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The primary objective of our ongoing research AFTE was fi rst tested as a treatment for motion program is to develop a behavioral method for fa- sickness. Because this malady is characterized by cilitating adaptation to space and readaptation to disturbances in autonomic nervous system func- Earth. This method, Autogenic Feedback Training tion involving many organ systems to varying de- Exercise (AFTE), is a combination of biofeedback grees across individuals, it was necessary to devel-and Autogenic Therapy (AT), which involves train- op a method for training individuals to simultane- ing subjects to voluntarily control up to 20 physi- ously control multiple responses. The training was
ological responses in 6 hours. AT was found useful tailored for each subject with emphasis placed for eliciting autonomic responses via techniques on those physiological variables that were most such as imagery, which was used to speed up the responsive to motion sickness stimulation. Re- elicitation of the correct autonomic response. sults of ground based studies indicate that AFTE Then biofeedback was used to reward and in- is eff ective for both men and women of diff erent crease the strength of that response. When AT is age groups and occupations, the training eff ects administered by a therapist without biofeedback transfer across a variety of motion sickness stimuli, displays, it can require up to 18 months to become and learned control is retained up to three years. eff ective, and biofeedback without the guided Clinical studies of patients with vestibular or au-imagery of AT produces considerable variability tonomic pathologies have shown that AFTE pro-in learning ability. AFTE is not simply a relaxation vides substantial relief from symptoms of nausea training paradigm, but rather involves "exercis- and syncope.
ing smooth muscle", because subjects are taught Figure 1 shows a list of the 20 physiological re- to both increase and decrease physiological re- sponses that subjects are taught to control and sponse levels (e.g., vasoconstriction alternating a detail of one of the training screens (screen 1, with vasodilatation of peripheral blood vessels, not shown, displays analog waveforms of these blood pressure increases and decreases, etc.). parameters) used during these training sessions. Changes in response levels are achieved through With this unique AFTE software, the trainer can alternating imagery of "emotional" stimuli and re- choose which displays to provide to subjects. Ro- laxation, where signifi cant learning is achieved in tating chair tests were used as the metric for de- only 6 hours of training.
termining the eff ectiveness of AFTE for symptom suppression. To induce motion sickness symptoms, Left fi nger pulse volume Right fi nger pulse volume Skin Conductance Level Left and temperature Blood fl ow – head Blood fl ow – toe left arm electromyography right arm electromyography left leg electromyography right leg electromyography Systolic blood pressure Diastolic blood pressure Mean arterial pressure Thoracic fl uid volume Total peripheral resistance Left, List of Physiological Responses Used in AFTE, Right Trainer's Console.
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Before AFT E
z-scores 000
After AFT E
bvp rh=blood fl ow to right hand, rr=respiration rate, hr=heart rate, scl=skin conductance Physiological Response Profi le of a Crewman Before & After AFTE.
rotation was initiated at 6 rpm, and the speed in- vals) before AFTE and following 2, 4 and 6 hours creased in 2 rpm increments at 5 minute intervals. of training. Successful training is achieved when During each 5 minute period, subjects executed subjects can: signifi cantly increase the number of 150 head movements (left, right, front and back rotations tolerated, report fewer (or no) symptoms in random order) at 2 second intervals. After each and show reduced physiological response magni- 5 minute interval at a constant velocity, subjects tudes. Figure 2 shows an example of one Shuttle were asked to report their symptom levels using crewmember's physiological response profi le be-a standardized diagnostic scale. The test contin- fore and after training. Responses are normalized ues until the subject requests a stop, the investiga- (z-scored) so that all parameters can be shown on tor decides to stop, or until completing 65 minutes the same graph. A mean and standard deviation of rotation with a top speed of 30 rpm. Rotating are calculated on a 10 minute pre-test baseline chair tests are administered (at one week inter- (setting means to zero and changes from baseline No Treatment Control 6 hrs - AFTE
4 hrs-AFTE
2 hrs-AFTE
rotating chair tests
Changes in Motion Sickness Tolerance (N=12 per group).
The Polish Journal of Aviation Medicine and Psychology 2013 Volume19 Issue 3 11
MIR SPACE STATION MISSIONS
are in standard deviations. Following training, this subject was able to completely suppress his symp- A study aboard the MIR space station was de- toms and maintain his responses near (or below) signed to study individual characteristics of adap-his pretest baseline.
tation (i.e., autonomic responses) to long duration Figure 3 shows improved motion sickness tol- spacefl ight and possibilities of their correction erance of 3 groups of test participants, matched using an AFTE [5,6]. The specifi c objectives of this for gender, age, and initial susceptibility to mo- tion sickness. AFTE is signifi cantly more eff ective – To determine if the degree of learned autono-(p<0.001) than the anti-motion sickness medica- mic control demonstrated prefl ight would be tion promethazine or a control group [3,4].
