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Biofeedback

Biofeedback

Definition

Biofeedback is a technique that uses monitoring instruments to measure and feed back information about muscle tension, heart rate, sweat responses, skin temperature, or brain activity.

Terms associated with biofeedback include applied psychophysiology or behavioral physiology. It is also viewed as a mind-body therapy method used in complementary and alternative medicine. Biofeedback is an important part of understanding the relationship between physical state and thoughts, feelings, and behaviors.

Purpose

The purpose of biofeedback is to enhance an individual's awareness of physical reactions to physical, emotional, or psychological stress , and their ability to influence their own physiological responses. The overall purpose is to develop self-regulation skills that play a role in improving health and well-being.

Biofeedback has been used as a part of a comprehensive treatment approach with a number of conditions, including chronic pain, irritable bowel syndrome (IBS), temporomandibular joint disorder (TMJ), Raynaud's syndrome, epilepsy, attention-deficit/hyper activity disorder (ADHD), anxiety, migraine headaches, depression, traumatic brain injury, and sleep disorders . There is some support for using biofeedback in the treatment of diabetes when self-monitoring of blood glucose levels is maintained and within the context of regular physician consultation and supervision.

Biofeedback has been a useful tool in helping individuals with urinary incontinence regain bladder control by controlling the muscles used in urination. Sensors are placed in the vaginal or anal canal to help individuals learn when the muscles are properly contracted. A recent study found that this type of biofeedback treatment was safe, effective, and well liked by women patients 55 years and older.

Conditions related to stress are also treated using biofeedback, such as certain types of headaches, high blood pressure, bruxism or teeth grinding, post-traumatic stress disorder (PTSD), eating disorders, substance abuse, and some anxiety disorders. In treatment of stress-related conditions, biofeedback is often used in combination with relaxation training. Sometimes, biofeedback is used to help individuals learn how to experience deeper relaxation, such as in childbirth education programs or general stress management. This is referred to as biofeedback-assisted relaxation training. Even for individuals who can achieve relaxation through other strategies such as meditation or relaxation, biofeedback can be a valuable added technique. Biofeedback offers special advantages, such as allowing the clinician to track closely the places where an individual tenses up and helps the individual learn what thoughts and feelings are associated with the tension.

Precautions

Biofeedback depends on the motivation and active participation of an individual. Thus, it may not be suitable for individuals with low motivation who are not willing to take a highly active role in treatment, such as those suffering from depression. Also, since biofeedback focuses on initiating behavioral changes, individuals inclined to examine their past to alleviate problems and symptoms may benefit more from other treatment types, such as psychotherapy . Individuals with cognitive impairment may be unable to remain engaged in the treatment, depending on their level of functioning. Also, individuals with a pacemaker or other implanted electrical devices should inform their health care professional before entering biofeedback training, as certain types of biofeedback sensors may interfere with the devices. Patients with specific pain symptoms in which the cause is unknown should have a thorough medical examination to rule out any serious underlying disease before starting biofeedback training. Biofeedback can be used in combination with conventional therapies; however, while it can be used in combination with conventional medical treatment for illnesses such as cancer and diabetes, it should not replace those treatments.

Research on the success of biofeedback in treating certain conditions is inconclusive or needs to be validated. Some research studies use a small number of participants, which makes it difficult to generalize the results to a larger population. Also, many conditions have different subtypes with a variety of psychological, social, and physical causes. This fact, combined with research design concerns, makes it difficult to compare research studies. For example, while most studies have reported positive outcomes in the treatment of alcohol abuse and dependence, problems with methods and statistical analyses have called study results into question. Also, its effectiveness in treating opiate abuse or dependence has not been consistently shown, as with its use in treating menopausal hot flashes, and there are limitations in studies relating to its use in cancer treatment. Continued research is needed to further evaluate and improve different biofeedback techniques for various conditions.

Description

According to the Association for Applied Psychophysiology and Biofeedback, the technique was developed in the early 1970s by psychologists and physicians. These techniques continue to be used by psychologists, physicians, nurses, and other health care professionals such as physical therapists. Prior to beginning any biofeedback training, individuals may need a comprehensive psychological, educational, and/or medical assessment. Biofeedback can be used in conjunction with nonmedical treatments, such as psychotherapy, cognitive-behavioral therapy , and behavioral treatment strategies.

How biofeedback works

Biofeedback utilizes electronic sensors, or electrodes, attached to various parts of the body to detect changes in physical responses. Signals then inform the individual of these changes by means of visual or auditory signals such as a light display or a series of beeps. While the individual views or listens to feedback, he or she begins to recognize thoughts, feelings, and mental images that influence his or her physical reactions. By monitoring this mind-body connection, the individual can use the same thoughts, feelings, and mental images as cues or reminders to become more relaxed, or to change heartbeat, brain wave patterns, body temperature, and other body functions. The individual uses trial-and-error to change the signals change in the desired direction. For example, individuals trying to control their blood pressure levels may see a light flash whenever the pressure drops below a certain level. They may then try to remember what their thoughts and feelings were at the moment and deliberately maintain them to keep the blood pressure level low.

Through training, the individual learns to control the targeted physical response and, over time, is able to recognize what is required to reduce problematic symptoms. Eventually, the external biofeedback becomes unnecessary as the individual learns to perceive internal physical responses and make the desired changes. The individual then has a powerful, portable, and self-administered treatment tool to deal with problematic symptoms.

Three stages of biofeedback training

  • Awareness of the problematic physical response: Individuals may complete a psychophysiological stress profile (PSP) to identify how their bodies respond to a variety of stressors and determine their ability to overcome undesired physical reactions. This involves a period of rest, stress, and recovery. For example, various sensors are attached to various parts of the body, and a baseline measurement lasting from two to four minutes records physical responses. The individual then goes through a standard set of stressors (such as rapid math calculations or running in place) each lasting from two to four minutes. This is followed by another relaxation period to determine the length of the recovery period.
  • Using signals from the biofeedback equipment to control physical responses: The individual is assisted in reaching certain goals related to managing a specific physical response.
  • Transferring control from biofeedback equipment or the health care professional: Individuals learn to identify triggers that alert them to implement their new-found self-regulation skills.

Types of biofeedback equipment

  • Electromyograph (EMG): Sensors (or electrodes) placed on the skin on pertinent parts of the body monitor electrical activity in muscles, specifically tension. This is the most frequently used biofeedback method in the treatment of various neurologic disorders such as stroke , cerebral palsy, traumatic brain injury, and multiple sclerosis. In children and adolescents, EMG may be used to treat tension headaches, enuresis , and encopresis . In treating TMJ or bruxism, EMG sensors are placed on jaw muscles. Chronic pain is treated by monitoring muscle tension in various places on the body.
  • Galvanic skin response (GSR): Sensors on the fingers monitor perspiration or sweating. This is also referred to as obtaining a skin conductance level (SCL). GSR may be used in the treatment of anxiety, fears or phobias, stress, and sleep problems.
  • Temperature or thermal sensors: Sensors monitor body temperature and changes in blood flow. Changes in hand temperature, for example, can indicate relaxation when there is increased blood flow to the skin. Temperature biofeedback may be useful for treating migraine headache, Raynaud's disorder, and anxiety disorders.
  • Heart rate sensors: A pulse monitor placed on the fingertip monitors pulse rate. Increases in heart rate are associated with emotional arousal, such as being angry or fearful. Decreases in heart rate are associated with relaxation.
  • Capnometry (CAP): Respiratory sensors monitor oxygen intake and carbon dioxide output. This differentiates correct breathing from problematic breathing practices. Breath control training may be used to treat panic attacks, asthma, and a variety of stress-related conditions.
  • Electroencephalographs (EEG) or neurofeedback: Sensors attached to the scalp monitor brain wave activity in different parts of the brain. It may be used to treat conditions with proven or suspected impact on brain wave patterns such as seizure disorders or epilepsy, ADHD, learning disabilities, migraine headaches, traumatic brain injury, and sleep disorders.

Biofeedback is geared toward whatever a person finds most appealing and understandable and provided in several formats such as auditory, visual, or multimedia. Audio feedback, that may take the form of changes in tone and pitch, is useful because visual attention is not necessary. Visual feedback can be provided in various forms such as bar or line graphs on a computer screen. Initially, it was thought thatover timecomputer signals could become boring or visually unappealing. In response to this, Barry Bittman developed Mindscope in 1992 that displays video scenes with realistic sounds on a high-definition television set connected to a computer. Physical responses detected by the biofeedback equipment control an engaging audiovisual environment of beautiful and realistic scenes. Clarity, perspective, motion, and sounds improve as the individual deepens their relaxation. For children and adolescents, this may be described as a "video game for the body." Visual displays for EMG biofeedback may include sports such as basketball, baseball, and golf, where the individual plays against the computer.

The setting in which biofeedback training takes place can vary. Sometimes the clinician, client, and equipment are in the same room. Sometimes the client may sit in comfortable seating in a semi-dark, quiet room while the clinician is in another room with the equipment. In this arrangement, the clinician and client may communicate using an intercom.

In some cases, children and adolescents may reach the desired level of control in three to five sessions. Depending on the condition, biofeedback training may require a series of sessions for several days or weeks. In general, it may take 10 or 15 sessions at the lower end to 40 or 50 sessions at the higher end.

Preparation

Biofeedback is most successful when individuals are motivated to learn. It is useful for people who have difficulty relaxing, even when they make efforts to do so. A receptive and open attitude is important for attaining desired responses rather than actively focusing on attaining them. It is important that individuals are willing to practice regularly at home to apply the skill to everyday life. Establishing a foundation of trust and confidence in the health care professional is an important component of biofeedback training.

Before beginning biofeedback training, an initial consultation will be conducted to record medical history, treatment background, and biofeedback goals. The procedure will be explained to provide a clear understanding of how and why the training will be helpful. The individual may be shown the equipment and told where they will be placed and how they work.

Before electrodes are placed on the body, the skin surface must be adequately prepared by using alcohol preparation pads to remove oils, makeup, and dead skin cells that may interfere with the biofeedback signal. An electrode paste is then applied to the sensor, or a small adhesive pad is used to adhere the sensor to the skin. Heart rate, temperature, and GSR monitors may be placed on the fingertip with a Velcro or elastic band. With CAP, the tip of a small, flexible, plastic tube is positioned in the nostril using tape. An individual may be taught several forms of biofeedback initially, then the training may be tailored to the individual's preference.

The biofeedback trainer must have technical skill, an understanding of basic anatomy and physiology, knowledge of various conditions, and familiarity with computer hardware and software. The American Psychological Association views biofeedback as a proficiency area, master's and doctoral level training programs are available through a variety of sources, and certification is available through the Biofeedback Certification Institute of America.

Aftercare

One or two follow-up sessions may be arranged two to four months after the initial set of appointments. In this way, long-term progress can be assessed, support can be provided, and adjustments can be made, if needed.

Risks

There are no known side effects with properly administered biofeedback. Problems may occur if biofeedback is used to treat certain conditions where the use of biofeedback is not advised.

Normal results

A normal result may be indicated by achieving the desired changes in muscle tension, heart rate, sweat activity, respiration rate, temperate change, and brainwave activity. Health care professionals may use various criteria or normal values that have been developed for some biofeedback equipment. These values indicate levels that can be expected from normal physiological functioning or relaxation. Importantly, an individual learns to control their physical reactions, which may lead to feelings of empowerment and confidence.

Abnormal results

Unusual results may arise from a number of factors, including poor sensor or electrode contact with the skin and interference from other electrical signals or "noise." Some equipment may react to room temperature conditions, especially when the room is very hot or very cold. Although inexpensive monitoring equipment is available, such as watches that monitor heartbeat and hand-held GSR devices, their results may not be accurate.

See also Anxiety and anxiety disorders; Substance abuse and related disorders

Resources

BOOKS

Culbert, Timothy P. "Biofeedback with Children and Adolescents." In Innovative Psychotherapy Techniques in Child and Adolescent Therapy., edited by C. Schaefer. 2nd ed. New York: John Wiley and Sons, 1999.

