Biofeedback

Overview

What Is It?
Biofeedback is a therapeutic technique that teaches you how to control physical responses such as breathing, muscle tension, hand temperature, heart rate, blood pressure and brain activity that are not normally controlled voluntarily.

Biofeedback is a therapeutic technique that teaches you how to control physical responses such as breathing, muscle tension, hand temperature, heart rate, blood pressure and brain activity that are not normally controlled voluntarily. This control is achieved by learning how to focus on and modify signals from your body. Biofeedback may be used to help people change the way their bodies respond to a variety of conditions, including chronic pain, stress and anxiety, to name a few.

The skill typically is taught by a health care professional with expertise in the techniques and uses a handful of clinical, noninvasive instruments. Once you understand how the technique is applied, and after some practice, it is usually possible to use the skill independently.

To understand biofeedback, think of a thermometer—an external device that measures a physiological change. Biofeedback uses electronic or electromechanical instruments to monitor, measure, process and feed back information about blood pressure, muscle tension, heart rate, brain waves and other physiological functions.

Audio and/or visual feedback signals, often provided through a computer, reflect this activity. This gives you greater awareness and voluntary control: First you learn to control the external signal and, eventually, you learn to recognize and use internal cues.

Biofeedback is a relatively recent approach, developed in the 1940s. The term came into use around 1969 to describe procedures that trained research subjects to alter brain activity, blood pressure, muscle tension, heart rate and other "involuntary" bodily functions. The goal is to train you, primarily by changing thought processes, to control physiologic responses.

At first, biofeedback was viewed with skepticism, but it has been increasingly accepted by mainstream health care professionals and insurers. In the last 40 years, scientists have been exploring the mind/body connection. More acceptance and widespread use of biofeedback therapy has resulted.

Studies indicate that it is an effective therapy. It is used to help treat a range of illnesses and ailments, from chronic pain to constipation to incontinence. It is usually used in addition to a primary treatment to emphasize self-control or self-regulation.

Biofeedback is most helpful for conditions involving muscle tension. It's a particularly useful therapy for reducing stress and anxiety, and the National Institutes of Health has approved its use in the treatment of chronic pain and insomnia. Biofeedback can be used as both a primary and secondary treatment. Secondary treatments are used in conjunction with traditional medicine. For example, biofeedback would be used to deal with the trauma or fear of having a disease like cancer; the pain associated with the condition; and the nausea from chemotherapy. Biofeedback is also a secondary treatment for diseases like multiple sclerosis, Crohn's disease and other conditions that are not considered curable by biofeedback, although some symptoms of these conditions can be alleviated with this therapy.

There are at least 150 applications for biofeedback, and the list continues to grow. Below are some of those uses:

• addiction to alcohol, tobacco and other drugs
• anxiety disorders
• asthma
• bruxism (teeth grinding)
• cardiac arrhythmia (abnormalities in heartbeat)
• chronic fatigue syndrome
• chronic pain
• circulatory problems (such as Raynaud's phenomenon)
• complex regional pain syndrome
• concentration improvement for education and meditation
• control of brain waves for spiritual development and inner tranquility
• constipation
• diabetes
• epilepsy
• fecal incontinence
• fibromyalgia
• headaches (including migraines)
• high blood pressure
• insomnia
• irritable bowel syndrome and other digestive disorders
• jaw pain and dysfunction (including temporomandibular joint syndrome)
• menopausal symptoms
• menstrual cramps
• migraine headaches
• mild depression
• nausea and motion sickness
• neuromuscular re-education
• paralysis, spinal cord injury and other movement disorders
• premenstrual syndrome
• stress
• torticollis (neck muscles contract involuntarily, causing the head to turn)
• Tourette's syndrome
• urinary incontinence
• vulvovaginal pain

Although biofeedback is perhaps most closely associated with stress relief, new applications are being developed regularly. Motion sickness is one of the newest applications. NASA used biofeedback to help astronauts deal with space sickness, and now the space agency's techniques are being used to help others who suffer from nausea, vomiting and motion sickness.

A particular type of biofeedback, called electroencephalographic (EEG) biofeedback, or neurofeedback, is used for a variety of conditions. Through neurofeedback, you learn to pay attention to brainwave activity and ultimately control it. It may be helpful in reducing hyperactivity and attention deficit hyperactivity disorder, though studies are continuing to determine its effectiveness.

