Essentials of Complementary and Alternative Medicine (June 1999)

H
OMEOSTASIS
When biofeedback was evolving into a clinical tool in the l970s, health professionals learning about the new procedure occasionally asked, “What kind of snake oil is 
this?” This question arose because many types of symptoms were responding to treatment. One explanation for this success is  homeostasis—the body's ability to 
maintain a “steady state.” Hundreds of homeostatic mechanisms allow the body to adapt to changes in the internal and external environments and to return to normal. 
We explain this principle to our patients by stating that “the body knows how to be healthy.” Bernard Cannon, who originated the term, wrote, “When we are afflicted 
and our bodily resources seem low, we should think of these powers of protection and healing which are ready to work for bodily welfare” (
24
). Cannon referred to “the 
wisdom of the body.” Unfortunately, there are many ways in which humans disrupt healthy homeostasis, including chronic stress, poor lifestyle habits, drug abuse, and 
injury. When the body is unable to maintain healthy homeostasis, symptoms appear.
We explain to our patients that although stress “pushes the body off-balance,” relaxation brings balance back. The ability to relax deeply and to achieve low arousal is 
a fundamental skill in the treatment of many disorders because relaxation facilitates return to healthy homeostasis and thus promotes healing. This appears to be true, 
regardless of the direction in which the body is off-balance. For example, hypoglycemia and hyperglycemia are both improved through relaxation training (
25
). The 
body's ability to return to healthy homeostasis explains why so many symptoms are alleviated through seemingly simple relaxation procedures and why people with 
certain conditions tend to recover without conventional medical treatment.
C
ONSCIOUSNESS
Consciousness facilitates control, and feedback facilitates consciousness. It is not possible to control behavior and physiological processes of which one has no 
awareness; therefore, being conscious is fundamental to change.
For example, Mrs. Jones comes to the clinic with raised and tense shoulders; she does not relax and drop her shoulders because she is not conscious of the tension. 
Although she is conscious of the headache, the muscle tension habit is unconscious. Through biofeedback and other procedures, Mrs. Jones becomes conscious of 
muscle tension, learns to relax, and develops a new habit. Consciousness facilitates control.
The value of information feedback in this process is analogous to removing the blindfold from a person attempting to play darts while blindfolded—that is, making an 
impossible task possible. Biofeedback removes mind-body “blindfolds.” The trainee (patient) uses information from the instrumentation and the therapist's coaching to 
become aware of subtle mind-body processes, to learn how to change them and, finally, to gain control of them.
S
ELF
-R
ESPONSIBILITY AND
 V
OLITION
As we say to our patients, the first three principles (i.e., mind-body interaction, homeostasis, and consciousness) are true, but without the fourth 
principle—self-responsibility and volition—self-regulation will not occur. Psychophysiological self-regulation occurs only when the patient assumes self-responsibility 
and uses willpower to learn, practice, and apply self-regulation skills and strategies. From the viewpoint of the autonomic nervous system, so named because of its 
apparent autonomy from the mind, volition is essential. To create change in this system (e.g., warming cold hands, lowering blood pressure) the patient must 
intervene, using volition and skills. In neuromuscular rehabilitation, when patients work to retrain muscles and regain function, the importance of willpower is obvious. 
Because lack of self-responsibility and willpower is the nemesis of successful outcome, biofeedback therapists continually motivate, encourage, and inspire their 
patients to “go the distance.” A patient who is self-motivated and is an enthusiastic  partner with the therapist may succeed; a patient who is not, or who hoped for a 
“quick fix,” may not succeed.
Principles Applied: Thermal Feedback
These principles and the process of biofeedback are illustrated in 
Figure 24.1
, which demonstrates a patient learning to relax and increase peripheral blood flow 
through thermal feedback. Blood flow is monitored and fed back to the trainee as skin temperature. Stress induces vasoconstriction, resulting in reduced blood flow in 
the periphery and decrease in skin temperature; relaxation induces vasodilation, resulting in increased blood flow in the periphery and an increase in skin 
temperature. Peripheral skin temperature therefore reflects both vasomotor activity and emotional/mental states of arousal and relaxation. Anyone who is a “vascular 
responder” is aware of having unusually cold hands when about to perform in some way.
F
IGURE
 24.1. The trainee uses skin temperature (blood flow) feedback as a guide while learning to relax and increase peripheral blood flow. Neurophysiological 
pathways mediate mind–body interaction.
To learn to relax and increase blood flow in the periphery, the patient uses thermal feedback and a variety of strategies taught by the therapist, including relaxed deep 
breathing, autogenic training phrases, imagery, and a kinesthetic experience of heaviness in the limbs. Feedback of finger temperature guides the patient and 
indicates progress in relaxing and increasing peripheral blood flow. Patients are impressed by the responsiveness of peripheral blood flow to the mind (mental 
activity). For example, when the mind wanders from the relaxation procedure to a confrontation with a colleague, temperature drops—an excellent 
psychophysiological demonstration.
