Introduction

To some extent, virtually all psychologists have some passing familiarity with biofeedback as a treatment modality. Biofeedback emerged as a treatment method from pioneering learning research during the 1950s of experimental psychologists, such as Neal Miller. It became a clinical modality in the late 1960s.

Biofeedback is a form of self-regulation in which individuals learn to control physiological responses by providing them with an information signal, as sensory feedback, about biological conditions of which they may not be ordinarily aware. Feedback responses include muscle tension, skin surface temperature, brain wave activity, galvanic skin response, blood pressure, and heart rate. In combination with therapeutic instruction and practice, the feedback signal(s) enable patients to become active participants in the rehabilitation or health maintenance process

Biofeedback Applications

Among the conditions being treated with biofeedback are certain types of migraine headaches, insomnia, Raynaud's disease, enuresis, encopresis, chronic pain, hypertension, muscular tension, irritable bowel syndrome, peptic ulcer, esophageal spasm, fecal incontinence, and a number of neurological diseases and their sequelae. Biofeedback may also be used to control the biological responses that contribute to health problems, such as chronically tense muscles due to accidents or sports injuries, asthma, high blood pressure, and cardiac arrhythmias. Often, it complements the use of medication in pain management.

More specifically, among disorders treated at present are the following:

	Outlet Disorders: Failure of the pelvic floor to relax during straining to void (or "anismus") may be treated with biofeedback-assisted relaxation training.
	Pain syndromes: Used as one of many noninvasive, physical and psychosocial modalities.
	Stress incontinence among geriatric patients: Although surgery is the most effective treatment, for those wishing to avoid surgery and who can adhere to a program, pelvic muscle exercises combined with biofeedback may be effective.
	Tinnitus: The perception of abnormal ear or head noises, when severe and persistent, interferes with sleep and concentration, resulting in considerable psychologic distress.
	Urology: Prostatodynia, a noninflammatory, pelvic floor muscle dysfunction disorder affecting young and middle-aged men with normal prostate glands may respond to diazepam (Valium) and biofeedback techniques.
	Tension headaches: These may occur daily, impact concentration, are exacerbated by emotional stress, fatigue and noise and are typically not associated with neurologic symptoms. Although simple analgesics are the primary treatment of choice, relaxation techniques-including biofeedback-may be useful.

Treatment Methodology: What's Old is New Again

In 1968, I was given the opportunity to use the first commercially available EEG biofeedback and diagnostic equipment. These were bulky, technically "dirty" devices equipped with large electrodes and cumbersome earphones. Although "tuning into and turning on with alpha" developed an almost cult-like popularity, the initial faddishness waned as interest shifted towards exploration of other modalities, such as sEMG (surface EMG or electromyography), galvanic skin response (GSR; now electrodermal response, or EDR) and thermal feedback.

The evolution of microcomputers, miniaturization, and digital technology has caused a rejuvenation in EEG feedback, re-christened "neurobiofeedback" or "neurofeedback therapy" (NFT). Among the areas of growing importance to clinicians (as reported at recent Brain/Neurofeedback Meetings) include quantified (Q) EEG, the training of Peak or Optimal Performance, ADD/ADHD, treatment of dissociation, pain management in fibromyalgia and other areas of chronic pain, and enhancing mental functioning in the elderly.

Modern EEG feedback equipment offers real time--actual time in which a physical process under computer study or control occurs--topographic EEG mapping, presenting colorful graphic representations of ongoing brainwave activity in addition to providing additional channels that measure EMG, EKG (electrocardiogram) and EDR. These connect easily to desktop PCs or Notebooks for use in the clinic, the field and, on occasion, in the patient's home.

One EEG neuromapping system offers a 16--channel device designed for use with a personal computer. It features two and three hemispheric histogram dimensional topographic visualization and routine EEG study, automatically sets itself and runs thorough checks of the entire biofeedback system for accuracy and interference.

Extensive software is available for EEG monitoring, Stress Profile software measures stressor reactivity over a variety of stressors with results viewed as text or a graph. EMG Work Cycles measure up to four simultaneous EMGs in separate Assessment and Training protocols. Relaxation training software has incentives and generalization strategies built in, prompting the patient at each step There are pop-up instructions and graduated protocols to teach hand warming, autogenics, progressive relaxation, and abdominal breathing.

Although EEG appears to have captured clinical attention once more, EMG feedback remains a fundamental area of use in the field and has also profited from the same technological advances in equipment. At the World's First Clinical, Applied Surface EMG, Advanced Muscle Topics Colloquium/Meeting (1996), topics focused on pain and kinesiology, concepts of muscle imbalance and movement dysfunction and the role of surface EMG, myofascial pain syndrome, and kinesiologic EMG using video.

Technological Enchantment and the Need for Pragmatism

The swing back towards intense interest in and study of EEG training puts into practical use the technological advances of the last 30 years. The Salt Lake Tribune (9/8/98) reported that EEG biofeedback (or neurofeedback) has gaining adherents, but that research has not kept pace with the growing number of uses and that its many clinical applications have not yet been appropriately validated.

While attractive, clinicians should be aware of the limitations of biofeedback technology in terms of the considerable research that remains to be accomplished and the older, unanswered questions awaiting answers. Of key significance is the identification of those patients who are or are not appropriate for biofeedback training. Without this information, clinical decisions are based upon individual practitioner's experience/conjecture.

Finally, we must not forget that biofeedback, no matter how technologically advanced and professionally stimulating, biofeedback is one of many treatment modalities. As such, it must be considered more comprehensively as appropriate or not in any given case. Barbara Brown (1978) contends that the principles and procedures of augmented biofeedback to optimize learning in a variety of settings are a more appropriate conceptual and methodological approach in the clinical use of biofeedback. Simkins (1982) warns that the principles of operant conditioning are inadequate in biofeedback training and are consistently misapplied in research and clinical studies.

Enamoured as we may be with advances in biofeedback and hopeful at its clinical usefulness, considerable research remains to be achieved to better understand its applications and to whom the methodologies may be applied fruitfully.

References:

	Brown, B. B. (1978). Critique of biofeedback concepts and methodologies. American Journal of Clinical Biofeedback, 1(1), 10-14.
	McQuaid, K. R. (1998) Alimentary Tract. In L. M. Tierney, Jr., S. J. McPhee, M. A. Papadakis (Eds.) Current medical diagnosis & treatment (37th Ed.) Stamford, CT: Appleton & Lange. Resnick, N. M. Geriatric Medicine (1998) General approach to the patient; In L. M. Tierney, Jr., S. J. McPhee, M. A. Papadakis (Eds.) Current medical diagnosis & treatment (37th Ed.) Stamford, CT: Appleton & Lange.
	Simkins, L. (1982). Biofeedback: Clinically valid or oversold? Psychological Record, 32(1), 3-17.
	Weiss, D. S. (1995). Behavioral Medicine techniques. In H. H. Goldman (Ed.) Review of general psychiatry (4th Ed.). Norwalk, CT: Appleton & Lange.

Recommended Readings:

	Benjamin, John V., Biofeedback (1989); Carroll, Douglas, Biofeedback in Practice (1984);
	Green, Elmer and Alyce, Beyond Biofeedback (1989);
	Hatch, J. P., et al., eds., Biofeedback: Studies in Clinical Efficacy (1987);
	Jones, Marcer, Donald, Biofeedback and Related Therapies in Clinical Practice (1986);
	Richter-Heinrich, E., and Miller, N. E., Biofeedback (1982).