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Biofeedback is an evidence-based approach to enhancing personal awareness and control over body and mind. Biofeedback combines the values of the complementary and alternative medicine movement with the biotechnology of modern scientific medicine. The basic biofeedback paradigm suggests that whenever we provide a human being with feedback on about a biological process, that feedback enables the individual to increase awareness of the process, and gain conscious control. Biofeedback uses electronic instruments to monitor and feed back information on about physiological responses1,2.
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Biofeedback: paradigm and history
Biofeedback is an evidence-based approach to enhancing
personal awareness and control over body and mind.
Biofeedback combines the values of the complementary
and alternative medicine movement with the biotech-
nology of modern scientific medicine. The basic biofeed-
back paradigm suggests that whenever we provide a
human being with feedback about a biologic process,
that feedback enables the individual to increase aware-
ness of the process and gain conscious control. Biofeed-
back uses electronic instruments to monitor and feed
back information about physiologic responses1,2.
Any physiologic response that can be monitored is
suitable for biofeedback. The most common responses
trained in biofeedback are the electrical activity of the
brain (EEG), skin temperature (thermal), muscle tension
or surface electromyography (SEMG), galvanic skin
response (GSR) or electrodermal response (EDR), respi-
ration (RESP), heart rate (HR) and heart rate variability
(HRV), and blood pulse volume (BPV)1,2. This infor-
mation is presented to the patient through visual and/or
auditory signals, often through a computer monitor dis-
play. The aim of biofeedback treatment is to establish the
patient’s mastery over the body independently of the
biofeedback instrument. When biofeedback is used to
enable personal control over brain activity, it is often
called neurofeedback or neurotherapy3,4.
Biofeedback developed from several streams of
research in the 1960s and 1970s, including scientific
psychophysiology, sleep research, and the newly emerg-
ing neurosciences2. The term biofeedback was adopted
at the first conference of the Biofeedback Research Soci-
ety in Santa Monica in 1969. The conference attendance
was diverse, including laboratory scientists interested in
voluntary control of physiologic systems, behavioral
psychologists wishing to apply principles of behavior
change to health and disease, and humanistic and trans-
personal psychologists searching for the higher potentials
of human beings5.
Early research showed voluntary control of electroen-
cephalographic (EEG) brain wave activity6, internal vis-
ceral functioning7, and muscle activity8. Biofeedback
was shown to increase the human being’s awareness and
control of many bodily processes previously thought to
be beyond voluntary control. Positive benefits included
enhanced learning of relaxation skills, reduction of
stress-related medical symptoms, and re-acquisition of
motor control after injury or stroke. Later research
showed that biofeedback training can reduce seizure
activity, enhance academic learning in individuals with
attention problems and learning disabilities, moderate a
host of medical and psychologic disorders, and optimize
the functioning of athletes and performing artists. The
applications sections of this chapter will review the most
common applications of biofeedback, and their relative
efficacy and clinical effectiveness based on available out-
come research.
Biofeedback and CAM
Many biofeedback practitioners argue that biofeedback
is not CAM but belongs in the mainstream of health
care. The biofeedback approach is now over three
decades old, shares the mainstream biomedical emphasis
on physiologic disease pathways and mechanisms, and
has been supported by thousands of empirically-based
research studies. Nevertheless, there are critical philo-
sophical and practical factors in its approach that make
biofeedback a natural sibling to other complementary
and alternative therapies9. As a result, leading CAM
authors regularly promote biofeedback as a CAM
Biofeedback seems to share several core values with
the complementary and alternative approaches to health
F. S haffer and D. Moss
Textbook of Complementary and Alternative Medicine2
(1) Adopting a holistic view of mind, body and spirit;
(3) Assigning an active role to the patient in the heal-
ing process;
(4) Emphasizing the inherent healing power of the liv-
ing organism;
(5) Encouraging lifestyle and habit changes as tools to
optimize health; and
(6) Avoiding invasive treatments that crush disease but
harm the patient.
Biofeedback implements these values concretely,
enabling the patient to directly experience the body–
mind linkage through physiologic feedback, and training
the individual to actively modify physiologic processes,
reducing the malignant effects of stress and enhancing
the healing powers of the body. Biofeedback is a non-
invasive therapy, with minimal aversive effects, and can
play a powerful role in restoring natural homeostatic bal-
ance in the body. Biofeedback is also not practiced in iso-
lation, but rather in combination with other alternative
therapies. A biofeedback therapist educates patients
about their medical disorders, identifies relevant physio-
logic mechanisms, and promotes nutritional and lifestyle
factors that enhance the body’s recovery from illness.
Biofeedback therapists typically train patients in a vari-
ety of relaxation, imagery, and hypnotic techniques,
which induce an emotional and physiologic relaxation
response. The resulting low-arousal state is conducive to
emotional healing and spiritual recovery.
Biofeedback also brings to CAM a strong evidence-
based approach for many common medical and psycho-
logic disorders. This evidentiary base is much sought
after in CAM research, yet the research remains sparse
for most CAM therapies. Biofeedback emerged directly
from laboratory research on psychophysiology and
behavior therapy, and continues to advance by means of
both pure and applied empirical research. Better recog-
nition of underlying mechanisms inspires new biofeed-
back treatment approaches. A recent review of outcome
literature found relatively strong indications of efficacy
for a wide range of biofeedback applications, including
anxiety, asthma, headache, and urinary incontinence15.
Biofeedback provides individuals with information
about their performance and, in this sense, plays an
increasingly important part of American diet, exercise,
and personal health care. Americans unknowingly utilize
biofeedback when they weigh themselves, count ‘carbs’,
track miles run, record calories burned, monitor average
heart rate during a workout, and record their resting
blood pressures and blood glucose levels. Each of these
self-monitoring techniques provides individuals with
‘biofeedback’, information about their own body and
biologic condition. Similarly, the information provided
by home test kits about allergy, cholesterol, colorectal
cancer, hepatitis C, ovulation, and pregnancy constitutes
another form of biofeedback. Clinical biofeedback meas-
ures patient performance using devices ranging in
sophistication from small alcohol thermometers to com-
puter-interfaced data acquisition systems that instan-
taneously analyze, display, and store multiple biologic
Patient assessment and evidence-based treatment
protocols determine the modalities a therapist monitors
and trains. When assessment reveals dysfunctional pat-
terns of physiologic activity during resting, stressor,
recovery, or relaxation conditions, a therapist may
choose to simultaneously monitor several signals during
subsequent training sessions. For example, when treating
a hypertensive patient, a therapist may monitor blood
pressure, heart rate variability, respiration rate, and the
temperature of several hand sites across training sessions.
Therapists typically display only one or two of these sig-
nals to the patient during a training session to simplify
and maximize learning.
The main modalities used in clinical biofeedback are
summarized in Table 24.1 and include the electromyo-
graph, skin temperature, electrodermograph, electro-
encephalograph, respiration, and heart rate/heart rate
The electromyograph (EMG) uses surface electrodes to
detect muscle action potentials from underlying skeletal
muscles. At least two (and usually three) precious metal
electrodes, designated active and reference, are needed to
measure the EMG signal. Clinicians place the active
electrode(s) over a target muscle and the reference elec-
trode over a less electrically active site. Since the elec-
trodes should detect different amounts of EMG activity
(the active electrode(s) should detect more energy), a
voltage should develop between them. The EMG signal
is measured in microvolts (millionths of a volt). In
applications like stroke and low back pain, therapists
bilaterally monitor and train patients because more sym-
metric muscle activity may be critical to symptomatic
Biofeedback 3
improvement. In neuromuscular rehabilitation, thera-
pists monitor flexors and extensors located at the same
joint to prevent interference and enhance muscle coop-
eration in functional movement. Therapists use hand-
held EMG scanning devices with post-style electrodes to
rapidly measure muscle activity at a series of muscle sites
during assessment. EMG scanning requires less patient
preparation time and is more cost-effective than moni-
toring with conventional surface electrodes. Hand-held
EMG scanning devices may be stand-alone instruments
or mobile sensors that communicate with a data acquisi-
tion system17–20.
Therapists may use portable electromyographs and
EMG telemetry systems to dynamically monitor muscle
activity during training to correct gait, posture, and ath-
letic and musical performance. Patients often use
portable electromyographs at work or home to correct
dysfunctional muscle use patterns in their natural setting
(e.g. monitoring wrist flexors and extensors in repetitive
Biofeedback therapists use EMG biofeedback when
treating bruxism, chronic pain, essential hypertension,
headache (migraine and tension), and temporomandibu-
lar joint dysfunction2,15.
Skin temperature
A feedback thermometer detects skin temperature with a
thermistor (temperature-sensitive resistor) that is usually
attached to a finger or toe. Skin temperature mainly
reflects arteriole diameter. Hand warming and hand
cooling are produced by separate mechanisms and their
regulation involves different skills. Increased sympathetic
activation associated with anxiety and hypervigilance can
produce vasoconstriction and hand cooling. In tempera-
ture biofeedback, a patient watches temperature displays
with at least one-tenth of a degree resolution that are
updated every few seconds17–19.
