Applied Psychophysiology and Biofeedback

, Volume 35, Issue 3, pp 199–206 | Cite as

Restoration of Vagal Tone: A Possible Mechanism for Functional Abdominal Pain

  • Erik Sowder
  • Richard GevirtzEmail author
  • Warren Shapiro
  • Crystal Ebert


Functional abdominal pain (FAP) causes disruption of daily activities/missed school days, over utilization of healthcare, unnecessary surgeries, and anxiety in 10–15% of children. Its etiology is not clearly understood, however the success of several clinical protocols suggests that autonomic dysregulation is a factor. In this study autonomic activity, including heart rate variability (HRV), was compared between children with FAP and a comparison group. Twenty children with FAP and 10 children without FAP between the ages of 5 and 17 years old were compared on autonomic regulation using an ambulatory system at baseline and 8 weeks later. Children with FAP participated in 6 sessions of HRV biofeedback aimed at normalizing autonomic balance. At baseline, children with FAP appear to have more autonomic dysregulation than children without FAP. After completing HRV biofeedback, the FAP group was able to significantly reduce their symptoms in relation to significantly increasing their autonomic balance. In a sample of children with FAP, it appears that HRV biofeedback treatment improved their symptoms and that a change in vagal tone was a potential mediator for this improvement. The present study appears to point to excessive vagal withdrawal as an underlying mechanism of FAP.


