Essentials of Complementary and Alternative Medicine (June 1999)

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CHAPTER 24. B
IOFEEDBACK
 T
HERAPY
Essentials of Complementary and Alternative Medicine
CHAPTER 24. B
IOFEEDBACK
 T
HERAPY
Judith A. Green and Robert Shellenberger
Background
 
Definitions
 
History and Development
Models and Treatment Evaluation
Principal Concepts
 
Principles of Psychophysiological Self-Regulation
 
Principles Applied: Thermal Feedback
 
Etiology of Health and Illness
 
Diagnosis
 
Therapy
Provider–Patient Interaction
 
Patient Assessment Procedures
 
Determining Treatment
Therapy and Outcomes
 
Treatment Options
 
Description of Treatments and Interventions
 
Treatment Evaluation
Use of the System for Treatment
 
Major Indications
 
Least Useful Indications
 
Contraindications
 
Prevention
 
Scope of Therapy
Organization
 
Training
 
Quality Assurance and Certification
 
Legal Status and Regulation
 
Professional Societies and Continuing Education
 
Reimbursement Status
 
Relations with Conventional Medicine
Prospects for the Future
Chapter References
BACKGROUND
Definitions
A patient presents with tachycardia. A heart rate monitor is attached to her finger, so that she can see moment-to-moment changes in heart rate for the purpose of 
learning to lower her heart rate. This is biofeedback. To facilitate treatment, the patient is taught breathing and relaxation exercises as well as other techniques for 
reducing sympathetic arousal. The patient uses these techniques to alleviate and prevent the symptom. This is biofeedback therapy.
B
IOFEEDBACK
Biofeedback is the use of instrumentation to monitor, amplify, and feed back physiological information, so that a patient can learn to change or regulate the process 
being monitored. Biofeedback instrumentation may provide elaborate computer feedback or may be as simple as a thermometer taped to the finger; the feedback may 
be visual or auditory and may be analog, digital, or graphic. Feedback instrumentation provides accurate measurement and immediate meaningful information. The 
most commonly used biofeedback instruments and feedback modalities are as follows:
Electromyograph (EMG): feedback of striate muscle tension
Thermal: feedback of peripheral blood flow, which is monitored as skin temperature
Electroencephalograph (EEG): feedback of brain waves
Electrodermal response (EDR): feedback of sweat gland activity, measured from the patient's fingers
Perineometer: feedback of contraction of anal sphincter and pelvic floor muscles
The patient may receive feedback from two or three of these instruments, depending on the disorder being treated. For example, treatment of a stress-related disorder 
with somatic and autonomic nervous system components includes EMG and thermal (blood flow) feedback.
B
IOFEEDBACK
 T
HERAPY
Biofeedback therapy is the use of biofeedback instrumentation in conjunction with other therapeutic procedures for the clinical goals of symptom and medication 
reduction, enhanced quality of life, and prevention. An expert in neuromuscular rehabilitation describes biofeedback therapy as “an interaction between the therapist 
and the patient, with the biofeedback instrument functioning as an observer and partner” (
1
).
In biofeedback therapy, these clinical goals are achieved through  psychophysiological self-regulation, a term that accurately describes the process in which mental, 
emotional, and physiological strategies and skills are learned and  used by the patient. The feedback of information assists the patient in gaining self-regulation and 
physiological control. Biofeedback instrumentation is a useful tool during the learning process.
When biofeedback instrumentation is used in treatment, the feedback of physiological information may be the primary therapeutic procedure or it may be 
complementary to other therapeutic procedures. The relative importance of the biofeedback component depends on the disorder being treated, the particular needs 
and therapeutic goals of the patient, and the training of the therapist. For example, in the treatment of epilepsy for seizure reduction, EEG feedback is the primary 
therapeutic tool. In contrast, in the treatment of chronic myofascial pain exacerbated by depression, a variety of therapeutic procedures are used, including cognitive 
therapy, stress management, and EMG feedback. In this case the biofeedback component, EMG feedback, has an important complementary role in treatment.
Furthermore, a simple definition of biofeedback therapy as a single treatment entity is inaccurate. Biofeedback therapy is used in a variety of applications, from 
physical injury and disease to stress-related disorders in adults and children. It is used in a variety of settings, from hospital to classroom. These applications and 
settings necessitate different therapeutic procedures, and clinicians develop therapeutic techniques that are unique to their specialty and practice. For this reason, an 
official document of the Association for Applied Psychophysiology and Biofeedback on clinical efficacy refers to “biofeedback therapies” (
2
). In this chapter, we 
describe the principles and procedures of biofeedback therapy in broadest terms, noting briefly the many variations related to treatment goals for specific disorders.
Health care professionals who use biofeedback in treating patients within their specialty continue to refer to themselves by licensure or specialty—nurse, physical 
therapist, physician, psychologist. We use the term  biofeedback therapist to refer to professionals who use biofeedback within their specialty and to clinicians who 
have specialized in biofeedback therapy and are certified through the Biofeedback Certification Institute of America (BCIA).

