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
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
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
Tinnitus: The perception of abnormal ear or head
noises, when severe and persistent, interferes with sleep
and concentration, resulting in considerable psychologic
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
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
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
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
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
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.
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.
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