retained during 6 months in space. – Would AFTE improve post-fl ight orthostatic in- tolerance of subjects who demonstrated lear- SPACE SHUTTLE MISSIONS
Data were collected on 6 crewmembers dur- Two male cosmonauts were given 6 hours of ing two separate shuttle fl ights (3 treatment and prefl ight AFTE and tested for orthostatic tolerance 3 controls). Of the three crewmembers given AFTE on a tilt table (supine, head-up, and head down (no medications), two were symptom-free while tilt (Fig. 5). Infl ight, crewmembers were required one experienced only one minor symptom epi- to participate in 8-days of ambulatory monitor- sode on the third mission day. Of the three control ing (AFS-2) at 30-day intervals. Each of these fl ight group subjects, however, who took a variety of days included: anti-nausea medications, two experienced multi- – three 15-minute AFTE sessions, ple vomiting episodes, the fi rst occurring within – cognitive and psychomotor tasks, 10-minutes of orbit insertion. For these crewmem- – vestibular perception tests and PC-based self- bers, severe to moderate symptoms persisted reports of mood states, sleep and symptoms.
over 4 mission days while the third control subject
experienced only minor symptoms on the fi rst day RESULTS
in space. Although additional data from space is necessary to validate this countermeasure, these Figure 6 shows Subject 1 physiological re- fi ndings suggest that AFTE might be a successful sponses during his fi nal AFTE session. As can be countermeasure for space motion sickness. Figure seen, this subject had learned signifi cant and reli- 4 shows the ambulatory monitoring system used able control of multiple responses with mean arte-in space aboard both Space Shuttle and Mir Mis- rial pressure changes up to 25 mmHg. During the 6-month fl ight his control of autonomic responses AFS-2, Ambulatory Monitoring System as Worn Aboard Shuttle.
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Cosmonaut during Tilt-table Test AFTE delivered with simultaneous translation.
Subject 1, Final Prefl ight AFTE Session.
Subject 2, Final Prefl ight AFTE Session.
The Polish Journal of Aviation Medicine and Psychology 2013 Volume19 Issue 3 13
SEARCH AND RESCUE MISSIONS
was similar to his prefl ight control levels. Subject Research continues into applications of this 2, however, had more limited control as can be technology to commercial and military aviation. A seen by the relatively small changes in response collaboration between NASA, U.S. Army and Coast magnitudes across trials (Fig. 7). During the mis- Guard examined the eff ect of AFTE on search and sion, subject 1 performed all of the required in- rescue pilots fl ying under emergency conditions [2]. fl ight practice and monitoring sessions, while sub- The objective was to evaluate the eff ects of train- ject 2 did not begin AFTE practice until more than ing in physiological self-recognition and regula- 120 days into the mision. Treatment eff ectiveness tion on crew cockpit performance. The problems for post-fl ight orthostatic tolerance was evaluated to be addressed were: Sustained Operations 7-hrs after landing.
where fatigue, vigilance, sleep loss, contribute to Following 208-days in space subject 1 exhibited human error accidents; and Autonomous Mode improved post-fl ight orthostatic tolerance (while Behavior, a condition when a high state of physi-standing erect) compared to his previous 125 day ological arousal is accompanied by a narrowing of fl ight, with heart rate 22% higher, a 50% increase in the focus of attention. Participants were 17 pilots. arterial tone and a 13% increase in blood pressure Eight were given AFTE (4 HC-130, and 4 HH-65) compared to prefl ight baseline tests. He walked and 9 served as controls (3 HC-130 and 6 HH-65, away from the landing site, showing no signs of Figure 8). Before training, all pilots participated in orthostatic intolerance. Subject 2 experienced a simulated emergency scenario (described below pre-syncope within 15 minutes of standing erect. for the two aircraft). Then the AFTE group was giv-Results suggest that subject 2 might have been en twelve 30-minute daily sessions, followed by better protected if he had additional training and a post-training fl ight. Instructor pilots (IP) provid- practice sessions both pre- and in-fl ight.
ed instructions (simulated emergencies) to each pilot and rated them using a scale developed by U.S. Coast Guard Search and Rescue Aircraft.
Flight 2 (post-training) group comparisons: AFTE vs. Control *p<0.05.
Phases of Flight
Crew Coordination & Communication Planning & Situational Awareness Stress Management Aircraft Handling Checklist execution Cruise Search & Rescue Emergency Initiation Emergency Return to Base Emergency Approach and landing Note: Flight 1 (pre-training) group comparisons were not signifi cant except a higher score for Controls (+) on cruise search and rescue.
