Docket: IRS-2009-0008 

Request for Information for Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 

2008 

Comment On: IRS-2009-0008-0001 

Request for Information Regarding the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction 

Equity Act of 2008 

Document: IRS-2009-0008-0077 

Comment on FR Doc # E9-09629 

Submitter Information 

Name: David L. Stumph 

Address: 

Wheat Ridge, CO, 

Submitter's Representative: Barbara Trumbo 

Organization: Association for Applied Psychophysiology and Biofeedback 

General Comment 

May 22, 2009 

Dear Sirs: 

I am writing in reference to the Departments of Labor, Health and Human Services, 

and the Treasury’s invitation for public comments through a Request for Information 

(RFI) regarding issues related to the Wellstone - Domenici Mental Health Parity and 

Addiction Equity Act of 2008, HR-6983. 

On behalf of the Association for Applied Psychophysiology and Biofeedback (AAPB), I 

am contacting you to offer our strong support for this legislation. Parity in 

reimbursement for diagnoses, procedures and treatments for insurance coverage 

related to mental health treatment is essential for the well-being of the US population in 

addressing mental health disorders. 

Biofeedback and neurofeedback are well accepted and scientifically supported 

modalities that have been used in the successful treatment of mental health disorders 

for many years. They have been overlooked for their efficacy and their cost-effective 

approach. These modalities provide patients with training and the ability to self-regulate 

in addressing numerous disorders. In many instances, bio and neurofeedback 

treatments can eliminate the need for extensive and costly pharmaceutical therapies 

PUBLIC SUBMISSION 

As of: May 28, 2009 

Tracking No. 809b9d2c 

Comments Due: May 28, 2009
that can have far-reaching harmful side-effects, none of which are present with bio and 

neurofeedback. Therefore, these modalities need to be recognized in the manner that 

you have proposed. 

In support of these modalities, please find a copy of our publication, Evidence-Based 

Practice for Biofeedback and Neurofeedback, attached. You will find that these 

treatment modalities are scientifically supported for a significant number of disorders, 

not only in treating mental health disorders, but also for a number of other medical 

diagnoses. 

Thank you for taking this important initiative. Please do not hesitate to contact me 

directly if you have questions or need additional information. 

Sincerely, 

David L. Stumph, IOM, CAE 

Executive Director 

dstumph@resourcenter.com 

Attachments 

IRS-2009-0008-0077.1 Comment on FR Doc # E9-09629

IRS-2009-0008-0077.2 Comment on FR Doc # E9-09629
Evidence-Based

Practice in

Biofeedback

and

Neurofeedback

CAROLYN YUCHA, PH.D.

DOIL MONTGOMERY, PH.D.
Association for Applied Psychophysiology and Biofeedback (AAPB)

Founded in 1969, AAPB is the foremost international association for the study of biofeedback

and applied psychophysiology. AAPB is an interdisciplinary organization representing the fields

of psychology, psychiatry, medicine, dentistry, nursing, physical therapy, occupational therapy,

social work, education, counseling, and others.

The mission of AAPB is to advance the development, dissemination, and utilization

of knowledge about applied psychophysiology and biofeedback to improve health

and the quality of life through research, education, and practice.

Copyright/Ownership

Copyright © 2008

Association for Applied Psychophysiology and Biofeedback.

ISBN 1-887114-19-X

All rights reserved. No part of this publication may be reproduced or utilized in any form

or by any means, electronic or mechanical, including photocopying, recording, or by any

information storage and retrieval system, without permission in writing from the publisher.

AAPB

10200 W. 44th Ave #304

Wheat Ridge, CO 80033

303 422 8436 phone 303 422 8894 fax

email aapb@resourcenter.com

www.AAPB.org
 i

Acknowledgements — 2008 Edition 

The authors would like to thank Donald P. Moss, PhD, for his guidance in developing this 

monograph. They would also like to thank Pam Sherwill, MS, librarian at the University of 

Florida (2004 edition) and Eva Stowers, MS, librarian at the University of Nevada, Las Vegas 

(2008 edition) for their invaluable assistance in searching the literature for biofeedback articles. 

Thank you to Robert P. Whitehouse, EdD, and Ronald L. Rosenthal, PhD, for compiling the CPT 

Treatment Codes. We would like to acknowledge the work of Christopher Gilbert, PhD, for his 

work on the 2004 edition of this book. In addition, we would like to thank the following 

members of the Association for Applied Psychophysiology and Biofeedback who reviewed this 

edition of the monograph prior to publication. 

Frank Andrasik, PhD Angele McGrady, PhD, MEd, LPCC 

Steven M. Baskin, PhD Susan J. Middaugh, PhD, PT 

Jeffrey E. Bolek, PhD Vincent J. Monastra, PhD 

Patricia S. Cowings, PhD Fred Muench, PhD 

Aubrey K. Ewing, PhD, BCIAC Randy Neblett, MA, LPC 

Richard N. Gevirtz, PhD Olafur S. Palsson, PsyD 

Howard I. Glazer, PhD Stephen Porges, PhD 

Howard Hall, PsyD, PhD, BCIAC Richard A. Sherman, PhD 

Lynda P. Kirk, MA, LPC, BCIAC, QEEGT Andrea J. Sime, LCSW 

Paul M. Lehrer, PhD, BCIAC Gabriel Tan, PhD, ABPP, BCIAC 

Websites for further information 

Association of Applied Psychophysiology and Biofeedback www.aapb.org 

Biofeedback Certification Institute of America www.bcia.org 

Biofeedback Foundation of Europe www.bfe.org 

International Society for Neurofeedback and Research www.isnr.org

iii

Foreword: 

Evidence-Based Practice in Biofeedback and Neurofeedback 

Donald Moss, PhD, and Frank Andrasik PhD 

Biofeedback and Neurofeedback 

Biofeedback is a technique that enables an individual to learn how to change physiological 

activity for the purposes of improving health and performance (Gilbert & Moss, 2003; Schwartz & 

Andrasik, 2003; Shaffer & Moss, 2006).1

 Biofeedback instruments are used to feed back information 

about physiological processes, assisting the individual to increase awareness of these processes and to 

gain voluntary control over body and mind. Biofeedback instruments measure muscle activity, skin 

temperature, electrodermal activity (sweat gland activity), respiration, heart rate, heart rate variability, 

blood pressure, brain electrical activity, and blood flow. Research shows that biofeedback, alone and in 

combination with other behavioral therapies, is effective for treating a variety of medical and 

psychological disorders, ranging from headache to hypertension to temporomandibular to attentional 

disorders. The present publication surveys these applications and reviews relevant outcome research. 

Biofeedback is used by physicians, nurses, psychologists, counselors, physical therapists, occupational 

therapists, and others. Biofeedback therapies teach the individual to take a more active role in maintaining 

personal health and higher level mind-body health. 

Neurofeedback is a specialty field within biofeedback, which is devoted to training people to gain 

control over electro-physiological processes in the human brain (Demos, 2005; Evans & Abarbanel, 1999; 

LaVaque, 2003; Thompson & Thompson, 2003). Neurofeedback uses information from the 

electroencephalogram (EEG) to show the trainee current patterns in his or her cortex. Many neurological 

and medical disorders are accompanied by abnormal patterns of cortical activity (Hammond, 2006). 

Neurofeedback assessment uses a baseline EEG, and sometimes a multi-site quantitative EEG (QEEG), to 

identify abnormal patterns (LaVaque, 2003). Clinical training with EEG feedback then enables the 

individual to modify those patterns, normalizing or optimizing brain activity. Neurofeedback practice is 

growing rapidly with the widest acceptance for applications for attention deficit hyperactivity disorder 

(ADHD), learning disabilities, seizures, depression, acquired brain injuries, substance abuse, and anxiety 

(Clinical EEG, 2000). 

Complementary and Alternative Therapies 

Biofeedback and neurofeedback are attractive approaches for individuals who are seeking 

complementary and alternative medicine (CAM) therapies (Lake & Moss, 2003). The public appears to 

seek out therapies that 1) give the individual a more active role in his or her own health care, 2) involve a 

holistic emphasis on body, mind, and spirit, 3) are noninvasive, and 4) elicit the body’s own healing 

response (Jonas & Levin, 1999; Moss, 2003). James Gordon, the first chairman of the Federal Advisory 

Council of the NIH Office of Alternative Medicine, emphasizes that educating individuals in self-care

must be at the center of this new medicine in order to deal with the changing picture of health problems 

today, especially the increasing incidence of chronic conditions (Gordon, 1996). Both biofeedback and 

neurofeedback are holistic therapies, based on the recognition that changes in the mind and emotions 

affect the body and changes in the body also influence the mind and emotions. Biofeedback and 

neurofeedback emphasize training individuals to self-regulate, gain awareness, increase control over their 

bodies, brains, and nervous systems, and improve flexibility in physiologic responding. The positive 

 

1

 The Association for Applied Psychophysiology and Biofeedback and the International Society for Neurofeedback 

and Research are currently sponsoring a Task Force for Nomenclature, headed by Mark S. Schwartz, PhD, to 

develop an official definition of biofeedback. The present discussion draws on the Task Force language, but the 

Task Force has not yet reached final formulation. 
iv

effects of feedback training enhance health, learning, and performance. There are biofeedback protocols 

to address many of the disorders, including anxiety, depression, and chronic pain, for which the public is 

using CAM therapies in high numbers (Bassman & Uellendahl, 2003; Burke, 2003; Freeman, 2008; 

Kessler et al. 2001). 

Evidence-Based Practice 

Biofeedback and neurofeedback also provide the kind of evidence-based practice the health care 

establishment is demanding (Geyman, Devon, & Ramsey, 2000; Sackett, Straus, Richardson, Rosenberg, 

& Haynes, 2000). Evidence-based practice is a process of using the best evidence, preferably research 

findings, to guide delivery of health services. Levels of evidence range from case reports and 

observational studies to randomized clinical trials. From the beginning, biofeedback developed as a 

research-based approach, emerging directly from laboratory research on psychophysiology and behavior 

therapy. The field of feedback therapies has maintained its close relationship with both pure and applied 

empirical research. Pure research takes place largely in laboratories and seeks new understandings of 

neurophysiological mechanisms underlying disorders such as panic disorder and hypertension. Better 

recognition of underlying mechanisms continues to inspire new biofeedback treatment approaches. One 

such line of research is using high resolution magnetic resonance imaging (fMRI) to learn more about 

pathophysiology of various conditions and to identify brain areas activated during biofeedback (Andrasik 

& Rime, 2007). In turn, many biofeedback applications have been tested and proven, both in research and 

practice. 

Biofeedback and neurofeedback are also approaches that rely on well-developed professional 

standards and guidelines for competent practice. A national certification organization, the Biofeedback 

Certification Institute of America, has established a blueprint of necessary knowledge and skills and 

conducts examinations qualifying individuals for certification in general biofeedback, neurofeedback, and 

pelvic floor disorders such as urinary incontinence. (Information on certification standards is available at 

www.bcia.org.) 

Efficacy and Effectiveness 

The present volume fills a void in the biofeedback and neurofeedback practice world: the need for 

a standardized assessment of clinical efficacy and effectiveness for feedback-based therapies. “Efficacy” 

refers to the determination of a training or treatment effect derived from a systematic evaluation obtained 

in a controlled clinical trial (LaVaque et al. 2002). “Effectiveness” assesses how well a treatment works in 

actual clinical settings with more typical clinical populations. Everyday clinical practice includes more 

individuals who suffer with subsyndromal conditions and comorbid disorders and who are already 

participating in multiple treatments beyond the researcher’s control. It is rare for the average primary care 

physician or behavioral health practitioner to see a patient who has only one medical condition, who 

clearly meets diagnostic criteria, and who is not involved in other therapies. 

Evidence-based practice must take into account both efficacy in controlled research settings and 

effectiveness in the real world of clinical practice. Neither the general public nor the novice biofeedback 

practitioner can always assess which applications are well documented and which remain more 

experimental. Attending biofeedback and neurofeedback conferences, one hears discussion of many 

promising new approaches, and Websites often claim “well-documented efficacy” for a variety of new 

approaches. Nevertheless, today’s research climate has higher standards for “efficacy” and 

“effectiveness” than were current during much of the time period in which biofeedback and 

neurofeedback evolved. The present publication applies current standards of research methodology to 

biofeedback and neurofeedback practice. 

Efficacy Standards 

In 2001, the two professional associations in this practice area, the Association for Applied 

Psychophysiology and Biofeedback (AAPB) and the International Society for Neuronal Regulation, now 
 v

known as the International Society for Neurofeedback and Research (ISNR), together commissioned a 

Task Force to develop official standards for research methodology, establishing what kinds of research 

are required for each of five levels of efficacy, ranging from the lowest level, “not empirically supported,” 

to the highest level, “efficacious and specific.” That Task Force report has been published along with a 

brief introduction describing the context and need for its development (LaVaque et al. 2002; Moss & 

Gunkelman, 2002). The efficacy guidelines themselves can be found, with criteria for each rating, on 

page 4 of the present document. 