Di Franco, Joyce T. "Biofeedback." In Childbirth Education: Practice, Research and Theory, edited by F. H. Nichols and S. S. Humenick. 2nd ed. Philadelphia: W. B. Saunders, 2000.

Schwartz, Mark S. and Associates. Biofeedback: A Practitioner's Guide. New York: Guilford, 1987.

Spencer, John W. and J. J. Jacobs. Complementary/Alternative Medicine: An Evidence-Based Approach. Baltimore: Mosby, 1999.

Stoyva, Johann M. and Thomas H. Budzynski. "Biofeedback Methods in the Treatment of Anxiety and Stress Disorders." In Principles and Practice of Stress Management. edited by P. M. Lehrer and R. L. Woolfolk. 2nd ed. New York: Guilford Press, 1993.

PERIODICALS

American Psychological Association. "HCFA will cover biofeedback for incontinence." Monitor on Psychology 31, no.11 (December 2000).

Burgio, Kathryn L., Julie L. Locher, Patricia S. Goode, M. Hardin, B. Joan McDowell, and Dorothy C. Dombrowski. "Behavioral vs. Drug Treatment for Urge Urinary Incontinence in Older Women: A Randomized Controlled Trial." JAMA, The Journal of the American Medical Association 280, no. 23 (December 1998): 1995-2000.

ORGANIZATIONS

Association for Applied Psychotherapy and Biofeedback. 10200 W. 44th Avenue, Suite 304, Wheat Ridge, CO 80033-2840. (303) 422-8436. <http://www.aapb.org>.

Biofeedback Certification Institute of America. 1022 W. 44th Avenue, Suite 310, Wheat Ridge, CO 80033. (303) 420-2902. <http://www.bcia.org>.

Joneis Thomas, Ph.D.

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Biofeedback

Biofeedback

Definition

Biofeedback, or applied psychophysiological feedback, is a patient-guided treatment that teaches an individual to control muscle tension, pain , body temperature, brain waves, and other bodily functions and processes through relaxation , visualization, and other cognitive control techniques. The name biofeedback refers to the biological signals that are fed back, or returned, to the patient in order for the patient to develop techniques of manipulating them.

Origins

In 1961, Neal Miller, an experimental psychologist, suggested that autonomic nervous system responses (for instance, heart rate, blood pressure, gastrointestinal activity, regional blood flow) could be under voluntary control. As a result of his experiments, he showed that such autonomic processes were controllable. This work led to the creation of biofeedback therapy. Willer's work was expanded by other researchers. Thereafter, research performed in the 1970s by UCLA researcher Dr. Barry Sterman established that both cats and monkeys could be trained to control their brain wave patterns. Sterman then used his research techniques on human patients with epilepsy , where he was able to reduce seizures by 60% with the use of biofeedback techniques. Throughout the 1970s, other researchers published reports of their use of biofeedback in the treatment of cardiac arrhythmias, headaches, Raynaud's syndrome , and excess stomach acid, and as a tool for teaching deep relaxation. Since the early work of Miller and Sterman, biofeedback has developed into a front-line behavioral treatment for an even wider range of disorders and symptoms.

Benefits

Biofeedback has been used to successfully treat a number of disorders and their symptoms, including tempromandibular joint disorder (TMJ), chronic pain, irritable bowel syndrome (IBS), Raynaud's syndrome, epilepsy, attention-deficit hyperactivity disorder

(ADHD), migraine headaches, anxiety, depression , traumatic brain injury, and sleep disorders .

Illnesses that may be triggered at least in part by stress are also targeted by biofeedback therapy. Certain types of headaches, high blood pressure, bruxism (teeth grinding), post-traumatic stress disorder , eating disorders, substance abuse, and some anxiety disorders may be treated successfully by teaching patients the ability to relax and release both muscle and mental tension. Biofeedback is often just one part of a comprehensive treatment program for some of these disorders.

NASA has used biofeedback techniques to treat astronauts who suffer from severe space sickness, during which the autonomic nervous system is disrupted. Scientists at the University of Tennessee have adapted these techniques to treat individuals suffering from severe nausea and vomiting that is also rooted in autonomic nervous system dysfunction.

Recent research also indicates that biofeedback may be a useful tool in helping patients with urinary incontinence regain bladder control. Individuals learning pelvicfloor muscle strengthening exercises can gain better control over these muscles by using biofeedback. Sensors are placed on the muscles to train the patient where they are and when proper contractions are taking place.

Description

During biofeedback, special sensors are placed on the body. These sensors measure the bodily function that is causing the patient problem symptoms, such as heart rate, blood pressure, muscle tension (EMG or electromyographic feedback), brain waves (EEC or electroencophalographic feedback), respiration, and body temperature (thermal feedback), and translates the information into a visual and/or audible readout, such as a paper tracing, a light display, or a series of beeps.

While the patient views the instantaneous feedback from the biofeedback monitors, he or she begins to recognize what thoughts, fears, and mental images influence his or her physical reactions. By monitoring this relationship between mind and body, the patient can then use these same thoughts and mental images as subtle cues, as these act as reminders to become deeply relaxed, instead of anxious. These reminders also work to manipulate heart beat, brain wave patterns, body temperature, and other bodily functions. This is achieved through relaxation exercises, mental imagery, and other cognitive therapy techniques.

As the biofeedback response takes place, patients can actually see or hear the results of their efforts instantly through the sensor readout on the biofeedback equipment. Once these techniques are learned and the patient is able to recognize the state of relaxation or visualization necessary to alleviate symptoms, the biofeedback equipment itself is no longer needed. The patient then has a powerful, portable, and self-administered treatment tool to deal with problem symptoms.

Biofeedback that specializes in reading and altering brain waves is sometimes called neurofeedback. The brain produces four distinct types of brain wavesdelta, theta, alpha, and betathat all operate at a different frequency. Delta, the slowest frequency wave, is the brain wave pattern associated with sleep. Beta waves, which occur in a normal, waking state, can range from 12-35 Hz. Problems begin to develop when beta wave averages fall in the low end (underarousal) or the high end (over-arousal) of that spectrum. Underarousal might be present in conditions such as depression or attention-deficit disorder, and overarousal may be indicative of an anxiety disorder, obsessive compulsive disorder, or excessive stress. Beta wave neurofeedback focuses on normalizing that beta wave pattern to an optimum value of around 14 Hz. A second type of neurofeedback, alpha-theta, focuses on developing the more relaxing alpha (8-13 Hz) and theta waves (4-9 Hz) that are usually associated with deep, meditative states, and has been used with some success in substance abuse treatment.

Through brain wave manipulation, neurofeedback can be useful in treating a variety of disorders that are suspected or proven to impact brain wave patterns, such as epilepsy, attention-deficit disorder, migraine headaches, anxiety, depression, traumatic brain injury, and sleep disorders. The equipment used for neurofeedback usually uses a monitor as an output device. The monitor displays specific patterns that the patient attempts to change by producing the appropriate type of brain wave. Or, the monitor may reward the patient for producing the appropriate brain wave by producing a positive reinforcer, or reward. For example, children may be rewarded with a series of successful moves in a displayed video game.

Depending on the type of biofeedback, individuals may need up to 30 sessions with a trained professional to learn the techniques required to control their symptoms on a long-term basis. Therapists usually recommend that their patients practice both biofeedback and relaxation techniques on their own at home.

Preparations

Before initiating biofeedback treatment, the therapist and patient will have an initial consultation to record the patients medical history and treatment background and discuss goals for therapy.

Before a neurofeedback session, an EEG is taken from the patient to determine his or her baseline brainwave pattern.

ELMER GREEN 1917


A life dedicated to science has propelled Elmer Green, Ph.D. into careers as a physicist and a biological psychologist. Both led to his most noted work, the influence on the birth of the biofeedback movement. While the mechanics of moving parts and machinery lured the investigator from LaGrand, Oregon, to his work as a civilian scientist with the Navy in the late 1940s, it was his wife Alyce who caused him to ponder biophysiology and human development. In 1953 she read a book titled The Human Senses by Frank Geldard. It was their interests as a couple that led to their continued education at the University of Chicago. In 1957 Green began work for his Ph.D. studies in biopsychology, while Alyce studied for her Master's degree in psychology.

Numerous opportunities, including assisting with the development of a machine for the automated detection of brain damage, led to his position at the Menninger Institute in Topeka, Kansas, in 1964. While there he established the psychophysiology laboratory and the Voluntary Controls Program. It was his treatment of a colleague's wife's headaches that Green became convinced that skin temperature was an autonomic nervous system variable that was responsive to psychophysiologic self-regulation aided by thermal biofeedback. By learning to control temperature he found that headache control could be enhanced. Green's success attracted support by several of the Menninger staff who also began research and use of biofeedback therapy for headaches and hypertension.

The 1960s proved exciting for Green as he, Alyce, and colleague Dale Walters became involved with EEG Biofeedback, and studied the process of meditationa therapy the Greens had long practiced. In April 1969, Green and his wife organized the Council Grove Conference for the study of the voluntary control of internal states. The conference served as a step toward forming the Biofeedback Research Society, which later became the Biofeedback Society of America, and currently the Association for Applied Psychophysiology and Biofeedback.

Together, Elmer and Alyce Green authored numerous papers, book chapters, and wrote the book, Beyond Biofeedback (1977). They lectured throughout the United States and around the world for more than 20 years on multiple topics including EEG biofeedback training and psychophysiologic control.

Green co-founded the International Society For the Study of Subtle Energies and Energy Medicine (ISSSEEM) in 1990 and served as its director. Alyce died in 1994 of Alzheimer's disease. In 2000, 81-year-old Green worked as a professional consultant and director emeritus of the Voluntary Controls Program at the Menninger Clinic. He also served as the science director of the Dove Health Alliance in Aptos, California.

Beth A. Kapes

Biofeedback typically is performed in a quiet and relaxed atmosphere with comfortable seating for the patient. Depending on the type and goals of biofeedback being performed, one or more sensors will be attached to the patient's body with conductive gel and/or adhesives. These may include:

  • Electromyographic (EMG) sensors. EMG sensors measure electrical activity in the muscles, specifically muscle tension. In treating TMJ or bruxism, these sensors would be placed along the muscles of the jaw. Chronic pain might be treated by monitoring electrical energy in other muscle groups.
  • Galvanic skin response (GSR) sensors. These are electrodes placed on the fingers that monitor perspiration, or sweat gland, activity. These may also be called skin conductance level (SCL).
  • Temperature sensors. Temperature, or thermal, sensors measure body temperature and changes in blood flow.
  • Electroencephalography (EEG) sensors. These electrodes are applied to the scalp to measure the electrical activity of the brain, or brain waves.
  • Heart rate sensors. A pulse monitor placed on the finger tip can monitor pulse rate.
  • Respiratory sensors. Respiratory sensors monitor oxygen intake and carbon dioxide output.

Precautions

Individuals who use a pacemaker or other implantable electrical devices should inform their biofeedback therapist before starting treatments, as certain types of biofeedback sensors have the potential to interfere with these devices.

Biofeedback may not be suitable for some patients. Patients must be willing to take a very active role in the treatment process. And because biofeedback focuses strictly on behavioral change, those patients who wish to gain insight into their symptoms by examining their past might be better served by psychodynamic therapy.

Biofeedback may also be inappropriate for cognitively impaired individuals, such as those patients with organic brain disease or a traumatic brain injury, depending on their levels of functioning.

Patients with specific pain symptoms of unknown origin should undergo a thorough medical examination before starting biofeedback treatments to rule out any serious underlying disease. Once a diagnosis has been made, biofeedback can be used concurrently with conventional treatment.

Biofeedback may only be one component of a comprehensive treatment plan. For illnesses and symptoms that are manifested from an organic disease process, such as cancer or diabetes, biofeedback should be an adjunct to (complementary to), and not a replacement for, conventional medical treatment.

Side effects

There are no known side effects to properly administered biofeedback or neurofeedback sessions.

