a specialist in sport psychology I noted that about 90% of my athlete clients were coming to me struggling with, “How do I manage anxiety in sport?” I posed the question, “Do you think this could be helpful for enhancing performance?” That question was for the next seven years of my research and work with athletes using biofeedback to help reduce anxiety.
I began working with Dr. Lehrer and Dr. Evgeny Vaschillo, who had been the Russian physiologist for the Russian Olympic team many years ago. For two years I worked with the Rutgers golf team using biofeedback to enhance health and performance. We found that biofeedback had specific health benefits including, improving mood, reducing anxiety as well as some important performance benefits. Athletes who used to be affected by their anxiety could now perform at their peak during moments of challenge.
SZ: A sixteen year old golfer who has played for about four years currently plays and/or practices about two to three times a week. His goal is to play on the golf team at school but hasn’t made it yet. One area holding back his progress is that he has difficulty getting his momentum/focus going in the early rounds. It takes about two or three holes before he feel he settles into his game. How could biofeedback be useful to this player?
Dr. Lagos: It can be useful in the sense that anxiety and stress actually change how our body functions. It increases muscle tension, it changes our mood and it can impact our ability to focus. What we found with biofeedback is that as athletes improve their control over their autonomic nervous system they gain control over how their body responds to stress. One area that it impacts is gaining momentum or focus. His ability to manage stress would be significantly stronger after the biofeedback allowing him to have stronger focus, more effective focus, more efficient focus that happens more quickly as well as for a longer duration.
SZ: Over time this builds confidence in the athletes abilities.
Dr. Lagos: Absolutely.
SZ: What is an assessment of mental/emotional strengths? What does an assessment involve?
Dr. Lagos: The mental assessment usually occurs in the initial meetings in the office. I ask questions about their history of sport, their ability to manage stress and how they’ve coped with stress. I often times conduct a physiological assessment, called a Stress Profile. The Stress Profile has several different tasks such as counting backwards by seven, a Stroop Test, or when the client isn’t expecting it I clap my hands to create an unexpected scare. It allows me to see how their body actually reacts to the stressor. While the athlete is taking the test there are different physiological modalities that are being monitored including, galvanic skin response, brain activity, heart rate variability, respiration, and muscle tension. I look at how all of these areas respond during these different activities to see if there’s a particular area that we need to target and the areas that the athlete is particular strong in. Included in the assessment is having the athlete just talk to me about their perceived mental/emotional strengths and how they utilize these on the golf course. With all their physical training athletes tend to be very aware of their strengths.
Depending on the age of the golfer and with their permission, I may include the parent or a significant other in the assessment phase. What I’ve found is that parents, and significant others have a lot of specialized insight about the athlete that can expand the assessment of the athletes mental/emotional strengths.
SZ: Would you invite a coach in?
Dr. Lagos: In the very beginning just because the focus really is on the athlete and because the sessions are a confidential relationship, the parent knows, the significant other knows I don’t always bring the coach in.
SZ: A coach has such a powerful influence, the way that they deliver their verbal messages can influence the stress level of the athlete.
Dr. Lagos: Absolutely and what you’re saying is a very interesting point. There are certain types of athletes who I call physiologically gifted who have specialized responses to how coaches speak to them. In those cases I will bring a coach in, of course with the athletes approval, to help the coach learn about how their athlete actually has a physiological response to how they are being coached.
SZ: When a client begins a biofeedback training program how much time is spent in the office? How much if any time would be spent with the client on the golf course?
Dr. Lagos: The actual biofeedback training program requires meeting with me once a week for ten weeks in the office. The first year I worked with the Rutgers golf team I only met with the athletes in the office. At the end of our first year working together I asked them as a team about the process and how they liked it. They all loved it and asked me to work with them again the following year. This time though they asked for more training on how to actually use the skills on the golf course. So I implemented some virtual reality training sessions during week one, four, seven and ten at a virtual reality golf center. Being out on the golf course would have been just as effective but it was snowing at the time so this was the next best option.
