Biofeedback is a type of therapy that uses sensitive electronic instruments to measure a person’s bodily processes, such as heart rate, and then feeds back that information to the patient. With this information, an individual can learn how to control their own physiology and, in many cases, reduce symptoms or improve function.
There are two main types of biofeedback: peripheral biofeedback and neurofeedback. Both have been shown to be helpful in reducing a wide range of chronic pain conditions.
I’ve been using biofeedback as a therapist for over 25 years with hundreds of patients, treating conditions ranging from anxiety to brain injury. After a successful experience using biofeedback to treat my own disabling back pain condition (see my case example below), I’ve developed a special interest in working with chronic pain patients.
Peripheral biofeedback involves measuring a person’s muscle tension using electromyography (EMG), hand temperature (blood flow), heart rate, respiration rate, skin moisture (clinically known as galvanic skin response or GSR) – all of which relate to levels of stress. A person can gain voluntary control over these measures by combining relaxation techniques with the information provided.
These measures may be focused on individually or all together. EMG biofeedback can also be used to teach people to make more efficient use of their muscles or to normalize muscle function.
Peripheral biofeedback treatment can often be completed in 10 sessions or less.
Neurofeedback, also known as neurotherapy, involves electroencephalogram (EEG) biofeedback or brainwave biofeedback, which measures the electrical activity of the brain. This process is more complex because it involves unconscious learning, which can be achieved by rewarding the brain with audio and visual feedback for making desired changes in its electrical activity.
Neurofeedback typically takes 20 to 60 sessions to complete treatment and is may be used for those with more complex pain disorders or those that do not respond to peripheral biofeedback.
Biofeedback is not regulated or licensed as a separate specialty – although most equipment used goes through FDA review and approval.
The treatment, which is non-invasive, is usually administered by licensed healthcare practitioners with specialized training, including psychologists and social workers, as well as practicing doctors, nurses, physical therapists, chiropractors, and naturopaths.
Many biofeedback practitioners are certified by the Biofeedback Certification International Alliance (BCIA).
Biofeedback is, unfortunately, not usually covered by health insurance, but policies vary. Check with your provider regarding coverage and referrals.
Biofeedback can be used as a standalone treatment or be combined with other treatments, including medication, physical therapy, psychotherapy and/or nutritional interventions. In my experience, many patients seek out biofeedback to avoid or reduce medication usage.
Studies of biofeedback treatment have found that many patients experience widespread improvements in their emotional and physical wellbeing as they move toward a more relaxed state and better self-regulation.
A review by the Association for Applied Psychophysiology and Biofeedback found that peripheral biofeedback was effective in the treatment of the following chronic pain conditions:
A more specific analysis published in the International Journal of Behavioral Medicine evaluated the efficacy of peripheral biofeedback for treating chronic back pain. Twenty-one studies were reviewed that included a total of 1,062 patients. The reviewers found a significant small-to-medium effect on pain intensity reduction. Improvements were maintained or increased over an average of 8 months of follow-up, with a significant small-to-large effect size. Biofeedback also significantly reduced depression and muscle tension and improved cognitive coping, both at the end of treatment and at follow-up. The reviewers found that longer biofeedback treatments were more effective at reducing disability in general.
A study of children and teens (64 in total) with recurrent abdominal pain using hand temperature biofeedback alone or in combination with cognitive behavioral therapy (CBT) found that their pain significantly improved compared to an inactive (fiber-only) treatment control group.
A review of migraine treatments published by the American Academy of Neurology concluded that hand temperature (blood flow) and muscle tension (EMG) biofeedback with relaxation training were effective and recommended as a treatment option. A separate review on migraine prevention published in American Family Physician concluded that thermal (temperature) biofeedback and electromyographic (EMG) biofeedback were effective for migraine prevention.
Another randomized, controlled trial of people with fibromyalgia syndrome using peripheral or EMG biofeedback experienced significant improvement in tender points.
The pain research community has been doing a considerable amount of work on central sensitization. The Institute for Chronic Pain defines this as: “a condition of the nervous system that is associated with the development and maintenance of chronic pain. When central sensitization occurs, the nervous system goes through a process called wind-up and gets regulated in a persistent state of high reactivity. This persistent, or regulated, state of reactivity lowers the threshold for what causes pain and subsequently comes to maintain pain even after the initial injury might have healed.”
Central sensitization can also lead to excessive sensitivity to light, sounds, and odors as well as cognitive deficits.
Central sensitization can be associated with the following medical conditions: stroke, spinal cord injury, chronic low back pain, whiplash, chronic tension headaches, migraine headaches, rheumatoid arthritis, osteoarthritis of the knee, endometriosis, injuries sustained in a motor vehicle accident, postsurgical pain, fibromyalgia, irritable bowel syndrome, and chronic fatigue syndrome.