The Task Force has created rigorous standards, which are not easily applied to feedback 

therapies. There are inherent difficulties, for example, in creating a double-blind condition for a therapy 

that is founded on enhancing self-awareness of body and mind. For example, “sham feedback” (feedback 

that does not reflect the subject’s actual physiological state) has been used as a control condition in 

biofeedback research. Yet, perceptive individuals quickly notice the sound or light feedback does not fit 

with their perceptions of their bodies; they are not blinded as the methodology requires. There are also 

ethical implications today, following the international Declaration of Helsinki, published by the World 

Medical Association (2000), in using placebos or sham therapies when the relative efficacy of one of the 

treatment conditions is already known (LaVaque et al. 2002). 

In addition, most efficacy studies in the past have compared biofeedback alone to placebo or to 

currently accepted therapies. This approach attempts to isolate the specific therapeutic effects of 

biofeedback, which is important from a research standpoint. In clinical practice, however, biofeedback is 

often combined with a wide variety of adjunctive therapies, including relaxation training, visualization, 

behavior therapies, client education, and other strategies. James Gordon, director of the Center for MindBody Medicine, has advocated that future outcome research should compare integrative packages of 

alternative therapies, including biofeedback, to placebo alone or to accepted therapy packages (2003). 

Nevertheless, it is critical to apply prevailing standards for outcome research in order to provide a 

credible rating of therapeutic interventions for today’s evidence-based healthcare sector. Failing to do so 

exposes biofeedback and neurofeedback to the danger of being left by the wayside as irrelevant in today’s 

best practices–focused treatment milieu. 

Efficacy in Perspective 

The present volume does not attempt exhaustive reviews of all research on each application. 

Rather, this volume reviews a sampling of the best available evidence and, in concise form, rates each 

application according to the official AAPB/ISNR efficacy guidelines. 

A parallel series of white papers conducts a more comprehensive review. Seven white papers 

have been published to date, and the entire series will be published as a separate volume in 2009 – 2010 

(Moss, LaVaque, & Hammond, in preparation). The white paper series reviews the efficacy of 

biofeedback for attention deficit disorders (Monastra, Lynn, Linden, Lubar, Gruzelier, & LaVaque, 2005), 

anorectal disorders (Palsson, Heymen, & Whitehead, 2004), anxiety disorders (Moss & Shaffer, in 

preparation), hypertension (Linden & Moseley, 2006), temporomandibular disorders (Crider, Glaros, & 

Gevirtz, 2005), tension and migraine headache (Nestoriuc, Martin, Rief, & Andrasik, in preparation), 

Raynaud’s disease (Karavidas, Tsai, Yucha, McGrady, & Lehrer, 2006), substance abuse (Sokhadze, 

Cannon, & Trudeau, 2008), and urinary incontinence (Glazer & Laine, 2006). 

A lower efficacy rating does not necessarily indicate an application is not helpful. In some cases a 

lower rating has been applied chiefly because the relevant research has not yet been conducted. In other 

cases, a lower rating means the application benefits some subjects and not others because of wide intersubject variability. People are not all uniform. On a group comparison basis, these selective successes 

may not be statistically significant. 
vi

If a prospective client cannot tolerate the available medication therapies in traditional medicine, 

or if the individual is averse to staying with a medication, then “possibly efficacious” feedback therapies 

may be reasonable alternatives. 

Many of today’s well-accepted medical procedures have never been subjected to the rigorous 

efficacy standards adopted here. Many medications, in particular, are utilized off-label; that is, they are 

prescribed for specific medical conditions not indicated by the Food and Drug Administration and for 

which no rigorous clinical trials exist. Other medical therapies have been tested in randomized clinical 

trials and show reliable but relatively small effects. In a clinical drug trial with 10,000 subjects, even a 

small benefit will produce a statistically significant effect. At least one research report on antidepressants, 

for example, showed outcomes no better than placebo (Fava et al. 1998), yet these medications are among 

the most frequently prescribed in most primary care clinics. Similarly, many of the widely used 

educational methods for assisting students with learning disabilities have yet to be subjected to rigorous 

scrutiny. A “possibly efficacious” or “probably efficacious” biofeedback or neurofeedback application 

may still be relatively powerful compared to the mainstream alternatives available to an individual. The 

feedback therapies also provide a useful alternative for clients who show adverse effects to medications, 

those who fail to respond to mainstream therapies, and those who prefer more natural, self-regulation–

oriented treatment. 

References 

Andrasik, F., & Rime, C. (2007). Can behavioural therapy influence neuromodulation? Neurological 

Sciences, 28, S124-S129. 

Bassman, L.E., & Uellendahl, G. (2003). Complementary/alternative medicine: Ethical, professional, and 

practical challenges for psychologists. Professional Psychology: Research and Practice, 34, 264-270. 

Burke, A. (2003). Biofeedback and the CAM consumer. Biofeedback, 31(3), 13-15. 

Clinical EEG (2000). Special issue on “The State of EEG Biofeedback Therapy (EEG Operant 

Conditioning) in 2000.” Clinical Electroencephalography, 31(1), v-viii, 1-55. 

Crider, A., Glaros, A.G., & Gevirtz, R.N. (2005). Efficacy of biofeedback-based treatments for 

temporomandibular disorders. Applied Psychophysiology and Biofeedback, 30(4), 333-345. 

Demos, J.N. (2005). Getting Started with Neurofeedback. NY: W.W. Norton. 

Evans, J.R., & Abarbanel, A. (Eds.) (1999). Introduction to Quantitative EEG and Neurofeedback. San 

Diego: Academic Press. 

Fava, M., Amsterdam, J.D., Deltito, J.A., Salzman, C., Schwaller, M., & Dunner, D.L. (1998). A doubleblind study of paroxetine, fluoxetine, and placebo in outpatients with major depression. Annals of Clinical 

Psychiatry, 10(4), 145-150. 

Freeman, L. (2008) Mosby’s Complementary & Alternative Medicine: A Research-Based Approach (3rd. 

ed.). Philadelphia, PA: Elsevier Science. 

Geyman, J.P., Deyon, R.A., & Ramsey, S.D., (Eds.) (2000). Evidence-Based Clinical Practice: Concepts 

and Approach. Boston: Butterworth-Heinemann. 

Gilbert, C., & Moss, D. (2003). Biofeedback and biological monitoring. In D. Moss, A. McGrady, T. 

Davies, & I Wickramaskera (Eds.), Handbook of Mind-Body Medicine in Primary Care: Behavioral and 

Physiological Tools (pp. 109-122). Thousand Oaks, CA: Sage. 

Glazer, H.I., & Laine, C.D. (2006). Pelvic floor muscle biofeedback in the treatment of urinary 

incontinence: A literature review. Applied Psychophysiology and Biofeedback, 31(3), 187-201. 

Gordon, J. (1996). Manifesto for a New Medicine. Reading, MA: Perseus Books. 
vii

Gordon, J. (2003, March). Mind-body medicine and the future of health care. Keynote address to the 

annual meeting of the Association for Applied Psychophysiology and Biofeedback, Jacksonville, FL. 

Hammond, D.C. (2006). Quantitative electroencephalography patterns associated with medical 

conditions. Biofeedback, 34(3), 87-94. 

Jonas, W.B., & Levin, J.S. (Eds.) (1999). Essentials of Complementary and Alternative Medicine. 

Philadelphia, Baltimore, New York: Lippincott, Williams, & Wilkins. 

Karavidas, M., Tsai, P.-S., Yucha, C., McGrady, A., & Lehrer, P.M. (2006). Thermal biofeedback for 

primary Raynaud’s phenomenon: A review of the literature. Applied Psychophysiology and Biofeedback, 

31(3), 203-216. 

Kessler, R., Soukup, J., Davis, R., Foster, D., Wilkey, S., Van Rompay, M., & Eisenberg, D. (2001). The 

use of complementary and alternative therapies to treat anxiety and depression in the United States. 

American Journal of Psychiatry, 158(20), 289-294. 

Lake, J., & Moss, D. (2003). QEEG and EEG biofeedback in the diagnosis and treatment of psychiatric 

and neurological disorders: An authentic complementary therapy. Biofeedback, 31(3), 25-28. 

LaVaque, T.J. (2003). Neurofeedback, neurotherapy, and QEEG. In D. Moss, A. McGrady, T. Davies, & 

I. Wickramasekera (Eds.), Handbook of Mind Body Medicine for Primary Care (pp. 123-135). Thousand 

Oaks, CA: Sage. 

LaVaque, T.J., Hammond, D.C., Trudeau, D., Monastra, V., Perry, J., Lehrer, P., Matheson, D., & 

Sherman, R. (2002). Template for developing guidelines for the evaluation of the clinical efficacy of 

psychophysiological evaluations. Applied Psychophysiology and Biofeedback, 27(4), 273-281. Copublished in Journal of Neurotherapy, 6(4), 11-23. 

Linden, W., & Moseley, J.V. (2006). The efficacy of behavioral treatments for hypertension. Applied 

Psychophysiology and Biofeedback, 31(1), 51-63. 

Monastra, V.J., Lynn, S., Linden, M., Lubar, J.F., Gruzelier, J., & LaVaque, T.J. (2005). 

Electroencephalographic biofeedback in the treatment of attention-deficit/hyperactivity disorder. Applied 

Psychophysiology and Biofeedback, 30(2), 95-114. 

Moss, D. (2003). Mind/body medicine, evidence-based medicine, clinical psychophysiology, and 

integrative medicine. In D. Moss, A. McGrady, T. Davies, & I. Wickramaskera (Eds.), Handbook of Mind 

Body Medicine in Primary Care: Behavioral and Physiological Tools (pp. 3-18). Thousand Oaks, CA: 

Sage. 

Moss, D., & Gunkelman, J. (2002). Task force report on methodology and empirically supported 

treatments: Introduction and summary. Applied Psychophysiology and Biofeedback, 27(4), 261-262. Copublished in Journal of Neurotherapy, 6(4), 7-10. 

Moss, D., LaVaque, T.J., & Hammond, D.C. (Eds.) (in preparation). White papers on 

psychophysiological treatments of clinical disorders: Series. Wheat Ridge, CO: Association of Applied 

Psychophysiology and Biofeedback. 

Moss, D., & Shaffer, F. (in preparation). The efficacy of biofeedback for anxiety disorders. 

Nestoriuc, Y., Martin, A., Rief, W., & Andrasik, F. (in preparation). Biofeedback treatment for headache 

disorders: A comprehensive efficacy review. 

Palsson, O.S., Heymen, S., & Whitehead, W.E. (2004). Biofeedback treatment for functional anorectal 

disorders: A comprehensive efficacy review. Applied Psychophysiology and Biofeedback, 29(3), 153-174. 

Sackett, D.L., Straus, S.E., Richardson, W.S., Rosenberg, W., & Haynes, R.B. (Eds.) (2000). Evidencebased medicine: How to practice and teach EBM. Edinburgh; New York: Churchill Livingstone. 
viii

Schwartz, M., & Andrasik, F. (Eds.) (2003). Biofeedback: A Practitioner’s Guide (3rd ed.). NY: Guilford. 

Shaffer, F., & Moss, D. (2006). Biofeedback. In C.-S. Yuan, E.J. Bieber, & B.A. Bauer (Ed.), Textbook of 

Complementary and Alternative Medicine (2nd ed.) (pp. 291-312). Abingdon, Oxfordshire, UK: Informa 

Healthcare. 

Thompson, M., & Thompson, L., (2003), The Neurofeedback Book: An Introduction to Basic Concepts in 

Applied Psychophysiology. Wheat Ridge, CO: Association for Applied Psychophysiology. 

World Medical Association (2000). The Declaration of Helsinki. 52nd WMA General Assembly, 

Edinburgh, Scotland. www.wma.net. 
ix

Introduction 

Biofeedback and applied psychophysiology continues to be a vital, growing field. The 

Association for Applied Psychophysiology and Biofeedback (AAPB) originally created this 

efficacy series to summarize the current state of knowledge in the field. As you will see, there 

are a significant number of clinical problems for which biofeedback and applied 

psychophysiology are “efficacious” or “probably efficacious.” Biofeedback is no longer an 

“alternative” treatment modality but a clear first choice for some conditions and an excellent 

adjunctive treatment for others. 

This is the most comprehensive document of its kind on the efficacy of biofeedback and 

applied psychophysiology. The last edition of this work covered 37 areas; this one covers 41. 

The content of these areas has been updated to reflect current knowledge. 

The work summarized in this volume represents the efforts of several individuals: the 

investigators who do the difficult task of organizing and running clinical trials and Doil 

Montgomery and Carolyn Yucha, who took time to carefully summarize the available evidence. 

To all: We thank you for your hard work and for your vision in moving the field forward. 

