What Is Biofeedback?

How to Use Biofeedback and Neurofeedback for Chronic Pain

What Is Biofeedback?

These non-invasive therapies help teach you how to control your own physiology – and in many cases – can reduce pain symptoms in the back, neck, nerves, and more.

Biofeedback is a type of therapy that uses sensitive electronic instruments to measure a person’s bodily processes, such as heart rate, and then feeds back that information to the patient. With this information, an individual can learn how to control their own physiology and, in many cases, reduce symptoms or improve function.

There are two main types of biofeedback: peripheral biofeedback and neurofeedback. Both have been shown to be helpful in reducing a wide range of chronic pain conditions.

I’ve been using biofeedback as a therapist for over 25 years with hundreds of patients, treating conditions ranging from anxiety to brain injury. After a successful experience using biofeedback to treat my own disabling back pain condition (see my case example below), I’ve developed a special interest in working with chronic pain patients.

What Exactly is Biofeedback?

Peripheral biofeedback involves measuring a person’s muscle tension using electromyography (EMG), hand temperature (blood flow), heart rate, respiration rate, skin moisture (clinically known as galvanic skin response or GSR) – all of which relate to levels of stress. A person can gain voluntary control over these measures by combining relaxation techniques with the information provided.

These measures may be focused on individually or all together. EMG biofeedback can also be used to teach people to make more efficient use of their muscles or to normalize muscle function.

Peripheral biofeedback treatment can often be completed in 10 sessions or less.

Neurofeedback, also known as neurotherapy, involves electroencephalogram (EEG) biofeedback or brainwave biofeedback, which measures the electrical activity of the brain. This process is more complex because it involves unconscious learning, which can be achieved by rewarding the brain with audio and visual feedback for making desired changes in its electrical activity.

Neurofeedback typically takes 20 to 60 sessions to complete treatment and is be used for those with more complex pain disorders or those that do not respond to peripheral biofeedback.

What Type of Specialist Offers Biofeedback?

Biofeedback is not regulated or licensed as a separate specialty – although most equipment used goes through FDA review and approval.

The treatment, which is non-invasive, is usually administered by licensed healthcare practitioners with specialized training, including psychologists and social workers, as well as practicing doctors, nurses, physical therapists, chiropractors, and naturopaths.

Many biofeedback practitioners are certified by the Biofeedback Certification International Alliance (BCIA).

Biofeedback is, unfortunately, not usually covered by health insurance, but policies vary. Check with your provider regarding coverage and referrals.

Biofeedback can be used as a standalone treatment or be combined with other treatments, including medication, physical therapy, psychotherapy and/or nutritional interventions. In my experience, many patients seek out biofeedback to avoid or reduce medication usage.

Point Me to the Data on Biofeedback

Studies of biofeedback treatment have found that many patients experience widespread improvements in their emotional and physical wellbeing as they move toward a more relaxed state and better self-regulation.

A review by the Association for Applied Psychophysiology and Biofeedback found that peripheral biofeedback was effective in the treatment of the following chronic pain conditions:1

  • abdominal pain
  • complex regional pain syndrome (CRPS/RSD)
  • fibromyalgia
  • jaw pain (TMD)
  • low back pain
  • migraine and tension headaches
  • neck pain
  • phantom limb pain.

A more specific analysis published in the International Journal of Behavioral Medicine evaluated the efficacy of peripheral biofeedback for treating chronic back pain. Twenty-one studies were reviewed that included a total of 1,062 patients. The reviewers found a significant small-to-medium effect on pain intensity reduction.

Improvements were maintained or increased over an average of 8 months of follow-up, with a significant small-to-large effect size. Biofeedback also significantly reduced depression and muscle tension and improved cognitive coping, both at the end of treatment and at follow-up.