Research & general acceptance

Preliminary research published in late 1999 indicated that neurofeedback may be a promising new tool in the treatment of schizophrenia . Researchers reported that schizophrenic patients had used neurofeedback to simulate brain wave patterns that antipsychotic medications produce in the brain. Further research is needed to determine what impact this may have on treatment for schizophrenia.

KEY TERMS

Raynaud's syndrome
A vascular, or circulatory system, disorder which is characterized by abnormally cold hands and feet. This chilling effect is caused by constriction of the blood vessels in the extremities, and occurs when the hands and feet are exposed to cold weather. Emotional stress can also trigger the cold symptoms.

The use of biofeedback techniques to treat an array of disorders has been extensively described in the medical literature. Controlled studies for some applications are limited, such as for the treatment of menopausal symptoms and premenstrual disorder (PMS). There is also some debate over the effectiveness of biofeedback in ADHD treatment, and the lack of controlled studies on that application. While many therapists, counselors, and mental health professionals have reported great success with treating their ADHD patients with neurofeedback techniques, some critics attribute this positive therapeutic impact to a placebo effect .

There may also be some debate among mental health professionals as to whether biofeedback should be considered a first line treatment for some mental illnesses, and to what degree other treatments, such as medication, should be employed as an adjunct therapy.

Training & certification

Individuals wishing to try biofeedback should contact a healthcare professional trained in biofeedback techniques. Licensed psychologists, psychiatrists, and physicians frequently train their patients in biofeedback techniques, or can recommend a specialist who does. In some cases, a licensed professional may employ a biofeedback technician who works under their direct guidance when treating patients. There are several national organizations for biofeedback therapists, including the Biofeedback Certification Institute of America, which also certifies therapists in the practice.

Resources

BOOKS

Robbins, Jim. A Symphony in the Brain: The Evolution of the New Brain Wave Biofeedback. Boston, MA: Atlantic Monthly Press, 2000.

PERIODICALS

Burgio, K.L. et al. "Behavioral vs. Drug Treatment for Urge Urinary Incontinence in Older Women: A randomized controlled trial." Journal of the American Medical Association 280 (Dec. 1998): 1995-2000.

Robbins, Jim. "On the Track with Neurofeedback." Newsweek 135, no. 25 (June 2000): 76.

ORGANIZATIONS

The Association for Applied Psychotherapy and Biofeedback. 10200 W. 44th Avenue, Suite 304, Wheat Ridge, CO 80033-2840. (303) 422-8436. <http://www.aapb.org>.

Biofeedback Certification Institute of America. 10200 W. 44th Avenue, Suite 310, Wheat Ridge, CO 80033. (303) 420-2902.

Paula Ford-Martin

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Biofeedback

Biofeedback

Definition

Biofeedback, or applied psychophysiological feedback, is a patient-guided treatment that teaches an individual to control muscle tension, pain, body temperature, brain waves, and other bodily functions and processes through relaxation, visualization, and other cognitive control techniques. The name biofeedback refers to the biological signals that are fed back, or returned, to the patient in order for the patient to develop techniques of manipulating them.

Purpose

Biofeedback has been used to successfully treat a number of disorders and their symptoms, including temporomandibular joint disorder (TMJ), chronic pain, irritable bowel syndrome (IBS), Raynaud's syndrome, epilepsy, attention-deficit hyperactivity disorder (ADHD ), migraine headaches, anxiety, depression, traumatic brain injury, and sleep disorders.

Illnesses that may be triggered at least in part by stress are also targeted by biofeedback therapy. Certain types of headaches, high blood pressure, bruxism (teeth grinding), post-traumatic stress disorder, eating disorders, substance abuse, and some anxiety disorders may be treated successfully by teaching patients the ability to relax and release both muscle and mental tension. Biofeedback is often just one part of a comprehensive treatment program for some of these disorders.

NASA has used biofeedback techniques to treat astronauts who suffer from severe space sickness, during which the autonomic nervous system is disrupted. Scientists at the University of Tennessee have adapted these techniques to treat individuals suffering from severe nausea and vomiting that is also rooted in autonomic nervous system dysfunction.

Recent research also indicates that biofeedback may be a useful tool in helping patients with urinary incontinence regain bladder control. Individuals learning pelvic-floor muscle strengthening exercises can gain better control over these muscles by using biofeedback. Sensors are placed on the muscles to train the patient where they are and when proper contractions are taking place.

Description

Origins

In 1961, Neal Miller, an experimental psychologist, suggested that autonomic nervous system responses (for instance, heart rate, blood pressure, gastrointestinal activity, regional blood flow) could be under voluntary control. As a result of his experiments, he showed that such autonomic processes were controllable. This work led to the creation of biofeedback therapy. Willer's work was expanded by other researchers. Thereafter, research performed in the 1970s by UCLA researcher Dr. Barry Sterman established that both cats and monkeys could be trained to control their brain wave patterns. Sterman then used his research techniques on human patients with epilepsy, where he was able to reduce seizures by 60% with the use of biofeedback techniques. Throughout the 1970s, other researchers published reports of their use of biofeedback in the treatment of cardiac arrhythmias, headaches, Raynaud's syndrome, and excess stomach acid, and as a tool for teaching deep relaxation. Since the early work of Miller and Sterman, biofeedback has developed into a front-line behavioral treatment for an even wider range of disorders and symptoms.

During biofeedback, special sensors are placed on the body. These sensors measure the bodily function that is causing the patient problem symptoms, such as heart rate, blood pressure, muscle tension (EMG or electromyographic feedback), brain waves (EEC or electroencophalographic feedback), respiration, and body temperature (thermal feedback), and translates the information into a visual and/or audible readout, such as a paper tracing, a light display, or a series of beeps.

While the patient views the instantaneous feedback from the biofeedback monitors, he or she begins to recognize what thoughts, fears, and mental images influence his or her physical reactions. By monitoring this relationship between mind and body, the patient can then use these same thoughts and mental images as subtle cues, as these act as reminders to become deeply relaxed, instead of anxious. These reminders also work to manipulate heart beat, brain wave patterns, body temperature, and other bodily functions. This is achieved through relaxation exercises, mental imagery, and other cognitive therapy techniques.

KEY TERMS

Autonomic nervous system The part of the nervous system that controls so-called involuntary functions, such as heart rate, salivary gland secretion, respiratory function, and pupil dilation.

Bruxism Habitual, often unconscious, grinding of the teeth.

Epilepsy A neurological disorder characterized by the sudden onset of seizures.

Placebo effect Placebo effect occurs when a treatment or medication with no known therapeutic value (a placebo) is administered to a patient, and the patient's symptoms improve. The patient believes and expects that the treatment is going to work, so it does. The placebo effect is also a factor to some degree in clinically-effective therapies, and explains why patients respond better than others to treatment despite similar symptoms and illnesses.

Raynaud's syndrome A vascular, or circulatory system, disorder which is characterized by abnormally cold hands and feet. This chilling effect is caused by constriction of the blood vessels in the extremities, and occurs when the hands and feet are exposed to cold weather. Emotional stress can also trigger the cold symptoms.

Schizophrenia Schizophrenia is a psychotic disorder that causes distortions in perception (delusions and hallucinations), inappropriate moods and behaviors, and disorganized or incoherent speech and behavior.

Temporomandibular joint disorder Inflammation, irritation, and pain of the jaw caused by improper opening and closing of the temporomandibular joint. Other symptoms include clicking of the jaw and a limited range of motion.

As the biofeedback response takes place, patients can actually see or hear the results of their efforts instantly through the sensor readout on the biofeedback equipment. Once these techniques are learned and the patient is able to recognize the state of relaxation or visualization necessary to alleviate symptoms, the biofeedback equipment itself is no longer needed. The patient then has a powerful, portable, and self-administered treatment tool to deal with problem symptoms.

Biofeedback that specializes in reading and altering brain waves is sometimes called neurofeedback. The brain produces four distinct types of brain wavesdelta, theta, alpha, and betathat all operate at a different frequency. Delta, the slowest frequency wave, is the brain wave pattern associated with sleep. Beta waves, which occur in a normal, waking state, can range from 12-35 Hz. Problems begin to develop when beta wave averages fall in the low end (underarousal) or the high end (overarousal) of that spectrum. Underarousal might be present in conditions such as depression or attention-deficit disorder, and overarousal may be indicative of an anxiety disorder, obsessive compulsive disorder, or excessive stress. Beta wave neurofeedback focuses on normalizing that beta wave pattern to an optimum value of around 14 Hz. A second type of neurofeedback, alpha-theta, focuses on developing the more relaxing alpha (8-13 Hz) and theta waves (4-9 Hz) that are usually associated with deep, meditative states, and has been used with some success in substance abuse treatment.

Through brain wave manipulation, neurofeedback can be useful in treating a variety of disorders that are suspected or proven to impact brain wave patterns, such as epilepsy, attention-deficit disorder, migraine headaches, anxiety, depression, traumatic brain injury, and sleep disorders. The equipment used for neurofeedback usually uses a monitor as an output device. The monitor displays specific patterns that the patient attempts to change by producing the appropriate type of brain wave. Or, the monitor may reward the patient for producing the appropriate brain wave by producing a positive reinforcer, or reward. For example, children may be rewarded with a series of successful moves in a displayed video game.

Depending on the type of biofeedback, individuals may need up to 30 sessions with a trained professional to learn the techniques required to control their symptoms on a long-term basis. Therapists usually recommend that their patients practice both biofeedback and relaxation techniques on their own at home.

Preparations

Before initiating biofeedback treatment, the therapist and patient will have an initial consultation to record the patients medical history and treatment background and discuss goals for therapy.

Before a neurofeedback session, an EEG is taken from the patient to determine his or her baseline brainwave pattern.

Biofeedback typically is performed in a quiet and relaxed atmosphere with comfortable seating for the patient. Depending on the type and goals of biofeedback being performed, one or more sensors will be attached to the patient's body with conductive gel and/or adhesives. These may include:

  • Electromyographic (EMG) sensors. EMG sensors measure electrical activity in the muscles, specifically muscle tension. In treating TMJ or bruxism, these sensors would be placed along the muscles of the jaw. Chronic pain might be treated by monitoring electrical energy in other muscle groups.
  • Galvanic skin response (GSR) sensors. These are electrodes placed on the fingers that monitor perspiration, or sweat gland, activity. These may also be called skin conductance level (SCL).
  • Temperature sensors. Temperature, or thermal, sensors measure body temperature and changes in blood flow.
  • Electroencephalography (EEG) sensors. These electrodes are applied to the scalp to measure the electrical activity of the brain, or brain waves.
  • Heart rate sensors. A pulse monitor placed on the finger tip can monitor pulse rate.
  • Respiratory sensors. Respiratory sensors monitor oxygen intake and carbon dioxide output.

Precautions

Individuals who use a pacemaker or other implantable electrical devices should inform their biofeedback therapist before starting treatments, as certain types of biofeedback sensors have the potential to interfere with these devices.

Biofeedback may not be suitable for some patients. Patients must be willing to take a very active role in the treatment process. And because biofeedback focuses strictly on behavioral change, those patients who wish to gain insight into their symptoms by examining their past might be better served by psychodynamic therapy.

Biofeedback may also be inappropriate for cognitively impaired individuals, such as those patients with organic brain disease or a traumatic brain injury, depending on their levels of functioning.

Patients with specific pain symptoms of unknown origin should undergo a thorough medical examination before starting biofeedback treatments to rule out any serious underlying disease. Once a diagnosis has been made, biofeedback can be used concurrently with conventional treatment.

Biofeedback may only be one component of a comprehensive treatment plan. For illnesses and symptoms that are manifested from an organic disease process, such as cancer or diabetes, biofeedback should be an adjunct to (complementary to), and not a replacement for, conventional medical treatment.

Side effects

There are no known side effects to properly administered biofeedback or neurofeedback sessions.

Research and general acceptance

Preliminary research published in late 1999 indicated that neurofeedback may be a promising new tool in the treatment of schizophrenia. Researchers reported that schizophrenic patients had used neurofeedback to simulate brain wave patterns that antipsychotic medications produce in the brain. Further research is needed to determine what impact this may have on treatment for schizophrenia.