In temperature or thermal biofeedback, therapists
often monitor multiple sites to visualize the overall pat-
tern of blood flow within an extremity. Since tempera-
ture training can be so specific that only one of five dig-
its on a hand warms, therapists may train several sites on
the same or different extremity to ensure generalized
vasodilation. Therapists can use hand held infrared tem-
perature scanning devices to produce a composite pic-
ture of blood flow to all digits on both hands in less than
20 seconds21. Temperature scanning offers the same
advantages in patient preparation time and cost as EMG
Therapists may supplement temperature biofeedback
with blood volume pulse (BVP) feedback, which meas-
ures the relative blood flow through a digit using a pho-
toplethysmographic (PPG) sensor attached by a Velcro
band to the skin. An infrared light source is transmitted
through or reflected off the tissue, detected by a photo-
transistor, and quantified in arbitrary units. More light is
absorbed when blood flow is greater, reducing the
Table 24.1 Major biofeedback modalities
Modality Acronym Activity measured Sensor Measurement unit
Electromyograph EMG muscle action potentials precious metal or post microvolts (µV)
Feedback thermometer TEMP peripheral blood flow thermistor degrees F or C
Infrared thermometer TEMP peripheral blood flow infrared detector degrees F or C
Photoplethysmograph PPG peripheral blood flow, heart rate, PPG sensor arbitrary units
heart rate variability
Electrocardiogram EKG heart electrical activity, precious metal beats per minute
heart rate, heart rate variability
Electrodermograph EDR, GSR, eccrine sweat gland activity, zinc or precious metal microsiemens (µS)
SCL electrical conductance/resistance
in skin
Electroencephalograph EEG cortical postsynaptic potentials precious metal microvolts (µV)
Pneumograph RESP abdominal/chest expansion strain gauge arbitrary units
Capnometer CAP end-tidal CO2infrared detector torr
Textbook of Complementary and Alternative Medicine4
intensity of light reaching the sensor. Blood volume
pulse can provide useful feedback when temperature
feedback shows minimal change. This is because the
PPG sensor is more sensitive than a thermistor to minute
blood flow changes. During a training session, therapists
can switch from temperature biofeedback to blood vol-
ume pulse biofeedback when a patient plateaus (ceases to
warm), as long as the hand is not very cold17–19.
Patients may continuously self-monitor hand tem-
perature outside the clinic using inexpensive feedback
thermometers, small alcohol thermometers, and temper-
ature-sensitive liquid crystal bands, cards, dots, or rings.
These products can help patients increase their aware-
ness of hand temperature and the internal and environ-
mental events that trigger hand-cooling, and can acceler-
ate their development of hand-warming and stress
management skills.
Biofeedback therapists use temperature biofeedback
when treating chronic pain, edema, headache (migraine
and tension), essential hypertension, Raynaud’s disease,
and stress2,15.
An electrodermograph measures skin electrical activity
directly (skin conductance and skin potential) and indi-
rectly (skin resistance) using electrodes placed over the
digits or hand and wrist. Orienting responses to unex-
pected stimuli, arousal and worry, and cognitive activity
can increase eccrine sweat gland activity.
In skin conductance, an electrodermograph imposes
an imperceptible current across the skin and measures
how easily it travels through the skin. When anxiety
raises the level of sweat in a sweat duct, conductance
increases. Skin conductance is measured in micro-
siemens (millionths of a Siemen). In skin potential, a
therapist places an active electrode over an active site
(e.g. the palmar surface of the hand) and a reference elec-
trode over a relatively inactive site (e.g. forearm). Skin
potential is the voltage that develops between eccrine
sweat glands and internal tissues, and is measured in mil-
livolts (thousandths of a volt). In skin resistance, also
called galvanic skin response (GSR), an electrodermo-
graph imposes a current across the skin and measures the
amount of opposition it encounters. Skin resistance is
measured in kohms (thousands of ohms)17–19,22.
While therapists use skin conductance biofeedback
more extensively than skin potential and resistance, all
three forms of electrodermal biofeedback produce com-
parable results. The goal of electrodermal biofeedback is
to restore normal sweat gland function by reducing
excessive and lingering autonomic activation – not to
suppress sweating in response to sudden or threatening
stimuli. Patients may continuously self-monitor skin
electrical activity outside the clinic using inexpensive
portable electrodermographs.
Biofeedback therapists use electrodermal biofeedback
when treating anxiety disorders, hyperhidrosis (exces-
sive sweating), and stress, and as an adjunct to psycho-
An electroencephalograph uses precious metal electrodes
to detect a voltage between at least two electrodes located
on the scalp, The EEG records both excitatory postsy-
naptic potentials (EPSPs) and inhibitory postsynaptic
potentials (IPSPs) that largely occur in dendrites in
pyramidal cells located in macrocolumns, several mil-
limeters in diameter, in the upper cortical layers. EEG
biofeedback, which is also called neurofeedback, moni-
tors both slow and fast cortical potentials.
Slow cortical potentials are gradual changes in the
membrane potentials of cortical dendrites that last from
300 ms to several seconds. These potentials include the
contingent negative variation (CNV), readiness poten-
tial, movement-related potentials (MRPs), and P300 and
N400 potentials.
Fast cortical potentials range from 0.5 to 100 Hz.
The main frequency ranges include delta, theta, alpha,
the sensorimotor rhythm, beta, and gamma, as shown in
Table 24.2. The frequency ranges vary considerably
among professionals.
The synchronous delta rhythm ranges from 0.5 to
3.5 Hz, is the dominant frequency from ages 1–2, and is
associated in adults with deep sleep and brain pathology
like trauma and tumors, and learning disability.
The synchronous theta rhythm ranges from 4 to 7
Hz, is the dominant frequency in healthy young children,
and is associated with drowsiness or starting to sleep,
REM sleep, hypnagogic imagery (intense imagery experi-
enced before the onset of sleep), hypnosis, attention, and
processing of cognitive and perceptual information.
The synchronous alpha rhythm ranges from 8 to 13
Hz and is defined by its waveform and not by its fre-
quency. Alpha activity can be observed in about 75% of
awake, relaxed individuals and is replaced by low-ampli-
tude desynchronized beta activity during movement,
complex problem-solving, and visual focusing. This phe-
nomenon is called alpha blocking.
The synchronous sensorimotor rhythm (SMR) ranges
from 12 to 15 Hz and is located over the sensorimotor
Biofeedback 5
cortex (central sulcus). The sensorimotor rhythm is asso-
ciated with the inhibition of movement and reduced
muscle tone.
The beta rhythm consists of asynchronous waves and
can be divided into low beta and high beta ranges
(13–21 Hz and 20–32 Hz). Beta activity can be observed
during activation, information processing, and move-
ment. EEG activity from 36–44 Hz is also referred to as
gamma. Gamma activity changes when subjects learn to
perceive meaningful patterns, like a Dalmatian con-
cealed by a black and white background17–19,23.
Based on assessment and training goals, clinicians
select surface electrode configurations called montages to
detect localized or global EEG activity. The electrode
sites are located using the 21-electrode International
10–20 system or the 75-electrode modified expanded
International 10–20 system, which is also called the
10–10 system24. They may monitor a single electrode
site or a montage of 19, 72, or more sites. The quantita-
tive EEG (QEEG) calculates average EEG voltages
within selected frequency bands. Clinicians may refer-
ence patient values to a published database to aid diag-
nosis. In brain electrical activity mapping (BEAM), soft-
ware topographically plots the strength of EEG
frequencies across a computer model of the patient’s
scalp to reveal how the brain processes information3.
Neurotherapists use EEG biofeedback when treating
addiction, attention deficit disorder and hyperactivity
disorder (ADHD), learning disability, and tonic-clonic
A pneumograph or respiratory strain gauge uses a flexi-
ble sensor band that is placed around the chest,
abdomen, or both. The strain gauge method can pro-
vide feedback about the relative expansion/contraction
of the chest and abdomen, and measure respiration rate.
Strain gauge biofeedback has two limitations: measure-
ments are in relative units and breathing mechanics can
look correct while end-tidal CO2and respiratory sinus
arrhythmia (RSA) are reduced due to excessive effort
and while heart rate changes are out of phase with the
breathing cycle. Two identical respiration curves can be
associated with very different patterns of heart rate
Clinicians who treat respiratory disorders like asthma
and chronic obstructive pulmonary disease (COPD)
provide respiratory biofeedback using a capnometer,
which measures end-tidal CO2(the partial pressure of
carbon dioxide in expired air at the end of expiration)
exhaled through a nostril into a latex tube. The average
value of end-tidal CO2for a resting adult is 5% (36
torr)25. A capnometer is a sensitive index of the quality
of patient breathing26. Shallow, rapid, and effortful
breathing lowers CO2, while deep, slow, effortless
breathing increases it.
Biofeedback therapists use respiratory biofeedback
with patients diagnosed with anxiety disorders, asthma,
chronic pulmonary obstructive disorder (COPD), essen-
tial hypertension, panic, and stress2,15.
Heart rate variability
Biofeedback therapists are increasingly interested in the
new modality of heart rate variability (HRV) biofeed-
back. Heart rate is constantly changing, based on factors
as diverse as exertion, blood pressure changes, negative
emotions, and respiration27. The variability of heart rate
is measured in a number of ways, such as the statistical
variability of the interbeat interval (the length of time
between each heart beat). Alternatively, biofeedback can
measure the difference between the maximum heart rate
and the minimum heart rate in each cycle of heart rate
change. In either case, the variability of heart rate
correlates with both physical and emotional health.