Alan Glaros, PhD 

AAPB President 
 x

Table of Contents 

 PAGE 

 Acknowledgements i 

 Foreword iii 

 Introduction ix 

 Table of Contents x 

 Overview of Biofeedback 1 

 “Treatment” versus “Training” 1 

 Research Involving Behavioral Interventions 2 

 Clinical Efficacy of Biofeedback: Explanation of Efficacy Levels 4 

 Conditions for which Biofeedback Has Been Used 6 

 Alcoholism/Substance Abuse 6 

 Anxiety 8 

 Arthritis 10 

 Asthma 11 

 Attention Deficit Hyperactivity Disorder (ADHD) 12 

 Autism 22 

 Bell’s Palsy 23 

 Cerebral Palsy 23 

 Chronic Obstructive Pulmonary Disease (COPD) 24 

 Chronic Pain 24 

 Coronary Artery Disease 30 

 Cystic Fibrosis 31 

 Depressive Disorders 31 

 Diabetes Mellitus 32 

 Eating Disorders 33 

 Epilepsy 34 

 Erectile Dysfunction 35 

 Fecal Disorders 36 

 Fecal Disorders in Children 36 

 Fecal Incontinence: Adults 37 

 Constipation: Adults 38 

 Fibromyalgia/Chronic Fatigue Syndrome 41 

 Hand Dystonia 43 

 Headache – Pediatric 43 
xi

 Headache – Adult 44 

 Hypertension 46 

 Immune Function 47 

 Insomnia 48 

 Irritable Bowel Syndrome 49 

 Motion Sickness 50 

 Post-Traumatic Stress Disorder 52 

 Raynaud’s Disease 53 

 Repetitive Strain Injury 54 

 Respiratory Failure: Mechanical Ventilation 54 

 Spinal Cord Injury 55 

 Stroke (Cardiovascular Accident) 55 

 Syncope (Neurocardiogenic) 56 

 Temporomandibular Disorder (TMD) 57 

 Tinnitus 58 

 Traumatic Brain Injury (TBI) 59 

 Urinary Incontinence in Females 61 

 Urinary Incontinence in Males 64 

 Urinary Incontinence in Children 65 

 Vulvar Vestibulitis (Vulvodynia) 66 

 Emerging Applications 67 

 Sample Protocols 71 

 General EMG Training 71 

 Temperature Training 71 

 Skin Conductance Training 72 

 EEG Training or Neurofeedback 72 

 Heart Rate Variability 73 

 Additional Protocols of the Biofeedback Foundation of Europe 74 

 The Biofeedback Certification Institute of America 75 

 AAPB Code of Ethics 76 

 Answers to Common Questions about Biofeedback Treatment 77 

 Conclusion 79 

 Treatment Codes (AMA CPT and ABC CAM) 80 

 Page 1

Overview of Biofeedback 

Biofeedback therapies are nonpharmacologic treatments that use scientific instruments to 

measure, amplify, and feed back physiological information to the patient being monitored. The 

information assists the patient in gaining self-regulation of the physiological process being monitored. 

Psychophysiological self-regulation is a primary goal of biofeedback therapies, and feedback of 

information facilitates learned physiological control, just as feedback facilitates learning of any skill. 

For example, in the treatment of hypertension, surface electrodes are used to provide the patient with 

information about skin temperature and muscle tension. The feedback of information from the 

instrument guides the patient during training as he or she learns to warm the skin (by dilating blood 

vessels) and relax the muscles. This is generally accompanied by a reduction in blood pressure. In this 

example, the instrumentation provides physiological information that would otherwise be inaccessible 

to the patient. Biofeedback therapy always involves a therapist, a patient, and a monitoring 

instrument capable of providing accurate physiological information. 

 Modalities of biofeedback are varied. Depending on the goal of the training, biofeedback 

clinicians may use sensors that detect such parameters as skin temperature, muscle activity, heart 

rate, respiration, skin conductance, or brainwave activity. This stream of information is then 

presented in some form that allows patients to perceive changes in their physiological activity in 

real time. Numerical or graphic displays are most common, but audio or vibratory feedback might 

also be used. 

 Biofeedback training requires that patients observe their physiological responses in detail and 

try to learn to alter them. This takes effort and time. For certain conditions, such as urinary 

incontinence, significant improvement may occur within a few sessions. In contrast, up to 50 sessions 

of neurotherapy (brainwave biofeedback) for attention deficit disorder may be needed before 

improvement is seen.

“Treatment” versus “Training” 

 “Treatment” implies a passive patient receiving something therapeutic from an active practitioner. 

The patient’s automatic healing processes may be expected to operate, but beyond that, the patient is not 

asked to do much more than show up for procedures or swallow pills on schedule. “Treatment” is what 

insurance is traditionally designed to reimburse. 

 “Training,” on the other hand, implies more active participation; people are trained to ride a 

horse, perform a job, ice-skate, etc. Learning is interactive, guided by instruction and information in order 

to develop a skill. Most biofeedback is done with this orientation, even though the action may be internal 

and visible only with the biofeedback instruments. Insurance policies often exclude procedures labeled 

“educational.” The educational component in biofeedback, however, is more akin to speech therapy or 

rehabilitation than to a more abstract pursuit of knowledge. 

 A parallel can be drawn with physical therapy, which often directs a person to practice certain 

movements or exercises at home between sessions. This process requires active participation but is 

routinely considered treatment rather than training, even though therapeutic success may rest on the 

thoroughness of home practice. The patient must learn to do certain movements, carry out exercises, and 

avoid certain injurious activities and postures. Physical therapy and rehabilitation are considered 

reimbursable therapeutic procedures. Is this education, training, or treatment? 

 An insurer would not want to cover a course of biofeedback training done strictly for selfexploration, just as an insurer would not cover weekend courses in personal development or reading selfhelp books. But what if biofeedback is shown to be effective for a bona fide diagnosed disorder or if a 

self-control procedure is learned and then faithfully practiced? Is this now education, training, or 

treatment? 
 Page 2

 When biofeedback training is “prescribed” for a recognized disorder, the outcome usually 

depends on factors such as enhanced self-sensing, corrections in body use (changes in posture, breathing, 

muscle tension, or movement), relaxation, and managing emotions, all in conjunction with exposure to 

biofeedback signals and integrated into daily life via home practice. The biofeedback data serve as 

information only. The learner can use the information intelligently or not, and it is the use of the 

information, rather than exposure to it, that makes the difference. 

Research Involving Behavioral Interventions 

 Much biofeedback research seems to assume a treatment model, as if biofeedback is a procedure 

“done to” an individual. This approach strives to standardize doses, techniques, and subject variables as 

much as possible. In biofeedback research, this would include items such as number of sessions, type 

of feedback display, and behavior of the trainer. Controlling all the factors surrounding the biofeedback 

process is very difficult. Pursuit of experimental control often makes the research protocol too limited and 

standardized to represent how biofeedback is used in clinical practice. 

 Double-blind research is generally held in high regard because subtle expectations on the part of 

both subjects and practitioners are supposedly eliminated. However, the double-blind, or even singleblind procedure, does not make sense in biofeedback because ongoing knowledge of changes in a 

physiological variable is central to the learning process. Eliminating expectations by double-blinding 

supposedly keeps things pure, but expectations may be the essence of the placebo effect, which is a very 

interesting self-healing phenomenon, not simply a confounding factor in experiments. In biofeedback, at 

least, such an effect is something to be maximized and mastered, not eliminated. 

 Tailoring the biofeedback learning process to the individual may be more effective clinically, 

but it introduces uncontrolled variability, the bane of research designs. Although keeping subjects 

passive and standardizing the protocol might keep things tidy for research purposes, it works against the 

success of biofeedback and other self-regulation methods. 

 Instead of considering biofeedback research as “inconclusive” because it does not follow the 

double-blind model of pharmaceutical research, a different model should be considered in which selfregulation is the active ingredient. The training model is most applicable to biofeedback applications. The 

training concept involves active participation and individualizing of the biofeedback situation to fit the 

individual learner. For instance, one person may learn best with continuous exposure to the feedback 

signal, while another person may learn best while using imagery with minimal feedback. The very factors 

that would introduce unwanted variability into most treatment research constitute the essence of active 

learning. Wait-list controls, controlled case studies, and other clinical research methods are more 

appropriate for studying biofeedback than standardized clinical trials. 

 “Training to criterion” refers to the subject/trainee/patient practicing a certain mode of control 

until a criterion, which represents meaningful change, is reached: for instance, a particular level of muscle 

tension or hand temperature. Without demonstrating the ability to alter one’s physiologic responses, a 

subject in a biofeedback experiment cannot be said to be receiving the intended treatment. This would be 

comparable to a subject not taking the prescribed medication in a drug effectiveness study. Yet training to 

criterion is often ignored in biofeedback studies. 

 It follows that exposing someone to a course of biofeedback does not necessarily constitute an 

adequate intervention, any more than filling a prescription is adequate. Just as the pills must actually be 

swallowed, a person’s active attention must be engaged. Even if the necessary control (blood pressure for 

instance) has been learned well in the laboratory, the application of that control in real life will vary. 

Adherence to the prescribed self-regulation regimen, including periodic relaxation, altered breathing, and 

cognitive changes, will be applied with varying degrees of diligence, depending on the amount of 

commitment, belief, suffering, and conflicting demands on attention and time. This variability is not 
 Page 3

easily controlled and is comparable to drug research subjects taking the prescribed drugs in widely 

varying doses and concentrations at varying times from day to day and sometimes skipping days. 

 Understanding and applying the biofeedback information is certainly more complicated than 

swallowing a pill, but it constitutes the essence of the treatment and must be accommodated in the 

research design and accepted by those who evaluate biofeedback research. Bearing in mind these 

limitations, this monograph is a summary of the research findings over the past 20 years, examining the 

efficacy of biofeedback for various disorders. 
 Page 4

Clinical Efficacy of Biofeedback Therapy: 

Explanation of Efficacy Levels 

Biofeedback therapy has matured over the last 30 years, and today there are myriad disorders for 

which biofeedback therapy has been used. Large research grants have funded prospective studies on 

biofeedback therapy for a variety of disorders, such as headache (migraine, mixed, and tension), essential 

hypertension, and urinary incontinence. These studies consistently report positive results. 

On the other hand, several reports of unsuccessful biofeedback training have appeared in the 

research literature since the inception of biofeedback training three decades ago. Many of the 

unsuccessful studies conducted in the early development of the field reflect failure to thoroughly train 

patients. For example, some unsuccessful studies provided only minimal training with the biofeedback 

instrumentation (often one to four sessions of short duration), provided little coaching, involved no home 

practice, and failed to train to clinical criteria. 

In 2001, a Task Force of the Association for Applied Psychophysiology and Biofeedback and the 

Society for Neuronal Regulation developed guidelines for the evaluation of the clinical efficacy of 

psychophysiological interventions (Moss & Gunkelman, 2002). The board of directors of both 

organizations subsequently approved these guidelines. These Criteria for Levels of Evidence of Efficacy, 

described below, were used to assign efficacy levels for the vast number of conditions for which 

biofeedback has been used. 

Level 1: Not Empirically Supported 

Supported only by anecdotal reports and/or case studies in nonpeer-reviewed venues. Not empirically 

supported. 

Level 2: Possibly Efficacious 

At least one study of sufficient statistical power with well-identified outcome measures but lacking 

randomized assignment to a control condition internal to the study. 

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) 

control utilizing randomized assignment, the investigational treatment is shown to be statistically 

significantly superior to the control condition, or the investigational treatment is equivalent to a 

treatment of established efficacy in a study with sufficient power to detect moderate differences, 

and 

b. The studies have been conducted with a population treated for a specific problem, for whom 

inclusion criteria are delineated in a reliable, operationally 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, and 

e. The diagnostic and treatment variables and procedures are clearly defined in a manner that 

permits replication of the study by independent researchers, and 
 Page 5

f. The superiority or equivalence of the investigational treatment has been shown in at least two 

independent research settings. 

Level 5: Efficacious and Specific 

Evidence for Level 5 efficacy meets all of the criteria for Level 4. In addition, the investigational 

treatment has been shown to be statistically superior to credible sham therapy, pill, or alternative bona 

fide treatment in at least two independent research settings. 

 In this particular update, we asked a professional librarian (Eva Stowers, University of Nevada, 

Las Vegas) to provide a comprehensive literature search of biofeedback and neurofeedback articles. 

Criteria used included being published in a peer-reviewed journal between 2003 – 2007. When there were 

numerous higher level research studies available, case studies were not added to this version. Abstracts 

and articles in languages other than English were not included. This monograph is not meant to be an 

inclusive review of all literature published on every possible disorder, but rather is meant to provide 

rationale for efficacy ratings of biofeedback. 

References 

Moss, D., & Gunkelman, J. (2002). Task force report on methodology and empirically supported 

treatments: Introduction and summary. Biofeedback, 30(2), 19-20. 

Moss, D., & Gunkelman, J. (2002). Task force report on methodology and empirically supported 

treatments: Introduction and summary. Applied Psychophysiology and Biofeedback, 27(4), 261-262. 

Note: This document is also available online at www.aapb.org and www.isnr.org. 
 Page 6

Conditions for which Biofeedback Has Been Used 

The following review is not meant to be an exhaustive review of the literature, but rather an 

overview of the state of the evidence for biofeedback. The following process was used to select citations. 

First, a comprehensive literature search was done (PsychInfo and PubMed) with the help of librarians to 

find clinical research and systematic review articles mentioning biofeedback or neurofeedback between 

1993 and the present. Publications addressing efficacy were published by AAPB in 1994 and 2003. 