Recurrent abdominal pain FAP Vagal tone Biofeedback 


  1. Adeyemi, E. O., Desai, K. D., Towsey, M., & Ghista, D. (1999). Characterization of autonomic dysfunction in patients with irritable bowel syndrome by means of heart rate variability studies. American Journal of Gastroenterology, 94(3), 816–823.CrossRefPubMedGoogle Scholar
  2. Aggarwal, A., Cutts, T. F., Abell, T. L., Cardoso, S., Familoni, B., Bremer, J., et al. (1994). Predominant symptoms in irritable bowel syndrome correlate with specific autonomic nervous system abnormalities. Gastroenterology, 106(4), 945–950.PubMedGoogle Scholar
  3. Apley, J., & Naish, N. (1958). Recurrent abdominal pains: A field survey of 1,000 school children. Archives of Disease in Childhood, 33(168), 165–170.CrossRefPubMedGoogle Scholar
  4. Bassotti, G., & Whitehead, W. E. (1994). Biofeedback as a treatment approach to gastrointestinal tract disorders. American Journal of Gastroenterology, 89(2), 158–164.PubMedGoogle Scholar
  5. Berger, R. D., Akselrod, S., Gordon, D., & Cohen, R. J. (1986). An efficient algorithm for spectral analysis of heart rate variability. IEEE Transactions on Biomedical Engineering, 33(9), 900–904.CrossRefPubMedGoogle Scholar
  6. Berntson, G. G., Bigger, J. T., Jr., Eckberg, D. L., Grossman, P., Kaufmann, P. G., Malik, M., et al. (1997). Heart rate variability: Origins, methods, and interpretative caveats. Psychophysiology, 34, 623–648.CrossRefPubMedGoogle Scholar
  7. Borge, A. I., & Nordhagen, R. (1995). Development of stomach-ache and headache during middle childhood: Co-occurrence and psychosocial risk factors. Acta Paediatrica, 84(7), 795–802.CrossRefPubMedGoogle Scholar
  8. Bremner, A. R., & Sandhu, B. K. (2009). Recurrent abdominal pain in childhood: The functional element. Indian Pediatrics, 46(5), 375–379.PubMedGoogle Scholar
  9. Clouse, R. E., Mayer, E. A., Aziz, Q., Drossman, D. A., Dumitrascu, D. L., Monnikes, H., et al. (2006). Functional abdominal pain syndrome. Gastroenterology, 130(5), 1492–1497.CrossRefPubMedGoogle Scholar
  10. DiPalma, A. M., & DiPalma, J. A. (1997). Recurrent abdominal pain and lactose maldigestion in school-aged children. Gastroenterology Nursing, 20(5), 180–183.CrossRefPubMedGoogle Scholar
  11. Edwards, M. C. F., & Bonner, J. W. M. (1991). Matching treatment with recurrent abdominal pain symptoms: An evaluation of dietary fiber in relaxation treatments. Behavior Therapy, 20, 283–291.Google Scholar
  12. Feldman, W., McGrath, P., Hodgson, C., Ritter, H., & Shipman, R. T. (1985). The use of dietary fiber in the management of simple, childhood, idiopathic, recurrent, abdominal pain. Results in a prospective, double-blind, randomized, controlled trial. American Journal of Diseases of Children, 139(12), 1216–1218.PubMedGoogle Scholar
  13. Feuerstein, M., Barr, R. G., Francoeur, T. E., Houle, M., & Rafman, S. (1982). Potential biobehavioral mechanisms of recurrent abdominal pain in children. Pain, 13(3), 287–298.CrossRefPubMedGoogle Scholar
  14. Fritz, G. K., Fritsch, S., & Hagino, O. (1997). Somatoform disorders in children and adolescents: a review of the past 10 years. Journal of the American Academy of Child and Adolescent Psychiatry, 36(10), 1329–1338.CrossRefPubMedGoogle Scholar
  15. Garber, J., Van Slyke, D. A., & Walker, L. S. (1998). Concordance between mothers’ and children’s reports of somatic and emotional symptoms in patients with recurrent abdominal pain or emotional disorders. Journal of Abnormal Child Psychology, 26(5), 381–391.CrossRefPubMedGoogle Scholar
  16. Gevirtz, R. (2000). Resonant frequency training to restore homeostasis for treatment of psychophysiological disorders. Biofeedback, 27, 7–9.Google Scholar
  17. Gupta, V., Sheffield, D., & Verne, G. N. (2002). Evidence for autonomic dysregulation in the irritable bowel syndrome. Digestive Diseases and Sciences, 47(8), 1716–1722.CrossRefPubMedGoogle Scholar
  18. Huertas-Ceballos, A., Logan, S., Bennett, C., & Macarthur, C. (2008a). Pharmacological interventions for recurrent abdominal pain (RAP) and irritable bowel syndrome (IBS) in childhood. Cochrane Database System Review, (1), CD003017.Google Scholar
  19. Huertas-Ceballos, A., Logan, S., Bennett, C., & Macarthur, C. (2008b). Psychosocial interventions for recurrent abdominal pain (RAP) and irritable bowel syndrome (IBS) in childhood. Cochrane Database System Review, (1), CD003014.Google Scholar
  20. Humphreys, P. A., & Gevirtz, R. N. (2000). Treatment of recurrent abdominal pain: components analysis of four treatment protocols. Journal of Pediatric Gastroenterology and Nutrition, 31(1), 47–51.CrossRefPubMedGoogle Scholar
  21. Hyams, J. S., Burke, G., Davis, P. M., Rzepski, B., & Andrulonis, P. A. (1996). Abdominal pain and irritable bowel syndrome in adolescents: A community-based study. Journal of Pediatrics, 129(2), 220–226.CrossRefPubMedGoogle Scholar
  22. Jansdottir, G. (1997). The relationship between pains and various discomforts in school children. Childhood: Global Journal of Child Research, 4, 491–504.Google Scholar
  23. Karling, P., Nyhlin, H., Wiklund, U., Sjoberg, M., Olofsson, B. O., & Bjerle, P. (1998). Spectral analysis of heart rate variability in patients with irritable bowel syndrome. Scandinavian Journal of Gastroenterology, 33(6), 572–576.CrossRefPubMedGoogle Scholar
  24. Kent, L., O’Neill, B., Davison, G., Nevill, A., Elborn, J. S., & Bradley, J. M. (2009). Validity and reliability of cardiorespiratory measurements recorded by the LifeShirt during exercise tests. Respir Physiol Neurobiol, 167(2), 162–167.CrossRefPubMedGoogle Scholar