Unlike many other approaches to health care, biofeedback puts you in charge. It requires you to learn from the signals your body sends and make changes accordingly. It even involves practice at home. And after you finish your biofeedback sessions, you need to use what you learned regularly. You will use it, of course, to affect the condition. Daily practice, even when your symptoms are responding to treatment, reinforces your skills.

Depending on the condition you're trying to change, your practice period may range from a couple of minutes intermittently during the day to half-hour sessions. You might focus on a particular muscle group, a hand-warming technique or some other technique specific to your needs.

Biofeedback and Hypnosis

Many health professionals use both hypnosis and biofeedback, often together. In fact, it is impossible to teach biofeedback without also teaching a type of self-hypnosis exercise, such as imagery relaxation, progressive relaxation or imagery change.

One benefit from using the combination of hypnotherapy and biofeedback is that the participant recognizes quickly that changing thinking changes physiologic responses. This encourages mental practice toward the goal of making a desired physiologic change permanent.

Diagnosis

Although biofeedback is harmless, your health care professional will want to do a thorough exam related to your condition. This gives a better understanding of the causes of your medical condition and guides the biofeedback therapist in developing an appropriate treatment plan. In addition, the physiological testing that is done before beginning treatment can help you measure your progress as you proceed with treatment.

Biofeedback is generally not a substitute for conventional medical treatment. Rather, it should be used with any other therapies prescribed by your health care professional.

Overall, biofeedback is safe: It is noninvasive and generally has no side effects. However, if you are deeply apprehensive, be sure to discuss your concerns with the therapist. A healthy dose of skepticism and interest in the details of your care should be welcome. If a therapist doesn't answer your questions, seek another therapist. Ultimately, you don't have to believe in biofeedback for it to work. But you will have to practice the techniques to discover whether or not they are effective for you. Biofeedback requires that you be a responsive participant in the process.

Whether biofeedback works for you depends on your particular condition and your ability to learn from the feedback you receive. The amount of time you commit to helping your body and mind make the necessary changes is crucial. Once a commitment is there, change will take place, but the extent will depend on the severity of your complaint and the ability of your body to make the necessary changes.

Getting started

To get started, you'll need a trained professional who can operate the monitoring equipment and interpret the results. Biofeedback professionals come from a number of health-related disciplines, including psychology, psychiatry, social work, medicine, dentistry and nursing.

Your health care professional may be able to make a referral. Physicians, dentists, psychologists and others use biofeedback. The psychology or psychiatry department at a nearby university also may be able to point you in the right direction. And check with your health care plan—it may cover your visits to approved biofeedback therapists.

Although the practice isn't licensed, biofeedback therapists can receive certification from the Biofeedback Certification Institute of America (BCIA). To be certified, they must meet certain education requirements, pass an exam and either be licensed in a health care field or work under the supervision of a licensed health care professional. The organization offers referrals (www.bcia.org). BCIA estimates that about 1,500 health care professionals in 25 countries are certified either in general biofeedback, EEG biofeedback or pelvic muscle dysfunction.

Treatment

Biofeedback typically involves a series of sessions over several weeks. The length and number of sessions you need will depend on your condition and how fast you can learn to control your physical responses. Some conditions require as few as three or four sessions, especially for children, while others may require 10 times that many or more.

Electroencephalographic (EEG) biofeedback—which measures, displays and teaches you to control brainwaves—can take longer. Some conditions may require 40 or 50 EEG sessions in the clinic. You and your biofeedback therapist will come up with a schedule that's right for your condition.

You can expect a session to last from 30 minutes to an hour. (Your first one may take longer as the therapist explains the process to you.)

The biofeedback therapist will first explain the process to you and show you the various pieces of equipment. You'll sit in a comfortable chair, and the therapist will apply sensors to various points on your body (most typically, the shoulders, fingers, back and/or head) depending on your complaint and the protocol developed to bring about beneficial change. This may vary among clinics. For instance, if you have headaches or insomnia, the sensors will probably be placed on your scalp.