The reviewers found that longer biofeedback treatments were more effective at reducing disability in general.2

A study of children and teens (64 in total) with recurrent abdominal pain using hand temperature biofeedback alone or in combination with cognitive behavioral therapy (CBT) found that their pain significantly improved compared to an inactive (fiber-only) treatment control group.3

A review of migraine treatments published by the American Academy of Neurology concluded that hand temperature (blood flow) and muscle tension (EMG) biofeedback with relaxation training were effective and recommended as a treatment option.4 A separate review on migraine prevention published in American Family Physician concluded that thermal (temperature) biofeedback and electromyographic (EMG) biofeedback were effective for migraine prevention.5

Another randomized, controlled trial of people with fibromyalgia syndrome using peripheral or EMG biofeedback found that patients receiving biofeedback treatment experienced significant improvement in tender points.6

What's New with Neurofeedback

Central Sensitization

The pain research community has been doing a considerable amount of work on central sensitization. The Institute for Chronic Pain defines this as: “a condition of the nervous system that is associated with the development and maintenance of chronic pain.

When central sensitization occurs, the nervous system goes through a process called wind-up and gets regulated in a persistent state of high reactivity.

This persistent, or regulated, state of reactivity lowers the threshold for what causes pain and subsequently comes to maintain pain even after the initial injury might have healed.”7

Central sensitization has two main characteristics:

  • allodynia – that is, a tendency to experience pain with stimuli that are not normally painful
  • hyperalgesia – in which a painful stimulus is experienced as much more painful than it normally would.

Central sensitization can also lead to excessive sensitivity to light, sounds, and odors as well as cognitive deficits.7

Central sensitization can be associated with the following medical conditions: stroke, spinal cord injury, chronic low back pain, whiplash, chronic tension headaches, migraine headaches, rheumatoid arthritis, osteoarthritis of the knee, endometriosis, injuries sustained in a motor vehicle accident, postsurgical pain, fibromyalgia, irritable bowel syndrome, and chronic fatigue syndrome.8

The condition also appears to be associated with changes in the dorsal horn of the spinal cord and in the brain. The former is affected by many descending pathways from the brain. Neurofeedback aims to correct this abnormal brain function.

Neurofeedback Use for Specific Chronic Pain Conditions

To date, there have been no large-scale clinical trials to test the efficacy of neurofeedback for a specific chronic pain problem, most ly due to lack of funding sources. However, many pilot studies and case series have been published that show the potential of neurofeedback to help patients with chronic pain.

Protocols vary but tend to fall into two major categories.

  • The first is an understanding of the brain and targeting the brain regions and frequencies believed to be involved in the presenting problem, in this case, pain generation. This is known as a functional approach.
  • The second is an individualized brain assessment called a quantitative EEG (qEEG). A qEEG, also known as a brain map, is a numerical analysis of the EEG to determine where brainwave patterns may be abnormal. Those abnormalities that relate to the presenting problem (ie, the type and location of pain) are then targeted for neurofeedback treatment.

Brainwave frequencies refer to the speed at which your neurons are firing. At any given time, different neurons are firing at different frequencies. Traditionally, neurofeedback has targeted brainwave frequencies of 1 to 30Hz. These frequencies are grouped as delta (1 to 4Hz), theta (4 to 8Hz), alpha (8 to 12Hz), and beta (12 to 30Hz). A qEEG includes analyses of 1 to 30Hz.

More recently, researchers and clinicians have been training frequencies as low as 0.001 millihertz (mHz), known as infralow frequencies, as well as higher frequencies, called gamma, with 40Hz of particular interest. When targeting millihertz, neurofeedback is actually targeting the glial cells of the brain rather than the neurons (glial cells are the white matter of the brain).

Scientists used to think the white matter was just filler for the brain, but now it is known that glial cells have important brain maintenance functions.