Reports studying only normal subjects were excluded. Remaining articles were sorted as to 

treatment condition, and the most pertinent ones were summarized briefly. Separate, more specific, 

literature searches were done on those conditions with few citations in order to expand the evidence, and 

these were incorporated into the document. This draft was sent to AAPB’s board of directors and those 

listed in the acknowledgements for comments. These persons were asked to identify unlisted studies, if 

any, that might alter the efficacy levels. Certain classic studies were then added to the citations. It must 

again be emphasized that this book is NOT a comprehensive review of the field, and many important 

studies were not included. However, the authors feel confident that these studies would not alter the 

efficacy levels as reported here. Although this is not a comprehensive review of the field, the authors feel 

the studies reported represent the current status of research in the field. 

Alcoholism / Substance Abuse 

Level 3: Probably Efficacious

 Researchers have used both biofeedback-assisted relaxation training and neurofeedback (alphatheta brainwave feedback) to deal with alcoholism and its accompanying symptoms (e.g., depression). In 

comparison to a control group, thermal biofeedback increased drinking-related locus of control in a study 

of adolescent alcoholics (Sharp, Hurford, Allison, Sparks, & Cameron, 1997). Alpha-theta brainwave 

training was accompanied by significant decreases in certain factors measured using the Millon Clinical 

Multiaxial Inventory (schizoid, avoidant, passive-aggression, schizotypal, borderline, paranoid, anxiety, 

somatoform, dysthymia, alcohol abuse, psychotic thinking, psychotic depression, and psychotic 

delusional) in comparison to those receiving traditional medical treatment (Peniston & Kulkosky, 1990). 

Taub, Steiner, Weingarten, and Walton (1994) studied 118 chronic alcoholics randomly assigned to one 

of four treatment conditions: 1) routine treatment of Alcoholics Anonymous and counseling (RTT), 2) 

RTT plus transcendental meditation, 3) RTT plus EMG biofeedback, and 4) RTT plus neurotherapy. Selfreport of abstinence for the four groups were 25%, 65%, 55%, and 28%, respectively. This study suggests 

the addition of meditation or EMG biofeedback enhances RTT while neurotherapy does not. 

 A number of case studies and uncontrolled studies show the benefit of neurofeedback for treating 

alcoholic depression (Kumano et al. 1996; Waldkoetter & Sanders, 1997). A few controlled 

neurofeedback studies (Peniston & Kulkosky, 1989; Saxby & Peniston, 1995) provided further evidence 

for this reduction in depression and reported sustained prevention of relapse at 21-month follow-up in 

alcoholics who had completed the training (Saxby & Peniston, 1995). Another showed that six of 10 

alcohol-dependent males had not relapsed four months post self-regulation of slow cortical potentials 

(Schneider et al. 1993). These studies demonstrate promise in altering alcoholic behavior via alpha-theta 

brainwave feedback. Further, a very recent review concludes alpha-theta training — either alone, for 

alcoholism, or in combination with beta training, for stimulant and mixed substance abuse, and combined 

with residential treatment programs — is probably efficacious (Sokhadze, Cannon, & Trudeau, 2008). 

 Recent studies are beginning to provide evidence that EEG biofeedback improves treatment for 

cocaine addiction with improvements in length of stay (Burkett, Cummins, Dickson, & Skolnick, 2004) 
 Page 7

and urinalysis, depression, and other self-report measures (Burkett, Cummins, Dickson, & Skolnick, 

2005). A recent RCT comparing EEG biofeedback to control showed those in the treatment group 

remained in treatment longer than the control group, and 77% of those completing the protocol were 

abstinent at 12 months compared to 44% of the control group (Scott, Kaiser, Othmer, & Sideroff, 2005). 

Another RCT showed two sessions of motivational interviewing using EEG feedback led to a reduction in 

positive urine screens at 63%, compared to 85% in the control group (Stotts, Potts, Ingersoll, George, & 

Martin, 2006). 

References 

Burkett, V.S., Cummins, J.M., Dickson, R.M., & Skolnick, M. (2005). An open clinical trial utilizing 

real-time EEG operant conditioning as an adjunctive therapy in the treatment of crack cocaine 

dependence. Journal of Neurotherapy, 9(2), 27-47. 

Burkett, V.S., Cummins, J.M., Dickson, R.M., & Skolnick, M.H. (2004). Treatment effects related to 

EEG-biofeedback for crack cocaine dependency in a faith-based homeless mission. Journal of 

Neurotherapy, 8(2), 138-140. 

Kumano, H., Horie, H., Shidara, T., Kuboki, T., Suematsu, H., & Yasushi, M. (1996). Treatment of a 

depressive disorder patient with EEG-driven photic stimulation. Biofeedback and Self-Regulation, 21(4), 

323-334. 

Peniston, E.G., & Kulkosky, P.J. (1989). Alpha-theta brainwave training and beta-endorphin levels in 

alcoholics. Alcoholism, Clinical and Experimental Research, 13(2), 271-279. 

Peniston, E.G., & Kulkosky, P.J. (1990). Alcoholic personality and alpha-theta brainwave training. 

Medical Psychotherapy, 3, 37-55. 

Saxby, E., & Peniston, E.G. (1995). Alpha-theta brainwave neurofeedback training: An effective 

treatment for male and female alcoholics with depressive symptoms. Journal of Clinical Psychology,

51(5), 685-693. 

Schneider, F., Elbert, T., Heimann, H., Welker, A., Stetter, F., Mattes, R., et al. (1993). Self-regulation of 

slow cortical potentials in psychiatric patients: Alcohol dependency. Biofeedback and Self-Regulation,

18(1), 23-32. 

Scott, W.C., Kaiser, D., Othmer, S., & Sideroff, S.I. (2005). Effects of an EEG biofeedback protocol on a 

mixed substance abusing population. The American Journal of Drug and Alcohol Abuse, 31(3), 455-469. 

Sharp, C., Hurford, D.P., Allison, J., Sparks, R., & Cameron, B.P. (1997). Facilitation of internal locus of 

control in adolescent alcoholics through a brief biofeedback-assisted autogenic relaxation training 

procedure. Journal of Substance Abuse Treatment, 14(1), 55-60. 

Sokhadze, T.M., Cannon, R.L., & Trudeau D.L. (2008). EEG biofeedback as a treatment for substance 

use disorders: review, rating of efficacy, and recommendations for further research. Applied 

Psychophysiology and Biofeedback, 33(1), 1-28. 

Stotts, A.L., Potts, G.F., Ingersoll, G., George, M.R., & Martin, L.E. (2006). Preliminary feasibility and 

efficacy of a brief motivational intervention with psychophysiological feedback for cocaine abuse.

Substance Abuse, 27(4), 9-20. 

Taub, E., Steiner, S.S., Weingarten, E., & Walton, K.G. (1994). Effectiveness of broad spectrum 

approaches to relapse prevention in severe alcoholism: A long-term, randomized controlled trial of 

transcendental meditation, EMG biofeedback, and electronic neurotherapy. Alcoholism Treatment 

Quarterly, 11(1/2), 187-220. 

Waldkoetter, R.O., & Sanders, G.O. (1997). Auditory brainwave stimulation in treating alcoholic 

depression. Perceptual and Motor Skills, 84(1), 226. 
 Page 8

Anxiety 

Level 4: Efficacious

Multiple case studies have demonstrated clinically significant outcomes with carefully screened 

and thoroughly assessed participants for various forms of anxiety-related disorders. There are also several 

treatment-only group studies with moderate sample sizes, demonstrating positive results of various forms 

of biofeedback that were often combined with other behavioral interventions. A few well-controlled, 

randomized studies have shown biofeedback to be equivalent to other relaxation and self-control methods 

for reducing anxiety while it is occasionally shown to be superior to another intervention. Most show 

biofeedback (EMG, GSR, thermal, or neurofeedback) to be roughly equivalent to progressive relaxation 

or meditation. 

Lehrer, Carr, Sargunaraj, and Woolfolk (1994) evaluated the hypothesis that biofeedback is most 

effective when applied in the same modality as the disorder (autonomic feedback for ANS disorders, 

EMG feedback for muscular disorders, etc.). Other researchers have asserted self-relaxation techniques 

have in common the process of using conscious intent to calm oneself, and for anxiety reduction, it may 

matter little which modality is used because the central component is the cognitively based conscious 

intent. Clarification of this issue must await further clinical outcome studies. 

Two studies showed biofeedback’s efficacy in reducing anxiety without making comparisons 

with other relaxation techniques. Hurley and Meminger (1992) used frontal EMG biofeedback with 40 

subjects trained to criterion and assessed anxiety over time using the State-Trait Anxiety Inventory 

(STAI). State anxiety improved more than trait anxiety. Wenck, Leu, and D’Amato (1996) trained 150 

seventh- and eighth-graders with thermal and EMG feedback and found significant reduction in state and 

trait anxiety. 

Roome and Romney (1985) compared progressive muscle relaxation to EMG biofeedback 

training with 30 children and found an advantage for biofeedback; however, Scandrett, Bean, Breeden, 

and Powell (1986) found some advantage of progressive muscle relaxation over EMG biofeedback in 

reducing anxiety in adult psychiatric inpatients and outpatients. 

Rice, Blanchard, and Purcell (1993) studied reduction in generalized anxiety by comparing 

groups given EMG frontal feedback, EEG alpha-increase feedback, and EEG alpha-decrease feedback to 

two control conditions (a pseudo-meditation condition and a wait-list control). All treatment groups had 

comparable and significant decreases in the STAI and drops in the Psychosomatic Symptom Checklist. 

The alpha-increasing biofeedback condition produced one effect not found with the other treatment 

conditions: a reduction in heart-rate reactivity to stressors. Similar results were obtained by Sarkar, 

Rathee, and Neera (1999), who compared the generalized anxiety disorder response to pharmacotherapy 

and to biofeedback; the two treatments had similar effects on symptom reduction. Hawkins, Doell, 

Lindseth, Jeffers, and Skaggs (1980) concluded, from a study with 40 hospitalized schizophrenics, that 

thermal biofeedback and relaxation instructions had an equivalent effect on anxiety reduction. However, 

Fehring (1983) found adding GSR biofeedback to a Benson-type relaxation technique reduced anxiety 

symptoms more than relaxation alone. 

Vanathy, Sharma, and Kumar (1998), applying EEG biofeedback to generalized anxiety disorder, 

compared increased alpha with increased theta. The two procedures were both effective in decreasing 

symptoms. In a recent case study, Hammond (2003) reported on two cases using EEG biofeedback for 

OCD. Clinically significant improvements for both participants were reported. In a single case study 

(Goodwin & Montgomery, 2006) of a 39-year-old male with panic disorder and agoraphobia, 

electrodermal biofeedback was combined with CBT, graded exposure. They reported a complete 

cessation of panic attacks, a remission of agoraphobia, and a clinically significant reduction in depression. 
 Page 9

In a study by Gordon, Staples, Blyta, and Bytyqi (2004) a total of 139 PTSD postwar high school 

students were provided a six-week program of biofeedback, meditation, drawings, autogenics, guided 

imagery, genograms, and breathing techniques. No control group was used, but they reported a significant 

reduction immediately after treatment and at follow up. In a two-treatment group comparison study 

(n=50) of anxiety in individuals with chronic pain, Corrado, Gottlieb, and Abdelhamid (2003) reported a 

significant improvement in anxiety and somatic complaints in the group that received biofeedback of 

finger temperature increase and muscle tension reduction when compared to a pain education group. 

In an RCT study of 87 participants, Bont, Castilla, and Maranon (2004) presented the outcome of 

three intervention programs applied to fear of flying: a reattributional training-based program, a mixedexposure procedure, and finally a biofeedback training program in order to change psychophysiological 

responses. A fourth group of wait-list controls were also assessed. They found a significant reduction in 

anxiety for the treatment groups when compared to the control group of no treatment. In another RCT 

study of imipramine and imipramine plus biofeedback, Coy, Cardenas, Cabrera, Zirot, and Claros (2005) 

found the biofeedback group plus medication (n=18) was significantly improved compared to the 

medication-only group (n=14). 

From a group of 312 high school students in Shanghai, Dong and Bao (2005) recruited 70 

students who met criteria for high levels of anxiety and assigned 35 students to a group who were treated 

with biofeedback and 35 to a group of no-treatment controls. They reported a significant improvement in 

anxiety, somatization, and depression in the treatment group when compared to the controls. 

In conclusion, biofeedback of various modalities is effective for anxiety reduction. It is often 

found to compare favorably with other behavioral techniques and occasionally found to be superior to 

those and medication alone. 

References 

Bont, J.I.C., Castilla, C.D.S., & Maranon, P.P. (2004). Comparison of three fear of flying therapeutic 

programs. Psicothema, 16(4), 661-666. 

Corrado, P., Gottlieb, H., & Abdelhamid, M.H. (2003). The effect of biofeedback and relaxation training 

on anxiety and somatic complaints in chronic pain patients. American Journal of Pain Management,

13(4), 133-139. 

