Biofeedback

What Is It?

Biofeedback uses various devices to measure physiological activities, with the intent of improving health or performance by learning to consciously control those activities.  Clinical biofeedback emerged as a discipline starting in the late 1950s, as increasing numbers of technologies were developed to measure different body functions.  Since that time, it has expanded dramatically.

Any number of body functions can be monitored in biofeedback.  Certain biofeedback devices work best for different conditions.  For example, measuring muscle tension can help with tension headaches, while neurofeedback works well for attention deficit and hyperactivity disorder (ADHD).  Important examples of biofeedback devices include the following:

  • Hand temperature (thermal biofeedback therapy)
  • Skin conductance (electrodermal response)
  • Respiratory rate and chest wall expansion
  • Cardiovascular measurements, including heart rate (pulse) and heart rate variability (HRV), which are the beat-to-beat differences noted on a heart monitor
  • Electroencephalography (EEG). EEG biofeedback is typically referred to as neurofeedback.
  • Muscle tension (electromyelography)
  • Number of steps, measured on a pedometer or other wearable device
  • Body weight (even your scale is a biofeedback device of sorts)

A variety of qualified professionals can offer biofeedback, ranging from psychologists and physicians to dentists, nurses, social workers, occupational therapists, physical therapists, and social workers.

How It Works

Seeing how these measurements change in real time in response to different emotions, thoughts, or behaviors empowers a person to mentally control physical functions they may not have previously been aware they could control.  The end goal is to learn how to change body functions to improve health and/or performance, in a way where ideally the changes will endure without continued use of an instrument.

In a clinical setting, a practitioner might combine biofeedback with other treatments, such as Cognitive Behavioral Therapy (CBT) or relaxation techniques.  Biofeedback can provide one element of a multifaceted intervention, enhancing the efficacy of other treatments by drawing a person’s awareness to their own ability to consciously change their body functions.

How To Use It

Biofeedback is often offered by various mental health providers, particularly psychologists who have done additional certification.  There are various products a person can use on their own to do biofeedback as well, but it is best to have support from a trained professional, especially early on.

When To Use It

Consider biofeedback for people who tend to be more technology-minded or like to see concrete data related to how their mental efforts affect them physically.

Recent studies have been especially favorable regarding the potential for biofeedback to treat various types of chronic pain[1] and swallowing function.[2]  HRV can be useful for enhancing sports performance[1] and improving pulmonary function during asthma attacks.[3]  A recent, large-scale review and meta-analysis found no benefit for biofeedback for stress urinary incontinence in women.[4]  A 2018 study found benefit of muscle tension biofeedback for stroke rehabilitation.[5]  More studies are needed, but biofeedback shows potential benefit for treating OCD as well.[4]  Neurofeedback was found to benefit people with uncontrolled seizures.[6]  Biofeedback helps with various types of headaches and has been given a “Grade A” evidence rating by various national organizations.[7]  A recent systematic review found support for visual biofeedback for balance in elderly populations.[8]  A 2019 Cochrane review concluded more irritable bowel syndrome (IBS) studies were needed to draw conclusions[9], but a study indicates that home biofeedback helps with dyssynergic defecation.[10]  Electrodermal feedback shows promise with reducing pain and chronic inflammation.[11]

A 2017 meta-analysis found benefit for HRV training for stress and anxiety.[12]  One study found benefit for chronic back pain,[1] another found it may help with reducing cravings in substance use disorders,[13] and still another found it reduced risk of admissions, emergency room visits, and depression in people with coronary artery disease.[14]  Phone-based HRV interventions can improve cardiovagal function.[15]

Biofeedback Research: A Summary

A rating system for efficacy for biofeedback is used by national and international groups.  Some of their ratings, as featured on the website of the Association for Applied Psychophysiology and Biofeedback, are listed below.[16][17]

Level 5: Efficacious and Specific

  • Constipation and fecal incontinence in females
  • Fecal elimination disorders in females
  • Urinary incontinence in females

Level 4: Efficacious

  • Anxiety
  • Attention deficit disorder and attention deficit and hyperactivity disorder
  • Constipation and fecal incontinence in males
  • Fecal elimination disorders in males
  • Headache in adults
  • Hypertension
  • Jaw area pain
  • Temporomandibular disorders
  • Urinary incontinence in males

Level 3: Probably efficacious

  • Alcoholism/substance abuse
  • Arthritis
  • Asthma and other breathing problems
  • Chest pain (non-cardiac)
  • Chronic pain
  • Epilepsy
  • Hyperventilation
  • Insomnia
  • Low back pain
  • Pediatric migraines
  • Phantom limb pain
  • Posture-related pain
  • Stump pain

Level 2: Possibly efficacious

  • Cancer and HIV, effect on immune function
  • Cerebral palsy
  • Chronic obstructive pulmonary disease
  • Depressive disorders
  • Diabetes mellitus
  • Fibromyalgia
  • Foot ulcers
  • Hand dystonia
  • Irritable bowel syndrome
  • Knee pain
  • Kneecap subluxation
  • Mechanical ventilation
  • Motion sickness
  • Myocardial infarction
  • PTSD
  • Raynaud’s
  • Repetitive strain injury
  • Stroke
  • Traumatic brain injury
  • Tinnitus
  • Urinary incontinence in children
  • Vulvar vestibulitis

Level 1: Not empirically supported

  • Autism
  • Eating disorders
  • Multiple sclerosis
  • Spinal cord injury
The ratings of efficacy presented are compiled from The Association for Applied Psychophysiology and Biofeedback’s list of disorders and treatments as well as Yucha and Gilbert’s 2004 book on biofeedback and neurofeedback.

