What Is Biofeedback Therapy? A Beginner’s Guide

It may sometimes feel like you have little control over what happens inside your body, and how that affects your overall health. But there is a way to harness physiological functions like breathing, muscle tension, heart rate, skin temperature, and even brain waves so they work to your healing advantage.

How? Through a method known as biofeedback.

The Association for Applied Psychophysiology and Biofeedback (AAPB) defines biofeedback as a process that enables people to learn how to change physiological functions to improve health and performance. It may sound far-fetched, but biofeedback is actually used in many healthcare settings to manage and treat a range of health issues, from urinary incontinence to anxiety to chronic pain.

Keep reading to learn what biofeedback therapy is, how it works, its potential health benefits and risks, and how to get started working with a trained biofeedback therapist.

Biofeedback is a relatively modern treatment that began around the start of the 20th century, according to a research article published in the January–December 2020 issue of Therapeutic Advances in Urology.

Biofeedback wasn't officially recognized as a method of therapy in the United States until about 1969, when the Biofeedback Research Society (now known as the AAPB) was established.

Since then, biofeedback has evolved into a mainstream methodology for treating and managing certain medical conditions, largely because of scientific research that demonstrated its potential effectiveness, notes the AAPB.

Biofeedback is now used to manage many physical and mental health issues, including anxiety, chronic pain, fecal and urinary incontinence, high blood pressure, and asthma, per the Mayo Clinic.

A biofeedback practitioner connects the patient to a device that measures physiological changes in their body, such as heart rate, brain waves, breathing patterns, and muscle activity. The aim is to provide information about your body so you can learn how to control some of your body's functions, the Mayo Clinic explains.

For example, physical therapists often use biofeedback to help people with urinary incontinence. "When we use biofeedback for urinary incontinence, it's not specifically to strengthen the pelvic floor muscles; it's to help patients understand how to coordinate their pelvic floor muscles better," says Nancy Silva-Mullins, a pelvic health specialist at Northwell Health in New York City.

To help patients learn how to coordinate their muscles, Silva-Mullins attaches external sensors to the lower abdomen or inserts an internal sensor into the vagina. The sensors measure the tension of pelvic floor muscles, record it, and relay the information to a handheld device that lights up or emits noises when the patient performs the suggested contractions correctly.

"It's very helpful because the pelvic floor muscles are internal, so it's not like you can watch yourself in a mirror," Silva-Mullins says. "By using the biofeedback unit, patients can visually see when they’re not fully contracting their muscles and adjust accordingly."

State laws regulating biofeedback practitioners vary. Many biofeedback practitioners are licensed in another area of healthcare, such as psychology or physical therapy, according to the Mayo Clinic.

Still, some practitioners choose to become certified to ensure they’re providing the standard of care. The Biofeedback Certification International Alliance (BCIA) is one institute that grants board certification to biofeedback practitioners.

According to the Mayo Clinic, here are some biofeedback methods and devices.

With this type of biofeedback, a therapist attaches sensors to your scalp to monitor brain activity using an electroencephalograph (EEG). According to the 2020 Therapeutic Advances in Urology article mentioned above, this technique is often used to treat children with attention deficit hyperactivity disorder (ADHD).

Breathing bands placed around your abdomen and chest help monitor your breathing patterns. This type of biofeedback may be helpful in the treatment of asthma, per the aforementioned research paper.

This type of biofeedback can involve a couple of approaches: finger or earlobe sensors with a device used to detect blood volume changes that show your heart rate or heart rate variability (photoplethysmography), or sensors placed on your chest, lower torso, or wrists to measure your heart rate using an electrocardiograph (ECG). This may be used for stress management, research has found.

Placing sensors over your skeletal muscles with an electromyograph (EMG) can monitor the electrical activity that causes muscle contraction. This type of feedback is often used to help treat urinary and fecal incontinence, and in rehabilitation settings.

