Biofeedback

What is biofeedback?

Biofeedback is a treatment used for a variety of chronic pain and other medical conditions that consists of sensors placed on the patient’s body while physiological data is viewed on a computer screen or other monitor in real time. It is considered a self-regulatory therapy because it is a tool for increasing awareness of and changing individual physiological responses to reduce symptoms or improve performance. The Association for Applied Psychophysiology and Biofeedback (AAPB), the Biofeedback Certification International Alliance (BCIA), and International Society for Neurofeedback and Research (ISNR) provide this standard definition:

Biofeedback is a process that enables an individual to learn how to change physiological activity for the purposes of improving health and performance. Precise instruments measure physiological activity such as brainwaves, heart function, breathing, muscle activity, and skin temperature. These instruments rapidly and accurately "feed back" information to the user. The presentation of this information -- often in conjunction with changes in thinking, emotions, and behavior -- supports desired physiological changes. Over time, these changes can endure without continued use of an instrument.¹

Biofeedback treatment may include use of one or more of the following modalities:

• Galvanic skin response meter measuring eccrine sweat gland activity (skin conductance).
• Thermistor measuring peripheral skin temperature.
• Electrocardiogram or photoplethysmograph measuring peripheral blood flow, heart rate, and heart rate variability (HRV)*.
• Electromyogram (SEMG) measuring surface neuromuscular responses.
• Respiratory gauge and capnometry measuring breathing patterns, rate, and expired carbon dioxide.
• Electroencephalography (EEG)** measuring electrical activity of the cortex.

Although biomedical engineering and medical instruments have been used for over 150 years, most instruments are used for diagnostic information or passive treatment (i.e. scan or surgical device). Biofeedback devices are used to train people to increase control of their physiological responses through awareness, practice, and learning over time. It is valuable on a face value level, or “seeing is believing,” but the various biofeedback modalities also represent more complex activities of the central nervous system. A treatment goal is often to reduce sympathetic activation (stress response) and increase parasympathetic activation (relaxation response) of the nervous system, with more conscious control over each response.

Many people already experience biological information fed back to them in daily life with simple low-tech devices such as a mirror, scale, thermometer, or blood pressure cuff. More recently, higher-tech forms include exercise monitors that report the number of steps walked, heart rate and other physiological measures. Most of the time autonomic physiological responses such as heart rate, breathing, skin temperature, skin sweating, and muscle tension are out of one’s immediate awareness until more extreme limits are reached or symptoms appear. Subtle, moment-to-moment changes in such physiological conditions are hard to detect and may seem unimportant until a problem develops.

Many factors affect chronic pain conditions and they are often associated with central nervous system dysregulation where stress and pain can make each other worse. Biofeedback is a tool to learn to re-regulate this system and master more adaptive responses. For example, postural or breathing habits can perpetuate and exacerbate symptoms of pain. Awareness of specific habitual patterns (e.g. muscle tension or shallow breathing) and persistent attempts to change them to adaptable responses can interrupt the pain-stress feedback loop.

What conditions are treated with biofeedback?

In 2002, a task force formed to rank how effective biofeedback is for different disorders.*** ² Biofeedback has evidence-based support for chronic pain conditions including migraines,³ tension headaches,^4,5 temporomandibular joint pain,⁶ and is also used for non-cardiac chest pain,⁷ arthritic conditions,⁸ irritable bowel syndrome,⁹ Raynaud’s disease, and other chronic pain conditions.¹⁰ There is evidence biofeedback may help related problems such as insomnia and anxiety, but often demonstrates comparable gains to cognitive behavioral therapy for these conditions. Thus, biofeedback is often used in conjunction with other therapies such as physical therapy or cognitive behavioral therapy, mindfulness and meditation.¹¹

What should I know as a patient?

Biofeedback Certification International Alliance (BCIA) is the non-profit organization that has been certifying biofeedback practitioners since 1981.  Biofeedback practitioners do not have to be board certified, but finding someone who is certified will help you know that your provider has met the minimal requirements of education and training according to BCIA. Biofeedback is a multidisciplinary practice and may be used by psychologists, physical therapists, occupational therapists, nurses, physicians or other licensed healthcare professionals.