Table 24.2 Common EEG frequencies
EEG frequency Frequency range Activity
Delta rhythm 0.5–3.5 sleep, traumatic brain injury
Theta rhythm 4–7 daydreaming, drowsiness, imagery, inattention
Alpha rhythm 8–13 meditation, receptiveness
Sensorimotor rhythm (SMR) 12–15 inhibition of movement
Low beta rhythm 13–21 activation, focused thinking
High beta rhythm 20–32 anxiety, hypervigilance, panic, peak performance, worry
Gamma rhythm 36–44 active attention, pattern recognition
Textbook of Complementary and Alternative Medicine6
Individuals with more variability are more likely to
recover and survive longer after a heart attack28. Young
persons have fairly high variability in heart rate, for
example exhibiting baseline oscillations in heart rate of
20 or more points. As individuals age, this variability is
reduced, with baseline oscillations declining to 10 points
or less in most persons over 50 years of age. Exercise
training increases the variability of the heart in normal
healthy adults29, while individuals with lower variability
are more vulnerable to death from all causes.
During healthy breathing, heart rate accelerates dur-
ing inhalation and slows during exhalation. When sub-
jects relax and breathe more slowly, this effect of respira-
tion on heart rate change is increased and produces
maximal overall heart rate variability. Therapists use
either the electrocardiogram (EKG) or photoplethysmo-
graph (PPG) to monitor the frequency bands that com-
prise heart rate variability. They also use a respiratory
strain gauge to measure abdominal or chest expansion
and contraction during each respiratory cycle and respi-
ration rate. Relaxed breathing produces a biofeedback
display showing a smooth sinusoidal line, depicting
exhalation and inhalation, and a parallel smooth sinu-
soidal line showing heart rate variation. Anxious
thoughts, on the other hand, produce a jagged irregular
respiration signal and a jagged irregular variation in heart
rate. Producing this coherence – or smoothly organized
and regular variation30 – of the respiratory and heart rate
displays is also a training goal for biofeedback.
Advanced software provides HRV biofeedback that
displays the effect of breathing on heart rate variability,
including spectral displays showing how much of the
heart’s overall variability falls into each frequency range.
Synchrony develops between the respiratory and cardio-
vascular system at slower respiration rates, usually
around six breaths per minute. The respiration rate that
produces the greatest heart rate variability is called the
resonant frequency. Cultivating this resonant frequency
also seems to have an optimal effect on biological home-
ostasis and health31. Initially, the effects of HRV biofeed-
back training were interpreted to be the result of
strengthening parasympathetic nervous system influ-
ences on physiology, inducing a relaxation response.
However, more recently, HRV has been conceptualized
as a process of training an active balancing between the
sympathetic and parasympathetic branches’ effects on
the heart rhythm2,27,30,32,33.
Biofeedback therapists use HRV biofeedback when
treating patients diagnosed with anxiety disorders,
asthma, chronic obstructive pulmonary disease, and car-
diovascular disease2,15.
While biofeedback has a remarkable safety record, there
are several disorders and conditions where it is con-
traindicated or where considerable caution is required34.
When a patient requests biofeedback for a medical con-
dition like hypertension, a biofeedback therapist should
require a current evaluation by the patient’s health-care
provider and a report of these findings to determine
whether biofeedback is appropriate. Where biofeedback
is indicated, the biofeedback therapist should regularly
communicate with the health-care provider concerning
patient progress. In addition, Moss advocates compre-
hensive evaluation by the biofeedback therapist, includ-
ing identification of the presenting problem, medical
and psychosocial histories, assessment of the patient’s
risk for suicide and homicide, well-lifestyle, spirituality,
diagnosis, and often a psychophysiologic stress profile
(PSP) before deciding whether biofeedback is appropri-
ate. Such an evaluation also enables better selection of
specific biofeedback training modalities and objectives35.
Schwartz34 observes that biofeedback therapists gen-
erally agree that biofeedback is contraindicated or should
be conducted with considerable caution in acute medical
decompensation, agitation, delirium, severe depression,
dissociation (depersonalization, dissociative reaction,
and fugue), mania, severe obsessive-compulsive disorder
(OCD), paranoid disorders, and schizophrenia. Biofeed-
back therapists require special expertise when treating
patients with moderate-to-severe attentional or memory
deficits and seizure disorders, and when patients receive
considerable secondary gains (reinforcement) from their
presenting complaints.
Infrequently, biofeedback-assisted relaxation training
reduces a patient’s medication requirement in specific
medical disorders (e.g. asthma, diabetes mellitus,
epilepsy, glaucoma, hypertension, and hypothyroidism).
To address this problem, the patient’s health-care
provider and biofeedback therapist should know which
drugs the patient routinely takes, discuss this issue before
initiating biofeedback training, and ensure adequate
monitoring of the patient’s medical condition. The
patient should agree to consult with the health-care
provider before reducing dosage or discontinuing med-
Striefel cautions that biofeedback-assisted relaxation
can produce negative reactions in any patient36. While
Budzynski advises that a thorough psychologic history
can identify patients with an elevated risk of negative
reaction, therapists must be prepared to respond to prob-
lems in patients without DSM-IV disorders37. Schwartz
Biofeedback 7
and Schwartz believe that while severe negative reactions
are rare, mild-to-moderate negative reactions can inter-
fere with therapy, reduce patient practise of assigned
relaxation exercises, and in extreme cases end promising
When patients experience negative reactions like anx-
iety, muscle spasms and tics, and increased sympathetic
activation, the biofeedback therapist can reassure the
patient and adjust biofeedback therapy and home prac-
tise assignments. In the rare case of a severe negative
reaction that exceeds the therapist’s expertise, he or she
may need to consult with or obtain supervision from a
more experienced professional or refer the patient to
another clinician36.
A Task Force of the Association for Applied Psychophys-
iology (AAPB) and the International Society for Neu-
ronal Regulation (ISNR) developed clinical efficacy
guidelines for the evaluation of biofeedback and neuro-
feedback treatments. The guidelines, which were
adopted by both organizations’ Boards of Directors,
established five levels of efficacy for conditions treated by
Level 1: Not empirically supported
Supported only by anecdotal reports and/or case studies
in non-peer-reviewed venues.
Level 2: Possibly efficacious
At least one study of sufficient statistical power with
well-identified outcome measures, but lacking random-
ized assignment to a control condition internal to the
Level 3: Probably efficacious
Multiple observational studies, clinical studies, wait-list
controlled studies, and within-subject and intrasubject
replication studies that demonstrate efficacy.
Level 4: Efficacious
(a) In a comparison with a no-treatment control group,
alternative treatment group, or sham (placebo) con-
trol utilizing randomized assignment, the investiga-
tional treatment is shown to be statistically signifi-
cantly superior to the control condition or the
investigational treatment is equivalent to a treat-
ment of established efficacy in a study with suffi-
cient power to detect moderate differences, and
(b) The studies have been conducted with a pop-
ulation treated for a specific problem, for whom
inclusion criteria are delineated in a reliable, opera-
tionally defined manner, and
(c) The study used valid and clearly specified outcome
measures related to the problem being treated, and
(d) The data are subjected to appropriate data analysis,
(e) The diagnostic and treatment variables and proce-
dures are clearly defined in a manner that permits
replication of the study by independent researchers,
(f) The superiority or equivalence of the investiga-
tional treatment has been shown in at least two
independent research settings.
Level 5: Efficacious and specific
The investigational treatment has been shown to be sta-
tistically superior to credible sham therapy, pill, or alter-
native bona fide treatment in at least two independent
research settings.
These efficacy guidelines are more rigorous than the
standards applied to many mainstream medical therapies
because they require both statistical superiority to credi-
ble placebo and alternative bona fide treatments, and at
least moderate effects. Interventions that receive low
ratings may still be clinically valuable if the rating is
based on insufficient research or failure to achieve statis-
tical significance due to high within-group variability.
Interventions that receive ‘possibly efficacious’ or ‘proba-
bly efficacious’ ratings may actually produce greater clin-
ical improvement for a particular patient than well-
accepted medical procedures. Due to the excellent
side-effect profiles of most biofeedback and neurofeed-
back interventions, they can serve as invaluable altern-
atives for patients who cannot tolerate medication, do
not respond to traditional medical alternatives, and pre-
fer self-regulation over self-medication15.
In this section, we will review several of the most effi-
cacious biofeedback treatments: urinary incontinence,
temporomandibular disorders (TMD), hypertension,
adult headache, anxiety, attention deficit hyperactivity
disorder (ADHD), alcoholism/substance abuse, epilepsy,
and fecal elimination disorders15. The efficacy of these
treatments is summarized in Table 24.3.
Urinary incontinence
Urinary incontinence is the involuntary loss of urine.
This problem affects approximately 13 million Ameri-
cans, mainly women. Three common types of inconti-
Textbook of Complementary and Alternative Medicine8
following prostatectomy was superior to a no-treatment
control44. Floratos et al. showed that biofeedback for uri-
nary incontinence was equivalent to pelvic floor exer-
Temporomandibular disorders
Temporomandibular disorders (TMD) are the second
most common cause of orofacial pain after toothache.
While TMD is a heterogeneous group of disorders, oro-
facial pain and/or masticatory problems may be classi-
fied as TMD secondary to myofacial pain and dysfunc-
tion (MPD), TMD secondary to articular disease, or
both. TMD is characterized by dull pain around the ear,
tenderness of jaw muscles, a clicking or popping noise
when opening or closing the mouth, limited or abnor-
mal opening of the mouth, headache, tooth sensitivity,
and abnormal wearing of the teeth.