The use of biofeedback techniques to treat an array of disorders has been extensively described in the medical literature. Controlled studies for some applications are limited, such as for the treatment of menopausal symptoms and premenstrual disorder (PMS). There is also some debate over the effectiveness of biofeedback in ADHD treatment, and the lack of controlled studies on that application. While many therapists, counselors, and mental health professionals have reported great success with treating their ADHD patients with neurofeedback techniques, some critics attribute this positive therapeutic impact to a placebo effect.

There may also be some debate among mental health professionals as to whether biofeedback should be considered a first line treatment for some mental illnesses, and to what degree other treatments, such as medication, should be employed as an adjunct therapy.

Resources

BOOKS

Robbins, Jim. A Symphony in the Brain: The Evolution of the New Brain Wave Biofeedback. Boston, MA: Atlantic Monthly Press, 2000.

PERIODICALS

Robbins, Jim. "On the Track with Neurofeedback." Newsweek 135, no. 25 (June 2000): 76.

ORGANIZATIONS

Association for Applied Psychotherapy and Biofeedback. 10200 W. 44th Avenue, Suite 304, Wheat Ridge, CO 80033-2840. (303) 422-8436. http://www.aapb.org.

Biofeedback Certification Institute of America.10200 W. 44th Avenue, Suite 310, Wheat Ridge, CO 80033. (303) 420-2902.

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Biofeedback

Biofeedback

A technique that allows individuals to monitor their own physiological processes so they can learn to control them.

Biofeedback originated with the field of psychophysiology, which measures physiological responses as a way of studying human behavior. Types of behavior that may be studied in this way range from basic emotional responses to higher cognitive functions. Today, biofeedback is also associated with behavioral medicine, which combines behavioral and biomedical science in both clinical and research settings. In biofeedback training, the monitoring of physiological responses is performed for therapeutic instead of (or in addition to) investigative purposes. Biofeedback has been applied with success to a variety of clinical problems, ranging from migraine headaches to hypertension.

The technique provides people with continuous information about physiological processes of which they are normally unaware, such as blood pressure or heart rate. Through special equipment, these processes are recorded, and the information is relayed back to the person through a changing tone or meter reading. With practice, people learn strategies that enable them to achieve voluntary control over the processes involved. For example, persons trying to control their blood pressure levels may see a light flash whenever the pressure drops below a certain level. They may then try to remember and analyze what their thoughts or emotions were at that moment and deliberately repeat them to keep the pressure level low. Initially, they may simply be asked to try and keep the light flashing for as long as possible and given verbal reinforcement for their efforts.

The biofeedback training may continue for several days or weeks, with the subjects trying to keep the light flashing for longer periods in subsequent sessions. Eventually they will need to produce the desired response without electronic feedback, a goal which can be accomplished through various methods. They may practice the learned response at the end of the training session or at home between sessions. There can also be random trials without feedback during the sessions. An alternate strategy is the gradual and systematic removal of the feedback signal during the training sessions over a period of time. After the initial training is completed, subjects may return to the biofeedback facility to assess their retention of the skills they have learned or for additional training.

Biofeedback training has been used in treating a number of different clinical problems. Monitoring of patients' heart rates has been used with some success to help people suffering from heartbeat irregularities, including premature ventricular contractions (PVCs) and tachycardia, while hypertensive individuals have been

able to control high blood pressure through the use of biofeedback. Clinicians have been particularly successful in their use of neuromuscular feedback to treat complaints arising from tension in specific muscles or muscle groups. Tension headaches have been alleviated through the reduction of frontalis (forehead) tension, and relaxation of the face and neck muscles has been helpful to stutterers. Feedback from muscle groups has been helpful in the rehabilitation of stroke patients and other persons with neuromuscular disorders such as foot drop. These patients may be unable to relax or contract muscles at will, and biofeedback can make them aware of small, otherwise imperceptible changes in the desired direction and allow them to repeat and eventually increase such changes.

In addition to its alleviation of physical complaints, neuromuscular biofeedback has been an effective tool in the treatment of chronic anxiety, even when it has resisted psychotherapy and medication. By learning deep muscle relaxation, anxious patients, including those suffering from related conditions such as insomnia, have seen a reduction in their symptoms. Even for patients who have been able to achieve relaxation through other means, such as meditation or progressive relaxation, biofeedback can be a valuable supplementary technique that offers special advantages, such as allowing a therapist to track closely the points at which a patient tenses up and try to learn what thoughts are associated with the tension. Biofeedback-induced relaxation of forehead muscles has also been effective in treating asthma.

Another type of biofeedback involves the monitoring of brain activity through electroencephalographs (EEGs). A reduction of seizures in epileptics has been reported through biofeedback techniques involving EEG activity near the sensorimotor cortex, known as sensory motor rhythm. Brain wave activity has also been of interest in connection with alpha waves, which are thought to characterize a desirable state of relaxed alertness. Patients have been taught to increase their alpha rhythms in three or four 30-minute conditioning sessions.

Further Reading

Andreassi, John L. Psychophysiology: Human Behavior and Physiological Response. New York: Oxford University Press, 1980.

Beatty, J., and H. Legewie, eds. Biofeedback and Behavior. New York: Plenum Press, 1977.

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Biofeedback

Biofeedback

A term covering a range of EEG (electroencephalographic) feedback instruments and techniques, as well as apparatus giving information on other biological functions. Biofeedback instruments can convey to the subject the characteristics of his own brainwaves, skin resistance, or heartbeats so that he can learn to modify these functions consciously. In this way, the subject can enhance his capacity for relaxation or reproduce some of the psycho-physiological control shown by yogis and Zen masters.

Modification of brainwaves by biofeedback machines was first introduced in the United States by Joe Kamiya in the late 1960s; Elmer Green of the Menninger Clinic promoted the practice through the 1970s. It appeared that biofeedback could become a major technique within transpersonal psychology, and that subjects could be trained to control or to generate brain wave activity at will, thus achieving altered states of consciousness leading to the production of various psychic, spiritual, and mystical experiences.

The chief brain waves identified within biofeedback studies are: alpha (related to relaxation and dream states), frequency 8 to 13 cycles per second (cps); beta (mental and visual activity), 14 to 50 cps; theta (dream and sleep states), 4 to 7 cps; and delta (deep sleep states), 0.5 to 3.5 cps.

The simple relationship first thought to exist between brain waves and psychic and spiritual development proved to be much more complicated and ambiguous than originally believed. At present biofeedback has been used mainly in teaching people to alter various body functions to improve their health; it has been particularly effective in cases of migraine headaches.

Sources:

Green, Elmer. "Biofeedback for Mind-Body Self-Regulation: Healing and Creativity." In The Varieties of Healing Experience: Exploring Psychic Phenomena and Healing. Los Altos, Calif.: Academy of Parapsychology and Medicine, 1971.

Kamiya, Joe. "Conscious Control of Brain Waves." Psychology Today 1, no. 11 (April 1968).

Stearn, Jess. The Power of Alpha-Thinking: Miracle of the Mind. New York: William Morrow, 1976. Reprint, New York: New American Library, 1977.

Timmons, Beverly, and Joe Kamiya. "The Psychology and Physiology of Meditation and Related Phenomena." Journal of Transpersonal Psychology 1 (1970).

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biofeedback

biofeedback, method for learning to increase one's ability to control biological responses, such as blood pressure, muscle tension, and heart rate. Sophisticated instruments are often used to measure physiological responses and make them apparent to the patient, who then tries to alter and ultimately control them without the aid of monitoring devices. Biofeedback programs have been used to teach patients to relax muscles or adjust blood flow in the case of headache, to help partially paralyzed stroke victims activate muscles, and to alleviate anxiety in dental patients.

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biofeedback

biofeedback In alternative medicine, the use of monitoring systems to provide information about body processes to enable them to be controlled voluntarily. By observing data on events that are normally involuntary, such as breathing and the heartbeat, many people learn to gain control over them to some extent in order to improve well-being. The technique has proved helpful in a number of conditions, including migraine and hypertension.

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biofeedback

biofeedback The technique whereby a subject can learn to control certain body functions, such as heart rate or blood pressure, that are usually unconsciously regulated by the autonomic nervous system. It is facilitated by the use of monitoring devices, such as pulse monitors, electroencephalographs, and electromyographs, and can be useful in treating high blood pressure, migraine, epilepsy, and other disorders.

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biofeedback

bi·o·feed·back / ˌbīōˈfēdˌbak/ • n. the use of electronic monitoring of a normally automatic bodily function in order to train someone to acquire voluntary control of that function.

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Biofeedback

Biofeedback

Definition

Purpose

Precautions

Description

Preparation

Aftercare

Risks

Normal results

Abnormal results

Resources

Definition

Biofeedback is a technique that uses monitoring instruments to measure and feed back information about muscle tension, heart rate, sweat responses, skin temperature, or brain activity.

Terms associated with biofeedback include applied psychophysiology or behavioral physiology. It is also viewed as a mind-body therapy method used in complementary and alternative medicine. Biofeedback is an important part of understanding the relationship between physical state and thoughts, feelings, and behaviors.

Purpose

The purpose of biofeedback is to enhance an individual’s awareness of physical reactions to physical, emotional, or psychological stress, and their ability to influence their own physiological responses. The overall purpose is to develop self-regulation skills that play a role in improving health and well-being.

Biofeedback has been used as a part of a comprehensive treatment approach with a number of conditions, including chronic pain, irritable bowel syndrome (IBS), temporomandibular joint disorder (TMJ), Raynaud’s syndrome, epilepsy, attention deficit/hyperactivity disorder (ADHD), anxiety, migraine headaches, depression, traumatic brain injury, and sleep disorders. There is some support for using biofeedback in the treatment of diabetes when self-monitoring of blood glucose levels is maintained and within the context of regular physician consultation and supervision.

Biofeedback has been a useful tool in helping individuals with urinary incontinence regain bladder control by controlling the muscles used in urination. Sensors are placed in the vaginal or anal canal to help individuals learn when the muscles are properly contracted. A recent study found that this type of biofeedback treatment was safe, effective, and well liked by women patients 55 years and older.

Conditions related to stress are also treated using biofeedback, such as certain types of headaches, high

blood pressure, bruxism or teeth grinding, post-traumatic stress disorder (PTSD), eating disorders, substance abuse, and some anxiety disorders. In treatment of stress-related conditions, biofeedback is often used in combination with relaxation training. Sometimes, biofeedback is used to help individuals learn how to experience deeper relaxation, such as in childbirth education programs or general stress management. This is referred to as biofeedback-assisted relaxation training. Even for individuals who can achieve relaxation through other strategies such as meditation or relaxation, biofeedback can be a valuable added technique. Biofeedback offers special advantages, such as allowing the clinician to track closely the places where an individual tenses up and helps the individual learn what thoughts and feelings are associated with the tension.

Precautions

Biofeedback depends on the motivation and active participation of an individual. Thus, it may not be suitable for individuals with low motivation who are not willing to take a highly active role in treatment, such as those who have depression. Also, since biofeedback focuses on initiating behavioral changes, individuals inclined to examine their past to alleviate problems and symptoms may benefit more from other treatment types, such as psychotherapy. Individuals with cognitive impairment may be unable to remain engaged in the treatment, depending on their level of functioning. Also, individuals with a pacemaker or other implanted electrical devices should inform their health care professional before entering biofeedback training, as certain types of biofeedback sensors may interfere with the devices. Patients with specific pain symptoms in which the cause is unknown should have a thorough medical examination to rule out any serious underlying disease before starting biofeedback training. Biofeedback can be used in combination with conventional therapies; however, while it can be used in combination with conventional medical treatment for illnesses such as cancer and diabetes, it should not replace those treatments.