Coy, P.C., Cardenas, S.J., Cabrera, D.M., Zirot, G.Z., & Claros, M.S. (2005). Psychophysiological and 

behavioral treatment of anxiety disorder. Salud Mental, 28(1), 28-37. 

Dong, W., & Bao, F. (2005). Effects of biofeedback therapy on the intervention of examination-caused 

anxiety. Chinese Journal of Clinical Rehabilitation, 9(32), 17-19. 

Fehring, R.J. (1983). Effects of biofeedback-aided relaxation on the psychological stress symptoms of 

college students. Nursing Research, 32(6), 362-366. 

Goodwin, E.A., & Montgomery, D.D. (2006). A cognitive-behavioral, biofeedback-assisted relaxation 

treatment for panic disorder with agoraphobia. Clinical Case Studies, 5(2), 112-125. 

Gordon, J.S., Staples, J.K., Blyta, A., & Bytyqi, M. (2004). Treatment of posttraumatic stress disorder in 

postwar Kosovo high school students using mind-body skills groups: A pilot study. Journal of Traumatic 

Stress, 17(2), 143-147. 

Hammond, D.C. (2003). QEEG-guided neurofeedback in the treatment of obsessive-compulsive disorder.

Journal of Neurotherapy, 7(2), 25-52. 

Hawkins, R.C., II, Doell, S.R., Lindseth, P., Jeffers, V., & Skaggs, S. (1980). Anxiety reduction in 

hospitalized schizophrenics through thermal biofeedback and relaxation training. Perceptual & Motor 

Skills, 51(2), 475-482. 
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Hurley, J.D., & Meminger, S.R. (1992). A relapse-prevention program: Effects of electromyographic 

training on high and low levels of state and trait anxiety. Perceptual and Motor Skills, 74(3, Pt. 1), 

699-705. 

Lehrer, P.M., Carr, R., Sargunaraj, D., & Woolfolk, R.L. (1994). Stress management techniques: Are they 

all equivalent, or do they have specific effects? Biofeedback & Self Regulation, 19(4), 353-401. 

Rice, K.M., Blanchard, E.B., & Purcell, M. (1993). Biofeedback treatments of generalized anxiety 

disorder: Preliminary results. Biofeedback & Self-Regulation, 18(2), 93-105. 

Roome, J.R., & Romney, D.M. (1985). Reducing anxiety in gifted children by inducing relaxation. 

Roeper Review, 7(3), 177-179. 

Sarkar, P., Rathee, S.P., & Neera, N. (1999). Comparative efficacy of pharmacotherapy and biofeedback 

among cases of generalised anxiety disorder. Journal of Projective Psychology & Mental Health, 6(1), 

69-77. 

Scandrett, S.L., Bean, J.L., Breeden, S., & Powell, S. (1986). A comparative study of biofeedback and 

progressive relaxation in anxious patients. Issues in Mental Health Nursing, 8(3), 255-271. 

Vanathy, S., Sharma, P.S.V.N., & Kumar, K.B. (1998). The efficacy of alpha and theta neurofeedback 

training in treatment of generalized anxiety disorder. Indian Journal of Clinical Psychology, 25(2), 

136-143. 

Wenck, L.S., Leu, P.W., & D’Amato, R.C. (1996). Evaluating the efficacy of a biofeedback intervention 

to reduce children’s anxiety. Journal of Clinical Psychology, 52(4), 469-473. 

Arthritis 

Level 3: Probably Efficacious

Both thermal and EMG biofeedback have been used to teach relaxation techniques to adults with 

chronic arthritis. A recent meta-analysis of 25 randomized controlled studies demonstrated significant 

pooled effect sizes post-intervention for pain, functional disability, psychological status, coping, and self 

efficacy (Astin, Becker, Soeken, Hochberg, & Berman, 2002). Thermal biofeedback coupled with 

cognitive behavioral therapy decreased pain behaviors, self-reports of pain intensity, and rheumatoid 

factor titer (a measure of disease activity), in comparison to control subjects and those receiving social 

support only (Bradley, 1985; Bradley et al. 1987). This intervention was associated with a reduction in 

rheumatoid arthritis–related clinic visits and days hospitalized, thereby decreasing medical costs (Young, 

Bradley, & Turner, 1995). EMG biofeedback also reduced duration, intensity, and quality of pain in 

comparison to control groups (Flor, Haag, Turk, & Koehler, 1983), and these beneficial effects were 

maintained two and a half years later (Flor, Haag, & Turk, 1986). Finally, a small study of eight six- to 

17-year-olds with juvenile rheumatoid arthritis were given relaxation training including EMG and thermal 

biofeedback; 50 to 62% of the children showed at least a 25% reduction in pain immediately after 

treatment, and 62 to 88% showed a 25% reduction by six-month follow up (Lavigne, Ross, Berry, & 

Hayford, 1992). 

References 

Astin, J.A., Beckner, W., Soeken, K., Hochberg, M.C., & Berman, B. (2002). Psychological interventions 

for rheumatoid arthritis: A meta-analysis of randomized controlled trials. Arthritis and Rheumatism,

47(3), 291-302. 
 Page 11

Bradley, L.A. (1985). Effects of cognitive-behavioral therapy on pain behavior of rheumatoid arthritis 

(RA) patients: Preliminary outcomes. Scandinavian Journal of Behaviour Therapy, 14(2), 51-64. 

Bradley, L.A., Young, L.D., Anderson, K.O., Turner, R.A., Agudelo, C.A., McDaniel, L.K., et al. (1987). 

Effects of psychological therapy on pain behavior of rheumatoid arthritis patients: Treatment outcome 

and six-month follow up. Arthritis and Rheumatism, 30(10), 1105-1114. 

Flor, H., Haag, G., & Turk, D.C. (1986). Long-term efficacy of EMG biofeedback for chronic rheumatic 

back pain. Pain, 27(2), 195-202. 

Flor, H., Haag, G., Turk, D.C., & Koehler, H. (1983). Efficacy of EMG biofeedback, pseudotherapy, and 

conventional medical treatment for chronic rheumatic back pain. Pain, 17(1), 21-31. 

Lavigne, J.V., Ross, C.K., Berry, S.L., & Hayford, J.R. (1992). Evaluation of a psychological treatment 

package for treating pain in juvenile rheumatoid arthritis. Arthritis Care & Research, 5(2), 101-110. 

Young, L.D., Bradley, L.A., & Turner, R.A. (1995). Decreases in health care resource utilization in 

patients with rheumatoid arthritis following a cognitive behavioral intervention. Biofeedback and SelfRegulation, 20(3), 259-268. 

Asthma 

Level 2: Possibly Efficacious 

 A review of all randomized controlled research on relaxation techniques to affect asthma 

(Huntley, White, & Ernst, 2002) failed to find convincing evidence of efficacy as measured by pulmonary 

function testing or symptom change. Biofeedback studies were included, mostly using EMG. A second 

review of biofeedback interventions also showed little evidence biofeedback can substantially contribute 

to the treatment of asthma (Ritz, Dahme, & Roth, 2004). Finally, a Cochrane systematic review of 15 

studies involving 687 participants led to the inability to draw firm conclusions for the role of 

psychological interventions in asthma, mainly because of the inadequate evidence base (Yorke, Fleming, 

& Shuldham, 2007). This review did report, however, a significant difference in forced expiratory volume 

(FEV1) with biofeedback. 

A study examining the effect of EMG feedback on immune system components found changes in 

neutrophils and basophils, suggestive of reduced inflammation, along with some improvement in asthma 

symptoms (Kern-Buell, McGrady, Conran, & Nelson, 2000). Respiratory sinus arrhythmia training (selfregulation of breathing for maximum heart rate variability) seems to produce beneficial changes in asthma 

symptoms and reductions in respiratory impedance (Lehrer, Carr, et al. 1997; Lehrer, Smetankin, & 

Potapova, 2000). 

 More recent work using heart rate variability biofeedback showed those in the treatment groups 

were prescribed less medication than those in the control groups and improved an average of one full 

level of asthma severity (Lehrer, Vaschillo, Vaschillo, et al. 2004). The decreases in the need for 

controller medication were independent of age (Lehrer, Vaschillo, Lu, et al. 2006). There is also 

some evidence that capnometry-assisted breathing training can raise end-tidal pCO2, resulting in a 

decrease in respiratory rate and frequency and distress of symptoms of asthma (Meuret, Ritz, Wilhelm, & 

Roth, 2007). 

References 

Huntley, A., White, A.R., & Ernst, E. (2002). Relaxation therapies for asthma: A systematic review. 

Thorax, 57(2), 127-131. 
 Page 12

Kern-Buell, C.L., McGrady, A.V., Conran, P.B., & Nelson, L.A. (2000). Asthma severity, 

psychophysiological indicators of arousal and immune function in asthma patients undergoing 

biofeedback-assisted relaxation. Applied Psychophysiology and Biofeedback, 25(2), 79-91. 

Lehrer, P., Carr, R.E., Smetankin, A., Vaschillo, E., Peper, E., Porges, S., et al. (1997). Respiratory sinus 

arrhythmia versus neck/trapezius EMG and incentive inspirometry biofeedback for asthma: A pilot study. 

Applied Psychophysiology and Biofeedback, 22(2), 95-109. 

Lehrer, P., Smetankin, A., & Potapova, T. (2000). Respiratory sinus arrhythmia biofeedback therapy for 

asthma: A report of 20 unmedicated pediatric cases using the Smetankin method. Applied 

Psychophysiology and Biofeedback, 25(3), 193-200. 

Lehrer, P., Vaschillo, E., Lu, S.E., Eckberg, D., Vaschillo, B., Scardella, A., et al. (2006). Heart rate 

variability biofeedback: Effects of age on heart rate variability, baroreflex gain, and asthma. Chest,

129(2), 278-284. 

Lehrer, P.M., Vaschillo, E., Vaschillo, B., Lu, S.E., Scardella, A., Siddique, M., et al. (2004). 

Biofeedback treatment for asthma. Chest, 126(2), 352-361. 

Meuret, A.E., Ritz, T., Wilhelm, F.H., & Roth, W.T. (2007). Targeting pCO2 in asthma: Pilot evaluation 

of a capnometry-assisted breathing training. Applied Psychophysiology and Biofeedback, 32(2), 99-109. 

Ritz, T., Dahme, B., & Roth, W.T. (2004). Behavioral interventions in asthma: Biofeedback techniques.

Journal of Psychosomatic Research, 56(6), 711-720. 

Yorke, J., Fleming, S.L., & Shuldham, C.M. (2007). Psychological interventions for adults with asthma.

Cochrane Database of Systematic Reviews, CD002982. 

Attention Deficit Hyperactivity Disorder (ADHD) 

Level 4: Efficacious 

A variety of techniques such as slow cortical potentials, hemoencephalographic feedback, and 

cranial electrotherapy for treatment of ADHD have recently been reported. However, the majority of 

biofeedback studies have utilized EEG biofeedback; therefore, this technique will be the only one used to 

evaluate the efficacy for this disorder. The other techniques will be briefly presented at the end of this 

section.Even studies using EEG biofeedback to treat ADHD are difficult to summarize because they use a 

variety of training protocols and a variety of outcome measures. However, because the majority of studies 

used protocols that were directed toward reducing the abundance of slow frequencies while increasing the 

abundance of fast frequencies, some generalizations across studies are warranted. Numerous case studies; 

a multitude of treatment-only studies; some treatment compared to wait-list or no-treatment controls; and 

a few random-assignment, treatment-comparison groups have been reported. There are also a few review 

articles. These review articles should be evaluated with caution as they tend to have many of the same 

studies incorporated within their results. While the majority of the review articles conclude EEG 

biofeedback is effective when compared to no treatment, a placebo, or another treatment group, some of 

the reviews find fault with either the methodologies or outcome measurements of some studies. 

 Earlier uncontrolled studies using neurofeedback (NF) contingent on decreasing slow wave 

activity and increasing fast wave activity show persons with ADHD improved in symptoms, intelligence 

score, and academic performance (Grin’-Yatsenko et al. 2001; Lubar, Swartwood, Swartwood, & 

O’Donnell, 1995; Thompson & Thompson, 1998). In one study, only those individuals who significantly 

reduced theta over the training sessions showed a 12-point increase in Wisconsin Intelligent scale for 
 Page 13

children-revised (WISC-R) IQ, improved Test of Variables of Attention (TOVA), and Attention Deficit 

Disorders Evaluation Scale (ADDES) rating score (Lubar et al. 1995). One large multicenter study (1,089 

participants, aged five to 67 years) showed sensorimotor-beta EEG biofeedback training led to significant 

improvement in attentiveness, impulse control, and response variability as measured on the TOVA 

(Kaiser & Othmer, 2000) in those with moderate pretraining deficits. 

A few early controlled studies compared EEG biofeedback to other treatments. The first of these 

was a study with four hyperkinetic children under six conditions: 1) no drug, 2) drug only, 3) drug and 

sensory motor rhythm (SMR) training, 4) drug and SMR reversal training, 5) drug and SMR training II, 

and 6) no drug and SMR training (Shouse & Lubar, 1979). Combining medication and SMR training 

resulted in substantial improvements in behavioral indices that exceeded the effects of drugs alone and 

were sustained with SMR training after medication was withdrawn. These changes were absent in the one 

highly distractible child who failed to acquire the SMR task. 