Biofeedback therapy is unique among medical treatments because the treatment is self-regulation that is achieved through skills that are learned and used by the 
patient. Successful treatment involves instrumentation feedback, counseling, and coaching by the therapist, and training and practice by the patient.
In summary, biofeedback therapy is behavioral medicine. It is a skills-oriented, multi-modal approach in which the treatment protocol is tailored to the individual needs 
of the patient, self-responsibility is encouraged, and a successful outcome depends on the patient's use of self-regulation skills and strategies.
History and Development
In the mid-1960s, the concept that information feedback enhances learning was not new (nor was the concept of physiological feedback). In that decade, however, 
several researchers in the United States independently developed instrumentation for monitoring and feeding back physiological information, and they unexpectedly 
established the foundation for a new therapy. These researchers were of different backgrounds—some worked solely with operant conditioning in animal labs and 
viewed biofeedback from an operant conditioning model, others worked with human subjects and viewed biofeedback from a self-regulation model. Their common 
interest was to demonstrate and explore the extent to which subjects can change or regulate physiological processes governed by the autonomic and somatic nervous 
systems.
In 1969, Barbara Brown, a pioneer in EEG feedback, organized the first conference at which the term  biofeedback was coined and the national organization, the 
Biofeedback Research Society, was formed. In 1976, the name of the organization was changed to the Biofeedback Society of America, and in 1988 the membership 
voted for a more comprehensive name, the Association for Applied Psychophysiology and Biofeedback (AAPB). These changes reflect the evolution of the field from 
research to clinical applications.
The possibility that humans can gain some control over normally unconscious and autonomic processes seemed unlikely to practitioners trained in traditional 
medicine and Western science, and skepticism was common. The development of biofeedback instrumentation enabled the scientific demonstration and investigation 
of psychophysiological self-regulation not previously possible. It soon became apparent that biofeedback is a powerful tool for helping patients alleviate a variety of 
symptoms, and the new procedure moved rapidly from the research laboratory to the clinic. Biofeedback therapy evolved as clinicians learned to effectively combine 
biofeedback and therapeutic procedures.
Early clinical research that launched biofeedback into clinical use includes treatment of migraine headache (
3
), tension headache (
4
), torticollis (
5
), hypertension (
6
), 
Raynaud's Disease (
7
), muscular dysfunction of cerebral palsy (
8
), neuromuscular disorders (
9
), and epilepsy (
10
). The simplicity and logic of feedback prompted a 
rapid development.
By the early l980s, clinicians in many fields (e.g., primary care, family practice, neurology, psychotherapy, neuromuscular rehabilitation, alcohol and drug 
rehabilitation, dentistry, pain management) had incorporated biofeedback procedures into their practice, either acting as the therapist or working in conjunction with a 
biofeedback therapist. Biofeedback therapy evolved from an interaction of these disciplines, which continues to enliven and broaden the field today. Key references 
for biofeedback therapy are as follows:
Biofeedback and Self-Regulation, Volumes 1–21 (
11
)
Biofeedback and Self-Control, Volumes I–IV (
12
)
Basmajian: Biofeedback—Principles and Practice for Clinicians (
13
)
Birk: Biofeedback: Behavioral Medicine (
14
)
Blanchard and Andrasik: Management of Chronic Headache: A Psychological Approach (
15
)
Brown: Stress and the Art of Biofeedback (
16
)
Green and Green: Beyond Biofeedback (
17
)
Green and Shellenberger:  The Dynamics of Health and Wellness (
18
)
Hatch: Biofeedback: Studies in Clinical Efficacy (
19
)
Peper: Mind/Body Integration (
20
)
Schwartz: Biofeedback: A Practitioner's Guide (
21
)
Shellenberger and Green:  From the Ghost in the Box to Successful Biofeedback Training (
22
)
Amar and Streifel: Standards and Guidelines for Biofeedback Applications in Psychophysiological Self-regulation (
23
)
MODELS AND TREATMENT EVALUATION
The model of biofeedback used in research is an important issue in the history of the field. In early biofeedback research, two inappropriate models were often 
used—we refer to these as the operant conditioning model and the drug model. Both are based on the model of scientific research in which the independent variable 
is isolated and its specific effects are determined (
22
).
Although there is still debate as to the most appropriate model for studying biofeedback, we feel that the operant conditioning and drug modes are erroneous, often 
