US Pharm. 2018;43(8):HS13-HS16.
In the United States, there has been increasing interest in biofeedback therapy as a noninvasive approach to healthcare. As a nonpharmacologic treatment modality, biofeedback has clinical applications for a wide range of medical disorders. Accordingly, it has been recommended by many healthcare providers, such as general practitioners, psychiatrists, psychologists, and others. Although exactly how or why biofeedback works has not yet been determined, it is known that biofeedback promotes relaxation, which can help alleviate a variety of stress-related conditions.1 The principle behind biofeedback is that the mind and body are connected and that people can use the power of this connection to alter physical activity and improve their health.2
In biofeedback therapy, special equipment is used to measure physiological activity such as brain impulses, heart function, breathing, muscle activity, and skin temperature. This equipment rapidly and accurately provides feedback to the user. Over time, this information, in conjunction with changes in the patient’s thinking, emotions, and behavior, supports desired physiological functioning. Eventually, the patient is able to control these functions on his or her own, without this equipment.3
Defining Biofeedback Therapy
In 2008, the Association for Applied Psychophysiology and Biofeedback, the Biofeedback Certification International Alliance, and the International Society for Neurofeedback and Research crafted a standard definition of biofeedback therapy in order to prevent ambiguity.4 These organizations jointly defined biofeedback as a process that teaches a person how to alter his or her physiological activity for the purpose of improving health and physical performance. The purpose of this definition is to help consumers recognize legitimate practitioners and methods, as well as understand the role of insurance companies and government agencies, so that they can make informed decisions about biofeedback and neurofeedback health coverage and regulation.4
Recent literature has shown biofeedback therapy to be an effective treatment for migraines and tension-type headaches, urinary incontinence, hypertension, anxiety, and various other conditions.5 A growing body of research indicates that neurofeedback is an effective treatment for attention-deficit/hyperactivity disorder (ADHD) and that it can help manage the symptoms of autism spectrum disorders, brain injury, posttraumatic stress, seizures, and depression.6,7 Currently, most biofeedback practitioners follow a standard of care based on scientific evidence that supports the use of particular biofeedback and neurofeedback methods, equipment, and claims of efficacy.4
How Does Biofeedback Work?
Biofeedback is a technique for helping a patient learn to control a physiological function. This therapy often uses electrodes and sensors to transform bodily signals indicative of such functions as heart rate, blood pressure, skin temperature, salivation, peripheral vasomotor activity, and gross muscle tone into a sound or a light, the loudness or brightness of which denotes the extent of activity in the function being measured.8
These physiological functions are altered when a person is under stress. Increases in heart rate, blood pressure, and breathing rate take place, the patient perspires, and the muscles tighten. As these stress responses occur, they are seen on the monitor, and when the patient attempts to stop them, immediate feedback is given. This feedback helps the patient focus on making subtle changes in the body, such as relaxing certain muscles and reducing pain.9
Biofeedback sessions are usually performed in a therapist’s office; however, a computer program may be used that connects biofeedback sensors to a personal computer. Each therapy session lasts 30 to 60 minutes. Patients generally start to see biofeedback benefits in 10 sessions or less, although some conditions—such as hypertension—may take 20 or more sessions to improve. Generally, the length and number of sessions are determined by the nature of the condition being addressed and by how quickly the patient learns to control his or her physiological responses.9
A biofeedback therapist coaches patients in practicing relaxation techniques that are geared toward controlling different bodily functions. For example, by using a relaxation technique, a person can turn down the brain impulses that activate when a headache occurs.10
Several relaxation techniques are used in biofeedback therapy, including deep breathing, progressive muscle relaxation (alternately tightening and relaxing different muscle groups), guided imagery (concentrating on a specific image to focus the mind and promote relaxation), and mindfulness meditation (focusing the mind and letting go of negative emotions).10
Different types of biofeedback are used to monitor different bodily functions4,10:
Electromyogram—This technique measures muscle activity and tension. It may be used for back pain, headache, anxiety disorders, muscle retraining after injury, and incontinence. Biofeedback teaches the patient how to use the right muscle.
Thermal biofeedback—This method measures skin temperature. It may be used for headache and for Raynaud phenomenon, a condition of reduced blood supply to the skin that causes some parts of the body to feel numb and cool in response to cold temperatures or emotional stress.
Electroencephalography—This form of biofeedback measures brain impulses or waves. It may be used for ADHD, epilepsy, and other seizure disorders.
Electrodermal activity—This technique measures sweating, and it may be used for pain and anxiety.
Heart-rate variability—This method measures heart rate. It may be used for anxiety, asthma, chronic obstructive pulmonary disease, and irregular heartbeat.
Biofeedback therapy is administered in physical therapy clinics, medical centers, and hospitals. A growing number of biofeedback devices and programs are also being marketed for home use.