TMD pain is located in the preauricular area, the
muscles used for chewing (masseter, temporalis, and
pterygoids), or the temporomandibular joint (TMJ). It
is triggered by chewing, is unilateral or bilateral in MPD,
and is reported along with headache, other facial pain,
neck pain, and pain in the shoulder and back.
EMG biofeedback for TMD received a rating of level
4: efficacious15. Crider and Glaros conducted a meta-
analysis of 13 studies of EMG biofeedback for the mas-
seter and/or frontales muscles and stress management
treatment of TMD. Biofeedback was superior to no treat-
ment or placebo on patient pain ratings, clinical exami-
nation, and/or global improvement46. EMG biofeedback
reduces TMD pain and associated disability. EMG
biofeedback improves clinical outcome when used with
intraoral devices and cognitive-behavioral therapy47,48.
Wang and Wang estimated that almost 60% of Ameri-
can adults can be classified with prehypertension or
hypertension. Groups at highest risk include African
Americans, the elderly, individuals with low socio-
economic status, and those who are overweight. While
the prevalence of hypertension has increased 10% in the
past decade, patient control of hypertension remains
low. Thirty-one percent were unaware that they were
hypertensive, only 66% were instructed by health pro-
fessionals to modify lifestyle and take drugs to control
their blood pressure, and only 31% achieved satisfactory
Biofeedback for hypertension received a rating of level
4: efficacious15. Jacob et al.50 reported a meta-analysis
Table 24.3 Efficacious biofeedback treatments
Disorder Level Efficacy rating
ADHD 4 efficacious
Adult headache 4 efficacious
(migraine and tension)
Alcoholism/substance 3 probably efficacious
Anxiety 4 efficacious
Epilepsy 3 probably efficacious
Fecal elimination 3 probably
disorders efficacious
Hypertension 4 efficacious
disorders (TMD) 4 efficacious
Urinary incontinence 5 efficacious
(females) and specific
Urinary incontinence 4 efficacious
nence are urge incontinence, stress incontinence, and
mixed incontinence40–42. Biofeedback for urinary incon-
tinence in females received a rating of level 5: efficacious
and specific15.
Clinicians use three strategies to treat urinary incon-
tinence: reducing detrusor overactivity by monitoring
the bladder using an inserted catheter, increasing the
strength of pelvic floor muscles using EMG sensors
(vaginal or anal) or pressure sensors, and combining the
previous methods while minimizing intra-abdominal
pressure which is monitored by a rectal balloon (multi-
measurement method).
Tries and Brubaker recommend the multi-measure-
ment method because it reinforces ‘a more discriminate
pelvic floor contraction’ than single-channel methods. In
their study, the multi-measurement method achieved
superior reductions in incontinence episodes from 75.9
to 82% in about five sessions, compared with 43 to 61%
reductions with single-channel biofeedback in an average
of 11 sessions43.
Researchers have found that biofeedback for urinary
incontinence in females is superior to no treatment,
comparable or superior to alternative behavioral treat-
ments like pelvic floor exercises, and superior to drugs
like oxybutynin chloride, regardless of patient age. A
stepped program that combines drug and behavioral
treatments may be superior to a single treatment15.
Biofeedback for urinary incontinence in males
received a rating of level 4: efficacious15. Van Kampen et
al. reported that biofeedback for urinary incontinence
Biofeedback 9
of 75 treatment groups and 41 control groups. The treat-
ment groups produced markedly greater blood pressure
reductions than control groups. The treatments that pro-
duced the greatest blood pressure reductions were ranked
in descending order of efficacy: stress management,
EMG biofeedback, and temperature biofeedback. Relax-
ation and blood pressure biofeedback produced the
smallest reductions in systolic blood pressure, and medi-
tation produced the smallest reductions in diastolic
blood pressure. Patient expectations concerning treat-
ment efficacy and their perception of relaxation depth
during treatment discriminated between treatment suc-
cess and failure.
Yucha et al.51 conducted a meta-analysis of 23 stud-
ies between 1975 and 1996 that compared biofeedback
training with active treatments like meditation and inac-
tive treatments like sham biofeedback controls and
blood pressure measurement. Both biofeedback and
active treatments produced significant, but equivalent,
reductions in systolic and diastolic blood pressure.
Biofeedback produced greater systolic (6.7 mmHg) and
diastolic (3.8 mmHg) blood pressure reductions than
the inactive treatments.
Adult headache
Approximately 28 million Americans experience
migraine headache each year. While women are three
times more likely than men to suffer from migraines,
men are five times more likely to experience cluster
headaches. A classic migraine features a prodrome or
neurologic symptoms occurring hours to days before
headache onset, and accounts for about 20% of all
migraines. The headache is preceded (10–20 minutes) by
painless neurologic symptoms that are mainly visual
(scintillating scotomata and visual field defects); these
symptoms persist from 20 to 30 minutes, often overlap-
ping with the headache. Headache onset may occur at
any time and may last from several hours to 6 days (1–2
days typical). A common migraine lacks a prodrome and
accounts for about 80% of all migraines. This headache
often lasts longer than a classic migraine and may be
bilateral. The trigeminal nerve may be activated in all
primary headaches – cluster, migraine, and tension-type.
Migraine patients may be hypersensitive to headache
triggers and have an abnormally low threshold for acti-
vating the trigeminal nerve, compared with occasional
tension-type headache patients. Repeated migraine
episodes may reduce migraineurs’ ability to block pain52.
Diverse internal triggers (hormonal fluctuations,
stress, and sleep deprivation) and external triggers (aller-
gens, diet, and weather changes) increase the firing of
neurons in the brainstem, hypothalamus, and cortex,
which send signals to a hypothesized migraine generator
that produces nausea and vomiting. A migraine genera-
tor in the dorsal raphe nucleus in the upper brainstem
activates the trigeminal nerve, whose extensive branches
cover the brain ‘like a helmet’ and initiate the migraine.
Trigeminal nerve endings in the brain’s dura mater
release proteins that dilate blood vessels and increase the
nerves’ sensitivity. Thus, blood vessel swelling is the
effect, instead of the cause, of a migraine53,54.
Tension-type headache is characterized by a steady,
non-throbbing pain that may involve the fronto-tempo-
ral vertex and/or occipito-cervical areas with a lateral or
bilateral distribution. This headache typically lasts 1–4
hours, but pain localized in one region may persist for
years. The chronic subtype persists for an average of 8.7
Tension-type headache is divided into episodic and
chronic headache. Episodic tension-type headache is
diagnosed when the patient has at least 10 previous
headaches and fewer than 15 per month. Chronic ten-
sion-type headache is diagnosed when there is an average
headache frequency of more than 15 days per month for
more than 6 months. Recent studies have shown that
tension-type headache patients show higher EMG levels
than healthy controls. Researchers have monitored
frontalis, occipitalis, temporalis, and trapezius muscles to
study the role of muscle activity in tension-type
Biofeedback treatment for adult migraine, tension-
type, or mixed headache received a rating of level 4: effi-
McGrady et al.55 reported that biofeedback-assisted
relaxation produced greater improvement in transcranial
Doppler measurements of cerebral blood flow than self-
guided relaxation. An Agency for Health Care Policy and
Research meta-analysis concluded that temperature
biofeedback, relaxation, and cognitive-behavioral inter-
ventions were at least moderately effective for treating
migraine when compared to a wait-list control56. Silber-
steins review of migraine treatment for the American
Academy of Neurology – US Consortium recommended
EMG and temperature biofeedback as effective treat-
ments when delivered in the context of relaxation train-
Several treatment components should be considered
based on the tension-type headache outcome literature:
frontal EMG biofeedback, trapezius EMG biofeedback,
temperature biofeedback, relaxation training, and cogni-
tive behavior therapy.
Textbook of Complementary and Alternative Medicine10
Arena et al.58 compared forehead and trapezius EMG
biofeedback with a progressive muscle relaxation control
condition for treatment of tension headache. Trapezius
EMG biofeedback produced the best clinical outcomes.
The National Institutes of Health Technology Assess-
ment Panel concluded that EMG biofeedback was supe-
rior to psychologic placebo and comparable to relaxation
therapies in treating tension headache59. The National
Headache Foundation’s Standards of Care for Headache
Diagnosis and Treatment found that ‘biofeedback has
been shown to be an excellent treatment in the long term
management of migraine and tension-type headache dis-
A meta-analysis by McCrory et al.61 showed that
EMG biofeedback, relaxation therapy, and cognitive-
behavioral therapy were moderately effective treatments
for tension-type headache. A review of more than 100
studies by McGrady et al.62 found that biofeedback,
relaxation training, and stress management training pro-
duced an average 50% reduction of headache pain.
Moss et al.63 argue
‘Biofeedback also has particular advantages over most
medical treatments for headaches. Not only can it pro-
duce long-term remission of symptoms, but it does so
without side effects. On the contrary, common side
effects of medical treatments of headache include weight
gain, sedation, and impaired concentration, and
headache medications frequently lose their effectiveness
over time. There is even preliminary evidence to suggest
that successful treatment with biofeedback and relax-
ation can result in substantial cost savings’.