Thermal feedback is a tool for relaxation training because increased blood flow in the periphery is a correlate of generalized relaxation. In addition, increase in 
peripheral blood flow is a treatment for Raynaud's disease and for the vascular pathology of diabetes and arthritic conditions, and it is useful in the treatment of other 
illnesses with a vascular component, such as migraine headache and hypertension. With increased awareness of stress and relaxation, and with practice, the patient 

learns to relax and to reduce or prevent symptoms.
The simplicity of this feedback modality belies the complexity of the process and significance of results. Cortical, limbic, hypothalamic, and autonomic processes are 
regulated through relaxation and counter the extensive physiological effects of the stress response. Without these four principles, psychophysiological self-regulation 
would not be possible. In addition, therapists rely on important principles of learning, such as generalization (i.e., transfer of training) and mastery, to ensure 
successful outcome. Patients are trained to master skills, so that they can transfer learning from the clinic to any symptom-triggering situation. Patients are also taught 
to anticipate triggers and to prevent stress. These principles underlie the ability of humans to achieve a significant degree of psychophysiological self-regulation, 
implying that we do not have to be passive victims of chronic stress and illness. We can learn to be active in recovery and proactive in maintaining health and 
wellness.
Etiology of Health and Illness
Biofeedback therapists accept a biopsychosocial, or multicausal, etiology of health and illness. The biopsychosocial approach describes the complex interaction of 
biological, psychological, and social variables in health and illness, recognizing that in a given disorder one variable may have the greatest effect (although all are 
important). For example, a car accident victim with chronic pain from physical injury brings to biofeedback therapy a host of psychological and social factors that 
influence the injury, the experience of pain, and therapeutic outcome. Another example is a gastric ulcer patient experiencing a flare-up during times of 
stress—biological factors ( Helicobacter pylori) and psychological factors with physiological components (stress-induced vasoconstriction and thinning of the mucosa) 
interact. Stress-related illnesses and organic disorders that are sensitive to stress, such as epilepsy and asthma, illustrate the importance of psychosocial factors in 
the etiology of illness; likewise, physical disorders, such as cardiovascular disease resulting from obesity or smoking, illustrate that strong social and psychological 
forces play a causal role.
Based on the biopsychosocial etiology, a distinction can be made between  simple and complex disorders (
18
). Simple disorders are stress-related and are not the 
result of complex biopsychosocial factors; they are easily treated with relaxation and stress management techniques. Complex disorders necessitate more extensive 
therapy.
Diagnosis
Biofeedback therapists who are credentialed to diagnose do so based on standard diagnostic procedures used in the therapist's specialty. When the therapist is not 
credentialed to make a diagnosis, the patient is requested to obtain a medical diagnosis before therapy if a diagnosis has not been made. In neuromuscular 
rehabilitation, biofeedback instrumentation is used to assess and diagnose reflex patterns and functional capacity. Experts in this specialty are becoming 
sophisticated in the use of surface EMG for these purposes and subsequent treatment (
26
, 
27
). Although biofeedback therapy does not include medical procedures 
for diagnosis, therapists continually assess psychological, social, and physical factors that contribute to the symptom or illness.
Therapy
The principles of psychophysiological self-regulation naturally focus biofeedback therapy on mind-body skills and therapeutic procedures that enhance these skills. 
Furthermore, the goals of biofeedback therapy reach beyond symptom reduction and include improved self-image and self-efficacy, improved quality of life, and skills 
and resources for health and wellness. The bio-psychosocial approach to health and illness automatically leads to a repertoire of therapeutic procedures for 
addressing the multicausal nature of complex disorders. In summary, the multi-causal etiology of psychosomatic and organic disorders necessitates a multimodal 
biopsychosocial treatment, such as biofeedback therapy, in which remediation of causes and symptoms is the focus.
PROVIDER–PATIENT INTERACTION
Patient Assessment Procedures
H
ISTORY
-T
AKING AND
 P
HYSICAL
 D
IAGNOSIS
For most applications of biofeedback therapy, history-taking provides an opportunity for the therapist and patient to examine psychosocial and physical factors 
involved in the symptom. It also sets the stage for mind–body work. In addition to the verbal history, we use a lengthy inventory that the patient completes at home. 