In a study of 16 elementary-age children who were randomly assigned to conditions comparing 

EEG biofeedback to a waiting-list control, Carmody, Radvanski, Wadhwani, Sabo, and Vergara (2001) 

reported conflicting outcomes as measured by the TOVA and teacher reports. They found improvements 

in the reduction of errors of commission, anticipation, and attention, but no improvements in impulsivity 

or hyperactivity. Another small (n=18) controlled study showed increased intelligence scores and reduced 

inattentive behaviors as rated by parents in comparison to the waiting-list control (Linden, Habib, & 

Radojevic, 1996). Another study by Rossiter and La Vaque (1995) comparing EEG biofeedback to 

stimulant medication demonstrated both groups improved on measures of inattention, impulsivity, 

information processing, and variability as measured by the TOVA. Since 2002, a number of studies on the 

effectiveness of EEG biofeedback have been published, and they are presented briefly below. Some are 

outcome studies, and where available, the methodologies and outcome measures are presented while 

others are reviews. Some studies were not based on slow-wave reduction and fast-wave enhancement, so 

their techniques need to be considered separately from the typical EEG biofeedback protocol. 

In a study of EEG biofeedback and stimulant medication effects, Fuchs, Birbaumer, 

Lutzenberger, Gruzelier, and Kaiser (2003) compared the effects of a three-month EEG biofeedback 

program providing reinforcement contingent on the production of cortical SMR (12-15 Hz) and beta-l 

activity (15-18 Hz) with stimulant medication. Participants were aged eight to 12 years; 22 were assigned 

to the EEG biofeedback group and 12 to the methylphenidate group according to their parents’ 

preference. Both EEG biofeedback and methylphenidate were associated with improvements on all 

subscales of the TOVA and on the speed and accuracy measures of the d2 Attention Endurance Test. 

Furthermore, behaviors related to the disorder were rated as significantly reduced in both groups by both 

teachers and parents on the IOWA-Conners Behavior Rating Scale. Another study relating stimulant 

medication to EEG biofeedback training reported 16 of 24 patients taking medications were able to lower 

their dose or discontinue medication totally after 30 sessions of EEG biofeedback (Alhambra, Fowler, & 

Alhambra, 1995). Finally, Monastra, Monastra, and George (2002) studied one hundred children with 

ADHD receiving Ritalin, parent counseling, and academic support at school. Based on parent preference, 

50 children also received EEG biofeedback. While children improved on the TOVA and an ADHD 

evaluation scale while taking Ritalin, only those who had EEG biofeedback sustained these improvements 

without Ritalin. 

In a multiple case study (n=7), five participants completed an ABAB reversal methodology 

designed to alter the SMR/theta ratio in ADHD children (Heywood & Beale, 2003). Two participants 

failed to complete all training sessions, and the effects of training on behavior were analyzed both 

including and excluding these noncompleters. During alternate periods, they were trained using a placebo 

protocol identical to the treatment protocol except the association between EEG patterns and feedback 

was random. When all participants were included in analyses that controlled for overall trend, EEG 

biofeedback was found to be no more effective than the placebo control condition involving 

noncontingent feedback, and neither procedure resulted in improvements relative to baseline levels. The 
 Page 14

authors state, correctly, the chosen single-case design elements control for the effects of internal validity, 

such as maturation, history, and treatment order, but it does not control for carry-over from a treatment 

that has sustained effects, which EEG biofeedback has been shown to have in numerous studies. Because 

of a small number in the control group (n=2), possible carry-over effects, and a limited number of 

treatments (eight to 11), the reported lack of difference is tenuous at best. 

Pryjmachuk (2003) presented a review of randomized controlled trials (RCTs) evaluating 

treatment for ≥ 12 weeks in children with ADHD. Articles were selected if they were full reports 

published in any language in peer-reviewed journals. Fourteen RCTs (1,379 participants, 42% in one 

RCT) met the selection criteria. The findings relevant to EEG biofeedback state EEG biofeedback was 

superior to no treatment (one RCT), and treatment with EEG biofeedback led to better results on an 

intelligence test than did a waiting-list control (one RCT). 

In a replication of a previous study (Rossiter & La Vaque, 1995), Rossiter (2004) reports on a 

study with a larger sample, expanded age range, and improved statistical analysis. Thirty-one ADHD 

patients who chose stimulant drug treatment were matched with 31 patients who chose an EEG 

biofeedback treatment program. EEG biofeedback patients received either office (n = 14) or home (n = 

17) EEG biofeedback. Stimulants for medication patients were titrated using the (TOVA). Both groups 

showed statistically and clinically significant improvement on the TOVA measures of attention, impulse 

control, processing speed, and variability in attention. The EEG biofeedback group demonstrated 

statistically and clinically significant improvement on behavioral measures (Behavior Assessment System 

for Children and Brown Attention Deficit Disorder Scales). The TOVA Confidence interval and 

nonequivalence null hypothesis testing confirmed the EEG biofeedback program produced outcomes 

equivalent to those obtained with stimulant drugs. 

To explore the effectiveness of EEG biofeedback on children with ADHD, a randomized selfcontrolled study with assessment taken before and after treatment was conducted (Chen et al. 2004). A 

total of 30 ADHD children were selected for the study from the Children's Mental Health Clinic of 

Nanjing Brain Hospital. Children were treated with EEG biofeedback. The Integrated Visual and 

Auditory continuous performance test (IVA) was used to evaluate before treatment and after 20 and 40 

treatments. Main outcome measures were the control quotient and attention quotient of the IVA. After 20 

treatments, the control quotients significantly increased and continued to significantly increase after 40 

treatments 

Cho et al. (2004) reported a study on the effectiveness of EEG biofeedback, along with virtual 

reality (VR), in reducing the level of inattention and impulsiveness. Twenty-eight male adolescents with 

social problems took part in this study. They were separated into three groups: a control group, a VR 

group, and a nonVR group. Both the VR and nonVR groups underwent eight sessions of EEG 

biofeedback training while the control group just waited during the same period. All participants 

performed a continuous performance task (CPT) before and after the complete training session. The 

results showed both the VR and nonVR groups (both also received EEG biofeedback training) achieved 

better scores in the CPT after training while the control group showed no significant difference. 

Eisenberg, Ben-Daniel, Mei-Tal, and Wertman (2004) reported a study to determine the effect of 

a new noninvasive technique of noncognitive biofeedback called Autonomic Nervous System 

Biofeedback Modality on the behavioral and attention parameters of a sample of children with attention 

deficit hyperactivity disorder. Nineteen subjects who met DSM-IV criteria for ADHD received four 

sessions of Autonomic Nervous System Biofeedback Modality treatment. The heart rate variability was 

measured before and after the treatment, as were measures of efficacy, including Conners Teacher 

Questionnaires (28 items), the Child Behavior Check List for parents and teachers, and Continuous 

Performance Test. Positive treatment effect was observed in all the subjects. A positive correlation 

between heart rate variability changes and improvement of symptoms of attention deficit hyperactivity 

disorder was found. 
 Page 15

Orlando and Rivera (2004) selected a number of elementary students (n=28) with identified 

learning problems for EEG biofeedback. Pre- and post-test reading and cognitive assessments were 

administered to sixth-, seventh-, and eighth-graders. Control and experimental groups were chosen at 

random. EEG biofeedback training was provided to the participants of the experimental group only. The 

control group had no treatment, just normal school-related activities. Seventeen students were assigned to 

each group. For various reasons, 12 finished treatment, and 14 were available for post measures in the 

control group. EEG biofeedback training lasted approximately 30 to 45 minutes and was conducted 

weekly for seven months. Some students received more sessions than others because of absences, field 

trips, testing, and other natural rhythms of home and school life. The average number of sessions per 

student was 28. EEG biofeedback was significantly more effective in improving scores on reading tests 

than no EEG biofeedback training. There were significant interactions between EEG biofeedback and 

time on basic reading, and EEG biofeedback training was more effective in improving both the verbal and 

full-scale IQ scores than no EEG biofeedback training. There was a significant interaction between EEG 

biofeedback and time on verbal IQ and on full-scale IQ. There was a trend interaction for EEG 

biofeedback and performance IQ, but it was not significant. The results support the hypothesis that 

biofeedback training is effective in improving reading quotients and IQ in LD children. 

In a study by Hanslmayr, Sauseng, Doppelmayr, Schabus, and Klimesch (2005), increasing upper 

alpha power while lowering theta in eight sessions improved cognitive functioning as measured by a 

mental rotation task performed before and after training. Only those subjects who were able to increase 

their upper alpha power performed better. Training success (extent of EEG biofeedback training–induced 

increase in upper alpha power) was positively correlated with the improvement in cognitive performance 

and significant increase in reference upper alpha power. 

Fleischman and Othmer (2005) reported a case study of mildly developmentally delayed twins. 

They observed improvements in IQ scores and maintenance of the gains following EEG biofeedback. 

Full-scale IQ scores increased 22 and 23 points after treatment and were maintained at three follow-up 

retests over a 52-month period. ADHD symptom checklists completed by their mother showed a similar 

pattern of improvement and maintenance of gains. 

Jacobs (2005) describes the application of EEG biofeedback with two children who manifested 

multiple diagnoses, including learning disabilities (LD), ADHD, social deficits, mood disorders, and 

pervasive developmental disorder (PDD). Both boys had adjusted poorly to school, family, and peers. 

They received individualized protocols based on their symptoms and functional impairments. They were 

administered semiweekly 20-minute sessions of one-channel EEG biofeedback training for approximately 

six months. In both cases, symptoms were identified and tracked with a parent rating scale and one case 

with the Symptom Assessment-45 questionnaire (SA-45) also. Each boy improved in all tracked 

symptoms without adverse effects. 

In a study (Kropotov et al. 2005) of the effects of EEG biofeedback on Evoked Response 

Potentials (ERP)s in 86 ADHD children (ages nine to 14), ERPs were recorded in an auditory Go/No Go 

task before and after 15 to 22 sessions of EEG biofeedback. Each session consisted of 20 minutes of 

enhancing the ratio of the EEG power in the 15-18 Hz band compared to the EEG power in the rest of 

spectrum and seven to 10 minutes of enhancing the ratio of the EEG power in 12-15 Hz to the EEG power 

in the rest of spectrum. On the basis of quality of performance during training sessions, the patients were 

divided into two groups: good performers and bad performers. ERPs of good performers to Go and No 

Go cues gained positive components evoked within 180-420 ms latency. At the same time, no statistically 

significant differences between pre- and post-training ERPs were observed for bad performers. The ERP 

differences between post- and pre-treatment conditions for good performers were distributed over frontalcentral areas and appear to reflect an activation of frontal cortical areas associated with beta training. 

A series of three studies by Li and collegues are reported below: Li, Wu, & Chang, (2003) 

investigated the therapeutic effect of EEG biofeedback for ADHD. Sixty children aged six to 10 years 
 Page 16

were selected (30 children with attention deficit associated with hyperkinetic syndrome in the 

experimental group; 30 healthy children in the control group). The EEG recorded from the experiment 

group was significantly different from the control group. There was no significant difference in EEG 

between male and female children. Ten children received EEG biofeedback training and showed brain 

function was improved. In a second study by Li and Yu-Feng (2005), ADHD children with comorbid tic 

disorder (n=14) received EEG biofeedback treatment (average 34 sessions). The outcome was evaluated 

with a variety of outcome measures before and after treatment. Significant reductions in multiple 

symptoms were reported. Tic symptoms were greatly reduced in all but two children who also had 

Tourette’s syndrome. In the third study (Li, Tang, et al. 2005), 113 outpatient children (88 male and 25 

female, mean age of 10 ± three years) from the Psychology Hyperactivity Department of the Central 

Hospital of Anshan City were selected. Inclusion criteria were from six to 14 years of age. Exclusion 

criteria were nervous system organic diseases, pervasive developmental disorder (PDD), mental 

retardation, epilepsy, psychotic disorder, and acoustical and visual abnormalities. ADHD children were 

diagnosed, and then the EEG diagnostic accuracy was calculated. The diagnostic sensitivity of EEG on 

ADHD was 83.58%, the specificity was 82.61%, and misdiagnosis was 16.4%. These results compare 

favorably with the diagnostic accuracy of the Intermediate Visual and Auditory test (IVA). The EEG 

biofeedback system was also used for EEG biofeedback with 27 ADHD children. Conners Parent 

Symptom Questionnaire was used to assess pre- and post-hyperactivity levels. There was a significant 

difference between the EEG values before and after treatment, and the hyperactivity index scores were 

significantly declined from pre-treatment to post-treatment. 

 A study by Pop-Jordanova, Markovska-Simoska and Zorcec (2005) comprised 12 children of 

both sexes diagnosed as ADHD with the mean age of nine and a half years (seven to 13 years old). Each 

participated in a five-month program of EEG biofeedback training performed twice weekly. Posttreatment results showed improved EEG patterns expressed in increased 16-20 Hz (beta) activity and 

decreased 4-8 Hz (theta) activity. In parallel, higher scores on WISC-R, better school notes, and improved 

social adaptability and self-esteem were obtained. 