The sensors are connected to equipment that provides instantaneous feedback on the function you are trying to control. What's this feedback like? It varies. Some machines show you the changes on a computer monitor. Others beep or buzz or blink or otherwise indicate fluctuations in the function you are targeting.

Before the training begins, the biofeedback professional will take a baseline reading to find what your "normal" state is; this makes it possible to gauge changes.

Next, the therapist will guide you through various mental or physical exercises that are designed to bring about the desired biological changes—exercises that can help you control a particular function. And by paying attention to the feedback, you'll learn to associate certain thoughts and actions with the desired change in your previously involuntary responses. Sensors are attached to your body to monitor certain physical processes such as temperature, heart rate and muscle tension, for example. This information is fed back by electronic signals, which help to speed the learning process so that you know immediately if the desired effect has been achieved.

For instance, you may be connected to a device that indicates muscle tension via an electronic signal. This signal increases as you tense and decreases as you relax. This approach is particularly helpful to women with incontinence. It raises awareness of and control over pelvic floor muscles. By using electronic devices to gauge bladder and urethral muscle contractions, you can learn to control and strengthen these muscles. Sometimes the pelvic floor muscles are strong but are spastic or in spasm and need to be retrained so they relax appropriately.

Your therapist will serve as a coach who guides and encourages you in various relaxation techniques, self-regulation, self-awareness and home practices. By practicing these techniques, you gain greater control over your bodily functions. Once you gain competence practicing at the clinic, the idea is to become so good that you no longer need to be monitored by the instrumentation or a therapist.

In some clinics you are first taught to close your eyes and focus inward to listen to bodily changes. After you're familiar with the technique, you are taught to open your eyes and focus on the sounds, lights or computer display to help fine-tune skills learned with your eyes closed.

Gradually, you'll be able to do this without the audio or visual aids. Just by concentration, you can contract and/or relax certain muscles. At that point, you can use biofeedback on your own, without the equipment and guidance of a clinic session.

There are several basic methods and instruments:

• Electromyography (EMG) measures muscle activity. This approach is used for a number of conditions, including muscle stiffness, stress incontinence, urge incontinence, overflow incontinence, urinary urgency and frequency, headaches, tooth grinding, stress and chronic pain. It's also used when muscles are healing or being reconditioned. Sensors are usually attached to the affected muscles.
• Thermal biofeedback provides information about skin temperature, an indication of blood flow. You might take this approach if you suffer from migraines, Raynaud's phenomenon, anxiety or high blood pressure. Sensors often go on your fingers or feet.
• Galvanic skin response training measures changes in your skin's surface—particularly perspiration rates. This is a common method for dealing with stress, phobias and stuttering.
• Heart rate variability biofeedback. Commonly used in commercial devices, this type of biofeedback helps you control your heart rate in order to improve blood pressure and lung function and to ease stress and anxiety.
• Respiration (rate, rhythm and type of breathing) can be monitored—often through a strain gauge wrapped around your chest or waist. This method is often used for asthma, hyperventilation, anxiety, panic and angina with chest pain.
• Electroencephalographs (EEG) (EEG) measure brainwaves. Ideally, an EEG will help you learn how to recognize and modify your brainwave activity by identifying certain brainwave patterns. EEG biofeedback (also called neurofeedback) can help improve attention and reduce impulsivity and is used to treat attention deficit hyperactivity disorder, head injuries and mild depression. It also has been used to treat epilepsy and depression and to promote recovery from head injuries and stroke. Sensors are placed on the head in various locations dependent on the treatment.

In addition to the actual biofeedback, your therapist will probably work with you on relaxation exercises, stress-coping techniques, deep breathing and muscle relaxation.

There also are biofeedback tools available online. While it is still recommended that you start out working with a professional, some of the new tools make it easier to practice at home. HeartMath offers software compatible with the iPhone, iPad, iTouch and computers that teaches you to monitor your body signals to better manage stress. The company offers online training and works with therapists worldwide to help you get started.

Many people learn to control various functions, including heart rate, blood pressure and muscle tension. (This ability enables some people to go off certain medications, such as those for blood pressure and mild depression. But don't make this decision alone; talk to the prescribing health care professional before discontinuing any drug regimen.)