The Diagnostic and Statistical Manual of Mental Disorders
(DSM-IV) of the American Psychiatric Association iden-
tifies the major anxiety disorders as panic disorder, the
phobias, generalized anxiety disorder, obsessive-compul-
sive disorder, post-traumatic stress disorder, acute stress
disorders, and ‘adjustment disorder with anxious fea-
tures’64. The Epidemiological Catchment Area Survey
estimates that the lifetime prevalence of anxiety disorder
is 15%. The one-month incidence of anxiety disorders is
twice as high in women (9.7%) as in men (4.7%). Anx-
iety disorders are most diagnosed in 25–44-year-olds,
individuals who are separated or divorced, and those
with low socioeconomic status65.
Moss’s comprehensive model of anxiety focuses on
the interaction among neurotransmitter imbalances,
neurophysiologic overactivation, threat perception and
cognitive escalation, avoidant behavior and stimulus
generalization, and environmental stressors33.
Quantitative EEG (QEEG) studies of patients diag-
nosed with anxiety disorders have revealed excessive fast-
wave often coupled with deficient slow-wave activity,
excessive slow-wave activity often coupled with deficient
fast-wave activity, and excessive activity in midline cen-
tral and frontal regions. Neurotherapy guided by the
neurometric QEEG attempts to train patients to correct
abnormal EEG patterns33.
Biofeedback treatment for anxiety received a rating of
level 4: efficacious15. The majority of controlled, ran-
domized experiments have found that biofeedback (elec-
trodermal, neurofeedback, EMG, and temperature) and
relaxation procedures (meditation and progressive relax-
ation) produce comparable reductions in anxiety.
Rice et al.66 studied 45 patients with generalized anx-
iety. Thirty-eight of these patients satisfied the DSM-III
criteria for generalized anxiety disorder (GAD) and
seven were subclinical for GAD and only met two of
these criteria. They randomly assigned patients to one of
five conditions: frontal EMG biofeedback, EEG
biofeedback to increase alpha, EEG biofeedback to
decrease alpha, pseudomeditation, or a wait-list control.
For the two EEG biofeedback conditions, the electrodes
were placed at OZ, the right mastoid process, and the
forehead. All four treatment groups received eight 60-
minute sessions and achieved significant reductions on
STAI-trait anxiety scores and psychosomatic symptom
checklist (PSC) scores. Only the alpha-increase condi-
tion decreased heart rate reactivity to stressors. Subjects
in the frontal EMG, alpha-increase, and alpha suppres-
sion conditions maintained improvement in STAI-trait
anxiety and PSC scores at 6 weeks post-treatment. The
alpha-increase and alpha-suppression groups actually
showed further improvement in PSC scores at 6 weeks
Attention deficit hyperactivity disorder
Attention deficit hyperactivity disorder (ADHD), which
is diagnosed in 3–10 percent of school-age children, is
the most common childhood psychologic disorder. From
15 to 70% of diagnosed children receive stimulant med-
ication. While central nervous system stimulants gener-
ally improve ADHD symptoms for as long as correctly
diagnosed children continue to take their medication,
clinicians have been concerned about stimulants’ long-
term effects on developing brains67. A recent study that
administered methylphenidate (Ritalin) to young rats
raised the possibility that stimulants can permanently
Biofeedback 11
alter the brain and produce adult depression68. In addi-
tion, the majority of individuals with childhood atten-
tion deficits will display similar difficulties in adult years,
manifesting in underachievement in the work sector and
impulsive behavior in their private lives69.
The DSM-IV of the American Psychiatric Associa-
tion now applies the single label of ADHD to the entire
syndrome, but identifies three main subtypes: inatten-
tive, hyperactive-impulsive, and combined. The primary
behavioral deficits involve attention, learning, self-con-
trol, and hyperactivity64.
Neurofeedback treatment for ADD and ADHD
received a rating of level 4: efficacious15. Neurofeedback
appears to be superior to no treatment and comparable
to stimulant medication. Patients require at least 20 ses-
sions, and as many as 50 sessions, to produce clinical
Neurophysiologic research reports electrical underac-
tivity over frontal and central areas of the cortex in the
majority of individuals with ADHD. Neurofeedback
treatment protocols have developed as strategies to
retrain and normalize brain function in children and
adults with this abnormal electro-cortical pattern. Alter-
native protocols have developed for other inattentive
individuals with divergent cortical patterns70. Lubar et
al.71 reported that training to reduce slow EEG activity
increased WISC-R and test of variables of attention
(TOVA) scores. Full-scale WISC-R scores increased
about 12 points. The increase in TOVA scores correlated
with decreases in slow EEG activity.
Lubar followed 52 patients treated with neurofeed-
back for as long as 10 years. Their improvement on the
Conners scale, used to measure attention, remained sta-
ble at follow-up72.
Rossiter and La Vaque matched and randomly
assigned 46 subjects to either Ritalin or neurofeedback.
Both groups improved on TOVA measures of inatten-
tion, impulsivity, information processing, and response
Linden and colleagues’ controlled study of 18 chil-
dren demonstrated that neurofeedback to increase beta
and suppress theta activity increased intelligence scores
and reduced inattention rated by their parents, when
compared to a wait-list control group74.
Thompson and Thompson reported the successful
treatment of 98 children and 13 adults over forty 50-
minute sessions using Lubar’s ADHD protocol. The
percentage of children using Ritalin declined from 30%
at the start of the study to 6% post-treatment.
Theta/beta ratios significantly declined for children, but
not for adults. Study participants achieved impressive
pretreatment to post-treatment gains on intelligence,
TOVA, and wide range achievement test scores75.
The Kaiser and Othmer multi-center study involved
1089 patients ranging from 5 to 67 years and demon-
strated that SMR-beta neurofeedback training produced
significant gains on TOVA measures of attentiveness,
impulse control, and response variability76.
Monastra et al. compared 49 children diagnosed with
ADHD who participated in a 1-year multi-modal pro-
gram (Ritalin, parent counseling, and academic consul-
tation) with 51 children who participated in the multi-
modal program combined with neurofeedback (weekly
30- to 40-min sessions using the Lubar protocol with a
cash reward for increased frontal cortical arousal). Both
groups significantly improved performance on TOVA
and the attention deficit disorders evaluation scale when
medicated with Ritalin, but only the group that received
neurofeedback maintained performance gains when
unmedicated. A QEEG scan only showed reduced corti-
cal slowing in children who received neurofeedback. Par-
enting style moderated behavioral symptoms at home,
but not in the classroom77.
Fuchs et al.78 compared the efficacy of 3 months of
sensorimotor rhythm (12–15 Hz) and beta1 (15–18 Hz)
neurofeedback against methylphenidate (Ritalin) in 46
ADHD children. The children were assigned to the neu-
rofeedback (22) and medication (12) based on their par-
ents’ preference (assignment was non-random). Both
treatment groups improved on all TOVA subscales, and
on speed and accuracy on the attention endurance test.
Teacher and parent ratings of ADHD behaviors on the
IOWA–Conners behavior rating scale also improved for
both groups.
Alcoholism/substance abuse
The 2004 National Survey on Drug Use and Health
(NSDUH) estimated that, in 2003, 21.6 million Amer-
icans aged 12 or older (9.1%) were dependent on or
abused alcohol or an illegal substance. Of these individ-
uals, 14.8 million were dependent on or abused alcohol
and 3.8 million were dependent on or abused illegal sub-
According to Morse and Flavin80:
Alcoholism is a primary chronic disease with genetic,
psychosocial, and environmental factors influencing
its development and manifestations. The disease is
often progressive and fatal. It is characterized by
impaired control over drinking, preoccupation with
Textbook of Complementary and Alternative Medicine12
the drug alcohol, use of alcohol despite adverse con-
sequences, and distortions in thinking, most notably
denial. Each of these symptoms may be continuous or
Neurofeedback for alcoholism received a rating of level
3: probably efficacious15.
The brains of alcoholics frequently show a deficiency
in alpha, theta, and delta range slow rhythms, and
excesses in beta range fast cortical activity. Ingestion of
alcohol increases alpha range activity in magnitude and
slows the dominant alpha frequency. Neurofeedback
protocols for alcoholism seek to normalize this electro-
cortical pattern. Peniston and Kulkosky81 reported that
patients who received alpha-theta neurofeedback
achieved significantly greater decreases on Millon clini-
cal multiaxial inventory factors than those who received
conventional medical treatment. Alcoholics who
received alpha-theta neurofeedback improved on
schizoid, avoidant, passive-aggressive, schizotypal, bor-
derline, paranoid, anxiety, somatoform, dysthymic, alco-
hol abuse, psychotic thinking, psychotic depression, and
psychotic delusional factors.
Taub and colleagues randomly assigned 118 chronic
alcoholics to one of four treatments: Alcoholics Anony-
mous and counseling (RTT), RTT combined with tran-
scendental meditation, RTT combined with EMG
biofeedback, or RTT plus neurotherapy. Rates of self-
reported abstinence were 25%, 65%, 55%, and 28%,
respectively. While the addition of transcendental medi-
tation and EMG biofeedback seemed to increase absti-
nence, neurotherapy did not82.
Saxby and Peniston demonstrated in a controlled
study that alpha-theta neurofeedback can reduce depres-
sion in alcoholics and increase the rate of abstinence
assessed over a 21-month follow-up period83.