The condition also appears to be associated with changes in the dorsal horn of the spinal cord and in the brain. The former is affected by many descending pathways from the brain. Neurofeedback aims to correct this abnormal brain function.
To date, there have been no large-scale clinical trials to test the efficacy of neurofeedback for a specific chronic pain problem, most likely due to lack of funding sources. However, many pilot studies and case series have been published that show the potential of neurofeedback to help patients with chronic pain.
Protocols vary but tend to fall into two major categories.
Brainwave frequencies refer to the speed at which your neurons are firing. At any given time, different neurons are firing at different frequencies. Traditionally, neurofeedback has targeted brainwave frequencies of 1 to 30Hz. These frequencies are grouped as delta (1 to 4Hz), theta (4 to 8Hz), alpha (8 to 12Hz), and beta (12 to 30Hz). A qEEG includes analyses of 1 to 30Hz.
More recently, researchers and clinicians have been training frequencies as low as 0.001 millihertz (mHz), known as infralow frequencies, as well as higher frequencies, called gamma, with 40Hz of particular interest. When targeting millihertz, neurofeedback is actually targeting the glial cells of the brain rather than the neurons (glial cells are the white matter of the brain).
Scientists used to think the white matter was just filler for the brain, but now it is known that glial cells have important brain maintenance functions.
In a 2019 study, individuals with chronic low back pain received 20 sessions of alpha-phase synchrony EEG training. The study found “great and lasting response” to the treatment, including pain reduction that was still present at 6-month and 12-month follow up.
In a 2010 study, individuals with fibromyalgia were treated with 20 sessions of neurofeedback focused on increasing sensory motor rhythm (SMR, 12-15Hz). All treated patients showed significant improvements in all outcome parameters, which included pain, psychological symptoms and impaired quality of life.
In 2011, a migraine headache study compared QEEG-guided neurofeedback to pharmaceutical treatment. Fifty-four percent of patients in the neurofeedback group experienced a complete remission of migraine headaches. An additional 39% experienced a decrease in migraine frequency of greater than 50%. In contrast, of patients in the study who elected to continue on drug therapy, 68% experienced no change in headache frequency, and only 8% achieved a reduction of greater than 50%.
Other small, pilot neurofeedback studies have shown reductions in pain and improvement in other quality of life issues, often with moderate to large effect sizes, for complex regional pain syndrome (CRPS/RSD), spinal cord injury, headache from traumatic brain injury, and chemotherapy-induced neuropathy. All of these studies used functional criteria to determine protocols, except for the study on chemotherapy-induced neuropathy, which used a QEEG-based approach to treatment.
My first encounter with biofeedback was as a patient in 1981. At the time, I was 28 years old and had been experiencing severe, disabling back pain for more than 3 years. The pain was so severe that I dropped out of graduate school and barely functioned during that time. Medications, including anti-inflammatories, benzodiazepines, and narcotics, had no impact on my pain.
After reading about biofeedback, I sought out a psychologist who offered the treatment. In the first session, he explained to me how my worrying about the pain was making it worse. He taught me a simple meditation technique along with a temperature biofeedback strategy. He explained that warm hands meant I was more relaxed and sent me home with a simple device to measure my hand temperature.
The reason hand temperature can be used as a measure is that part of the body's stress response is to withdrawal circulation from the peripheral tissues to concenrate blood flow in the heart, lungs, brain, and major muscle groups. Then, the body is prepared to "fight" or to "flee" - much of the science around pain response has to do with this very concept. Whenever I my hands felt cool, I practiced a simple meditation technique. In time, with and without devices, it works to reset one's physiology.
By the next day, my pain was reduced by 50%. Instead of worrying about the pain, I had something I could do to control it! I practiced that simple technique with the hand temperature biofeedback as much as I could and was able soon after to reduce my pain enough to get back to work and eventually back to school to complete my master’s degree in social work.
It’s been almost 40 years and I still use the technique to manage any aches and pains that come up as well as to manage stress and boost immune response.
A 32-year-old male consulted me for treatment of chronic low back pain subsequent to an industrial accident 12 years prior. A heavy piece of equipment had fallen on him, crushing his lower back. He had received spinal decompression and a spinal fusion.
At the time of the initial visit he was taking oxycodone (15 mg 3x per day) and ibuprofen (800 mg once per day). He was managing to maintain employment but was still in considerable pain.
He received 28 sessions of neurofeedback using an infralow two-channel protocol of 0.1mHz focusing on the connection between the right temporal (T4) and right parietal (P4) area while inhibiting excessive activity across 1-30hz frequencies. At the end of treatment, he was pain-free and medication-free.
Overall, given the safety profile of peripheral biofeedback and neurofeedback, their non-invasive approach, and their effectiveness for so many treatment-resistant, debilitating chronic pain conditions, I strongly believe that these treatments should be made more widely available to those living with pain.
While lack of insurance coverage and the small number of trained providers limits access to these valuable treatments, we can advocate for their use.