Research on the success of biofeedback in treating certain conditions is inconclusive or needs to be validated. Some research studies use a small number of participants, which makes it difficult to generalize the results to a larger population. Also, many conditions have different subtypes with a variety of psychological, social, and physical causes. This fact, combined with research design concerns, makes it difficult to compare research studies. For example, while most studies have reported positive outcomes in the treatment of alcohol abuse and dependence, problems with methods and statistical analyses have called study results into question. Also, its effectiveness in treating opiate abuse or dependence has not been consistently shown, as with its use in treating menopausal hot flashes, and there are limitations in studies relating to its use in cancer treatment. Continued research is needed to further evaluate and improve different biofeedback techniques for various conditions.

Description

According to the Association for Applied Psychophysiology and Biofeedback, the technique was developed in the early 1970s by psychologists and physicians. These techniques continue to be used by psychologists, physicians, nurses, and other health care professionals such as physical therapists. Prior to beginning any biofeedback training, individuals may need a comprehensive psychological, educational, and/or medical assessment. Biofeedback can be used in conjunction with nonmedical treatments, such as psychotherapy, cognitive-behavioral therapy, and behavioral treatment strategies.

How biofeedback works

Biofeedback utilizes electronic sensors, or electrodes, attached to various parts of the body to detect changes in physical responses. Signals then inform the individual of these changes by means of visual or auditory signals such as a light display or a series of beeps. While the individual views or listens to feedback, he or she begins to recognize thoughts, feelings, and mental images that influence his or her physical reactions. By monitoring this mind-body connection, the individual can use the same thoughts, feelings, and mental images as cues or reminders to become more relaxed, or to change heartbeat, brain wave patterns, body temperature, and other body functions. The individual uses trial-and-error to change the signals change in the desired direction. For example, individuals trying to control their blood pressure levels may see a light flash whenever the pressure drops below a certain level. They may then try to remember what their thoughts and feelings were at the moment and deliberately maintain them to keep the blood pressure level low.

Through training, the individual learns to control the targeted physical response and, over time, is able to recognize what is required to reduce problematic symptoms. Eventually, the external biofeedback becomes unnecessary as the individual learns to perceive internal physical responses and make the desired changes. The individual then has a powerful, portable, and self-administered treatment tool to deal with problematic symptoms.

Three stages of biofeedback training

  • Awareness of the problematic physical response:Individuals may complete a psychophysiological stress profile (PSP) to identify how their bodies respond to a variety of stressors and determine their ability to overcome undesired physical reactions. This involves a period of rest, stress, and recovery. For example, various sensors are attached to various parts of the body, and a baseline measurement lasting from two to four minutes records physical responses. The individual then goes through a standard set of stressors (such as rapid math calculations or running in place) each lasting from two to four minutes. This is followed by another relaxation period to determine the length of the recovery period.
  • Using signals from the biofeedback equipment to control physical responses: The individual is assisted in reaching certain goals related to managing a specific physical response.
  • Transferring control from biofeedback equipment or the health care professional: Individuals learn to identify triggers that alert them to implement their new-found self-regulation skills.

Types of biofeedback equipment

  • Electromyograph (EMG): Sensors (or electrodes) placed on the skin on pertinent parts of the body monitor electrical activity in muscles, specifically tension. This is the most frequently used biofeedback method in the treatment of various neurologic disorders such as stroke, cerebral palsy, traumatic brain injury, and multiple sclerosis. In children and adolescents, EMG may be used to treat tension headaches, enuresis, and encopresis. In treating TMJ or bruxism, EMG sensors are placed on jaw muscles. Chronic stress is treated by monitoring muscle tension in various places on the body.
  • Galvanic skin response (GSR): Sensors on the fingers monitor perspiration or sweating. This is also referred to as obtaining a skin conductance level (SCL). GSR may be used in the treatment of anxiety, fears or phobias, stress, and sleep problems.
  • Temperature or thermal sensors: Sensors monitor body temperature and changes in blood flow. Changes in hand temperature, for example, can indicate relaxation when there is increased blood flow to the skin. Temperature biofeedback may be useful for treating migraine headache, Raynaud’s disorder, and anxiety disorders.
  • Heart rate sensors: A pulse monitor placed on the fingertip monitors pulse rate. Increases in heart rate are associated with emotional arousal, such as being angry or fearful. Decreases in heart rate are associated with relaxation.
  • Capnometry (CAP): Respiratory sensors monitor oxygen intake and carbon dioxide output. This differentiates correct breathing from problematic breathing practices. Breath control training may be used to treat panic attacks, asthma, and a variety of stress-related conditions.
  • Electroencephalographs (EEG) or neurofeedback: Sensors attached to the scalp monitor brain wave activity in different parts of the brain. It may be used to treat conditions with proven or suspected impact on brain wave patterns such as seizure disorders or epilepsy, ADHD, learning disabilities, migraine headaches, traumatic brain injury, and sleep disorders.

Biofeedback is geared toward whatever a person finds most appealing and understandable and provided in several formats such as auditory, visual, or multimedia. Audio feedback, that may take the form of changes in one and pitch, is useful because visual attention is not necessary. Visual feedback can be provided in various forms such as bar or line graphs on a computer screen. Initially, it was thought that—over time—computer signals could become boring or visually unappealing. In response to this, Barry Bittman developed Mindscope in 1992 that displays video scenes with realistic sounds on a high-definition television set connected to a computer. Physical responses detected by the biofeedback equipment control an engaging audiovisual environment of beautiful and realistic scenes. Clarity, perspective, motion, and sounds improve as the individual deepens their relaxation. For children and adolescents, this may be described as a “video game for the body.” Visual displays for EMG biofeedback may include sports such as basketball, baseball, and golf, where the individual plays against the computer.

The setting in which biofeedback training takes place can vary. Sometimes the clinician, client, and equipment are in the same room. Sometimes the client may sit in comfortable seating in a semi-dark, quiet room while the clinician is in another room with the equipment. In this arrangement, the clinician and client may communicate using an intercom.

In some cases, children and adolescents may reach the desired level of control in three to five sessions. Depending on the condition, biofeedback training may require a series of sessions for several days or weeks. In general, it may take 10 or 15 sessions at the lower end to 40 or 50 sessions at the higher end.

Preparation

Biofeedback is most successful when individuals are motivated to learn. It is useful for people who have difficulty relaxing, even when they make efforts to do so. A receptive and open attitude, or “passive volition,” is important for attaining desired responses rather than actively focusing attaining them. It is important that individuals are willing to practice regularly at home to apply the skill to everyday life. Establishing a foundation of trust and confidence in the health care professional is an important component of biofeedback training.

Before beginning biofeedback training, an initial consultation will be conducted to record medical history, treatment background, and biofeedback goals. The procedure will be explained to provide a clear understanding of how and why the training will be helpful. The individual may be shown the equipment and told where they will be placed and how they work.

Before electrodes are placed on the body, the skin surface must be adequately prepared by using alcohol preparation pads to remove oils, makeup, and dead skin cells that may interfere with the biofeedback signal. An electrode paste is then applied to the sensor, or a small adhesive pad is used to adhere the sensor to the skin. Heart rate, temperature, and GSR monitors may be placed on the fingertip with a Velcro or elastic band. With CAP, the tip of a small, flexible, plastic tube is positioned in the nostril using tape. An individual may be taught several forms of biofeedback initially, then the training may be tailored to the individual’s preference.

The biofeedback trainer must have technical skill, an understanding of basic anatomy and physiology, knowledge of various conditions, and familiarity with computer hardware and software. The American Psychological Association views biofeedback as a proficiency area, master’s and doctoral level training programs are available through a variety of sources, and certification is available through the Biofeedback Certification Institute of America.

Aftercare

One or two follow-up sessions may be arranged two to four months after the initial set of appointments. In this way, long-term progress can be assessed, support can be provided, and adjustments can be made, if needed.

Risks

There are no known side effects with properly administered biofeedback. Problems may occur if biofeedback is used to treat certain conditions where the use of biofeedback is not advised.

Normal results

A normal result may be indicated by achieving the desired changes in muscle tension, heart rate, sweat activity, respiration rate, temperate change, and brainwave activity. Health care professionals may use various criteria or normal values that have been developed for some biofeedback equipment. These values indicate levels that can be expected from normal physiological functioning or relaxation. Importantly, an individual learns to control their physical reactions, which may lead to feelings of empowerment and confidence.

Abnormal results

Unusual results may arise from a number of factors, including poor sensor or electrode contact with the skin and interference from other electrical signals or “noise.” Some equipment may react to room temperature conditions, especially when the room is very hot or very cold. Although inexpensive monitoring equipment is available, such as watches that monitor heartbeat and handheld GSR devices, their results may not be accurate.

See alsoAnxiety and anxiety disorders; Substance abuse and related disorders.

KEY TERMS

Bruxism —Habitual, often unconscious, grinding of the teeth.

Epilepsy —A neurological disorder characterized by the onset of seizures. Seizures are caused by a disturbance in the electrical activity in the brain and can cause loss of consciousness, muscle spasms, rhythmic movements, abnormal sensory experiences, or altered mental states.

Incontinence —Inability to control the release of urine or feces.

Irritable bowel syndrome (IBS) —A condition affecting the small and large intestine, usually associated with emotional stress. There may be complaints of diarrhea and pain the lower abdomen.

Raynaud’s syndrome —A disorder of the circulatory or vascular system characterized by abnormally cold hands and feet because of constricted blood vessels in these areas.

Temporomandibular joint disorder (TMJ) —Inflammation, irritation, pain, limited range of motion, and clicking sounds in the jaw caused by improper opening and closing of the joint.

Resources

BOOKS

Culbert, Timothy P. “Biofeedback with Children and Adolescents.” In Innovative Psychotherapy Techniques in Child and Adolescent Therapy., edited by C. Schaefer. 2nd ed. New York: John Wiley and Sons, 1999.

Di Franco, Joyce T. “Biofeedback.” In Childbirth Education: Practice, Research and Theory, edited by F. H. Nichols and S. S. Humenick. 2nd ed. Philadelphia: W.B. Saunders, 2000.

Schwartz, Mark S., and Associates. Biofeedback: A Practitioner’s Guide. New York: Guilford, 1987.

Spencer, John W., and J. J. Jacobs. Complementary/Alternative Medicine: An Evidence-Based Approach. Baltimore: Mosby, 1999.

Stoyva, Johann M., and Thomas H. Budzynski. “Biofeedback Methods in the Treatment of Anxiety and Stress Disorders.” In Principles and Practice of Stress Management, edited by P. M. Lehrer and R. L. Woolfolk. 2nd ed. New York: Guilford Press, 1993.

PERIODICALS

American Psychological Association. “HCFA will cover biofeedback for incontinence.” Monitor on Psychology 31, no.11 (December 2000).

Burgio, Kathryn L.,Julie L. Locher, Patricia S. Goode, M. Hardin, B. Joan McDowell, and Dorothy C. Dombrowski. “Behavioral vs. Drug Treatment for Urge Urinary Incontinence in Older Women: A Randomized Controlled Trial.” JAMA, The Journal of the American Medical Association 280.23 (December 1998): 1995–2000.

ORGANIZATIONS

Association for Applied Psychotherapy and Biofeedback. 10200 W. 44th Avenue, Suite 304, Wheat Ridge, CO 80033-2840. Telephone: (303) 422-8436. <http://www.aapb.org>.

Biofeedback Certification Institute of America. 1022 W. 44th Avenue, Suite 310, Wheat Ridge, CO 80033. Telephone: (303) 420-2902. <http://www.bcia.org>.

Joneis Thomas, Ph.D.

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Biofeedback

Biofeedback

Development of modern biofeedback methods

Biofeedback training

Uses of biofeedback

Resources

Biofeedback is a means by which a person can mentally influence a natural physiologic process that may or may not be consciously regulated under normal conditions. This could include lowering blood pressure, regulating the heart rate, or influencing the skin temperature.

Deliberate control of bodily functions is not a new accomplishment. Many historical accounts exist of Indian yogis who controlled their body temperature with such precision that they could make the palm of one hand warmer or cooler on one side than the other. Biofeedback also played a role in the performances of the famous escape artist Harry Houdini who consciously suppressed his gag reflex to suspend a key in his throat so as to regurgitate it later to unlock his elaborate bindings.