A report by Putman, Othmer, Othmer, and Pollock (2005) that used the TOVA as the outcome 

measure was divided into three categories: a) primarily attentional deficits (n=12), b) primarily 

psychological complaints (n=20), and c) both (n=12). Participants were 44 males and females, six to 62 

years old, who underwent treatment for a variety of clinical complaints. The TOVA was administered 

prior to EEG biofeedback training and 20 to 25 sessions thereafter. After EEG biofeedback training, 

significant improvements on omission, commission, and variability were observed. There was no change 

in reaction time. Reaction time was predominantly in the normal range for this population and remained 

unchanged following training. 

Functional magnetic resonance imaging (fMRI) was used by Beauregard and Levesque (2006) to 

measure the effect of EEG biofeedback training in ADHD children. Twenty unmedicated ADHD children 

participated. Fifteen children were randomly assigned to the group trained to enhance the amplitude of the 

SMR (12-15 Hz) and beta 1 activity (15-18 Hz) and to decrease the amplitude of theta activity (4-7 Hz); 

whereas, the other five children were randomly assigned to the no-treatment group. Both groups were 

scanned one week before the beginning of EEG biofeedback and one week after the end of EEG 

biofeedback while they performed a “Counting Stroop” task and a Go/No Go task. Changes were noted in 

several subcortical areas after biofeedback treatment in the EEG biofeedback group but not in the control 

group. These results suggest EEG biofeedback has the capacity to functionally normalize the brain 

systems mediating selective attention and response inhibition in ADHD children. 

A study reported by Zhang, Zhang, and Jin (2006) compared EEG biofeedback with 

methylphenidate in ADHD children who were treated at the Department of Child Health Care, Xinhua 

Hospital. Participants were randomly assigned to groups. The EEG biofeedback group received 

treatments of reinforcing 16-20 Hz and suppressing 4-8 Hz; EEG biofeedback treatment was provided 

three to five times per week continuously for three months, totaling 35 to 40 sessions. The children in the 
 Page 17

medication group were treated with methylphenidate every morning. The dose started at 5 mg and 

increased gradually with the patients’ conditions until the effects were satisfied without any adverse 

effect. The Conners Parent Rating Scale was utilized to assess the behavioral changes. The children in the 

EEG biofeedback group and medication group were evaluated at pre-treatment, post-treatment and one, 

three, and six months of follow ups. Forty children who received EEG biofeedback and 16 who received 

medication were involved in the result analysis. Half the children who received EEG biofeedback were 

those who did not respond to medication after at least three months, so EEG biofeedback was provided. 

After treatment, the EEG biofeedback group demonstrated significant decreases in scores on all factors of 

the Conners Parent Rating Scale compared to those at pretreatment and remained stable during a sixmonth follow up. The medication group also showed significant decreases in scores of all factors except 

psychosomatic disorder and anxiety compared with those at pretreatment. The scores of psychosomatic 

disorder and anxiety were significantly lower in the EEG biofeedback group than in the medication group 

at post-treatment. 

In a controlled study of effectiveness of EEG biofeedback training on children with ADHD, 

Zhong-Gui, Hai-Qing, and Shu-Hua (2006) reported EEG biofeedback training was applied for 30 

minutes, two times per week for 40 sessions. The IVA was adopted to evaluate the effectiveness of EEG 

biofeedback training. The results from 60 children indicated the overall indexes of IVA were significantly 

improved. 

In a study by Kropotov et al. (2007), it was reported that changes in EEG spectrograms, eventrelated potentials, and event-related desynchronisation were induced by relative beta training in ADHD 

children. EEG, ERPs, and event-related synchronization/desynchronization (ERD/ERS) were recorded 

and computed in an auditory Go/No Go task before and after 15 to 22 sessions of EEG biofeedback. 

Eighty-six ADHD children participated in the study. Each session consisted of 30 minutes of relative beta 

training. The patients were divided into two groups (good performers and poor performers) depending on 

their ability to elevate beta activity during sessions. Amplitude of late positive components of evoked 

potentials in response to No Go stimuli increased, and event-related synchronization in alpha frequency 

band measured at central areas decreased in the group of good performers but did not change for the poor 

performers group. Evoked potential differences between post- and pre-treatment conditions for good 

performers were distributed over frontal-central areas, reflecting activation of frontal cortical areas 

associated with beta training. This activation likely indicates recovery of normal functioning of the 

executive system, but unfortunately, no clinical outcome measures were reported. 

This study (Leins et al. 2007) compared EEG biofeedback training of theta-beta frequencies and 

training of slow cortical potentials (SCPs). SCP participants were trained to produce positive and negative 

SCP shifts while the theta/beta participants were trained to suppress theta while increasing beta. 

Participants were blind to group assignment. Each group comprised 19 children with ADHD (aged eight 

to 13 years). Both groups were able to intentionally regulate cortical activity and improved in attention 

and IQ. Parents and teachers reported significant behavioral and cognitive improvements. Clinical effects 

for both groups remained stable six months after treatment. Groups did not differ in behavioral or 

cognitive outcome. 

A summary of recently published review articles is presented below. Most of the review articles 

include many of the same original studies; therefore, caution needs to be exercised in their interpretation. 

Eighty-three studies were reviewed by Riccio and French (2004) to determine the status of 

treatments for ADHD. The studies were reviewed and categorized by the type of trial, whether or not 

the study included a control group, and the nature of the control group. The methodology of each study 

was then rated and assigned to one of four categories (commendable, acceptable, marginal, and seriously 

flawed). The results were then categorized into three categories (positive, negative, and inconclusive). 

Twenty studies were identified for treatment of ADHD with EEG biofeedback, and of those, seven 

were determined to have acceptable methodologies while 13 had marginal methodologies. The 
 Page 18

clinical outcome of these EEG biofeedback studies was positive for 18, inconclusive for one, and 

negative for one. 

In another review, Fox, Tharp, and Fox (2005) reported that, in the last 30 years, multiple studies 

have consistently shown differences between ADHD children and nonADHD children in that the ADHD 

children have a surplus of slow-wave activity, mostly in the delta and theta bands, and deficiencies in the 

alpha and beta bands. They state that 70 to 80% of ADHD children respond favorably to stimulant 

medication, 35% respond favorably to placebo, and 25 to 40% do not respond favorably to medication. 

However, multiple studies have shown when stimulant medication is withdrawn, the improvements seen 

during medication usage in the medication responders are no longer maintained. In a summary of five 

EEG biofeedback outcome studies, they reported consistent improvements in behavior, IQ, and rating 

scales comparable to medication usage, and only those trained in biofeedback maintained their 

improvements when the treatment was withdrawn. 

In a review, Loo and Barkley (2005) report EEG measures have been used to study brain 

processes in children with ADHD for more than 30 years, and this research supports the EEG differences 

between ADHD and nonADHD children. The differences are primarily in the frontal and central areas 

with theta activity being more abundant and beta activity less abundant; therefore, the theta-beta ratio is 

consistently and diagnostically larger in ADHD than nonADHD children. They report evidence of a 

possible percentage of ADHD subtypes for which the EEG activity described above does not fit, and a 

number of these individuals seem to be between 10 and 20% of all ADHD children. Thompson and 

Thompson (2005) report these subtypes show distinctively different EEG patterns with an abundance of 

high-frequency beta. The reviewers report that, more recently, EEG has been used, not only in research to 

describe and quantify underlying neurophysiology of ADHD but also clinically in the assessment, 

diagnosis, and treatment of ADHD. For the treatment of ADHD with EEG biofeedback, they reported 

mixed results based on one study from an unpublished presentation at the American Psychological 

Association meeting in 1994 (so methodology and outcome assessment techniques cannot be determined) 

and three controlled studies. Of these three studies, one had a single-case design that was inappropriate 

for a treatment such as EEG biofeedback, which has a demonstrated carry-over effect. The two others 

demonstrated positive outcomes but were dismissed on what were viewed as weak methodical grounds 

because the studies did not use methodologies typically associated with pharmaceutical studies but used 

procedures usually associated with acceptable behavioral outcome studies. 

In a series of review articles (Monastra, 2005; Monastra et al. 2005; Monastra et al. 2006), the 

authors report, in the past three decades, EEG biofeedback has emerged as a nonpharmacologic treatment 

for ADHD. These articles present imaging and EEG findings that support the theory of cortical 

hypoarousal, especially in the central and frontal regions of the cortex and that this intervention was 

derived from operant conditioning studies. These conditioning studies have demonstrated the capacity for 

neurophysiologic training in both humans and other mammals and targets atypical patterns of cortical 

activation that have been identified consistently in neuroimaging and quantitative EEG studies. The 

research findings published to date from case studies and controlled clinical outcome studies have 

reported increased cortical activation on quantitative electroencephalographic examination, improved 

attention and behavioral control, gains on tests of intelligence, improvement on self- and other rating 

scales, improved CPTs, and academic achievement. Three standard protocols of SMR enhancement and 

beta reduction, theta enhancement and beta reduction, and SMR enhancement and beta reduction are also 

presented. 

A number of biofeedback articles based on techniques other than EEG biofeedback are presented 

below. These articles are presented in this section rather than the Emerging Applications section because 

they are treating individuals diagnosed with ADHD. 

The effect of ROSHI protocol and cranial electrotherapy stimulation on a nine-year-old anxious, 

dyslexic male with attention deficit disorder was studied by Overcash (2005). Psychological testing was 
 Page 19

administered, and QEEGs were recorded before and after treatment intervention. The patient was treated 

using the ROSHI Complex Adaptive Protocol, Cranial Electrotherapy Stimulation, and the Project Read 

Reading Program. This multimodal treatment lasted six months with follow-up testing administered 15 

months after initial diagnostic testing. Before and after, objective psychological test results and QEEG 

changes indicate significant improvement in reading, math, and spelling achievement and significant 

reduction in anxiety and ADD symptoms. 

Mize (2004) reported a single case study of hemoencephalography (HEG) with a 12-year-old 

male who had a well-established diagnosis of ADHD. He was performing well in school on Concerta 36 

mg at 7am and Ritalin 5 mg at 4pm. Off medication, he had significant abnormalities on IVA testing 

(attention quotient or AQ = 78) and in the QEEG. IVA and clinical status measurements were made 

before and after 10 sessions. Following the 10 sessions, the participant was tested off medication and 

showed a normal QEEG with improved Z scores for relative power and a normal IVA (AQ = 99.75). 

These results persisted in an 18-month follow up. His medication was lowered to Focalin 2.5 mg twice 

daily. 

In a study designed to test the effectiveness of self-regulation of slow cortical potentials in 

children with ADHD (Strehl et al. 2006), 23 children with ADHD aged between eight and 13 years 

received 30 sessions of self-regulation training of slow cortical potentials in three phases of 10 sessions 

each. Feedback was provided while increasing and decreasing slow cortical potentials at central brain 

regions. Measurement before and after the trials showed that children with ADHD learned to regulate 

negative slow cortical potentials. After training, significant improvement in behavior, attention, and IQ 

score were observed. All changes proved to be stable at six months’ follow up after the end of training. 

Clinical outcome was predicted by the ability to produce negative potential shifts in transfer sessions 

without feedback. In summary, based on these studies and the reviews, EEG biofeedback has typically 

been shown to be superior to control conditions and equivalent to other treatments such as stimulant 

medication. 

The utilization of EEG measures to facilitate diagnostic determination and protocol determination 

is strongly supported. Because the EEG protocols vary widely in specific bandwidths and thresholds 

selection, it is prudent for the practioner to know the literature to determine which specific settings to use 

for each client. In addition to the EEG assessment, multiple assessments, including psychological, family, 

and medical history; a clinical interview; and standardized assessments, such as a continuous performance 

test and ratings scales, should be used to formulate a comprehensive treatment plan. EEG biofeedback 

techniques other than those focused on EEG patterns are also under development. Further studies are 

needed to examine long-term effects of training sessions and whether or not refresher sessions are needed 

to maintain the effects. 

References 

Alhambra, M.A., Fowler, T.P., & Alhambra, A.A. (1995). EEG biofeedback: A new treatment option for 

ADD/ADHD. Journal of Neurotherapy, 1(2), 39-43. 

Beauregard, M., & Levesque, J. (2006). Functional magnetic resonance imaging investigation of the 

effects of EEG biofeedback training on the neural bases of selective attention and response inhibition in 

children with attention-deficit/hyperactivity disorder. Applied Psychophysiology and Biofeedback, 31(1), 

3-20. 

Carmody, D.P., Radvanski, D.C., Wadhwani, S., Sabo, M.J., & Vergara, L. (2001). EEG biofeedback 

training and attention-deficit/hyperactivity disorder in an elementary school setting. Journal of 

Neurotherapy, 4(3), 5-27. 