Studies on Neurofeedback for Chronic Pain

In a 2019 study, individuals with chronic low back pain received 20 sessions of alpha-phase synchrony EEG training. The study found “great and lasting response” to the treatment, including pain reduction that was still present at 6-month and 12-month follow up.9

In a 2010 study, individuals with fibromyalgia were treated with 20 sessions of neurofeedback focused on increasing sensory motor rhythm (SMR, 12-15Hz). All treated patients showed significant improvements in all outcome parameters, which included pain, psychological symptoms and impaired quality of life.10

In 2011, a migraine headache study compared QEEG-guided neurofeedback to pharmaceutical treatment. Fifty-four percent of patients in the neurofeedback group experienced a complete remission of migraine headaches.

An additional 39% experienced a decrease in migraine frequency of greater than 50%.

In contrast, of patients in the study who elected to continue on drug therapy, 68% experienced no change in headache frequency, and only 8% achieved a reduction of greater than 50%.11

Other small, pilot neurofeedback studies have shown reductions in pain and improvement in other quality of life issues, often with moderate to large effect sizes, for complex regional pain syndrome (CRPS/RSD),12 spinal cord injury,13 headache from traumatic brain injury,14 and chemotherapy-induced neuropathy.15 All of these studies used functional criteria to determine protocols, except for the study on chemotherapy-induced neuropathy, which used a QEEG-based approach to treatment.

How I Used Biofeedback for Back Pain

My first encounter with biofeedback was as a patient in 1981. At the time, I was 28 years old and had been experiencing severe, disabling back pain for more than 3 years. The pain was so severe that I dropped graduate school and barely functioned during that time. Medications, including anti-inflammatories, benzodiazepines, and narcotics, had no impact on my pain.

After reading about biofeedback, I sought out a psychologist who offered the treatment.  In the first session, he explained to me how my worrying about the pain was making it worse.

He taught me a simple meditation technique along with a temperature biofeedback strategy.

He explained that warm hands meant I was more relaxed and sent me home with a simple device to measure my hand temperature. 

The reason hand temperature can be used as a measure is that part of the body's stress response is to withdrawal circulation from the peripheral tissues to concentrate blood flow in the heart, lungs, brain, and major muscle groups.

Then, the body is prepared to «fight» or to «flee» — much of the science around pain response has to do with this very concept. Whenever my hands felt cool, I practiced a simple meditation technique.

In time, with and without devices, it works to reset one's physiology.

By the next day, my pain was reduced by 50%. Instead of worrying about the pain, I had something I could do to control it! I practiced that simple technique with the hand temperature biofeedback as much as I could and was able soon after to reduce my pain enough to get back to work and eventually back to school to complete my master’s degree in social work.

It’s been almost 40 years and I still use the technique to manage any aches and pains that come up as well as to manage stress and boost immune response.

How My Client Used Neurofeedback for Back Pain

A 32-year-old male consulted me for treatment of chronic low back pain subsequent to an industrial accident 12 years prior. A heavy piece of equipment had fallen on him, crushing his lower back. He had received spinal decompression and a spinal fusion.

At the time of the initial visit he was taking oxycodone (15 mg 3x per day) and ibuprofen (800 mg once per day). He was managing to maintain employment but was still in considerable pain.

He received 28 sessions of neurofeedback using an infralow two-channel protocol of 0.1mHz focusing on the connection between the right temporal (T4) and right parietal (P4) area while inhibiting excessive activity across 1-30hz frequencies. At the end of treatment, he was pain-free and medication-free.

Overall, given the safety profile of peripheral biofeedback and neurofeedback, their non-invasive approach, and their effectiveness for so many treatment-resistant, debilitating chronic pain conditions, I strongly believe that these treatments should be made more widely available to those living with pain.

While lack of insurance coverage and the small number of trained providers limits access to these valuable treatments, we can advocate for their use.

Updated on: 07/09/20

Am I a Candidate for Spinal Cord Stimulation?

Источник: https://www.practicalpainmanagement.com/patient/biofeedback-neurofeedback-chronic-pain-treatment


What Is Biofeedback?