With this type, the therapist attaches sensors around your fingers, palm, or wrist with an electrodermograph (EDG) to measure sweat gland activity. This method may help in the management of stress and anxiety.

Attaching sensors to your fingers or feet can measure blood flow to your skin. This may also be used to help people manage stress and anxiety.

If seeing a specialist isn't possible, there are consumer wearables and home biofeedback devices on the market, such as headbands that monitor your brain activity while you meditate, and wrist-worn sensors that monitor your breathing, though it's important to note that these devices have varying degrees of accuracy and usefulness.

One portable biofeedback device, RESPeRATE, has been approved by the U.S. Food and Drug Administration (FDA) for helping reduce stress and lowering blood pressure. Another example is the HeartMath Inner Balance sensor, which monitors heart rate variability.

Devices like these can be an entry point for those who can't pay for biofeedback therapy, since the device may be added as a complementary approach under the guidance of your primary healthcare team. Just make sure to do some research beforehand, and as always, ask your professional healthcare provider before trying anything new.

Biofeedback is increasingly recognized as an effective therapy for many health complaints. Here are some potential benefits.

Urinary incontinence (UI), or the accidental leakage of urine, affects more than 25 million American adults, according to Johns Hopkins Medicine. While the causes vary, UI is frequently the result of weakness in the pelvic floor muscles.

UI is often treated with exercises to strengthen the pelvic floor, dietary changes, and medications. Biofeedback is also a popular approach and is often used alongside pelvic-floor-strengthening exercises, according to Nora Arnold, DPT, a physical therapist with the Johns Hopkins Rehabilitation Network who specializes in pelvic health.

In fact, a past review found that pairing pelvic floor muscle training exercises with biofeedback was potentially more effective for treating urinary incontinence than pelvic floor muscle training alone.

Still, more research in people with urinary incontinence is needed.

By teaching you how to control components of your physiological stress response, such as breathing, heart rate, and blood pressure, biofeedback may help lower stress and anxiety.

According to a review of clinical guidelines published in November 2017 by the Canadian Agency for Drugs and Technologies in Health, patients with a diagnosis of PTSD, major depression, and generalized anxiety disorder who combined biofeedback with conventional mood therapies such as cognitive behavioral therapy (CBT) and psychotherapy saw more significant improvements in symptoms than people who relied on a single therapy.

That said, the authors say that many of the studies included small sample sizes and lacked relevant details. So, take these findings with a grain of salt — more research is needed.

Biofeedback is used in some rehabilitation settings to teach the muscles to start responding again after surgery, says Roger W. Gerland, the director of rehabilitation services at Northwell Health in New York City.

It's also used to improve muscle function following a stroke, spinal cord injury, seizure, or other event that causes paralysis in one side of your body (known as hemiplegia), according to a past review.

For example, a randomized controlled trial published in February 2021 in Acta Neurologica Belgica found that biofeedback, in conjunction with conventional physiotherapy, improved walking ability in patients with hemiplegia better than conventional physiotherapy alone.

Biofeedback is a low-risk therapy. No negative side effects have been reported, according to the Icahn School of Medicine at Mount Sinai. The most common forms of biofeedback, like EEG, EMG, and temperature feedback, which monitor at the skin level, are noninvasive.

But for the select group of patients with genitourinary and stooling dysfunction, there may be discomfort when it's needed to insert a biofeedback device into the vagina or anus to achieve a reading. "The concern with the internal devices is if someone has chronic urinary tract infections or chronic vaginal infections, it could be uncomfortable," Dr. Arnold says.

In addition, biofeedback devices may not work properly on people with certain medical conditions, such as a heart arrhythmia (irregular heartbeat), notes the Mayo Clinic.

Biofeedback can be an effective tool for managing various health concerns, including ADHD, urinary incontinence, anxiety, muscle spasms, hypertension, and constipation, according to Mount Sinai.