Biofeedback can enhance the effectiveness of other treatments by helping individuals become more aware of their own role in influencing health and disease; it can be quite empowering to patients.

What to Watch Out For (Harms)

Biofeedback is very safe, provided that instrumentation is operated correctly, and practitioners are able to set reasonable and safe parameters and goals for a person to aim for in terms of various physiological measures.

Tips From Your Whole Health Colleagues

Most experts would agree that it is best to obtain biofeedback from a qualified health care professional.  Get to know practitioners at your site and in your local community.  To find biofeedback professionals who practice in a certain part of the country, use the following as resources:

Resources

VA Whole Health Website and Other IHCC and VA Resources

Other Websites

Books

  • Evidence-Based Practice in Biofeedback and Neurofeedback (3rd ed), Gabriel Tan (2017)

Apps and Monitoring Software

  • BioZen. Created by U.S. Department of Defense.
  • Elite HRV

Author(s)

“Biofeedback” was written by Shilagh Mirgain, PhD and Janice Singles, PsyD. (2014, updated 2020)

This Whole Health tool was made possible through a collaborative effort between the University of Wisconsin Integrative Health Program, VA Office of Patient Centered Care and Cultural Transformation, and Pacific Institute for Research and Evaluation.

References

  1. Sielski R, Rief W, Glombiewski JA. Efficacy of Biofeedback in Chronic back Pain: a Meta-Analysis. Int J Behav Med. 2017;24(1):25-41.
  2. Albuquerque LCA, Pernambuco L, da Silva CM, Chateaubriand MM, da Silva HJ. Effects of electromyographic biofeedback as an adjunctive therapy in the treatment of swallowing disorders: a systematic review of the literature. Eur Arch Otorhinolaryngol. 2019;276(4):927-938.
  3. Taghizadeh N, Eslaminejad A, Raoufy MR. Protective effect of heart rate variability biofeedback on stress-induced lung function impairment in asthma. Respir Physiol Neurobiol. 2019;262:49-56.
  4. Nunes EFC, Sampaio LMM, Biasotto-Gonzalez DA, Nagano R, Lucareli PRG, Politti F. Biofeedback for pelvic floor muscle training in women with stress urinary incontinence: a systematic review with meta-analysis. Physiotherapy. 2019;105(1):10-23.
  5. Tsaih PL, Chiu MJ, Luh JJ, Yang YR, Lin JJ, Hu MH. Practice Variability Combined with Task-Oriented Electromyographic Biofeedback Enhances Strength and Balance in People with Chronic Stroke. Behav Neurol. 2018;2018:7080218.
  6. Tan G, Thornby J, Hammond DC, et al. Meta-analysis of EEG biofeedback in treating epilepsy. Clin EEG Neurosci. 2009;40(3):173-179.
  7. Silberstein SD. Practice parameter: evidence-based guidelines for migraine headache (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2000;55(6):754-762.
  8. Alhasan H, Hood V, Mainwaring F. The effect of visual biofeedback on balance in elderly population: a systematic review. Clin Interv Aging. 2017;12:487-497.
  9. Goldenberg JZ, Brignall M, Hamilton M, et al. Biofeedback for treatment of irritable bowel syndrome. Cochrane Database Syst Rev. 2019;2019(11).
  10. Rao SSC, Go JT, Valestin J, Schneider J. Home biofeedback for the treatment of dyssynergic defecation: does it improve quality of life and is it cost-effective? Am J Gastroenterol. 2019;114(6):938-944.
  11. Chrousos GP, Boschiero D. Clinical validation of a non-invasive electrodermal biofeedback device useful for reducing chronic perceived pain and systemic inflammation. Hormones (Athens, Greece). 2019;18(2):207-213.
  12. Goessl VC, Curtiss JE, Hofmann SG. The effect of heart rate variability biofeedback training on stress and anxiety: a meta-analysis. Psychol Med. 2017;47(15):2578-2586.
  13. Alayan N, Eller L, Bates ME, Carmody DP. Current Evidence on Heart Rate Variability Biofeedback as a Complementary Anticraving Intervention. J Altern Complement Med. 2018;24(11):1039-1050.
  14. Yu LC, Lin IM, Fan SY, Chien CL, Lin TH. One-Year Cardiovascular Prognosis of the Randomized, Controlled, Short-Term Heart Rate Variability Biofeedback Among Patients with Coronary Artery Disease. Int J Behav Med. 2018;25(3):271-282.
  15. Schumann A, Köhler S, Brotte L, Bär KJ. Effect of an eight-week smartphone-guided HRV-biofeedback intervention on autonomic function and impulsivity in healthy controls. Physiol Meas. 2019;40(6):064001.
  16. Association for Applied Psychophysiology and Biofeedback Inc. . Efficacy: How we rate the efficacy of our treatments or how to know if our treatments actually work. 2011; https://www.aapb.org/i4a/pages/index.cfm?pageID=3440. Accessed July 21, 2020.
  17. Yucha C, Montgomery D. Evidence-based practice in biofeedback and neurofeedback. Wheat Ridge, CO: AAPB; 2008.

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