Development of modern biofeedback methods

As a form of therapy, biofeedback is a relatively recent development that has begun to gain acceptance among some members of the medical community. Research in the topic began in the 1960s, and by the end of the decade a number of research projects had demonstrated its effectiveness. In particular, the research of Neal Miller of Yale University demonstrated that rats could be trained to alter their heart rate and brain activity in response to stimulation of the region of the brain responsible for sensations of pleasure. His work refuted the previously held view that that physiologic processes not usually under conscious control and so could not be consciously influenced.

During the 1970s biofeedback developed a devout following and as a result an entire industry was created for the manufacture and marketing of the instruments used to measure biofeedback alterations and alpha rhythms in the brain. Alpha rhythms are electrical waves formed by the brain at the rate of 8-13 cycles per second. Because they are associated with the state of meditation attained by practitioners of yoga or transcendental meditation, they were accepted as the optimal state of biofeedback. Instruments to detect and measure alpha rhythms soon became readily available.

Biofeedback training

Biofeedback training must begin with an auditory or visual signal to measure the activity of the organ being influenced and to indicate any changes that take place in it. Heart rate, for example, can be signaled by a beeping sound that occurs with each heartbeat. A subject can detect any increase or decrease in the number of heartbeats per minute by the increasing or decreasing rapidity of the beeping. A visual signal also could be devisedfor example, spikes in a horizontal line that appear closer together or farther apart as the heartbeat changes. The ultimate objective is to develop a such a high level of consciousness that such changes can be determined without the signal device.

Biofeedback can be separated into three processes or steps. The first involves detecting the biological process being measured and amplifying it so as to be seen or heard. The second step is to convert the electrical signal into an easily understood form from which its alterations can be read. The third step is to make this signal available to the subject as soon as possible after the event being measured has occurred.

Uses of biofeedback

Clinical applications for biofeedback include the control of blood pressure for patients with hypertension, relief or control of migraine headaches, easing of muscle cramps, and relief of insomnia.

Biofeedback training begins with the basic control of heart rate or other readily accessible and controllable functions. The subject is provided an auditory or visual signal at first and is gradually weaned from it as he becomes more skillful at the practice. Once the basic skill has been learned he or she can then shift concentration to a specific problem. Ideally, patients will continue to practice biofeedback techniques and so increase their effectiveness over time.

Biofeedback has gained acceptance in the United States as its clinical use has increased. Most major cities have a biofeedback association, and practitioners can be certified by a national certification institute. Certification standards are rigorous to assure that the practitioner has a thorough understanding of physiology and psychology to better apply the methodology.

See also Alternative medicine.

Resources

BOOKS

Blumenstein, Boris, Michael Bar-Eli, and Gershon Tenenbaum. Brian and Body in Sport and Exercise: Biofeedback Applications in Performance Enhancement. New York: John Wiley & Sons, 2002.

Schwartz, Mark S., and Frank Andrasik. Biofeedback, Third Edition: A Practitioners Guide. New York: The Guilford Press, 2005.

Larry Blaser

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Biofeedback

Biofeedback

Definition

Biofeedback, or applied psychophysiological feedback, is a patient-guided treatment that teaches an individual to control muscle tension, pain , body temperature, brain waves, and other bodily functions and processes through relaxation , visualization, and other cognitive control techniques. The name biofeedback refers to the biological signals that are fed back, or returned, to the patient in order for the patient to develop techniques of manipulating them.

Origins

In 1961, Neal Miller, an experimental psychologist, suggested that autonomic nervous system responses (for instance, heart rate, blood pressure , gastrointestinal activity, regional blood flow) could be under voluntary control. As a result of his experiments, he showed that such autonomic processes were controllable. This work led to the creation of biofeedback therapy. Willer's work was expanded by other researchers. Thereafter, research performed in the 1970s by UCLA researcher Dr. Barry Sterman established that both cats and monkeys could be trained to control their brain wave patterns. Sterman then used his research techniques on human patients with epilepsy, where he was able to reduce seizures by 60% with the use of biofeedback techniques. Throughout the 1970s, other researchers published reports of their use of biofeedback in the treatment of cardiac arrhythmias, headaches , Raynaud's syndrome, and excess stomach acid, and as a tool for teaching deep relaxation. Since the early work of Miller and Sterman, biofeedback has developed into a front-line behavioral treatment for an even wider range of disorders and symptoms.

Benefits

Biofeedback has been used to successfully treat a number of disorders and their symptoms, including tempromandibular joint disorder (TMJ), chronic pain, irritable bowel syndrome (IBS), Raynaud's syndrome, epilepsy, attention-deficit hyperactivity disorder (ADHD), migraine headaches, anxiety, depression , traumatic brain injury, and sleep disorders .

Illnesses that may be triggered at least in part by stress are also targeted by biofeedback therapy. Certain types of headaches, high blood pressure, bruxism (teeth grinding), post-traumatic stress disorder, eating disorders, substance abuse, and some anxiety disorders may be treated successfully by teaching patients the ability to relax and release both muscle and mental tension. Biofeedback is often just one part of a comprehensive treatment program for some of these disorders.

NASA has used biofeedback techniques to treat astronauts who suffer from severe space sickness, during which the autonomic nervous system is disrupted. Scientists at the University of Tennessee have adapted these techniques to treat individuals suffering from severe nausea and vomiting that is also rooted in autonomic nervous system dysfunction.

Recent research also indicates that biofeedback may be a useful tool in helping patients with urinary incontinence regain bladder control. Individuals learning pelvic-floor muscle strengthening exercises can gain better control over these muscles by using biofeedback. Sensors are placed on the muscles to train the patient where they are and when proper contractions are taking place.

Description

During biofeedback, special sensors are placed on the body. These sensors measure the bodily function that is causing the patient problem symptoms, such as heart rate, blood pressure, muscle tension (EMG or electromyographic feedback), brain waves (EEC or electroencophalographic feedback), respiration, and body temperature (thermal feedback), and translates the information into a visual and/or audible readout, such as a paper tracing, a light display, or a series of beeps.

While the patient views the instantaneous feedback from the biofeedback monitors, he or she begins to recognize what thoughts, fears, and mental images influence his or her physical reactions. By monitoring this relationship between mind and body, the patient can then use these same thoughts and mental images as subtle cues, as these act as reminders to become deeply relaxed, instead of anxious. These reminders also work to manipulate heart beat, brain wave patterns, body temperature, and other bodily functions. This is achieved through relaxation exercises, mental imagery, and other cognitive therapy techniques.

As the biofeedback response takes place, patients can actually see or hear the results of their efforts instantly through the sensor readout on the biofeedback equipment. Once these techniques are learned and the patient is able to recognize the state of relaxation or visualization necessary to alleviate symptoms, the biofeedback equipment itself is no longer needed. The patient then has a powerful, portable, and self-administered treatment tool to deal with problem symptoms.

Biofeedback that specializes in reading and altering brain waves is sometimes called neurofeedback. The brain produces four distinct types of brain waves—delta, theta, alpha, and beta—that all operate at a different frequency. Delta, the slowest frequency wave, is the brain wave pattern associated with sleep. Beta waves, which occur in a normal, waking state, can range from 12-35 Hz. Problems begin to develop when beta wave averages fall in the low end (underarousal) or the high end (overarousal) of that spectrum. Underarousal might be present in conditions such as depression or attention-deficit disorder, and overarousal may be indicative of an anxiety disorder, obsessive compulsive disorder, or excessive stress. Beta wave neurofeedback focuses on normalizing that beta wave pattern to an optimum value of around 14 Hz. A second type of neurofeedback, alpha-theta, focuses on developing the more relaxing alpha (8-13 Hz) and theta waves (4-9 Hz) that are usually associated with deep, meditative states, and has been used with some success in substance abuse treatment.

Through brain wave manipulation, neurofeedback can be useful in treating a variety of disorders that are suspected or proven to impact brain wave patterns, such as epilepsy, attention-deficit disorder, migraine headaches, anxiety, depression, traumatic brain injury, and sleep disorders. The equipment used for neurofeedback usually uses a monitor as an output device. The monitor displays specific patterns that the patient attempts to change by producing the appropriate type of brain wave. Or, the monitor may reward the patient for producing the appropriate brain wave by producing a positive reinforcer, or reward. For example, children may be rewarded with a series of successful moves in a displayed video game.

Depending on the type of biofeedback, individuals may need up to 30 sessions with a trained professional to learn the techniques required to control their symptoms on a long-term basis. Therapists usually recommend that their patients practice both biofeedback and relaxation techniques on their own at home.

Preparations

Before initiating biofeedback treatment, the therapist and patient will have an initial consultation to record the patients medical history and treatment background and discuss goals for therapy.

Before a neurofeedback session, an EEG is taken from the patient to determine his or her baseline brainwave pattern.

Biofeedback typically is performed in a quiet and relaxed atmosphere with comfortable seating for the patient. Depending on the type and goals of biofeedback being performed, one or more sensors will be attached to the patient's body with conductive gel and/or adhesives. These may include:

  • Electromyographic (EMG) sensors. EMG sensors measure electrical activity in the muscles, specifically muscle tension. In treating TMJ or bruxism, these sensors would be placed along the muscles of the jaw. Chronic pain might be treated by monitoring electrical energy in other muscle groups.
  • Galvanic skin response (GSR) sensors. These are electrodes placed on the fingers that monitor perspiration, or sweat gland, activity. These may also be called skin conductance level (SCL).
  • Temperature sensors. Temperature, or thermal, sensors measure body temperature and changes in blood flow.
  • Electroencephalography (EEG) sensors. These electrodes are applied to the scalp to measure the electrical activity of the brain, or brain waves.
  • Heart rate sensors. A pulse monitor placed on the finger tip can monitor pulse rate.
  • Respiratory sensors. Respiratory sensors monitor oxygen intake and carbon dioxide output.

Precautions

Individuals who use a pacemaker or other implantable electrical devices should inform their biofeedback therapist before starting treatments, as certain types of biofeedback sensors have the potential to interfere with these devices.

Biofeedback may not be suitable for some patients. Patients must be willing to take a very active role in the treatment process. And because biofeedback focuses strictly on behavioral change, those patients who wish to gain insight into their symptoms by examining their past might be better served by psychodynamic therapy.

Biofeedback may also be inappropriate for cognitively impaired individuals, such as those patients with organic brain disease or a traumatic brain injury, depending on their levels of functioning.

Patients with specific pain symptoms of unknown origin should undergo a thorough medical examination before starting biofeedback treatments to rule out any serious underlying disease. Once a diagnosis has been made, biofeedback can be used concurrently with conventional treatment.

KEY TERMS

Autonomic nervous system —The part of the nervous system that controls so-called involuntary functions, such as heart rate, salivary gland secretion, respiratory function, and pupil dilation.

Bruxism —Habitual, often unconscious, grinding of the teeth.

Epilepsy —A neurological disorder characterized by the sudden onset of seizures.

Placebo effectPlacebo effect occurs when a treatment or medication with no known therapeutic value (a placebo) is administered to a patient, and the patient's symptoms improve. The patient believes and expects that the treatment is going to work, so it does. The placebo effect is also a factor to some degree in clinically-effective therapies, and explains why patients respond better than others to treatment despite similar symptoms and illnesses.

Raynaud's syndrome —A vascular, or circulatory system, disorder which is characterized by abnormally cold hands and feet. This chilling effect is caused by constriction of the blood vessels in the extremities, and occurs when the hands and feet are exposed to cold weather. Emotional stress can also trigger the cold symptoms.

Schizophrenia —Schizophrenia is a psychotic disorder that causes distortions in perception (delusions and hallucinations), inappropriate moods and behaviors, and disorganized or incoherent speech and behavior.

Temporomandibular joint disorder —Inflammation, irritation, and pain of the jaw caused by improper opening and closing of the temporoman-dibular joint. Other symptoms include clicking of the jaw and a limited range of motion.