leading to false-negative results. The fundamental error in these models is the assumption that the biofeedback instrument itself, or a characteristic of the instrument 
such as feedback, is the independent variable, and that this independent variable should have specific physiological effects. This is analogous to attempting to isolate 
the specific effects of a mirror or scalpel blade. Biofeedback instrumentation is like a mirror; the instrument and information are useful, but in themselves have no 
specific symptom-reducing effects. Because operant conditioning and pharmaceutical research are not concerned with self-regulation, these models do not use 
self-regulation as the independent variable and the main focus of study.
In an effort to isolate the nonexistent specific effects of biofeedback, researchers using the drug model attempted to eliminate the so-called placebo effects and 
thereby isolate and measure effect of “biofeedback.” This was done by eliminating all variables except instrumentation feedback that might enhance self-regulation 
and symptom alleviation, such as home training and cognitive skills. Researchers using the operant conditioning model referred to the information feedback as a 
“reward.” Because this model assumes that behavior is controlled by rewards, as seems true in laboratory animals, researchers often failed to facilitate self-control in 
subjects. Both models assumed that the specific effects come from the instrument and not from the individual; this led to erroneous control groups and research 
designs and limited learning to a trial-and-error strategy. Neither model viewed the treatment as self-regulation based on learned skills. These models led to minimal 
training, used symptom reduction as the outcome measure rather than skills acquisition  and symptom reduction, and led to misleading conclusions. When the 
independent variable is a skill that must be learned for effective treatment, these research protocols generate misleading results because they hinder rather than 
enhance self-regulation skills and symptom reduction. In summary, these research models are not appropriate for clinical biofeedback and the demonstration of 
clinical efficacy.
Today clinical research protocols are comprehensive and, in general, a skills model of biofeedback therapy is used. Although research is no longer needed to 
determine the value of information feedback per se, it continues to refine and enhance training procedures. We include this brief discussion of models, however, 
because a reviewer of the research on biofeedback, or on any treatment, must critically assess the model being used.
PRINCIPAL CONCEPTS
Principles of Psychophysiological Self-Regulation
The principles that underlie biofeedback therapy are related to the interaction of mental/emotional and physiological processes. We describe four basic principles that 
are the foundation of psychophysiological self-regulation. By virtue of these principles, health is not merely a matter of good fortune—humans can learn and use 
self-regulation skills for overcoming illness and maintaining health.
M
IND
–B
ODY
 I
NTERACTION
The fact that mental images, cognitions, and emotions effect physiological processes has long been recognized in Western medicine as the basis of psychosomatic 
illness. But anyone who has experienced the instantaneous stress response upon stepping on a harmless garden hose perceived as a snake knows well the effect of 

the mind on the body. Biofeedback therapy uses this mind-body interaction for promoting health. In teaching mind-body interaction to children, we simply say that 
everyone has a mind-body team and explain that in biofeedback therapy we train the whole team—that is, mind and body. Biofeedback is an excellent tool for learning 
psychophysiological self-regulation because the instrumentation provides accurate and immediate information that both verifies mind-body interaction and guides the 
patient during training.
M
ECHANISMS
The neurophysiological mechanisms that enable mind-body interaction are fairly well understood and are referred to as the 
cortical-limbic-hypothalamic-pituitary-adrenal axis. These neuronal pathways in the brain and nervous system mediate mental processes and concomitant 
physiological responses. A perceived threat—whether to the body or to the ego, real or imagined, severe or mild—triggers physiological reactions. This mind-body 
interaction affects the stress response and the development of stress-related symptoms. However, these same pathways allow the body to respond to stress-reducing 
and health-enhancing emotions and mental processes, and ultimately enable psychophysiological self-regulation. Through these mechanisms, mental regulation of 
the autonomic nervous system occurs, as do all activities that are directed by the mind, whether of the striate voluntary system or the autonomic nervous system. 
Mind-body interaction is the sine qua non of biofeedback therapy, and feedback facilitates regulation of this interaction.