American life is fast-paced, busy, and focused on productivity. In that rush, it's easy to lose touch with the body's physical responses and psychological reactions to the stress of daily living. The headache that starts during an early morning meeting or while hunched over a computer can cause the neck and shoulders to tense, breathing to become shallow, and heart rate to speed up. In an hour or so, those unchecked physical reactions can lead to pain symptoms.
Biofeedback can help a person increase awareness of--and even prevent--typical stress responses like muscle tension. It is especially beneficial, however, for patients who have more significant physical, mental, or emotional stressors, such as a traumatic injury, difficulty sleeping, challenges brought on by stroke, anxiety, depression, and many types of chronic pain, including low back pain, chronic headaches/ migraines, fibromyalgia, and musculoskeletal pain, (1-6) Chronic pain patients may experience a downward spiral as their body reacts to stress and pain in ways that exacerbate their condition.
Biofeedback can stop this spiral by helping patients better recognize, understand, and control their physical, mental, and emotional responses. (7)
A valuable component of an interdisciplinary approach
Chronic pain creates complex biopsychosocial sequelae, and a traditional biomedical approach often doesn't address all of the pain patient's problems. (8) The limitations of a single-treatment approach can frustrate patients, and many move from one physician to another searching for pain relief. It's important to let patients know that there is no "magic" treatment, medication, or surgery for chronic pain. Believing that there is a such a single treatment can lead to decreased confidence, understanding, and motivation, as well as feelings of hopelessness, deteriorating emotional well-being, and an overall decrease of a patient's internal locus of control. (9) In addition, research shows that "how well patients manage chronic pain depends more on what they do for themselves rather than what is done to them; most of the 'work/change' of chronic pain management is done by the patient." (10)
It is critical to develop an interdisciplinary therapeutic team for managing patients with chronic pain. Compared with conventional medical treatments, an interdisciplinary team approach is more effective in reducing medication use, emotional distress, health care utilization, and iatrogenic consequences. It is also more effective in getting people back to work and closing disability claims. (11-13)
How biofeedback can help, who it can benefit
Many physicians view biofeedback and psychological services as a last-resort therapeutic option. Patients may be resistant, too, interpreting a referral to mean that "it's all in my head" or "because you think I'm crazy." But there is considerable evidence that supports the use of biofeedback as a nonpharmacologic therapy for chronic pain; patients with low back pain, chronic migraines, musculoskeletal pain, and other pain conditions have experienced reduced pain intensity and frequency with biofeedback training. (1-6)
Keep in mind that biofeedback is not a quick fix, but rather an investment in living with better health and recovery. Based on my experience in working with chronic pain patients, you should consider referring for biofeedback therapy when a patient:
* has consistently high pain complaints
* has pain that worsens despite treatment
* discontinues physical therapy because it causes too much pain
* exhibits signs of substance abuse, including misuse of medication
* progressively reduces activity
* has poor emotional regulation
* demonstrates exaggerated or inconsistent pain behaviors
* has a history of "shopping" for doctors or medication
* has a history of trauma or abuse.
For more on the referral process, see "Finding a biofeedback practitioner" on page S15.
The first visit
The first visit with a biofeedback practitioner involves an evaluation. In clinical practice, biofeedback evaluations are generally scheduled for 60 to 90 minutes, depending on the level of complication. The evaluation is similar to a basic psychological evaluation. In addition to obtaining the patient's history, identifying the reason for treatment, and assessing the patient's motivation, the biofeedback specialist involves the patient in the development of a treatment plan and goals.
Depending on the evaluation results and the patient's needs, the biofeedback therapist will schedule treatment sessions for once or twice a week, with each session lasting about 50 to 60 minutes. Based on my clinical experience, patients usually complete treatment in 12 to 24 sessions; about 30% of patients will later return for additional treatment, or "booster sessions."
Patients who return for further treatment often need support, encouragement, and feedback to assist them with tuning up the effectiveness of their home program, which was developed during the initial treatment phase. Typically, patients require 3 to 5 booster sessions. (For an example of how one of my patients combined a home-based program with professionally supervised biofeedback training, see "Case--The benefits of biofeedback: One patient's story," on page S16.)
What treatment entails
Biofeedback works like a complicated mirror that allows the brain and body to make adjustments to improve homeostasis. Biofeedback can be used to monitor heart rate, blood pressure, muscle tension, skin temperature, sweat response, breathing, brain waves, and more (TABLE). To identify the appropriate biofeedback modality for a particular patient, the therapist considers the patient's symptoms, emotional regulation, cognitive functioning, and past experiences and traumas. Modalities may be used alone--or in combination.
Various devices are used to measure change in the area of focus, and the data are then provided back to the patient. These devices include the following:
Scalp sensors can detect brainwave activity through electroencephalography (EEG). Therapists have used EEG biofeedback to treat headache, alcoholism, epilepsy, and a host of other disorders.