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Tab. 2. Flight 1 (pre-training) vs. Flight 2 (post-training): AFTE *p<0.05 Phases of Flight
Crew Coordination & Communication Planning & Situational Awareness Stress Management Aircraft Handling Checklist execution Cruise Search & Rescue Emergency Initiation Emergency Return to Base Emergency Approach and landing Note: fl ight 1 vs. fl ight 2 for Controls were not signifi cant, except a lower score for touch and go (+) on fl ight 2.
the Federal Aviation Authority (FAA). The IP's were training performance of the AFTE group only. not told group assignment of individual pilots, These subjects signifi cantly improved on all per-and rated the same individual on both fl ights.
These studies indicate that AFTE improves Simulated Emergency Flight Scenario:
overall performance and execution of duties, im- – Engine 1 fi re during touch and go proves crew coordination and communication – Search and Rescue case (downed A-4 pilot 20 (including: crew briefi ngs, workload delegation, miles off shore) planning, overall technical profi ciency). AFTE ap- – Engine 2 failure at 200 feet AGL pears to reduce physiological reactivity to stress, – Airframe damage, minor fuel leak and may aid in successful use and expansion of – AC bus failure, engine 1 fi re cockpit resource management training.
In conclusion, AFTE may be a valuable counter- Simulated Emergency Flight Scenario:
measure for multiple spacefl ight related biomedi- – Simulated engine stall at take off cal and performance problems. Additional data – Search and Rescue case (distressed boat within- from space and ground-based operational tests are needed to validate its eff ectiveness. Future – AC bus failure with loss of gyro, pitch and roll planned collaborations include transfer NASA – Servo-jam warning AFTE technology and validation studies: training – Hydraulic failure at 50 feet AGL of Polish military pilots; training of U.S. military – Landing gear malfunction pilots for airsickness mitigation; training of U.S. veterans as a treatment for Post-Traumatic Stress Syndrome (PTSD) and training of astronauts and cosmonauts in preparing for long duration mis- Table 1 shows that during the post-training sions with autonomous crew. To complete these fl ights, AFTE subjects performed signifi cantly bet- goals, we will use these studies to develop and ter than controls in three of four performance di- test new monitoring and training capabilities.
mensions: crew coordination and communication, planning and situational awareness, and stress management. Table 2 compares pre- and post- This article was originally published in the Proceedings of the International Workshop on the Psycho- physiological Aspects of Flight Safety in Aerospace Operation, 16-17 Sept 2011, Poland.
AUTHORS' DECLARATION:
Study Design: Patricia S. Cowings; Data Collection: Patricia S. Cowings; Manuscript Preparation:
Patricia S. Cowings; Funds Collection: Patricia S. Cowings. The Author declares that there is no confl ict
of interest.
The Polish Journal of Aviation Medicine and Psychology 2013 Volume19 Issue 3 15
1. Cowings, P.S. (1990) Autogenic-Feedback Training: A Treatment for Motion and Space Sickness. Chapter 17 in: G. H. Cramp- tom (Ed.). Motion and Space Sickness. (353-72) CRC Press: Boca Raton, Florida.
2. Cowings, P.S., Keller, M.A., Folen, R.A., Toscano, W.B., Burge, J.D. (2001) Autogenic feedback training and pilot performance: enhanced functioning under search and rescue fl ying conditions. International Journal of Aviation Psychology. 11(3). 305-15.
3. Cowings, P.S., Toscano W.B. (2000) Autogenic feedback training exercise is superior to promethazine for the treatment of motion sickness. Journal of Clincal Pharmacology. 40 (10). 1154-1165.
4. Cowings, P.S., Toscano, W.B., DeRoshia, C., Miller, N.E. (2000) Promethazine as a motion sickness treatment: impact on human performance and mood states. Aviation, Space and Environmental Medicine. 71 (10). 1013-32.
5. Cowings, P.S., Toscano, W.B., Kamiya, J., Miller, N.E., Pickering, T. and Shapiro, D. (1993) Autogenic Feedback Training as a Potential Treatment for Post Flight Orthostatic Intolerance in Aerospace Crews. Journal of Clinical Pharmacology. 3 (6). 599-608.
6. Kornilova, L.N., Cowings. P.S., Toscano, W.B., Arlaschenko, N.I., Korneev, D.Ju., Ponomarenko, A.V., Sagalovitch, S.V., Sa- rantseva, A.V., and Kozlovskaya, I.B., (1998b) Correction of the parameters of autonomous reactions in the organism of cosmonaut with the method of adaptive biocontrol. Aviaspace & Ecology Medicine (Russian journal). 34 (3). 66-69.
Cite this article as: Cowings PS: Psychophysiology of Spacefl ight and Aviation. Pol J Aviat Med Psychol, 2013; 19(3): 9-16.
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