That said, biofeedback isn't appropriate for everyone — even if you have one of the aforementioned health concerns.

For example, people with poor sensation or body awareness may not be good candidates for biofeedback. "I treat a gentleman with neurological and proprioception issues, and the biofeedback is more frustrating for him than anything else," Silva-Mullins notes, as anecdotal experience from her own practice.

In addition, people who just underwent surgery may need to start with electrical muscle stimulation (EMS), or a therapy that uses electrical impulses to stimulate the muscle to begin firing, before they try biofeedback. "I’ll use the example of somebody that has had knee surgery and their quad muscle is completely shut down in the first few days or weeks," Gerland says. "In those cases, biofeedback really isn't going to work, so a precursor is to use electrical muscle stimulation to create a muscle contraction through electricity."

You can receive biofeedback training in physical therapy clinics, medical centers, hospitals, and psychology practices. Some insurance companies cover biofeedback for certain conditions, whereas others do not, according to the Cleveland Clinic.

But Arnold typically sees biofeedback covered under physical therapy benefits. "I bill biofeedback as neuromuscular reeducation, which is one of the most common treatment codes," she says. "During my time as a physical therapist, I’ve never heard of insurance denying neuromuscular reeducation as a whole."

That said, be sure to check with your insurance company to see if the cost of biofeedback is covered under your plan.

At-home biofeedback devices may save you money if insurance doesn't cover everything. "Home devices can be helpful as part of a home routine if you’re on a maintenance plan, that way you don't have to come into the clinic and pay your copay," Arnold says. It's key to pair your at-home device with care and regular assessments from a health care provider, she adds. Don't try biofeedback on your own without input from a health professional.

Before heading into a biofeedback session, be sure your skin is dry and not covered in lotion. "You want to have good contact between the surface electrodes and the skin," Silva-Mullins says. "If there's not good contact, you [may not get] an accurate reading."

If you forget and mistakenly apply lotion beforehand, just let the practitioner know. "Sometimes I may use an alcohol pad just to quickly clean that area if needed," Silva-Mullins says.

You may also want to empty your bladder prior to the session so you’re more comfortable, she adds.

Once you’re ready, the practitioner will apply the sensors to the appropriate area on your body (or insert the vaginal or anal sensor, for indicated specific patients). You’ll hold a device or watch a monitor for the entire session, so you can view the information the sensors collect. The practitioner will guide you to make any adjustments needed to improve the feedback and retrain your physiological functions.

Generally speaking, biofeedback sessions last less than one hour, and many people see improvements within eight to 10 sessions, according to Mount Sinai.

That said, the number of biofeedback sessions you will need and how long each session lasts may vary depending on your condition and how well you respond to biofeedback. "For some people, it takes more sessions, more time with biofeedback, and for some people, results happen pretty quickly," Arnold says.

Association for Applied Psychophysiology and Biofeedback

Founded in 1969, the Association for Applied Psychophysiology and Biofeedback (AAPB) aims to promote a scientific understanding of biofeedback and encourage the use of the various methods. The AAPB offers e-newsletters, magazines, book reviews, a glossary of biofeedback terms, and other resources to help deepen your understanding of biofeedback.

BioFeedBack Resources International

Find free and paid online biofeedback training, biofeedback supplies and equipment, and background information through BioFeedBack Resources International. Plus, learn about various biofeedback topics through their blog, and access informational articles, free downloads, and audio files.

Biofeedback Certification International Alliance

The Biofeedback Certification International Alliance (BCIA) is a nonprofit organization that offers board certification in biofeedback. Use their directory to find qualified practitioners in your area.

Biofeedback Magazine

Published four times per year and distributed by the AAPB, Biofeedback Magazine provides expert-written articles about biofeedback. In one issue, experts outline how one weightlifter set world records in her age group by incorporating biofeedback into her training. In another issue, experts cover how biofeedback can be used in the treatment of headaches.

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