Biofeedback may only be one component of a comprehensive treatment plan. For illnesses and symptoms that are manifested from an organic disease process, such as cancer or diabetes, biofeedback should be an adjunct to (complementary to), and not a replacement for, conventional medical treatment.

Side effects

There are no known side effects to properly administered biofeedback or neurofeedback sessions.

Research & general acceptance

Preliminary research published in late 1999 indicated that neurofeedback may be a promising new tool in the treatment of schizophrenia. Researchers reported that schizophrenic patients had used neurofeedback to simulate brain wave patterns that antipsychotic medications produce in the brain. Further research is needed to determine what impact this may have on treatment for schizophrenia.

The use of biofeedback techniques to treat an array of disorders has been extensively described in the medical literature. Controlled studies for some applications are limited, such as for the treatment of menopausal symptoms and premenstrual disorder (PMS). There is also some debate over the effectiveness of biofeedback in ADHD treatment, and the lack of controlled studies on that application. While many therapists, counselors, and mental health professionals have reported great success with treating their ADHD patients with neurofeedback techniques, some critics attribute this positive therapeutic impact to a placebo effect.

There may also be some debate among mental health professionals as to whether biofeedback should be considered a first line treatment for some mental illnesses, and to what degree other treatments, such as medication, should be employed as an adjunct therapy.

Caregiver concerns

Individuals wishing to try biofeedback should contact a healthcare professional trained in biofeedback techniques. Licensed psychologists, psychiatrists, and physicians frequently train their patients in biofeedback techniques, or can recommend a specialist who does. In some cases, a licensed professional may employ a biofeedback technician who works under their direct guidance when treating patients. There are several national organizations for biofeedback therapists, including the Biofeedback Certification Institute of America, which also certifies therapists in the practice.

Resources

BOOKS

Robbins, Jim. A Symphony in the Brain: The Evolution of the New Brain Wave Biofeedback. Boston, MA: Atlantic Monthly Press, 2000.

PERIODICALS

Burgio, K.L. et al. “Behavioral vs. Drug Treatment for Urge Urinary Incontinence in Older Women: A randomized controlled trial.” Journal of the American Medical Association 280 (Dec. 1998): 1995–2000.

Robbins, Jim. “On the Track with Neurofeedback.”Newsweek 135, no. 25 (June 2000): 76.

ORGANIZATIONS

The Association for Applied Psychotherapy and Biofeedback. 10200 W. 44th Avenue, Suite 304, Wheat Ridge, CO 80033-2840. (303) 422-8436. http://www.aapb.org

Biofeedback Certification Institute of America. 10200 W. 44th Avenue, Suite 310, Wheat Ridge, CO 80033. (303) 420-2902.

Paula Ford-Martin

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Biofeedback

Biofeedback

Definition
Purpose
Description
Preparations
Precautions
Side effects
Research and general acceptance
Interactions

Definition

Biofeedback, or applied psychophysiological feedback, is a patient-guided treatment that teaches an individual to control muscle tension, pain, body temperature , brain waves, and other bodily functions and processes through relaxation, visualization, and other cognitive control techniques. The name biofeedback refers to the biological signals that are fed back, or returned, to the patient in order for the patient to develop techniques of manipulating them.

Purpose

Biofeedback has been used to successfully treat a number of disorders and their symptoms, including temporomandibular joint disorder (TMJ), chronic pain, irritable bowel syndrome (IBS), Raynaud’s syndrome, epilepsy, attention-deficit hyperactivity disorder (ADHD), migraine headaches, anxiety, depression, traumatic brain injury, and sleep disorders.

Illnesses that may be triggered at least in part by stress are also targeted by biofeedback therapy. Certain types of headaches, high blood pressure, brux-ism (teeth grinding), post-traumatic stress disorder, eating disorders, substance abuse, and some anxiety disorders may be treated successfully by teaching patients the ability to relax and release both muscle and mental tension. Biofeedback is often just one part of a comprehensive treatment program for some of these disorders.

The U.S. National Aeronautics and Space Administration (NASA) has used biofeedback techniques to treat astronauts who suffer from severe space sickness, during which the autonomic nervous system is disrupted. Scientists at the University of Tennessee have adapted these techniques to treat individuals suffering from severe nausea and vomiting that is also rooted in autonomic nervous system dysfunction.

Recent research also indicates that biofeedback may be a useful tool in helping patients with urinary incontinence regain bladder control. Individuals learning pelvic-floor muscle strengthening exercises can gain better control over these muscles by using biofeedback. Sensors are placed on the muscles to help the patient learn where they are and when proper contractions are taking place.

Description

Origins

In 1961, Neal Miller, an experimental psychologist, suggested that autonomic nervous system responses (for instance, heart rate, blood pressure, gastrointestinal activity, regional blood flow) could be under voluntary control. As a result of his experiments, he showed that such autonomic processes were controllable. This work led to the creation of biofeedback therapy. Miller’s work was expanded by other researchers. Research performed in the 1970s by UCLA researcher Dr. Barry Sterman established that both cats and monkeys could be trained to control their brain wave patterns. Sterman then used his research techniques on human patients with epilepsy; he was able to reduce seizures by 60% with the use of biofeedback techniques. Throughout the 1970s, other researchers published reports of their use of biofeedback in the treatment of cardiac arrhythmias, headaches, Raynaud’s syndrome, excess stomach acid, and as a tool for teaching deep relaxation. Since the early work of Miller and Sterman, biofeedback has developed into a front-line behavioral treatment for an even wider range of disorders and symptoms.

During biofeedback, special sensors are placed on the body. These sensors measure the bodily function that is causing the patient problem symptoms, such as heart rate, blood pressure, muscle tension (EMG or electromyographic feedback), brain waves (EEC or electroencephalographic feedback), respiration, and body temperature (thermal feedback), and translates the information into a visual and/or audible readout, such as a paper tracing, a light display, or a series of beeps.

While the patient views the instantaneous feedback from the biofeedback monitors, he or she begins to recognize what thoughts, fears, and mental images influence his or her physical reactions. By monitoring this relationship between mind and body, the patient can then use these same thoughts and mental images as subtle cues, as these act as reminders to become deeply relaxed, instead of anxious. These reminders also work to manipulate heart beat, brain wave patterns, body temperature, and other bodily functions. This is achieved through relaxation exercises, mental imagery, and other cognitive therapy techniques.

As the biofeedback response takes place, patients can actually see or hear the results of their efforts instantly through the sensor readout on the biofeedback equipment. Once these techniques are learned and the patient is able to recognize the state of relaxation or visualization necessary to alleviate symptoms, the biofeedback equipment itself is no longer needed. The patient then has a powerful, portable, and self-administered treatment tool to deal with problem symptoms.

Biofeedback that specializes in reading and altering brain waves is sometimes called neurofeedback. The brain produces four distinct types of brain waves—beta, alpha, theta, and delta—that all operate at a different frequency. Delta, the slowest frequency wave, is the brain wave pattern associated with deep sleep. Beta waves, the fastest frequency wave, occur in a normal, waking state and can range from 12–35 Hertz (Hz). Problems begin to develop when beta wave averages fall in the low end (underarousal) or the high end (overarousal) of that spectrum. Under-arousal might be present in conditions such as depression or attention deficit disorder, and overarousal may be indicative of an anxiety disorder, obsessive compulsive disorder, or excessive stress. Beta wave neurofeedback focuses on normalizing that beta wave pattern to an optimum value of around 14 Hz. A second type of neurofeedback, alpha-theta, focuses on developing the more relaxing alpha (8–13 Hz) and theta waves (4–9 Hz) that are usually associated with deep, meditative states, and has been used with some success in substance abuse treatment.

Through brain-wave manipulation, neurofeedback can be useful in treating a variety of disorders that are suspected or proven to impact brain-wave patterns, such as epilepsy, attention deficit disorder, migraine headaches, anxiety, depression, traumatic brain injury, and sleep disorders. The equipment used for neurofeedback usually uses a monitor as an output device. The monitor displays specific patterns that the patient attempts to change by producing the appropriate type of brain wave. Or, the monitor may reward the patient for producing the appropriate brain wave by producing a positive reinforcer, or reward. For example, children may be rewarded with a series of successful moves in a displayed video game.

Depending on the type of biofeedback, individuals may need up to 30 sessions with a trained professional to learn the techniques required to control their symptoms on a long-term basis. Therapists usually recommend that their patients practice both biofeedback and relaxation techniques on their own at home.

Preparations

Before initiating biofeedback treatment, the therapist and patient will have an initial consultation to record the patient’s medical history and treatment background and discuss goals for therapy.

Before a neurofeedback session, an EEG is taken to determine the patient’s baseline brainwave pattern.

Biofeedback typically is performed in a quiet and relaxed atmosphere with comfortable seating for the patient. Depending on the type and goals of biofeedback being performed, one or more sensors will be attached to the patient’s body with conductive gel and/or adhesives. These may include:

  • Electromyographic (EMG) sensors—EMG sensors measure electrical activity in the muscles, specifically muscle tension. In treating TMJ or bruxism, these sensors would be placed along the muscles of the jaw. Chronic pain might be treated by monitoring electrical energy in other muscle groups.
  • Galvanic skin response (GSR) sensors—These are electrodes placed on the fingers that monitor perspiration, or sweat gland, activity. These may also be called skin conductance level (SCL).
  • Temperature sensors—Temperature, or thermal, sensors measure body temperature and changes in blood flow.
  • Electroencephalography (EEG) sensors—These electrodes are applied to the scalp to measure the electrical activity of the brain, or brain waves.
  • Heart rate sensors—A pulse monitor placed on the finger tip can monitor pulse rate.
  • Respiratory sensors—Respiratory sensors monitor oxygen intake and carbon dioxide output.

Precautions

Individuals who use a pacemaker or other implantable electrical devices should inform their biofeedback therapist before starting treatments, as certain types of biofeedback sensors have the potential to interfere with these devices.

Biofeedback may not be suitable for some patients. Patients must be willing to take a very active role in the treatment process. And because biofeedback focuses strictly on behavioral change, those patients who wish to gain insight into their symptoms by examining their past might be better served by psychodynamic therapy.

Biofeedback may also be inappropriate for cognitively impaired individuals, such as those patients with organic brain disease or a traumatic brain injury, depending on their function level.

Patients with specific pain symptoms of unknown origin should undergo a thorough medical examination before starting biofeedback treatments to rule out any serious underlying disease. Once a diagnosis has been made, biofeedback can be used concurrently with conventional treatment.

Biofeedback may only be one component of a comprehensive treatment plan. For illnesses and symptoms that are manifested from an organic disease process, such as cancer or diabetes, biofeedback should be an adjunct to (complementary to), and not a replacement for, conventional medical treatment.

Side effects

There are no known side effects to properly administered biofeedback or neurofeedback sessions.

Research and general acceptance

Preliminary research published in late 1999 indicated that neurofeedback may be a promising new tool in the treatment of schizophrenia. Researchers reported that schizophrenic patients had used neuro-feedback to simulate brain wave patterns that antipsychotic medications produce in the brain. Further research is needed to determine what impact this may have on treatment for schizophrenia.

The use of biofeedback techniques to treat an array of disorders has been extensively described in the medical literature. Controlled studies for some applications are limited, such as for the treatment of menopausal symptoms and premenstrual disorder (PMS). There is also some debate over the effectiveness of biofeedback in ADHD treatment, and the lack of controlled studies on that application. While many therapists, counselors, and mental health professionals have reported great success with treating their ADHD patients with neurofeedback techniques, some critics attribute this positive therapeutic impact to a placebo effect.

There is also be some debate among mental health professionals as to whether biofeedback should be considered a first line treatment for some mental illnesses, and to what degree other treatments, such as medication, should be employed as an adjunct therapy.

Interactions

There are no known interactions with biofeedback.

Resources

BOOKS

Demos, J. N. Getting Started with Neurofeedback. New York: W. W. Norton & Company, 2004.

Robbins, J. A Symphony in the Brain: The Evolution of the New Brain Wave Biofeedback. New York: Grove Press, 2001.