Biofeedback does not do anything directly to a person, but rather gathers information from a person. Similar to other learning therapies, the relationship between patient and therapist is important to generate positive outcomes.¹

*HRV is the moment-to-moment (beat-to beat) change in heart rate that fluctuates in time (milliseconds) and frequency domain measures (hertz). The sympathetic and parasympathetic divisions of the nervous system influence HRV. Low HRV is a powerful predictor of morbidity and mortality; while higher variability is thought to signify sympathovagal balance and healthy adaptability.¹² 

**Neurofeedback is a type of biofeedback measuring electrical activity of the cortex and displaying brain wave patterns, usually in the form of electroencephalography (EEG), in order to alter brain function. Neurofeedback is used to treat disorders such as attention deficit disorder,¹³ substance abuse,¹⁴ and traumatic brain injuries.¹⁵

***Disorders ranked at level 3 out of 5 have had multiple observational, wait-list control, and replicated within-subject and intra-subject studies that demonstrate efficacy. Level 3 is considered on par with many treatments approved by the FDA. Level 4 includes randomized controlled trials (RCTs) and Level 5 includes RCTs that have found a specific modality of biofeedback superior to other credible medical treatments for that disorder.¹

Author

Jessica Del Pozo, PhD, is the founder of PACE, a four-week chronic pain management program (www.paceforpain.org) and co-author of The Gut Solution, a book for families with IBS utilizing SEEDS (Stress, Education, Exercise, Diet and Sleep), a biopsychosocial approach to IBS and RAP (www.thegutsolution.com). For the past seven years, she has worked for a year-long multi-disciplinary pain management program at Kaiser Permanente and helped many patients refocus their strengths to manage pain without opioids.

References

1. Schwartz, M. S., & Andrasik, F. (2016). Biofeedback: A practitioner’s guide, 4^th edition. New York: Guildford Press.

2. La Vaque, T., Hammond, D., Trudeau, D., Monastra, V., Perry, J., Lehrer, P., Matheson, D., & Sherman, R. (2002) Template for developing guidelines for the evaluation of the clinical efficacy of psychophysiological interventions. Applied Psychophysiology and Biofeedback, 27(4): 273-281.

3. Nestoriuc, Y., & Martin, A. (2007). Efficacy of biofeedback for migraine: A meta-analysis. Pain, 128(1-2): 111-127.

4. Nestoriuc, Y., Marcin, A., Rief, W., & Adrasik, F. (2008). Biofeedback treatment for headache disorders: A comprehensive efficacy review. Applied Psychophysiology and Biofeedback, 33, 125-140.

5. Nestoriuc, Y., Rief, W., & Martin, A. (2008). Meta-analysis of biofeedback for tension-type headache: Efficacy, specificity, and treatment moderators. Journal of Consulting and Clinical Psychology, 76(3): 379-396.

6. Crider, A. & Glaros, A. (1999). A meta-analysis of EMG biofeedback treatment of temporomandibular disorders. Journal of Orofacial Pain, 13: 29-37.

7. DeGuire, S., Gevritz, R., Hawkinson, D., & Dixon, K. (1996). Breathing retraining: A three-year follow-up study of treatment for hyperventilation syndrome and associated functional cardiac symptoms. Biofeedback and Self-Regulation, 21, 191-198.

8. Dissanayake, R. k., & Bertouch, J.V. (2010). Psychosocial interventions as adjunct therapy for patients with rheumatoid arthritis: A systematic review. International Journal of Rheumatic Disease, 13(4), 324-334).

9. Stern, M.J., Guiles, R. F., & Gevirtz, R. (2014). HRV biofeedback for pediatric irritable bowel syndrome and functional abdominal pain: A clinical replication series. Applied Psychophysiology and Biofeedback, 39(3-4), 287-291.

10 Tan, G., Shaffer, R., Lyle, R., & Teo, I. (2016). Evidence-based practice in biofeedback and neurofeedback, 3^rd edition. Association for Applied Psychophysiology and Biofeedback: Wheat Ridge, CO.

11. Schoenberg, P. & David, A. (2014). Biofeedback for psychiatric disorders: a systematic review. Applied Psychophysiology and Biofeedback, 39(2): 109-35.

12. Task Force of the European Society of Cardiology and the North American Society of Pacing and Electrophysiology. (1996). Heart rate variability: standards of measurement, physiological interpretation and clinical use. Circulation, 93, 1043–1065.

13. Arns, M., De Ridder, S., Strehl, U., Breteler, M., Coenen, A. (2009). Efficacy of neurofeedback treatment in ADHD; the effects of inattention, impulsivity and hyperactivity: a meta-analysis. Clinical EEG and Neuroscience, 40(3): 180-9.

14. Scott, W.C, Kasier, D., Othmer, S., & Sideroff, S. E, (2005). Effects of an EEG biofeedback protocol on a mixed substance abusing population. American Journal of Drug Alcohol Abuse, 31 (3): 455-469.

15. Ayers, M. E. (1987). Electroencephalic neurofeedback and closed head injury of 250 individuals. Head Injury Frontiers. National Head Injury Foundation, 380-392.