Kelley’s 3-year follow-up study of 20 Native Ameri-
can alcoholic inpatients reported the following changes:
increased EEG synchrony and alpha-theta amplitudes,
extinction of drinking behavior, less personally damag-
ing behavior (81%), and lower Beck depression inven-
tory scores84.
Schneider et al. reported that 6 of 10 male alcoholics
remained abstinent 4 months after completion of slow
cortical potential neurofeedback85.
Epilepsy represents a family of central nervous system
disorders characterized by chronic, relatively brief
seizures, often due to localized brain lesions. Prescription
drugs used to treat epilepsy prevent repetitive neuron fir-
ing by increasing inhibition or reducing excitation86.
Neurofeedback for epilepsy received a rating of level
3: probably efficacious15.
Sterman’s protocol trains an epileptic patient to
increase the sensorimotor rhythm (SMR) (12–14 Hz)
amplitude and duration, and suppress theta (4–7 Hz),
beta (20+ Hz), epileptiform spikes, and EMG artifact
during 36 sessions. The aim is to normalize the waking
and sleep EEG with elevated SMR and suppressed theta
and beta activity.
Sterman summarized 18 peer-reviewed studies in
which 174 patients were trained using his SMR proto-
col. The outcome data were impressive: 82% clinically
improved, reducing seizures by more than 30%. The
average seizure reduction was greater than 50%. Many
studies found decreased seizure severity. Five percent of
patients remained seizure free for as long as one year. In
those studies where researchers recorded pretreatment
and post-treatment EEG amplitudes, 66% normalized
their EEG power spectra87.
La Vaque considers slow cortical potential (SCP)
training to be highly effective in controlling ‘drug-resist-
ant’ epilepsy88.
Kotchoubey et al.89 reported that SCP neurofeedback
decreased the baseline seizure frequency in drug-resistant
epileptics and showed that this improvement was main-
tained 6 months post-treatment90.
Kotchoubey et al. concluded that both SMR and
SCP protocols improve epilepsy control in about 66% of
patients. While the mechanism underlying SCP training
remains unclear, it may involve increased 6.0–7.9 Hz
theta activity during training trials without feedback91.
Joy Andrews et al. found that a neurofeedback proto-
col, involving 5 consecutive days of training, enabled
79% of patients to control their seizures92.
Kotchoubey et al. treated patients with refractory
epilepsy with an anti-epileptic drug and psychosocial
counseling, a breathing training control group, or SCP
neurofeedback in a controlled clinical study. Only the
drug and SCP groups significantly reduced seizure fre-
Fecal elimination disorders
Fecal incontinence is the involuntary release of feces or
gas due to loss of anal sphincter control. The diverse
causes of fecal incontinence include congenital abnor-
malities that damage the spinal cord; anal sphincter
damage due to vaginal delivery, surgery, inflammatory
conditions, and cancer; inflammatory bowel conditions;
Biofeedback 13
and medical conditions, including diabetes mellitus,
stroke, spinal cord trauma, and neurodegenerative disor-
ders. The incidence of fecal incontinence is eight times
higher in women than men. Childbirth is the most com-
mon predisposing factor to fecal incontinence because it
may disrupt the internal or external anal sphincter, or
damage the pudendal nerve94.
Biofeedback for fecal elimination disorders received a
rating of level 3: probably efficacious15.This rating was
assigned due to the heterogeneous patient populations
studied and the absence of control groups.
Biofeedback should only be initiated following med-
ical evaluation and should be conducted under medical
supervision. Two major training procedures include an
anal EMG probe and a three-balloon manometry (pres-
sure) system.
The anal SEMG probe, based on John Perry’s vaginal
perinometer, detects muscle activity associated with the
external anal sphincter. Continence training teaches the
patient to increase external rectal sphincter strength to
prevent unwanted voiding of feces and to develop pro-
prioceptive cues so that signals from rectal wall stretch
receptors will contract the external rectal sphincter to
prevent leakage. A manometry system places one of three
balloons (Schuster anorectal probe or others) in the anal
canal to simulate movement of fecal material, adjacent to
the internal rectal sphincter, and adjacent to the external
rectal sphincter. As the anal canal balloon is inflated,
polygraph tracings show contraction of the internal and
external rectal sphincters. Training is designed to teach
the patient to contract the external rectal sphincter (pre-
venting leakage of feces) when the anal canal balloon
expands, activating rectal wall stretch receptors95.
Adjunctive training procedures used in addition to
biofeedback include bowel or habit training, dietary
counseling, medication, keeping logs (normal bowel
movements and incontinence episodes), and daily
sphincter control exercises.
Biofeedback has been effective in children diagnosed
with fecal incontinence and encopresis (constipation),
and in adults with chronic fecal incontinence and incon-
tinence due to obstetric complications and constipation.
Several researchers have shown that patients maintain
continence at long-term follow-up. Biofeedback does
not correct incontinence caused by surgery to correct
rectal prolapse.
Whitehead and Drossman concluded that, when
pelvic nerve injuries impair anal sphincter contraction or
sensory feedback from stretch receptors in the rectal
wall, biofeedback can eliminate or reduce the frequency
of incontinence by 90% for about 72% of patients96.
Most gastroenterologists consider biofeedback the treat-
ment of choice in these cases. Biofeedback is also pre-
ferred for treating constipation due to a patient’s inabil-
ity to relax pelvic floor muscles during elimination.
Biofeedback also shows promise for treating rectal pain
due to excessive pelvic floor muscle contraction96.
Heymen et al. estimated that biofeedback for fecal
incontinence achieves a 67–74% success rate. They crit-
icized the experimental design of several of the studies
they reviewed97.
Seymour concluded that the effectiveness of fecal
incontinence biofeedback has been demonstrated for
neurogenic and idiopathic anal incontinence, and incon-
tinence related to disruption of anal sphincters. Fecal
incontinence biofeedback reduced incontinence episodes
by 90% in more than 60% of patients. Electrical stimu-
lation of the anal sphincter combined with biofeedback
may result in greater symptom and pressure improve-
ment than biofeedback alone94.
Mahony and colleagues randomly assigned 60 symp-
tomatic women diagnosed with postpartum fecal incon-
tinence to 12 weekly sessions of intra-anal electromyo-
graphic biofeedback alone or combined with electrical
stimulation of the anal sphincter. They also assigned
these patients daily pelvic floor exercises. Fifty-four
women completed treatment. Both groups achieved
improved continence scores and squeeze anal pressures,
while resting anal pressures did not change. Patients in
both groups also reported improved quality of life. The
addition of electrical stimulation did not improve thera-
peutic outcome98.
HRV for asthma, COPD, and cardiovascular
Earlier we reviewed the new modality of HRV biofeed-
back. This trains patients to engage in full, smooth
diaphragmatic breathing, at a rate producing maximal
variability in heart rate. In addition, trainees learn to sus-
pend negative emotions and anxious thoughts, because
such negative cognitive processes suppress variability.
HRV biofeedback has been applied in research studies
to a handful of disorders, including asthma99, chronic
obstructive pulmonary disease (COPD)100, cardio-
vascular rehabilitation101, and hypertension102. In addi-
tion, clinical reports describe positive therapeutic effects
for HRV biofeedback with irritable bowel syndrome,
Textbook of Complementary and Alternative Medicine14
recurrent abdominal pain, rheumatoid arthritis,
migraine, muscle pain syndromes, fibromyalgia, and
chronic fatigue syndrome31.
Paul Lehrer and colleagues conducted an impressive
empirical study of 94 outpatients with asthma, using
four treatment conditions: (1) HRV biofeedback com-
bined with abdominal breathing training, (2) HRV
biofeedback alone, (3) placebo EEG biofeedback, and
(4) a wait-list control99. The study used medically reli-
able outcome measures, including daily asthma symp-
tom logs, twice daily peak expiratory flow measures,
spirometry measures, and measures of oscillation resist-
ance (pneumography). Subjects in both HRV groups
used less asthma medicine after the biofeedback treat-
ment. There were minimal differences between the two
HRV groups. Improvements measured one full level of
asthma severity, based on American Thoracic Society
measures. Forced oscillation pneumography also showed
improvement in pulmonary function in the HRV
groups. The placebo group showed an improvement in
their self-report of asthma symptoms, but not in func-
tional capacity.
Nicholas Giardino and his colleagues conducted a
small but innovative study treating COPD with a com-
bination of HRV biofeedback and a special walking pro-
gram100. The ten participants in the study received five
sessions of biofeedback, which included training to pace
their breathing and increase HRV. In addition, the par-
ticipants engaged in four weekly sessions of walking.
During the walks, they used their new paced breathing
skills to regulate their respiration. They self-monitored
with an oximeter to verify that their oxygen levels
remained satisfactory. They used two outcome measures,
a 6-minute walk distance test (6MWD), a well-validated
measure of functional capacity, and the St George’s res-
piratory questionnaire (SGRQ), a measure of overall
quality of life. The patients showed clinically significant
increases on both the 6MWD and the SGRQ quality of
life index. Eight of the ten participants showed clinically
significant improvements on both measures.
Jessica Del Pozo and colleagues studied 69 partici-
pants with known coronary artery disease and randomly
assigned them to either of two conditions, (1) conven-
tional cardiac rehabilitation, or (2) the experimental
condition with six sessions of abdominal breath training,
respiratory and HRV biofeedback, and 20 minutes per
day of home breathing practise. Her primary outcome
measure was a widely used medical index of heart rate
variability, the SDNN, the standard deviation of the
normalized interbeat interval – the R wave to R wave
interval – measured in milliseconds.