Biofeedback success rates vary widely based on the individual and the condition. There have been numerous published studies on the efficacy of biofeedback, and researchers continue to do further studies. The practice is increasingly gaining mainstream acceptance with more complex conditions.

Facts to Know

1. Biofeedback isn't a treatment or a cure. It's a set of techniques or methods for helping you become aware of your body processes in order to control them. These changes, not the biofeedback equipment itself, are what improve your health.
2. Biofeedback should never be used for treating symptoms that haven't been checked out by your primary health care professional.
3. Biofeedback uses audio, visual and digital cues to reflect changes in your physiology.
4. Biofeedback is frequently used to help people with stress-related disorders, insomnia and chronic pain. Currently, over 150 applications of biofeedback have been described and evaluated.
5. The term "biofeedback" comes from "biological feedback" and came into use around 1969.
6. Biofeedback is emerging as a therapy for vulvovaginal pain. The rationale is the same as for incontinence—biofeedback can help you train and strengthen your pelvic muscles, which in turn can help you control the muscle spasms that often accompany this condition. It is also useful in helping eliminate vaginismus, painful vaginal spasms often associated with intercourse.
7. Although biofeedback therapy is not licensed by the state, you can find accredited practitioners through the Biofeedback Certification Institute of America (www.bcia.org).
8. Biofeedback crosses many health care categories. It's used in several disciplines, including psychology, dentistry, physical therapy, pain management and internal medicine. (In fact, some nurses, physicians and dentists are also biofeedback therapists.)
9. Researchers aren't exactly sure why biofeedback works, but most think that learning how to relax can help the patient learn from biofeedback. Relaxation and stress-reduction exercises are an important part of biofeedback therapy.
10. Biofeedback is painless.

Questions to Ask

Review the following Questions to Ask about biofeedback so you're prepared to discuss this important health issue with your health care professional.

1. What kind of training do you have? Are you certified and by whom?
2. How long have you been doing this? What types of conditions do you most commonly address? How many times have you treated patients with my condition?
3. Which types of biofeedback do you use?
4. How much will this cost? Will my health care plan cover treatment?
5. How many sessions do you think I will need?
6. Tell me how each of these machines work.
7. I have a pacemaker. Do you need to take special precautions?
8. What types of exercises will I need to do at home?
9. Will I need follow-up visits once the initial treatment and training are finished?
10. I am pregnant. Will biofeedback affect my pregnancy? If so, how?

Key Q&A

Organizations and Support

For information and support on Biofeedback, please see the recommended organizations below.

Association for Applied Psychophysiology and Biofeedback
Website: https://www.aapb.org
Address: 10200 W. 44th Avenue, Suite 304
Wheat Ridge, CO 80033
Hotline: 1-800-477-8892
Phone: 303-422-8436
Email: aapb@resourcenter.com

Biofeedback Certification Institute of America (BCIA)
Website: https://www.bcia.org
Address: 10200 W. 44th Avenue, Suite 310
Wheat Ridge, CO 80033
Hotline: 1-866-908-8713
Phone: 303-420-2902
Email: info@bcia.org

Mid-Atlantic Society for Biofeedback and Behavioral Medicine
Website: https://www.masbbm.org/
Address: c/o Galena Kuiper, MASBBM President
4405 East-West Highway, Suite 309
Bethesda, MD 20814
Phone: 301-656-2487
Email: galena.kuiper@gmail.com

National Center for Complementary and Alternative Medicine
Website: https://www.nccam.nih.gov
Address: National Institutes of Health
9000 Rockville Pike
Bethesda, MD 20892
Hotline: 1-888-644-6226
Phone: 301-519-3153
Email: info@nccam.nih.gov

University of Pittsburgh Medical Center (UPMC): Biofeedback
Website: https://www.upmc.com/services/integrative-medicine/services/biofeedback
Address: UPMC
200 Lothrop Street
Pittsburgh, PA 15213
Hotline: 1-800-533-8762
Phone: 412-647-8762

Biofeedback
Website: https://www.nlm.nih.gov/medlineplus/spanish/ency/article/002241.htm
Address: U.S. National Library of Medicine
8600 Rockville Pike
Bethesda, MD 20894
Email: custserv@nlm.nih.gov