SZ: Biofeedback is a process in that with low-tech, high-tech, or no-tech tools the client becomes aware of the interrelationship between the psychological and physiological processes of their body’s communication which is dynamic and bidirectional. With awareness and training clients can over time voluntarily learn how to change physiological activity. Biofeedback requires that the client practice at home. Generally how much individualized homework will the client be required to do on his/her own?
What type of equipment would a client expect to use?
Dr. Lagos: Initially the client learns to voluntarily change their physiological activity but the aim of this is that after ten weeks where the client meets with me once per week and practices breathing exercises at home twice a day for twenty minutes they gain the ability to regulate how their body responds to stress involuntarily. The goal of this is that they are training a muscle, the heart, how to respond on its own automatically during moments of stress. If an athlete before a meet or a tournament feels tremendous anxiety there is going to be a need to voluntarily change the physiological activity but there’s also moments during let’s say a basketball game where the athlete doesn’t have much time to voluntarily change it and that’s why we’re doing the training because the stress response becomes moderated by the improved autonomic control that’s garnered by the biofeedback. Over time it becomes an involuntary response. We’ve studied and documented it to see if we could make this a shorter or faster training. Every athlete wants to be able to come in here and do it after two sessions. It does not work like that. Ten sessions tends to be the rule of thumb that produces the greatest effect. We do see changes begin to start happening as soon as week four but the maximum changes tend to occur around or after week ten. I’ve had athletes that continue doing this after the ten weeks and we continue to see gains in most of these athletes.
SZ: In there any drop off after a certain amount of time?
Dr. Lagos: What we found is that they don’t have to continue practice the breathing exercises twice a day for twenty minutes a day after the initial ten weeks. After the initial training breathing can be practiced once a day for twenty minutes to maintain the same level. Some athletes during their sport season practice twice a day and in the off season drop off to once a day practices.
The only equipment the athlete needs at home is a Breath Pacer. It’s a pacer you can get for the i-phone or for your computer. There are several applications out where you can actually set the breathing pacer to what’s called resonance frequency. That’s the rate of breathing identified in here by me or another biofeedback practitioner. Resonance frequency produces optimal heart rate oscillation. Everyone has a different rate of breathing that produces optimal heart rate. Oscillation, meaning as you inhale your heart rate goes up and as you exhale your heart rate goes down. These changes reflect important changes in autonomic control.
SZ: If there are not any issues such as technical flaws, impeding performance how much time will it typically take before an athlete begins to notice improvement in their mental game? How is that level of improvement measured?
Dr. Lagos: If the athlete has been practicing at a hundred percent and meeting with me once a week we begin to notice improvements in their ability to focus, their mood, and reductions in anxiety at week four. Those changes tend to increase and amplify through week ten and beyond. We measure the level of improvement certainly in sport performance comparing it at week one, four, seven and ten. I also have them fill out a questionnaire regarding mood, regarding anxiety, and regarding muscle tension at those intervals. I have them complete a before and after Stress Profile that looks at the physiological modalities that I spoke about earlier, galvanic skin response, respiration rate, heart rate and we look at how the athlete is performing under stress, at week one versus week ten.
SZ: You were the lead author of “Virtual Reality Assisted Heart Rate Variability Biofeedback: A Strategy to Enhance Golf Performance,” published in AAPB’s Biofeedback Magazine in 2011. Explain in layman’s terms what virtual reality assisted heart rate variability biofeedback is and how would a player access this method of biofeedback?
Dr. Lagos: The golfers are playing golf through a program and what it allows us to do is to bring biofeedback into the golf setting. At the virtual reality center you can recreate specific courses that the athlete may play. You can also recreate sounds such as applause, which some golfers are sensitive to. The golfer in this setting can learn to access their breathing and through biofeedback mitigate their stress response. The virtual reality is a method to bring biofeedback breathing to the golf course so that it isn’t just a procedure the athlete learns in the office.
SZ: Do you hook the athlete you are working with up to a portable biofeedback monitoring system such as the NeXus?
Dr. Lagos: We used Polar devices. Watches and heart rate monitors strapped around the athlete’s chest. It was a way for us to collect data about the heart rate responses during stress. If you use the Thought Technology portable device you can now collect more data than through the Polar devices, which tracks heart rate.