Schwartz, M. S., and F. Andrasik. Biofeedback: A Practitioner’s Guide, 3rd ed. New York: Guilford Press, 2003.

Swingle, P. G. Biofeedback for the Brain: How Neurotherapy Effectively Treats Depression, ADHD, Autism, and More. New Brunswick, NJ: Rutgers University Press, 2008.

PERIODICALS

Conde-Pastor, M., F. Javier-Menendez, M. T. Sanz, and E. Vila-Abad. “The influence of respiration on biofeedback techniques.” Applied Psychophysiology and Biofeedback 33, no. 1 (March 2008): 49–54.

Lourencao, M. I., L. R. Battistella, C. M. de Brito, G. R. Tsukimoto, and M. H. Miyazaki. “Effect of biofeedback accompanying occupational therapy and functional electrical stimulation in hemiplegic patients.” International Journal of Rehabilitation and Research 31, no. 1 (March 2008): 33–41.

Reiner, R. “Integrating a portable biofeedback device into clinical practice for patients with anxiety disorders: results of a pilot study.” Applied Psychophysiology and Biofeedback 33, no. 1 (March 2008): 55–61.

Roach, M., and J. A. Christie. “Fecal incontinence in the elderly.” Geriatrics 63, no. 2 (2008): 13–22.

OTHER

Association for Applied Psychophysiology and Biofeedback. Information about biofeedback. http://www.aapb.org/i4a/pages/index.cfm?pageid=1 (February 25, 2008).

Biofeedback Network. Information about biofeedback. http://www.biofeedback.net/ (February 22, 2008).

“Biofeedback: Using Your Mind to Improve Your Health.” Mayo Clinic. January 25, 2008. http://www.mayoclinic.com/health/biofeedback/SA00083 (February 24, 2008).

“What is Biofeedback?” American Cancer Society. February 12, 2000. http://www.cancer.org/docroot/NWS/content/NWS_2_x_What_is_Biofeedback_.asp (February 24, 2008).

ORGANIZATIONS

Association for Applied Psychotherapy and Biofeedback, 10200 W. 44th Avenue, Suite 304, Wheat Ridge, CO, 80033, (303) 422-8436, http://www.aapb.org.

Biofeedback Certification Institute of America, 10200 W. 44th Avenue, Suite 310, Wheat Ridge, CO, 80033, (303) 420-2902, http://www.bcia.org..

L. Fleming Fallon, Jr., M.D., Dr.P.H.

Birthmark excision seeHemangioma excision

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Biofeedback

Biofeedback

Biofeedback is a means by which a person can mentally influence a natural physiologic process that may or may not be consciously regulated under normal conditions. This could include lowering blood pressure , regulating the heart rate , or influencing the skin temperature .

Deliberate control of bodily functions is not a new accomplishment. Many historical accounts exist of Indian yogis who controlled their body temperature with such precision that they could make the palm of one hand warmer or cooler on one side than the other. Biofeedback also played a role in the performances of the famous escape artist Harry Houdini who consciously suppressed his gag reflex to suspend a key in his throat so as to regurgitate it later to unlock his elaborate bindings.


Development of modern biofeedback methods

As a form of therapy, biofeedback is a relatively recent development that has begun to gain acceptance among some members of the medical community. research in the topic began in the 1960s, and by the end of the decade a number of research projects had demonstrated its effectiveness. While some early studies indicated that physiologic processes not usually under conscious control could not be influenced by biofeedback, subsequent research soon disproved this assumption.

During the 1970s biofeedback developed a devout following and as a result an entire industry was created for the manufacture and marketing of the instruments used to measure biofeedback alterations and alpha rhythms in the brain . Alpha rhythms are electrical waves formed by the brain at the rate of 8-13 cycles per second. Because they are associated with the state of meditation attained by practitioners of yoga or transcendental meditation, they were accepted as the optimal state of biofeedback. Instruments to detect and measure alpha rhythms soon became readily available.


Biofeedback training

Biofeedback training must begin with an auditory or visual signal to measure the activity of the organ being influenced and to indicate any changes that take place in it. Heart rate, for example, can be signaled by a beeping sound that occurs with each heartbeat. A subject can detect any increase or decrease in the number of heartbeats per minute by the increasing or decreasing rapidity of the beeping. A visual signal also could be devised—for example, spikes in a horizontal line that appear closer together or farther apart as the heartbeat changes. The ultimate objective is to develop a such a high level of consciousness that such changes can be determined without the signal device.

Biofeedback can be separated into three processes or steps. The first involves detecting the biological process being measured and amplifying it so as to be seen or heard. The second step is to convert the electrical signal into an easily understood form from which its alterations can be read. The third step is to make this signal available to the subject as soon as possible after the event being measured has occurred.


Uses of biofeedback

Clinical applications for biofeedback include the control of blood pressure for patients with hypertension , relief or control of migraine headaches, easing of muscle cramps, and relief of insomnia .

Biofeedback training begins with the basic control of heart rate or other readily accessible and controllable functions. The subject is provided an auditory or visual signal at first and is gradually weaned from it as he becomes more skillful at the practice. Once the basic skill has been learned he or she can then shift concentration to a specific problem. Ideally, patients will continue to practice biofeedback techniques and so increase their effectiveness over time .

Biofeedback has gained acceptance in the United States as its clinical use has increased. Most major cities have a biofeedback association, and practitioners can be certified by a national certification institute. Certification standards are rigorous to assure that the practitioner has a thorough understanding of physiology and psychology to better apply the methodology.

See also Alternative medicine.


Resources

books

burton goldberg group. alternative medicine: the definitiveguide. puyallup, wa: future medicine publishing, 1993.

periodicals

fugh-berman, a. "the case for 'natural' medicine." the nation 257 (september 1993):240-244.

morrow, j., and r. wolff, "wired for wonders." readers digest 140 (may 1992):105-108.


Larry Blaser

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Biofeedback

Biofeedback

Biofeedback is a term that describes two distinct sports science concepts. Biofeedback is a methodology used to obtain data relating to various aspects of bodily function in athletic performance. Biofeedback is also a training and coaching method.

As a methodology, biofeedback is a monitoring process by which different kinds of equipment are used to obtain information concerning a number of different functions controlled by the autonomic nervous system. Biofeedback data will commonly include heart rate, blood pressure, respiration, and other quantifiable features of human performance.

Biofeedback also describes the ongoing relationship between the physical performance of the human body in conjunction with the thinking and the emotional processes of the subject. In this sense, biofeedback is a training and coaching method, one that is designed to alter the behavior of the subject; biofeedback is intended to permit an athlete to acquire a skill that may be used to best manage the relationship between physical and mental performance.

In the data-gathering sense, biofeedback utilizes a number of different tools. The most common of these devices is a heart monitor, which collects data with respect to heart rate and physical performance. Heart monitors are portable devices that do not interfere in the performance of an athlete to any significant degree. Sophisticated biofeedback technologies include the measurement of heart rate, blood pressure, oxygen uptake (VO2max, an expression as to how much oxygen can be processed by the body at different stages of exertion), and the perspiration rate (an indicator of how efficiently the thermoregulatory system functions under variable stresses). In addition to these factors, an electroencephalograph (EEG) may be employed to monitor the brain wave activity, coupled with an electromyography (EMG), which measures the amount of tension and electrical activity in the muscles at different times, when subjected to varying stresses.

The data obtained through these biofeedback measurements may be readily compared with the results of other physical tests of autonomic function, such as the analysis of urine and blood.

One of the prominent biofeedback applications employed by athletes is relaxation techniques. The ability of an athlete to relax in the stressful circumstances of competition is an important component of the overall emotional control required of the athlete in competition. The development of a relaxation strategy for the individual athlete begins with the biofeedback testing to provide the physical data concerning the function of the autonomic nervous system of the athlete. The data must be gathered in a fashion that simulates the athlete's actual competitive performance. Once obtained, the information can be plotted in comparison to actual progress made by the athlete from the start to the finish of the simulated competition. The scientist or trainer conducting the testing then evaluates the results in conjunction with the athlete. The athlete must provide their subjective input concerning the various parts of their performance. The question for the athlete is "How did I feel at each segment of the competition? How do my subjective feelings about my performance compare with the measured heart rate, perspiration rate and other data?". This process permits the athlete and the trainer to compare the objective data gathered through testing of the athlete's autonomic function with the athlete's subjective assessment of his or her performance.

By comparing objective biofeedback data with subjective athletic impression, the athlete can develop strategies to combat any competitive areas where they feel increased stress or nervousness. As an example, biofeedback techniques can be employed to assist a long jumper who repeatedly commits a foot fault (where the jumper's foot goes past the end of the jump board, rendering the jump illegal). A trainer, with the athlete performing a simulation of the event, will use the biofeedback data to identify the precise moment of excess tension in the athlete's body during the jump sequence to assist the athlete in developing a strategy to maintain a consistent emotional level throughout the jump. The moments of excess tension will be likely be apparent in the testing through indicators such as increased heart rate and breathing function, among other data gathered. To settle this athlete, a number of relaxation techniques may be employed, including deep breathing techniques and the use of positive mental images by the athlete as an aid to concentration. Breathing exercises are intended to relax the jumper before the approach by the athlete to the runway leading to the jump. Quick and irregular breathing patterns are evidence of stress and the corresponding invocation of the body's "flight or fight" response, which also signifies an elevation in levels of the hormone adrenaline. An overly stimulated long jumper is much more likely to fault than a jumper who is calm and composed.

The rhythm of regular breathing is designed to settle the athlete; imagery techniques such as directing the athlete's attention to the sensation of the air on the jumper's body as a successful jump is performed, or the sensation of the sand in the landing pit on the jumper's entry, create a sense of focus and concentration for the athlete on the event at hand.

Biofeedback can also be used to assist an athlete in the planning of future training sessions. The determination of an athletes maximum heart rate, a target against which individual workout intensity can be planned. At moderate training levels, the desired heart rate might be 65% of the athlete's maximum rate; in more intense workouts, the athlete might seek to achieve a heart rate at 90% or more of the maximum.

In warm weather environments, urine and perspiration samples can be tested to determine whether the athlete's diet has sufficient sodium or other electrolytes commonly lost through the body's fluid elimination. This biofeedback data assists both the athlete and coaches to develop an appropriate hydration strategy, to ensure that the athlete's fluid and electrolyte intake remains sufficient both before, during, and after all training and competitive sessions.

There is a powerful interrelationship between biofeedback techniques and the concept of visualization. Visualization is a technique that is intended to reduce stress, to enhance relaxation, and to sustain focus by directing the attention of the athlete to a specific aspect of the athlete's routine or performance. In this fashion, biofeedback can assist the athlete in developing mental cues to help eliminate distractions such as crowd noise or movements.

Auditory (hearing) clues can also be employed as the trigger to induce the athlete to maintain the desired level of autonomic function. The type of clue that will function best for a particular athlete will be tailored to the athlete, as a result of the biofeedback process; there are no set rules as to which type of clue is likely to work best. In shooting sports, athletes seek to reduce their heart rate through deep breathing and other relaxation methods, as they are in their most physically stable position to deliver a shot when their body is between heartbeats. The more efficiently the shooter can breathe and reduce the heart rate, the quicker the shots can be fired.

In some sports, biofeedback can be incorporated with the use of physical simulators to assist the athlete. Bobsledders are among the athletes who use a computer controlled simulator to precisely replicate the sensations that they experience on particular bobsled courses; the biofeedback data such as heart rate and its relationship to the effect of the gravitational forces experienced by the bobsledders is gathered as the simulation proceeds. When the bobsledder knows that a difficult corner or other physical element of the course lies ahead, he can anticipate that he will become more anxious or tense and prepare himself accordingly.

The successful use of biofeedback data is dependent upon both the quality of the physiological testing of the athlete, combined with motivation of the athlete to use the biofeedback process effectively. The gathering of data alone will not provide a remedy to deficiencies in athletic performance.

see also Eccrine sweat secretion; Heart rate monitors; Heart rate: Target heart rate; Metabolic response; Visualization in sport.

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