Bands placed around the patient's abdomen and chest can detect changes in respiratory rate and have been used to manage anxiety, hypertension, unexplained abdominal pain, and other disorders, while earlobe and finger sensors, in conjunction with electrocardiograph sensors on the chest and lower torso, have been used in the treatment of asthma, depression, and hypertension.
Muscle sensors and an electromyograph (EMG) monitor the electrical activity that causes skeletal muscle contraction. Muscle biofeedback has been used for managing low back pain, anxiety, cerebral palsy, and incontinence.
Additional biofeedback devices, including those that provide sweat gland and temperature data, also have their place in the therapist's armamentarium.
How biofeedback helps to relieve muscle tension
If a patient needs to focus on relaxing her shoulder muscles to reduce pain, EMG sensors would be placed on her shoulders above the areas identified as most likely involved with the experience of pain and/or tension. (See the photo on page S12.) These sensors send information gathered from the body to the therapist's computer to analyze the information--in this case, muscle tension. The patient then receives feedback about this information through various cues.
For instance, information about muscle tension may be translated into a tone or beep that varies in pitch depending on the intensity of the tension, or music may start playing when muscles start to relax and stop when muscles tense. For visual cues, a monitor may show a flower opening when muscles are relaxing, or lines may move across a graph to indicate changes.
Visual markers or tactile aids can be used to further increase the patient's body awareness and help to facilitate change. For example, placing medical tape on the body can generate a pulling sensation when maladaptive muscle tension or posture changes occur. Placing an object--a cell phone, book, or hand--on the individual's abdomen can raise awareness of diaphragm breathing. Positioning reference points, such as dot-shaped stickers or the therapist's hands, on the shoulders or other area while the patient views him-or herself in a mirror or on a video monitor can enhance awareness of asymmetry, body mechanics, or posture.
Each form of feedback enables physical observations to become more apparent to the patient, which in turn improves mind-body awareness.
During the biofeedback session, the therapist guides the patient in mental exercises and relaxation techniques to achieve the therapeutic goal, such as muscle relaxation. The biofeedback monitor enables the patient to see (or hear) the changes that occur in response to being stressed or relaxed.
Breaking the chronic pain cycle
Biofeedback can help patients improve how they manage pain by guiding them in more effective use of nonpharmacologic techniques. (12) For example, while a patient may already know that breathing from the diaphragm is beneficial, biofeedback can document just how effectively--or ineffectively--he or she is breathing. The patient can then use the feedback to mindfully adjust breathing.
In addition to becoming aware of how the body is functioning, patients must learn how to truly relax. While elusive, this requires one to incorporate 3 states of relaxation--mental, physical, and emotional--to implement the type of changes needed to improve health and well-being.
Armed with better awareness and control, patients can more easily recognize and change functional patterns to prevent or mitigate chronic pain. (14)
Because biofeedback focuses on the connection and communication between mind and body, it brings together both psychology and physical therapy. However, despite knowing that physical problems create mental stress and mental stress creates physical problems, many patients still struggle to address the negative effect that physical and mental stressors have on their health and quality of life. (14) Psychological factors, including mood, beliefs about pain, and coping style, play an important role in an individual's adjustment to chronic pain. (15)
Just as a scale doesn't change a person's weight, however, biofeedback doesn't change the body's stress response. Change remains the patient's responsibility, but biofeedback can greatly accelerate the learning process. Engaging in biofeedback may initially feel overwhelming, but with support and encouragement it becomes empowering. Instead of being a victim of pain, the patient learns to recognize and change physical responses, like tense muscles, shallow breathing, or cold hands, creating the shift needed to begin to disrupt the chronic pain cycle. (14,16)
The author reported no potential conflict of interest relevant to this article.
FINDING A BIOFEEDBACK PRACTITIONER
Two useful Web sites can help you locate biofeedback practitioners in your area. They are www.bcia.org, from the Biofeedback Certification International Alliance (BCIA), and www.aapb.org, from the Association for Applied Psychophysiology and Biofeedback. Both sites provide a "find the practitioner" search tool.
Licensing. Many state licensing boards include the practice of biofeedback within the purview of psychologists, physical therapists, nurses, physicians, social workers, and other professionals. Licensure, however, doesn't mean that the license holder has training or experience in providing biofeedback; certification by the BCIA does.
The BCIA offers various levels of certification in biofeedback, neurofeedback, and pelvic muscle dysfunction biofeedback. Certification programs are based on prerequisite educational degrees, anatomy/physiology course work, didactic course work in biofeedback, clinical training or mentoring to learn skills application, and a certification exam.
CASE The benefits of biofeedback: One patient's story
Jane M, 35 years old, slipped and fell on a wet floor. In addition to bruising her right hip and shoulder, she ruptured a disc in her cervical spine. The single-level fusion surgery that followed contributed to the development of unremitting chronic pain.
Over 2 years, her normal daily functioning eroded despite more than 100 physical therapy sessions, several sets of cervical injections, and a number of medications. When it was clear she was not a candidate for additional surgery, Ms. M's doctor recommended psychological counseling and/or biofeedback treatment.