SZ: Moving away from the topic of golf for a moment you have been doing research on the impact of ten weeks of heart rate variability biofeedback training on the post concussion symptoms of young athletes who have experienced mild traumatic brain injuries. What are some of the findings you have discovered through this research?
Dr. Lagos: In terms of post concussion syndrome as we know both in the news and research there is an increasing problem not only with professional athletes but athletes who make up the largest population, youth athletes. Post concussion is defined as having symptoms related to concussion for three weeks or longer. It means that some athletes are not healing within the normal time frame. Traditional therapies have included such things as cognitive behavioral therapy as well as anti-depressants and they’ve had limited effectiveness in actually treating post concussion syndrome.
About seven years ago I was at the University of Miami and a neurologist called me and said, “Dr. Lagos I have an athlete here who has had her second concussion. Medicine isn’t working, therapy isn’t working. Do you think your biofeedback can help her.” I said that there is no evidence at this time that heart rate variability biofeedback can improve brain functioning but I told him the if she is experiencing depression, anxiety, and problems focusing, biofeedback is likely to help her. He then referred the athlete to me.
This athlete has given me permission to discuss her case. In fact this athlete has created a non-profit organization for athletes who are suffering from post concussion syndrome. She came to me and her mood improved by about week six. Her anxiety reduced and around week seven she came in and said, “Dr. Lagos I can read again. I haven’t been able to read past three sentences in over six months. It’s due to biofeedback.” I said there’s really not a ton of research in this area, it’s an interesting concept but let’s not be too hasty, although we will continue doing it.
I told this story to a sport medicine doctor who was treating high school athletes with post concussion syndrome in New Jersey. He said, “Well if you can tell me you can improve the mood, reduce the anxiety and enhance the focus of kids who are simply not able to attend school because they are laying in bed and don’t have any other alternative, I think it’s a great option.” In the past three years this doctor has sent me over thirty high school athletes with this debilitating condition. What I began finding is that at week seven they are reporting the same types of results as my athlete at the University of Miami. Biofeedback treatment was not only improving mood, reducing anxiety and enhancing focus this was impacting their cognitive functioning. So I published my first case study in this area. It was the first and only research in this area about the potential for this to help athletes who are suffering from post concussion syndrome.
We found in this case study and reported that several symptoms of the concussion had reduced. Not just anxiety but headaches had decreased and then there was also some shifts in cognitive functioning that prior to working with biofeedback hadn’t changed. We need further studies and I’ve recommended along with my colleagues who co-authored the article with me that further studies be conducted in a randomized controlled trial.
SZ: Biofeedback requires a state of self reflection and inner connection which is sometimes a challenge for young athletes to access within themselves. What advice do you have that works to keeps these kids using biofeedback long enough so they understand they do have the capability to manage their mind/body connection?
Dr. Lagos: After about two weeks the athletes I work with see, feel and embrace the changes of being able to control their stress response and it’s only the beginning. It becomes self reinforcing. The first two weeks I say to them, “Let’s set some clear goals. What do you want out of this process? Let’s stay very focused on these goals and keep checking in with these goals every three weeks and see how you are doing with your progress.” I tell them upfront that they are not going to feel much of a change except it’ll be slightly more relaxing and they may sleep a little bit better. After about four weeks they will notice some difference. It takes about a month, although after two weeks there’s enough change and it’s reinforcing.
SZ: How do you monitor the quality of the practices?
Dr. Lagos: It’s generally self report. I ask them to fill out a training card for each of their practices. The cards have fields to write in the time they start, the time they finish and their mood on the scale of one to four. For example recording their level of anxiety, level four would be the highest and level one the lowest level of anxiety. We track those changes over time and we have data for each of their breathing sessions for the ten weeks.
SZ: Do you have an upcoming appearances, or research coming out that you would like the public to be aware of?
Dr. Lagos: I will be speaking at the University of Florida, Nov. 15th with their academic and athletic faculty about, “Optimizing Health and Performance for Collegiate Students and Athletes.”
SZ: Dr. Lagos thank you for taking the time out of your busy schedule to share how you utilize biofeedback with athletic performance.
*Featured guests are not current nor former clients of Susan Zaro
*The article may also be read @ Examiner
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