Interactive Computer and Mobile Device Programs: As mentioned earlier, some biofeedback methods measure physiological changes in the body, such as skin changes and heart-rate activity, via one or more sensors that attach to the ear or fingers and are plugged into a personal computer. Through the use of computer graphics and prompts, the program helps the patient conquer stress by relaxing the muscles, pacing the breathing, and thinking positive thoughts. These types of programs may effectively improve responses during times of stress and result in feelings of well-being and calmness.4,11,12
In another type of biofeedback therapy, the patient wears a headband that monitors brain activity during meditation. This therapy uses sound to indicate when the mind is calm and when it is active, which helps the patient learn how to control stress responses. The information from each session may be stored in a computer or mobile device.4,11,12
Wearable Devices: One type of wearable device involves a sensor worn around the waist that monitors the patient’s breathing and tracks breathing patterns using a downloadable app. The app alerts the patient if he or she is experiencing prolonged tension, and it offers guided breathing activities to help restore calm.4,11,12
One biofeedback device, called RESPeRATE, is FDA-approved for decreasing stress and reducing blood pressure. This wearable electronic device lowers blood pressure by relaxing constricted blood vessels that cause hypertension. To accomplish this, slow-paced breathing is combined with prolonged exhalation in a way that would be impossible for most patients to achieve on their own.
Importantly, it should be noted that many home-use biofeedback devices are not regulated by the FDA. Before at-home biofeedback therapy is attempted, the patient and his or her physician should discuss the various devices to determine the best option. The patient should be advised that some products are fraudulently marketed as biofeedback devices and that not all practitioners of biofeedback therapy are reputable.4,11,12
Biofeedback can help alleviate many different conditions4,9,12,13:
Chronic pain—By helping patients identify tight muscles and then learn to relax them, biofeedback may help relieve the discomfort of conditions such as low back pain, abdominal pain, temporomandibular joint disorders, and fibromyalgia. For pain relief, biofeedback can benefit people of all ages, from children to older adults.
Headaches—Treatment of headaches is one of the best-studied uses of biofeedback. Muscle tension and stress can trigger migraines and other types of headaches and can make headache symptoms worse. Strong evidence exists that biofeedback therapy can relax the muscles and ease stress, resulting in a reduction of both the frequency and severity of headaches.
Anxiety—Anxiety is one of the most common conditions biofeedback is used to treat. Biofeedback helps patients not only become more aware of the body’s responses when they are anxious and feeling stress, but also learn how to control those responses.
Urinary/fecal incontinence—Biofeedback therapy can help people who have trouble controlling the urge to void. Biofeedback can help women find and strengthen the pelvic-floor muscles that control bladder emptying. After several biofeedback sessions, these patients may be able to reduce their urgent need to urinate and the number of accidents they have. Biofeedback can also help children who wet the bed, as well as persons who have fecal incontinence (inability to control bowel movements). Unlike drugs used to treat incontinence, biofeedback tends not to cause side effects.
Chronic constipation—Patients with organic neuromuscular impairment who have difficulty with outlet obstruction have benefited from biofeedback therapy.
Hypertension—Evidence on the use of biofeedback for hypertension is mixed. Although biofeedback seems to lower blood pressure slightly, it is less effective than medication for blood-pressure control.
Nocturnal bruxism—This term refers to clenching, bracing, grinding, or gnashing of the teeth and jaws during sleep. Patients have benefited from biofeedback techniques to reduce these tendencies.
If biofeedback therapy is successful, it can help the patient control symptoms of his or her condition or reduce the amount of medication needed. Eventually, patients can practice biofeedback techniques on their own. Patients considering this therapy should keep in mind that although learning biofeedback can take time, it has no risks or side effects.
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3. Andrasik F. Biofeedback in headache: an overview of approaches and evidence. Cleve Clin J Med. 2010;77(suppl 3):S72-S76.
4. Schwartz MS, Andrasik F, eds. Biofeedback: A Practitioner’s Guide. 4th ed. New York, NY: Guildford Press; 2016:3-8.
5. Collura TF, Thatcher RW. Clinical benefit to patients suffering from recurrent migraine headaches and who opted to stop medication and take a neurofeedback treatment series. Clin EEG Neurosci. 2011;42(2):viii-ix.
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7. Coben R, Padolsky I. Assessment-guided neurofeedback for autistic spectrum disorder. J Neurotherapy. 2007;11(1):5-23.
8. Gevirtz R. The promise of heart rate variability biofeedback: evidence-based applications. Biofeedback. 2013;41(3):110-120.
9. Frank DL, Khorshid L, Kiffer JF, et al. Biofeedback in medicine: who, when, why and how? Ment Health Fam Med. 2010;7(2):85-91.
10. WebMD. Overview of biofeedback. www.webmd.com/a-to-z-guides/biofeedback-therapy-uses-benefits#. Accessed May 31, 2018.
11. Mann DT, Janelle CM. Psychophysiology: equipment in research and practice. In: Edmonds WA, Tenenbaum G, eds. Case Studies in Applied Psychophysiology: Neurofeedback and Biofeedback Treatments for Advances in Human Performance. Walden, MA: John Wiley & Sons Ltd; 2012:257-274.
12. Mayo Clinic. Biofeedback. www.mayoclinic.org/tests-procedures/biofeedback/about/pac-20384664. Accessed July 12, 2018.
13. Kayiran S, Dursun E, Ermutlu N, et al. Neurofeedback in fibromyalgia syndrome. Agri. 2007;19(3):47-53.
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