What did the evaluation reveal?
Despite first resisting the suggestion, Ms. M eventually agreed. Her initial heart rate variability assessment indicated that her autonomic nervous system was not effectively autoregulating. As more data were obtained and behaviors were observed, her therapist recognized that overactive sympathetic arousal was causing an ongoing state of "flight or fight." The overactivity of the sympathetic system prevented her body from shifting to a parasympathetic-dominated relaxed state, which was needed to allow healing and recovery. It was likely that the limited flexibility of the autonomic nervous system contributed to her struggles with increasing pain, lack of progress in physical therapy, and poor responses during other treatment attempts.
Learning proper breathing technique. During the first 8 biofeedback sessions, Ms. M learned to use diaphragm breathing and breathing awareness to facilitate the relaxation response. Her heart rate decreased from the mid to high 90s to the low 80s/high 70s. When she first attempted to achieve the relaxation response, her average respiratory rate was 20 to 24 breaths per minute; as she developed improved slow-paced breathing skills, her average breath rate was 6 to 8 breaths per minute (6 breaths per minute, plus or minus one, is the general goal to maximize the potential benefits from the various breathing exercises).
Addressing muscle tension. Once Ms. M began to develop a solid foundation of improved autoregulation and enhanced mind- body awareness, the treatment plan addressed her continued struggles with severe muscle tension and chronic neck pain. She had bilateral pain that radiated up and down her neck nearly parallel with the spine, as well as severe burning and aching pain in her right shoulder with occasional sharp/stabbing episodes.
Finding the best program
Based on Ms. M's symptoms and the lack of improvement despite some positive gains, her therapist recommended a surface electromyography (sEMG) assessment. In muscle tension-based biofeedback, the therapist places electrodes above targeted muscles and measures the intensity of muscle activity in microvolts ([micro]V) (microvolt intensity increases when a muscle activates and decreases when it relaxes). Four stages of tension levels are measured while the patient is at rest and engaged in controlled activation of specific muscle groups.
During sEMG assessment, the patient is guided through a structured protocol based on the muscles being reviewed. Ms. M's findings indicated that she had mild-to-moderate tension levels in the cervical paraspinal muscles and masseter muscles; severe tension and asymmetry were observed in the upper trapezius muscles. When she was at rest in a sitting position, tension levels averaged 31.3 [micro]V on the right and 17.7 [micro]V on the left.
The shoulder shrug protocol. Muscle release and recovery can be assessed by having the patient hold a shoulder shrug for 20 seconds and then measuring tension upon relaxation. Normally, muscle tension after this exercise would almost immediately return to [less than or equal to] 4 [micro]V and remain at that level until further activation. In Ms. M's case, muscle tension actually increased in intensity on her right side after the 20-second shoulder shrug: tension was 34.7 [micro]V on the right side and 15.2 [micro]V on the left. In addition, asymmetry was increasing. Ms. M reported little awareness of the significant fluctuations in tension.
Biofeedback cues. Over the next 10 weeks, Ms. M engaged in sEMG training to increase her awareness of muscle tension and muscle behavior in her upper trapezius muscles. During her sessions, she was given visual, auditory, and tactile feedback; she would then use the feedback to aid in achieving desired changes, such as decreased muscle tension, improved release of tension after activation, and general changes in muscle tension behavior.
For a primary visual aid, Ms. M preferred a picture of a flower that slowly bloomed as she released or lowered tension levels; when tension began to elevate the flower would start to close. Music was also used to provide feedback: It would start and stop in relation to changes in tension and/or asymmetry.
Ms. M continued working to improve autoregulation in the biofeedback sessions as well as in a home-based treatment program. For her home program, the therapist encouraged her to incorporate a combination of breathing, relaxation, and mindfulness techniques into her daily activities; these were to be practiced 1 to 3 times daily for about 5 to 15 minutes. Exercises included diaphragmatic breathing techniques, progressive muscle relaxation, and positive affirmations. Depending on a patient's learning preferences, the therapist may provide instructional handouts, audio CDs, videos, or Web site links to reinforce proper skill development.
After completing 10 sessions, Ms. M. underwent a follow-up sEMG assessment of the upper trapezius muscles. Improvement in muscle tension was excellent, with her resting tension levels averaging 3.7 [micro]V on the right and 4.1 [micro]V on the left (compared with pretreatment tensions levels of 31.3 [micro]V on the right and 17.7 [micro]V on the left).
Ms. M still struggles to fully release muscle tension after activation, but her improved body awareness helps her recognize the residual tension, and she uses diaphragm breathing to quickly reduce it to within normal range. She describes feeling empowered by having learned the biofeedback techniques that have helped her improve chronic pain management, enhance her quality of life, and strengthen her internal locus of control.
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Anthony Whitney, MS, LMHC, BCB
Structured Intensive Multidisciplinary Program and Psychology Department
St. Luke's Rehabilitation Institute