At pretreatment, the groups did not significantly dif-
fer on SDNN. During the course of the study, the con-
ventional care group actually decreased in their mean
SDNNs, while the HRV biofeedback group increased
their mean SDNN from 28 to 42 ms. These SDNN
increases with biofeedback were of such a magnitude
that the researchers inferred a high likelihood of clinical
improvement. The cardiac risk status, measured by
SDNN, improved for several participants from the
unhealthy’ to the ‘compromised health’ range (from <
50 ms to > 50 ms). This research did not measure clini-
cal improvement, and future research will need to docu-
ment that this experimental modification of the SDNN
actually translates into reduced cardiac morbidity and
Neurofeedback for depression
The field of EEG biofeedback or ‘neurofeedback’ con-
tinues to evolve, with new applications often inspired by
research in the neurosciences. For example, research by
neuroscientist Richard Davidson showed that the two
sides of the prefrontal cortex contribute differently to
human mood103,104. The left prefrontal cortex appears to
operate as a behavioral approach and positive emotion
system, whereas the right prefrontal cortex operates as an
aversive/negative emotion system and behavioral avoid-
ance system. Lesions or injuries to the left frontal cortex
result in labile and dysphoric mood, frequently includ-
ing clinical depression. Gotlib and colleagues extended
this work by a study showing that currently depressed
and previously depressed individuals showed increased
right-sided frontal activation relative to normal con-
trols105. Using PET scans to track bilateral activation,
Davidsons group also induced positive and negative
mood by films. The films inducing positive affect
increased left frontal activation, and those inducing neg-
ative affect increased right frontal activation103–105. This
suggests that the asymmetry effect is reciprocal: right-
sided frontal activation disposes the individual to experi-
ence negative mood, and negative mood induces right-
sided activation.
Based on this research, Rosenfeld, Baehr, and col-
leagues developed a neurofeedback protocol to reverse
the asymmetry disposing individuals toward depressive
moods106,107. Specifically, Rosenfeld’s team trained sub-
jects to increase right frontal alpha, a slow wave form
(8–13 Hz), which acts to ‘idle’ the right frontal func-
tions. His team calls this increase in right frontal alpha
brainwave activation an ‘inverse activation’ index. Their
neurofeedback protocol trains the subject at two sites
Biofeedback 15
over the frontal cortex, F3 and F4 (based on the inter-
national 10–20 system for EEG sites), with success being
defined as an increase in right frontal alpha activity, over
left frontal activation. Rosenfeld’s team developed an
asymmetry index based on the amplitudes of electrocor-
tical activity at these two sites. Positive scores on this
index, defined as (F3–F4)/(F3+F4), show relative reduc-
tions in right-sided activation. A study by Rosenfeld’s
team showed that the best discriminator between
depressed and non-depressed individuals was not the
overall magnitude of the asymmetry index, but the per-
centage of the time that the individual’s asymmetry
index is greater than zero108. Thus, the more often an
individual is disposed toward right frontal dominance in
activation, the more negative the resultant mood.
In clinical biofeedback sessions the trainee’s asymme-
try score can be displayed using a bar graph, digital dis-
play, or an animation. The trainees receive rewards, such
as auditory tones, as this asymmetry score shifts in the
desired direction. One can also create a direct display
rewarding the percentage of the time that the index is in
positive territory and gradually shape the subject toward
left frontal dominance. Rosenfeld’s initial studies on
clinically depressed subjects reported that individuals
completing the asymmetry training substantially
increased their asymmetry indices and showed clinically
significant corresponding reductions in scores on the
Beck depression inventory and the MMPI depression
scale. A later study showed that the initial asymmetry
trainees maintained their improvements at 1- to 5-year
follow-up109. Case studies by Elsa Baehr and others
report successful improvement of mood through asym-
metry training in several individuals for whom conven-
tional medications and psychotherapies had failed110.
Neurofeedback for traumatic brain injury
Traumatic brain injury (TBI) produces a variety of
motor and cognitive deficits affecting an estimated 1.5
million Americans each year. The economic costs are
estimated at $48.3 billion per year111,112. Car accidents
and falls account for approximately 70% of traumatic
brain injuries, affecting individuals of all ages.
Traumatic injuries to brain tissue produce structural
and electrophysiologic abnormalities measurable with
MRI, EEG, and PET scans. Correlated with the changes
in brain structure and function are a wide variety of cog-
nitive deficits, including problems with orientation,
comprehension, problem solving, attention/concentra-
tion, memory/retention, organizational skills, motiva-
tion, and other functions. In addition, individuals with
TBI display fatigue, depression, anxiety, agitation,
headache, impulsiveness, personality disturbance, and
loss of initiative. Ayers reports that those persons with
open head injuries show more language problems and
often show frontal lobe problems affecting planning and
Efforts at remediation following TBI have tradition-
ally assumed that the brain dysfunction is irreversible
and have attempted to teach the individual to ‘work
around’ or compensate for the neurocognitive deficits.
These compensation-oriented approaches have shown
limited effectiveness. A number of cognitive strategies
have been developed to help patients compensate,
including repetitive practise, repetitive recall drills, visu-
alization, cognitive strategies, and mnemonic devices. In
general, the results are limited, and patients rarely con-
tinue to use such compensatory techniques when the
training period ends111,114. Recent reviews of cognitive
rehabilitative therapy report similar mixed and disap-
pointing results115.
The neurofeedback approach is to directly modify
brain function instead of attempting to teach the indi-
vidual strategies to compensate. Many of the effects of
traumatic brain injury are electrophysiologic – they pro-
duce modifications in the electrical rhythms of the brain,
with functional significance. The neurofeedback practi-
tioner typically utilizes a diagnostic QEEG to sample
cortical electrical activity, recorded at 19 to 128 different
electrode sites88. The basic EEG recording is digitized
and subjected to a statistical analysis. In cases where ade-
quate normative databases are available, the QEEG data
can be subjected to statistical analysis for comparison to
age-specific population norms. By comparing this
patient’s QEEG to those of others with known neuro-
logic impairment, the practitioner develops a mathemat-
ical understanding, first, of how this brain differs in its
current functioning from intact and normal brains, and
second, how it resembles the brains of others with com-
parable injuries and cognitive impairments88,116. Differ-
ences tracked include deviations in amplitude and rela-
tive power, in each frequency range by brain region, as
well as in symmetry, coherence, phase, and other vari-
ables involving the organization and connectivity of
function among cortical locations. Newer statistical pro-
grams also allow some inferential mapping of subcortical
abnormalities, based on surface cortical recordings. The
LORETA technique (for low resolution brain electro-
magnetic tomography), for example, allows assessment
of subcortical brain structures117. The QEEG techniques
are relatively new, and some controversies remain.
The same multi-site EEG recording, when examined by
Textbook of Complementary and Alternative Medicine16
available experts in QEEG, or analyzed by available sta-
tistical packages using different normative databases,
often produces divergent conclusions118.
The QEEG, augmented by the use of normative
databases, enables the neurofeedback practitioner to
develop a specific plan, introducing EEG biofeedback
training. Determining how this individual’s brain devi-
ates from a well-functioning brain establishes training
criteria designed to normalize this brain. If frontal slow
wave activity is excessive and frontal fast wave activity is
deficient, then one will up-train fast waveforms and
inhibit slow waveforms in the training process. This lat-
ter example, training an increase in faster waveforms in
the frontal cortex, will typically increase the attentiveness
and the ability to plan and organize behavior in the indi-
vidual with TBI.
Clinical reports have accumulated for two decades of
substantial amelioration of cognitive deficits in patients
with TBI through neurofeedback111,113. Large studies
with adequate methodologic controls remain lacking for
the neurofeedback treatment of TBI. However, in an
unpublished article, Thornton has compared evidence
for improvement in cognitive abilities for traumatic
brain injured patients through traditional cognitive reha-
bilitation with the studies available on neurofeedback.
The data available thus far suggest that neurofeedback
produces three to seven times more improvement in
paragraph recall, word list recall, and attention, while
costing approximately one-third of conventional inter-
ventions119. In addition, increasing numbers of studies
show that the QEEG can reliably discriminate between
those individuals with TBIs and normal controls, and
can also reliably measure prognosis for rehabilitation120.
Constraint-induced movement therapy with
In clinical practise biofeedback, therapies are rarely
delivered in isolation. Rather, a comprehensive treat-
ment package is designed, typically including patient
education, biofeedback training with specific physiologic
objectives, and a prescribed plan for lifestyle and behav-
ioral change, designed to moderate the presenting com-
plaint. The constraint-induced movement therapy (or
CI therapy) protocol is a new treatment approach within
rehabilitative medicine and physical therapy, applying
basic behavioral principles and neurophysiologic
research findings to the restoration of motor function
after cerebral vascular accident (CVA), TBI, or cerebral
palsy121. CI therapy consists of a ‘family of treatments
having a common element of inducing patients to
increase use of an affected extremity’ for many hours a
day over a period of 14 to 21 consecutive days122.