The inventory includes symptom history and causes, medications, previous treatments, and impact of the symptom on various activities. The inventory also assesses 
symptom triggers, stress signs, Type A behaviors, dietary patterns, physical exercise and relaxation activities, assertiveness, goals, and self-image. In our practice, 
the patient also completes the Cornell Medical Index (
28
) and the State-Trait Anxiety Scale (
29
). These inventories are used for treatment design and provide a 
doorway for addressing psychosocial issues. Intake procedures vary according to the application and preferences of the clinician and are appropriate to the specialty 
in which biofeedback is used. For example, in neuromuscular rehabilitation, other procedures (e.g., tests of range of motion) are used to assess type and degree of 
dysfunction.
Finally, some clinicians use a procedure known as the stress profile, or psychophysiological profile, to assess the patient's mode of responding to stress. In a typical 
profile, EMG, finger temperature, EDR, and heart rate are monitored without feedback while the patient alternately relaxes and experiences a variety of stressors, 
such as an unexpected loud noise, thinking of a stressful situation, or solving a math problem mentally (
23
). The profile is a useful teaching tool, and the patient may 
begin therapy by training on the modality that is most responsive to these stressors. Many biofeedback therapists are knowledgeable about criteria for differential 
diagnosis but do not diagnose unless qualified to do so.
Determining Treatment
In biofeedback therapy, initial treatment procedures are determined by the presenting symptom and the immediate needs of the patient. The treatment of simple 
stress-related disorders incorporates standard procedures (e.g., diaphragmatic breathing, autogenic training, progressive relaxation) that are the foundation for 
relaxation skills and stress management. Treatment protocols for complex psychophysiological disorders include standard procedures and psychotherapy, whereas 
protocols for treatment of epilepsy or fecal incontinence are unique to these disorders.
THERAPY AND OUTCOMES
Treatment Options
Patients who choose biofeedback therapy receive one or more types of biofeedback training and, in most applications, some type of home practice is required. The 
options are the range of therapeutic procedures available to the patient based on clinical goals, therapist skill, and specialty. The therapist and patient may decide 
together on the most effective procedures for meeting the patient's goals. The patient may also be referred to another type of treatment, and it is not uncommon to 
work with a patient who is referred by another therapist and continues therapy with that therapist.
Description of Treatments and Interventions
Patient education is an important ingredient in biofeedback therapy. Patient education covers the following:
The symptom (in our clinic we use handouts, anatomy charts,  The Merck Manual, and other resources)
The effects of stress, relaxation, and lifestyle on the symptom
The principles of psychophysiological self-regulation and biofeedback procedures
We also recommend books related to the patient's goals and use a variety of handouts to facilitate training. In addition to biofeedback, the treatment protocol may 
include other procedures, such as breathing exercises, autogenic training, progressive relaxation, short relaxation techniques, the quieting response, the relaxation 
response, visualization, stress inoculation training, desensitization, cognitive restructuring, dialogue techniques, and stress management techniques (e.g., time 
management and assertiveness training). We conscientiously foster hope and positive expectations—essential ingredients for compliance and successful 

outcome—as we teach and train our patients.
Biofeedback therapists create therapeutic procedures as needed, and they continually seek psychological, social, and physical strategies that aid in recovery and 
prevention. The therapy is skills-oriented and involves training; the patient learns the therapeutic procedures. To ensure generalization and mastery, home training is 
required, and patients may be given audio tapes of the relaxation procedures to use at home. An individualized relaxation and visualization tape may also be made for 
the patient. Temperature feedback is used primarily for home training programs and is possible because the feedback devices are inexpensive and effectively monitor 
autonomic nervous system activity. Fortunately, one of the best indicators of sympathetic nervous system activity, blood flow in the periphery, is easily measured and 
amenable to home training. Children are trained in the same manner as adults but often earn prizes for completing homework and achieving behavioral goals (
30
).
Table 24.1
 provides specific examples of biofeedback therapy. These examples, however, can only capsulate treatment protocols and cannot capture the richness of 
a therapy in which human interaction, teaching, learning, and individual needs are paramount.
Table 24.1. Biofeedback Clinical Procedures Used in Certain Disorders
Treatment Evaluation
E
XPECTED
 C
HANGES
In biofeedback therapy, many changes are expected and nurtured: symptom and/or medication reduction, symptom prevention, increased knowledge of symptom 
dynamics including biopsychosocial factors, increased knowledge of the dynamics of stress and relaxation, development of a variety of skills involving knowledge, 
practice, and application. In addition, some patients achieved enhanced sense of self-responsibility and self-efficacy, enhanced self-image, more healthful lifestyle 
habits, and enhanced quality of life.
U
NEXPECTED
 C
HANGES
The unexpected changes that occur during therapy are often as significant and informative as the expected changes. For example, a woman undergoing biofeedback 
for chronic reflux had a long-standing case of eczema on her hands clear up after mastering temperature (bloodflow) training. Unusual and unexpected results of 
self-regulation training are not rare (although rarely published), demonstrating the potentials of mind-body interaction and the ability of the body to heal.