Biofeedback therapy is an instrument-based learning process that is “operant conditioning” techniques. The governing principle is that any behavior-be it a complex maneuver such as eating or a simple task such as muscle contraction-when reinforced its lihood of being repeated and perfected increases several fold.[1]

Physical therapists use biofeedback to help refine a movement sequence or activation pattern to assist patients to achieve a goal.

This technique involves using visual, physical and/or auditory feedback to guide the patient to give their optimal performance.

[2] The ultimate purpose is that the patient gets to know his own body signs and that he can control them consciously in first place using biofeedback equipment, afterwards even without.[3]

Different types of biofeedback[edit | edit source]

Many different forms of biofeedback are currently used in the clinical setting including:

  • Electromyography (EMG) — measures muscle tension
  • Thermal biofeedback — measures skin temperature
  • Neurofeedback/ electroencephalography (EEG) — measures brain wave activity
  • Electrodermography (EDG) — measures skin electrical activity
  • Heat Flux — measures the rate at which heat is being dissipated from body
  • Pneumography — measures abdominal/chest movement when breathing
  • Capnometry — measures end-tidal carbon dioxide
  • Hemoencephalography — measures the differences in the color of light reflected back through the scalp the relative amount of oxygenated and unoxygenated blood in the brain
  • Photoplethysmography (PPG) — measures peripheral blood flow, heart rate, and heart rate variability[4][5]

The limitations to biofeedback applications lay largely with the therapist. Given a solid understanding of the basic principles of the therapy in combination with a clinical understanding of the patients problem, there are many novel applications for the therapy.

This page will focus exclusively on EMG Biofeedback.

Mechanism of Action[edit | edit source]

The autonomic nervous system regulates the functioning of the organs and functions of the body breathing and heart beating. It isn’t dominated by our will, but it reacts to our mood.

There are two major components of the autonomic nervous system, the sympathetic and the parasympathetic systems. The parasympathetic works in particular at rest and recuperation while the sympathetic works at efforts.

Due to chronic stress the autonomic nervous system can function worse, consequently the regulation of the body may get disrupted and an imbalance between the two systems may arise.[6]

Biofeedback as a Component of Treatment[edit | edit source]

It is important at the outset to emphasize that biofeedback is not at its most effective when used as a treatment in its own right, but should be integrated with other therapeutic interventions. It acts as an enhancer of the therapy, enabling the patient (and the therapist) to make more effective and rapid progress towards the rehabilitation goal.

Furthermore, it is useful in that it helps the patient to reduce their reliance on the therapist and become more reliant on their own performance.

Clearly this is not fully achieved if the patient becomes reliant on the machine instead of the therapist! It can be used effectively to enable the patient to take some control or ownership over their rehabilitation — empowerment is an often used phrase in this context.

The key to success of biofeedback in rehabilitation is to use the device as an adjunct to therapy, to enable the patient to gain control without reliance on the therapist, and once gained, to maintain control without either the therapist or the machine. This approach is entirely in keeping with the general aim of modern physiotherapy, and the technology is an aid to the outcome, not a magical solution.

Electromyography[edit | edit source]

The principles of EMG biofeedback (EMGBF) are usefully reviewed, as a reasonable understanding of what the machine is doing will assist the therapist in determining the most appropriate machine settings and applications.

Read more about the Physiological principles

Indications[edit | edit source]

There are many indications for biofeedback. Stress urinary incontinence is an indication for biofeedback. We found in the literature that the addition of biofeedback to the training of the pelvic floor muscles for the treatment of stress urinary incontinence improved pelvic floor muscles function, reduced urinary symptoms, and improved of the quality of life.[7][8]

Pelvic floor muscle exercises and biofeedback are also an effective treatment for men with erectile dysfunction.[9]

Further we found that EMG therapy is useful in enhancing knee extension after an ACL reconstruction but only in the early phase of the rehabilitation after the reconstruction.[10]