Biofeedback serves as an adjunct within this treatment
Edward Taub is a behavioral scientist who has
received widespread recognition – including the Ameri-
can Psychological Association’s Award for Distinguished
Scientific Applications of Psychology123 – for the CI ther-
apy protocol, which applies basic behavioral principles to
rehabilitation. Taub recognized that at least a portion of
the loss of function following stroke and injury involves
‘learned non-use’124. The body is conditioned by the
long period of inactivity during convalescence toward
treating the affected limb as useless. Using an example
from animal research, when one limb is damaged exper-
imentally, the animal immediately begins to attempt to
use the affected limb, and finds that it cannot. It learns
that it can move about and complete tasks in a progres-
sively more successful fashion with the three remaining
limbs, providing behavioral reinforcement for reliance
on the intact limbs. The sporadic efforts to use the dam-
aged limb lead to aversive consequences, such as incoor-
dination, falling, and failure at tasks. This is a natural
behavioral conditioning paradigm, which produces a
learned non-use of the affected limb. Simultaneously, the
nervous system is recovering to some extent, hypotheti-
cally making possible a partial return of function, yet the
animal is now conditioned to neglect the damaged
In addition, the CI protocol draws on the principle of
neuroplasticity, the capacity of the nervous system to
restore or reorganize sensory and motor pathways fol-
lowing injury. This concept highlights the laboratory
research showing substantial restoration of motor func-
tion in primates, even when sensory nerve pathways were
deliberately destroyed, leaving no sensation in the dam-
aged limb to guide movement125.
Taub’s team combines an intensive physical therapy
regimen with two crucial behavioral interventions. First,
the team physically constrains the non-affected limb. If
the right arm is damaged by stroke, then the left arm is
immobilized in a restraining device, forcing the individ-
ual to use the damaged arm for any and every task. Sec-
ond, the team uses the behavioral principles of operant
conditioning, and especially shaping, to induce purpo-
sive movement. Each of these techniques was initially
perfected in animal studies, but is now successfully uti-
lized in rehabilitation of humans with limbs paralyzed by
stroke or traumatic brain injury.
Shaping is a behavioral conditioning principle
leading to motor learning. The behavioral objective is
Biofeedback 17
approached in small steps, by successive approximations.
Initially, the trainee is encouraged or reinforced for any
small movement in the direction of the eventual goal
behavior. The task is gradually made more difficult as
training proceeds.
In restraint, the intact limb is initially restrained in a
sling or mitt, which prevents all adaptive use. This con-
straint of the intact limb is paired with an intensive
training process guiding a gradual resumption of activity
in the damaged limb.
Taub’s team at the University of Alabama at Birm-
ingham uses well-defined behavioral strategies to practi-
cally accomplish the restoration of function. The reha-
bilitation team gives extensive verbal feedback to the
patient on performance in each shaping trial. They coach
the patient verbally with suggestions to improve per-
formance on each shaping trial. The therapists model the
desired behavior for the patient prior to each trial. The
therapists engage in encouragement,to provide motiva-
tion for each successive task in the shaping process.
These behavioral principles are essential to overcome the
negative conditioning which is involved in learned non-
use following a neurologic injury. The CI therapy also
depends on an intense intervention schedule – using
massed practise’ several hours per day for 2 to 3 weeks
(depending on the severity of the motor deficit). This
schedule far surpasses the quantity and intensity of
today’s typical outpatient physical therapy treatment.
Verbal and visual feedback are crucial elements in the
implementation of shaping in CE therapy. The thera-
pists continuously report to the patient any changes in
movement, and use ‘shaping data forms’ to show
progress visually over time. Biofeedback with electronic
instruments is a useful adjunct, especially for lower limb
training, providing the patient with immediate feedback
on specific movement dynamics in the course of train-
ing. The biofeedback relies on feedback-enhanced limb
load monitors and electric goniometers. According to
Taub (personal communication) ‘the limb load monitor
provides continuous feedback of the force and timing of
each foot fall. It is used to correct stance time on the
more affected leg, increase weight supported by it, and
increase the cadence of gait. The electric goniometer
gives either continuous or error feedback of the knee
joint angle’.
The Taub team uses a microcomputer-based instru-
mentation system to provide the patient with feedback
from the limb load monitor. The computer system quan-
tifies the movement of the affected leg, and provides
feedback to shape the patient’s behavior based on ‘the
extent and quality of increased use of the affected leg’122.
The CI therapy approach has now been applied to
several hundred patients at the University of Alabama at
Birmingham and has been replicated at a number of
other facilities. Virtually all of these patients, who had
suffered mild to moderately severe strokes, have substan-
tially improved in their ability to use their stroke-weak-
ened limbs. Additional studies have reported outcomes
for patients with upper limb CVA damage, lower limb
CVA damage, more severe CVA damage (lower func-
tioning patients), cerebral palsy, traumatic brain injury,
and focal hand dystonias in performing artists126.
Biofeedback and neurofeedback provide research-based,
clinically-effective therapeutic tools, which enable the
individual to increase awareness and control over mind
and body. Biofeedback is useful in moderating clinical
symptoms, enhancing the academic learning process,
and enabling individuals to reach optimal performance.
Biofeedback provides a useful adjunct to many medical
treatments in treating a variety of disorders, from asthma
to headache to heart disease. In some cases, such as
attention deficit and hyperactivity disorder, biofeedback
provides an alternative to mainstream therapies.
Association for Applied Psychophysiology and Biofeed-
back (AAPB): 10200 W. 44th Avenue,
Suite 304, Wheat Ridge, CO 80033-2840. This website
is the most comprehensive source of biofeedback infor-
mation for consumers and professionals, and lists profes-
sional training programs and workshops
Biofeedback Certification Institute of America (BCIA): 10200 W. 44th Avenue, Suite 310, Wheat
Ridge, CO 80033-2840. An invaluable website that pro-
vides detailed information about certification prepara-
tion and testing in general biofeedback, EEG biofeed-
back or neurofeedback, and pelvic muscle dysfunction
biofeedback. A search engine helps visitors locate certi-
fied biofeedback practitioners
International Society for Neuronal Regulation (ISNR): 3620 W. 10th Street, Unit B, PMB 128,
Greeley, CO 80634-1821. A highly informative website
that provides neurofeedback articles, on-line abstracts of
the journal Neurotherapy, and a comprehensive neuro-
feedback bibliography.
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The aim of this paper is to monitor and control the pollutants in the vehicles.The air pollution monitoring system contains smoke sensors to monitor the interested pollution parameter in environment. We simulated the three air pollutants gases including carbon monoxide,carbon dioxide&sulphur dioxide in smoke from the bike. These gases decide the degree of pollution level. When a vehicle reaches beyond certain threshold pollution level then the speed of the system gets automatically slowdown. Then the system gets switched off.Then the owner should service the vehicle for further activation. The RFID reader used to read the information about the owner The GSM module is used to send the one time pass word to the owner mobile. By using the keypad a one time password is entered in the system then the vehicle gets started. The IR sensor is used to check whether the person wear the helmet or not. Vibration sensor is used to indicate during the time of an accident where the information is transmitted to the owner.
Objective. - To provide physicians with a responsible assessment of the integration of behavioral and relaxation approaches into the treatment of chronic pain and insomnia. Participants. - A nonfederal, nonadvocate, 12- member panel representing the fields of family medicine, social medicine, psychiatry, psychology, public health, nursing, and epidemiology. In addition, 23 experts in behavioral medicine, pain medicine, sleep medicine, psychiatry, nursing, psychology, neurology, and behavioral and neurosciences presented data to the panel and a conference audience of 528 during a 1 1/4 - day public session. Questions and statements from conference attendees were considered during the open session. Closed deliberations by the panel occurred during the remainder of the second day and the morning of the third day. Evidence. - The literature was searched through MEDLINE, and an extensive bibliography of references was provided to the panel and the conference audience. Experts prepared abstracts with relevant citations from the literature. Scientific evidence was given precedence over clinical anecdotal experience. Assessment Process. - The panel, answering predefined questions, developed their conclusions based on the scientific evidence presented in open forum and the scientific literature. The panel composed a draft statement that was read in its entirety and circulated to the experts and the audience for comment. Thereafter, the panel resolved conflicting recommendations and released a revised statement at the end of the conference. The panel finalized the revisions within a few weeks after the conference. Conclusions. - A number of well-defined behavioral and relaxation interventions now exist and are effective in the treatment of chronic pain and insomnia. The panel found strong evidence for the use of relaxation techniques in reducing chronic pain in a variety of medical conditions as well as strong evidence for the use of hypnosis in alleviating pain associated with cancer. The evidence was moderate for the effectiveness of cognitive-behavioral techniques and biofeedback in relieving chronic pain. Regarding insomnia, behavioral techniques, particularly relaxation and biofeedback, produce improvements in some aspects of sleep, but it is questionable whether the magnitude of the improvement in sleep onset and total sleep time are clinically significant.
Most people who have even heard of biofeedback think you need an enormous lab with expensive equipment to “do it.” No so! Biofeedback has emerged in the last decade or so as a particular application of a much broader perspective called cybernetics. Cybernetics attempts to develop a theory of communication and control in machines and in living organisms (Weiner, 1954). The word is from the Greek kybernetes, meaning steersman. It was chosen to describe the basic concept of a feedback mechanism. Using this concept, the central nervous system no longer remains a self-contained organ receiving sensory information and contracting the muscles. In fact, some of its most characteristic activities are explainable only as circular processes traveling from the nervous system into the muscles and reentering the nervous system through the senses.