A
SSESSING THE
 M
AGNITUDE OF
 C
HANGE
Symptom Reduction and Prevention: The Treatment Effect
Symptom reduction and prevention are the primary goals of therapy. In most applications, the patient has a well-documented history of a recurrent or ongoing 
symptom, such as headache or hypertension. Symptom change is usually assessed by the patient through “symptom charting.” Symptom charts are comprehensive 
enough to track key dimensions of the symptom, such as duration and intensity of headache and medication use, and are simple enough to encourage compliance in 
charting. In addition, days absent from work, physician visits, and related indices can be recorded. In assessing behavioral change in children, parents and teachers 
may keep behavioral records.
Developing Skills: The Training Effect
When treatment is a skill, one cannot assess the treatment effect without assessing the training effect: did the patient learn the necessary skills? Biofeedback 
instrumentation simultaneously feeds back information to the trainee and continually measures the physiological processes being monitored. Measurement enables 
comparison of baseline and ending readings within and across clinic sessions. Simple temperature feedback devices enable the patient to keep records of home 
training.
In many applications, training goals or learning criteria are used as indicators of successful training. For example, the ability to increase finger temperature 1°F per 
minute indicates successful training in relaxation and blood flow control. Although biofeedback therapists use guidelines and goals for training, individual differences 
necessitate variation in the criteria for successful training.
After it became evident that a training effect is important for successful outcome, we developed a  mastery model of training that emphasizes the importance of both 
learning a skill and mastering it, meaning that the skill can be used during challenging circumstances (
13
). For example, a patient with Raynaud's disease may be 
able to increase finger temperature easily in the clinic and at home, indicating that the skill is learned; maintaining finger temperature while shopping in the freezer 
section of the grocery store indicates mastery. Mastery is assessed through  mastery tasks in the clinic or in the daily environment. For some patients, life presents 
many mastery tasks, and these patients demonstrate mastery by overcoming life stressors and coping in healthful ways. Patients' reports of success or failure during 
life challenges provide ongoing assessment of the training effect.
Changes in cognitions, emotions, and personality traits can be assessed with standard pre- and post-measurements, although verbal report and clinical observation 
are usually the primary sources of information regarding these variables as well as changes in quality of life, lifestyle, self-image, and self-efficacy.
T
IME
 P
ERIOD
There are three time periods of interest in biofeedback therapy: one relating to the training effect, one to mastery, and one to the treatment effect. Each time period 
varies according to the patient's disorder, the patient's compliance, and the type of feedback used. In the treatment of uncomplicated stress-related disorders using 
EMG and thermal feedback, the time period for learning self-regulation strategies and relaxation skills may be only 2 to 4 sessions when the patient practices at 
home; learning to relax quickly during stressful situations may take another 2 to 4 weeks of training and practice; significant reduction or elimination of the symptom 
may take longer. In our experience, children learn faster than adults and require fewer therapy sessions for stress-related disorders.
Patients may learn needed skills and achieve a degree of mastery while in therapy; however, the greatest change in symptoms may occur after termination of therapy. 
If the patient continues to use self-regulation strategies and skills, improvement will continue. For this reason, patients need not continue therapy until the treatment 
effect is achieved; once the skills are learned, the patient continues on his or her own with follow-up sessions as needed. Self-responsibility is an important underlying 
principle of psychophysiological self-regulation.
Treatment of long-term disorders with an organic component, such as epilepsy, may be lengthy. In this case, a minimum of 3 months (36 sessions) of EEG feedback 
training is common (
31
). Neuromuscular reeducation using EMG feedback for treatment of congenital disorders, such as cerebral palsy, may also be lengthy (
8
). In all 

cases, however, biofeedback therapists seek ways of helping the patient develop and use self-regulation skills outside the clinic. For example, a variety of behavioral 
strategies can reduce seizure rate and, in treating epilepsy, the patient is instructed to use these strategies in daily life (
32
).
E
VALUATING
 C
HANGE
As biofeedback evolved into biofeedback therapy, research with patients raised an important question: is statistically significant change clinically significant? This is a 
continuing question in medical research. Clearly, the answer is “not necessarily.” In biofeedback therapy, the significance of changes in the physiological processes 
being monitored are evaluated by accompanying clinical results, not on changes in their absolute values. For example, some therapists use 94°F to 96°F as the 
training goal for finger temperature in treating migraine headache and hypertension (
33
, 
34
), but symptom reduction may occur in patients who do not reach this goal 
and patients who reach this goal may not experience symptom reduction (
19
). As in most medical treatments, change is evaluated by clinical effects—what works.
Behavioral changes are also evaluated by the ability of the patient to maintain the new behavior and cope with mastery tasks. Biofeedback therapists help patients 
transform procedures for symptom relief into lifelong skills.