If we search evidence for biofeedback as the treatment for headaches we found that biofeedback-related approaches to headache therapy fall into two broad categories: general biofeedback techniques (often augmented by relaxation-based strategies) and methods linked more directly to the pathophysiology underlying headache. [11]

The use of general biofeedback-assisted relaxation techniques for headache has been evaluated extensively. We can conclude that:

  • Various forms of biofeedback are effective for migraine and tension-type headache;
  • Outcomes with biofeedback rival outcomes with medication therapy;
  • Combining biofeedback with medication can enhance outcomes;
  • Despite efficacy in many patients, biofeedback fails to bring significant relief to a sizeable number of headache patients. [11]

Biofeedback methods that more directly target headache pathophysiology have focused chiefly on migraine and tension-type headache. These headache-specific approaches include blood volume pulse biofeedback, which has considerable supportive evidence, and electroencephalographic feedback.

[11] For tension-type headache we found that biofeedback was more effective than headache monitoring, placebo, and relaxation therapies. The strongest improvements were found for frequency of headache episodes. Further significant effects were observed for muscle tension. [12][13] Biofeedback is also used for patients with migraine.

This treatment is found effective to reduce the number of headaches per week but there were no change in intensity, disability and length of headache. [14]

Other indications for biofeedback are:

Stabilizer[edit | edit source]


A stabilizer has come into general use for stabilization exercises for all parts of the body.

A stabilizer is a pressure biofeedback unit and consists of an inelastic, three-section air-filled bag, which is inflated to fill the space between the target body area, a firm surface and a pressure dial for monitoring the pressure in the bag for feedback on position. The bag is inflated to an appropriate level for the purpose and the pressure recorded. Movement of the body part off the bag results in a decrease in pressure while movement of the body part into the bag results in an increase in pressure. Its use in assessing the abdominal drawing-in action has become its most important use in relation to the treatment of problems for the local muscle system in patients with low back pain. [16]

Use in lumbar stabilization exercises


The patient is position in hook-lying. The feet remain flat and the arms are held alongside the body. The stabilizer is positioned under the lumbar lordosis. During exercises the spine cannot make any movements.

The transversus abdominis is contracted while doing the exercises to maintain an appropriate position.

Below the woman is holding the feedback unit to monitor the amplitude of her spinal movement ( the pressure change on the dial). [17], [18]


Computer-supported test and training systems[edit | edit source]

Computer-supported test and training systems Centaur (left) and Pegasus (right)

Centaur[edit | edit source]

With this device the global torso musculature can be specifically strengthened and its coordination trained. Furthermore, for the first time it is possible to directly train the local, deeper lying muscles (stabilizer). CTT CENTAUR works on the basis of the following active principles:

  • By a coordinated tilt of the body, the torso needs to be stabilized against gravity.
  • By tilting and rotating the body is put into an instable position so that the balance analyser sends impulses to the deeper lying muscles.
  • Due to the upright posture during the training, the muscles are strengthened in the position in which they have to do the most supporting work.
  • The precisely reproducible application of strain allows for a targeted and exactly documentable therapy and training. [19][20]

Pegasus[edit | edit source]

Computer-supported test and training system PEGASUS are measur the range of motion and the strength profiles of the spine-stabilizing musculature in all anatomical planes. Thus mobility and strength deficits and imbalances are identified.

On the basis of these results a specific training (maximum strength, strength endurance, strength coordination and mobility training) of the sensorimotor systems of the lumbar spine can be realized.

Thereby can existing muscular imbalances and performance deficits are tackled and resilience of the spine reestablished.[19]

References[edit | edit source]

  1. ↑ Satish S.C. Rao. Dyssynergic Defecation & Biofeedback Therapy. Gastroenterology Clinics of North America, Volume 37, Issue 3, Pages 569-586, September 2009 (level 2A) Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2575098/
  2. ↑ Basmajian J. Biofeedback: Principles and Practices for Clinicians, Williams & Wilkins ,1989

Источник: https://www.physio-pedia.com/Biofeedback

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