  25. Kristjansdottir, G. (1996). Sociodemographic differences in the prevalence of self-reported stomach pain in school children. European Journal of Pediatrics, 155(11), 981–983.CrossRefPubMedGoogle Scholar
  26. Lee, C. T., Chuang, T. Y., Lu, C. L., Chen, C. Y., Chang, F. Y., & Lee, S. D. (1998). Abnormal vagal cholinergic function and psychological behaviors in irritable bowel syndrome patients: a hospital-based Oriental study. Digestive Diseases and Sciences, 43(8), 1794–1799.CrossRefPubMedGoogle Scholar
  27. Lehrer, P. M., Vaschillo, E., & Vaschillo, B. (2000). Resonant frequency biofeedback training to increase cardiac variability: Rationale and manual for training. Appl Psychophysiol Biofeedback, 25(3), 177–191.CrossRefPubMedGoogle Scholar
  28. Lehrer, P. M., Vaschillo, E., Vaschillo, B., Lu, S. E., Eckberg, D. L., Edelberg, R., et al. (2003). Heart rate variability biofeedback increases baroreflex gain and peak expiratory flow. Psychosomatic Medicine, 65(5), 796–805.CrossRefPubMedGoogle Scholar
  29. Mortimer, M. J., Kay, J., Jaron, A., & Good, P. A. (1992). Does a history of maternal migraine or depression predispose children to headache and stomach-ache? Headache, 32(7), 353–355.CrossRefPubMedGoogle Scholar
  30. Naliboff, B., Fullerton, S.,& Mayer, E. (1999). Measurement of symptoms in irritable bowel syndrome clinical trials. American Journal of Medicine, 81s–84s.Google Scholar
  31. Oster, J. (1972). Recurrent abdominal pain, headache and limb pains in children and adolescents. Pediatrics, 50(3), 429–436.PubMedGoogle Scholar
  32. Parcel, G. S., Nader, P. R., & Meyer, M. P. (1977). Adolescent health concerns, problems, and patterns of utilization in a triethnic urban population. Pediatrics, 60(2), 157–164.PubMedGoogle Scholar
  33. Poole, S. R. (1984). Recurrent abdominal pain in childhood and adolescence. American Family Physician, 30(2), 131–137.PubMedGoogle Scholar
  34. Sanders, M., Morrison, M., Rebgetz, M., Bor, W., Dadds, M., & Shepherd, R. (1990). Behavioral treatment of childhood recurrent abdominal pain: Relationships between pain, children’s psychological characteristics and family functioning. Behaviour Change, 7, 16–24.Google Scholar
  35. Sanders, M. R., Rebgetz, M., Morrison, M., Bor, W., Gordon, A., Dadds, M., et al. (1989). Cognitive-behavioral treatment of recurrent nonspecific abdominal pain in children: An analysis of generalization, maintenance, and side effects. Journal of Consulting and Clinical Psychology, 57(2), 294–300.CrossRefPubMedGoogle Scholar
  36. Sanders, M. R., Shepherd, R. W., Cleghorn, G., & Woolford, H. (1994). The treatment of recurrent abdominal pain in children: a controlled comparison of cognitive-behavioral family intervention and standard pediatric care. Journal of Consulting and Clinical Psychology, 62(2), 306–314.CrossRefPubMedGoogle Scholar
  37. Saps, M., Youssef, N., Miranda, A., Nurko, S., Hyman, P., Cocjin, J., et al. (2009). Multicenter, randomized, placebo-controlled trial of amitriptyline in children with functional gastrointestinal disorders. Gastroenterology, 137(4), 1261–1269.CrossRefPubMedGoogle Scholar
  38. Schrof, J. (1997). Easing hurt in small bodies. US News and Worls Report, 57.Google Scholar
  39. Smart, H. L., & Atkinson, M. (1987). Abnormal vagal function in irritable bowel syndrome. Lancet, 2(8557), 475–478.CrossRefPubMedGoogle Scholar
  40. Smith, M. S., & Womack, W. M. (1987). Stress management techniques in childhood and adolescence. Relaxation training, meditation, hypnosis, and biofeedback: Appropriate clinical applications. Clinical Pediatrics, 26(11), 581–585.CrossRefPubMedGoogle Scholar
  41. Turck, D. (1998). Chronic abdominal pain in children. Revue du Praticien, 48(4), 369–375.PubMedGoogle Scholar
  42. Vlieger, A. M., Menko-Frankenhuis, C., Wolfkamp, S. C., Tromp, E., & Benninga, M. A. (2007). Hypnotherapy for children with functional abdominal pain or irritable bowel syndrome: A randomized controlled trial. Gastroenterology, 133(5), 1430–1436.CrossRefPubMedGoogle Scholar
  43. Walker, L. S., Guite, J. W., Duke, M., Barnard, J. A., & Greene, J. W. (1998). Recurrent abdominal pain: A potential precursor of irritable bowel syndrome in adolescents and young adults. Journal of Pediatrics, 132(6), 1010–1015.CrossRefPubMedGoogle Scholar
  44. Weydert, J. A., Ball, T. M., & Davis, M. F. (2003). Systematic review of treatments for recurrent abdominal pain. Pediatrics, 111(1), e1–e11.CrossRefPubMedGoogle Scholar
  45. Whitehead, W. E. (1992). Biofeedback treatment of gastrointestinal disorders. Biofeedback and Self Regulation, 17(1), 59–76.CrossRefPubMedGoogle Scholar
  46. Whitehead, W. E. (1996). Psychosocial aspects of functional gastrointestinal disorders. Gastroenterology Clinics of North America, 25(1), 21–34.CrossRefPubMedGoogle Scholar
  47. Wood, B., Watkins, J. B., Boyle, J. T., Nogueira, J., Zimand, E., & Carroll, L. (1989). The “psychosomatic family” model: An empirical and theoretical analysis. Family Process, 28(4), 399–417.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2010

Authors and Affiliations

  • Erik Sowder
    • 1
  • Richard Gevirtz
    • 1
    Email author
  • Warren Shapiro
    • 2
  • Crystal Ebert
    • 1
  1. 1.CSPP@Alliant International UniversitySan DiegoUSA
  2. 2.Kaiser PermanenteSan DiegoUSA

Personalised recommendations