Chen, Y., Jiao, G., Wang, C., Ke, X., Wang, M., & Chen, Y. (2004). Therapeutic effectiveness of 

electroencephalography biofeedback on children with attention deficit hyperactivity disorder. Chinese 

Journal of Clinical Rehabilitation, 8(18), 3690-3691. 
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Cho, B.H., Kim, S., Shin, D.I., Lee, J.H., Lee, S.M., Kim, I.Y., et al. (2004). EEG biofeedback training 

with virtual reality for inattention and impulsiveness. Cyberpsychology & Behavior: The Impact of the 

Internet, Multimedia and Virtual Reality on Behavior and Society, 7(5), 519-526. 

Eisenberg, J., Ben-Daniel, N., Mei-Tal, G., & Wertman, E. (2004). An autonomic nervous system 

biofeedback modality for the treatment of attention deficit hyperactivity disorder — an open pilot study. 

The Israel Journal of Psychiatry and Related Sciences, 41(1), 45-53. 

Fleischman, M.J., & Othmer, S. (2005). Case study: Improvements in IQ score and maintenance of gains 

following EEG biofeedback with mildly developmentally delayed twins. Journal of Neurotherapy, 9(4), 

35-46. 

Fox, D.J., Tharp, D.F., & Fox, L.C. (2005). NF: An alternative and efficacious treatment for attention 

deficit hyperactivity disorder. Applied Psychophysiology and Biofeedback, 30(4), 365-373. 

Fuchs, T., Birbaumer, N., Lutzenberger, W., Gruzelier, J.H., & Kaiser, J. (2003). Neurofeedback 

treatment for attention-deficit/hyperactivity disorder in children: A comparison with methyphenidate. 

Applied Psychophysiology and Biofeedback, 28(1), 1-12. 

Grin’-Yatsenko, V.A., Kropotov, Yu., D., Ponomarev, V.A., Chutko, L.S., & Yakovenko, E.A. (2001). 

Effect of biofeedback training of sensorimotor and beta-sub-1EEG rhythms on attention parameters. 

Human Physiology, 27(3), 259-266. 

Hanslmayr, S., Sauseng, P., Doppelmayr, M., Schabus, M., & Klimesch, W. (2005). Increasing individual 

upper alpha power by EEG biofeedback improves cognitive performance in human subjects. Applied 

Psychophysiology and Biofeedback, 30(1), 1-10. 

Heywood, C., & Beale, I. (2003). EEG biofeedback vs. placebo treatment for attentiondeficit/hyperactivity disorder: A pilot study. Journal of Attention Disorders, 7(1), 43-55. 

Jacobs, E.H. (2005). EEG biofeedback treatment of two children with learning, attention, mood, social, 

and developmental deficits. Journal of Neurotherapy, 9(4), 55-70. 

Kaiser, D.A., & Othmer, S. (2000). Effect of neurofeedback on variables of attention in a large 

multicenter trial. Journal of Neurotherapy, 4(1), 5-15. 

Kropotov, J.D., Grin’-Yatsenko, V.A., Ponomarev, V.A., Chutko, L.S., Yakovenko, E.A., & Nikishena, 

I.S. (2005). ERPs correlates of EEG relative beta training in ADHD children. International Journal of 

Psychophysiology: Official Journal of the International Organization of Psychophysiology, 55(1), 23-34. 

Kropotov, J.D., Grin’-Yatsenko, V.A., Ponomarev, V.A., Chutko, L.S., Yakovenko, E.A., & Nikishena, 

I.S. (2007). Changes in EEG spectrograms, event-related potentials, and event-related desynchronization 

induced by relative beta training in ADHD children. Journal of Neurotherapy, 11(2), 3-11. 

Leins, U., Goth, G., Hinterberger, T., Klinger, C., Rumpf, N., & Strehl, U. (2007). EEG biofeedback for 

children with ADHD: A comparison of SCP and theta/beta protocols. Applied Psychophysiology and 

Biofeedback, 32(2), 73-88. 

Li, G., Wu, B., & Chang, S. (2003). Diagnosis and treatment for child attention deficit and hyperactivity 

disorder by biofeedback electroencephalograph. Chinese Journal of Clinical Rehabilitation, 7(22), 

3104-3105. 

Li, L., & Yu-Feng, W. (2005). EEG biofeedback treatment on ADHD children with comorbid tic 

disorder. Chinese Mental Health Journal, 19(4), 262-265. 

Li, Y., Tang, Y., Liu, B., Long, S., Sun, G., Shen, L., et al. (2005). Electroencephalogram diagnosis and 

biofeedback treatment for the child with attention deficit hyperactivity disorder. Chinese Journal of 

Clinical Rehabilitation, 9(8), 236-237. 
 Page 21

Linden, M., Habib, T., & Radojevic, V. (1996). A controlled study of the effects of EEG biofeedback on 

cognition and behavior of children with attention deficit disorder and learning disabilities. Biofeedback 

and Self Regulation, 21(1), 35-49. 

Loo, S.K., & Barkley, R.A. (2005). Clinical utility of EEG in attention deficit hyperactivity disorder. 

Applied Neuropsychology, 12(2), 64-76. 

Lubar, J.F., Swartwood, M.O., Swartwood, J.N., & O’Donnell, P.H. (1995). Evaluation of the 

effectiveness of EEG neurofeedback training for ADHD in a clinical setting as measured by changes in 

TOVA scores, behavioral ratings, and WISC-R performance. Biofeedback and Self Regulation, 20(1), 

83-99. 

Mize, W. (2004). Hemoencephalography — A new therapy for attention deficit hyperactivity disorder 

(ADHD): Case report. Journal of Neurotherapy, 8(3), 77-97. 

Monastra, V.J. (2005). Electroencephalographic biofeedback (neurotherapy) as a treatment for attention 

deficit hyperactivity disorder: Rationale and empirical foundation. Child and Adolescent Psychiatric 

Clinics of North America, 14(1), 55-82. 

Monastra, V.J., Lynn, S., Linden, M., Lubar, J.F., Gruzelier, J., & La Vaque, T.J. (2006). 

Electroencephalographic biofeedback in the treatment of attention-deficit/hyperactivity disorder. Journal 

of Neurotherapy, 9(4), 5-34. 

Monastra, V.J., Lynn, S., Linden, M., Lubar, J.F., Gruzelier, J., & LaVaque, T.J. (2005). 

Electroencephalographic biofeedback in the treatment of attention-deficit/hyperactivity disorder. Applied 

Psychophysiology and Biofeedback, 30(2), 95-114. 

Monastra, V.J., Monastra, D.M., & George, S. (2002). The effects of stimulant therapy, EEG 

biofeedback, and parenting style on the primary symptoms of attention-deficit/hyperactivity disorder. 

Applied Psychophysiology and Biofeedback, 27(4), 231-249. 

Orlando, P.C., & Rivera, R.O. (2004). Elementary students with identified learning problems. Journal of 

Neurotherapy, 8(2), 5-19. 

Overcash, S.J. (2005). The effect of ROSHI protocol and cranial electrotherapy stimulation on a nineyear-old anxious, dyslexic male with attention deficit disorder: A case study. Journal of Neurotherapy, 

9(2), 63-77. 

Pop-Jordanova, N., Markovska-Simoska, S., & Zorcec, T. (2005). EEG biofeedback treatment of children 

with attention deficit hyperactivity disorder. Prilozi/Makedonska akademija na naukite i umetnostite, 

Oddelenie za bioloski i medicinski nauki — Contributions/Macedonian Academy of Sciences and Arts, 

Section of Biological and Medical Sciences, 26(1), 71-80. 

Pryjmachuk, S. (2003). Review: Extended stimulant medication is effective in children with attention 

deficit hyperactivity disorder. Evidence-Based Nursing, 6(1), 11-11. 

Putman, J.A., Othmer, S.F., Othmer, S., & Pollock, V.E. (2005). TOVA results following interhemispheric bipolar EEG training. Journal of Neurotherapy, 9(1), 37-52. 

Riccio, C.A., & French, C.L. (2004). The status of empirical support for treatments of attention deficits. 

The Clinical Neuropsychologist, 18(4), 528-558. 

Rossiter, T.R. (1998). Patient-directed neurofeedback for ADHD. Journal of Neurotherapy, 2(4), 54-63. 

Rossiter, T.R., & La Vaque, T.J. (1995). A comparison of EEG biofeedback and psychostimulants in 

treating attention deficit/hyperactivity disorders. Journal of Neurotherapy, 1(1), 48-59. 

Rossiter, T. (2004). The effectiveness of EEG biofeedback and stimulant drugs in treating AD/HD: Part 

II. Replication. Applied Psychophysiology and Biofeedback, 29(4), 233-243. 
 Page 22

Shouse, M.N., & Lubar, J.F. (1979). Operant conditioning of EEG rhythms and Ritalin in the treatment of 

hyperkinesis. Biofeedback and Self Regulation, 4(4), 299-312. 

Strehl, U., Leins, U., Goth, G., Klinger, C., Hinterberger, T., & Birbaumer, N. (2006). Self-regulation of 

slow cortical potentials: A new treatment for children with attention-deficit/hyperactivity disorder. 

Pediatrics, 118(5), e1530-1540. 

Thompson, L., & Thompson, M. (1998). Neurofeedback combined with training in metacognitive 

strategies: Effectiveness in students with ADD. Applied Psychophysiology and Biofeedback, 23(4), 

243-263. 

Thompson, L., & Thompson, M. (2005). Neurofeedback intervention for adults with ADHD. Journal of 

Adult Development, 12(2), 123-130. 

Zhang, F., Zhang, J., & Jin, X. (2006). Effect of electroencephalogram biofeedback on behavioral 

problems of children with attention deficit hyperactivity disorder. Chinese Journal of Clinical 

Rehabilitation, 10(10), 74-76. 

Zhong-Gui, X., Hai-Qing, X., & Shu-Hua, S. (2006). The controlled study of effectiveness of EEC 

biofeedback training on children with attention deficit hyperactivity disorder. Chinese Journal of Clinical 

Psychology, 14(2), 207-208. 

Autism 

Level 2: Possibly Efficacious 

 One case study of an eight-year-old boy with mild autism reported the effect of neurofeedback. 

After 31 sessions, the boy showed positive changes in all the diagnostic dimensions defining autism in the 

Mental Disorders-III-Revised (Sichel, Fehmi, & Goldstein, 1995). 

More recently, a wait-list controlled study (Coben & Padolsky, 2007) provided assessmentguided EEG biofeedback over 20 sessions for 37 patients with autistic spectrum disorder. EEG 

biofeedback was determined for each treated subject based on locating the site of maximum 

hyperconnectivity. Once the treatment characteristics were determined, they stayed the same for the 

duration of the 20 treatment sessions. Improvement in symptoms was reported for 89% of the 

experimental group, significantly different than that reported in the control group. A 40% reduction in 

Autism Treatment Evaluation Checklist (ATEC) scores for the treatment group was noted as well as a 

76% reduction in hyperconnectivity. A reduction in cerebral hyperactivity was associated with positive 

clinical outcome. This improvement was supported by neuropsychological tests in attention, visual 

perceptional functioning, executive function, and language skills. 

References 

Coben, R., & Padolsky, I. (2007). Assessment-guided neurofeedback for autistic spectrum disorder. 

Journal of Neurotherapy, 11(1), 5-19. 

Sichel, A.G., Fehmi, L.G., & Goldstein, D.M. (1995). Positive outcome with neurofeedback treatment in 

a case of mild autism. Journal of Neurotherapy, 1(1), 60-64. 
 Page 23

Bell’s Palsy 

Level 2: Possibly Efficacious 

 EMG biofeedback was shown to be more effective than kinesitherapy in a study of 74 persons 

with Bell’s Palsy (Dalla Toffola et al. 2005). The first 32 patients were treated with therapeutic exercises 

performed by therapists and the latter 42 patients were treated using biofeedback/EMG methods with 

inhibition of synkinetic movement as the primary goal. Biofeedback patients showed better clinical 

recovery and minor synkinesis than kinesitherapy patients. 

Reference 

Dalla Toffola, E., Bossi, D., Buonocore, M., Montomoli, C., Petrucci, L., & Alfonsi, E. (2005). 

Usefulness of biofeedback/EMG in facial palsy rehabilitation. Disability and Rehabilitation, 27(14), 

809-815. 

Cerebral Palsy 

Level 2: Possibly Efficacious

There are few studies examining the efficacy of EMG biofeedback to improve posture and 

walking in children with cerebral palsy. Biofeedback of the triceps surae muscle group in the leg 

improved gait symmetry in comparison to physical therapy alone (Colborne, Wright, & Naumann, 1994). 

Portable EMG units to help train ankle dorsiflexor recruitment improved ankle function as evaluated 

through tapping ability (Toner, Cook, & Elder, 1998). The addition of EMG biofeedback to conventional 

exercise programs has improved ankle movement and gait function (Bolek, 2003; Bolek, 2006; Dursun, 

Dursun, & Alican, 2004). Using surface EMG, two children were able to learn to contol their anterior 

tibialis and walk using this new gait pattern (Bolek, 2003). In a later study of 16 children, customized 

treatment plans using multiple surface EMG sites led to improved motor control during standing or sitting 

or in upper extremity or head control (Bolek, 2006). Dursun, Dursun, and Alican (2004) evaluated the 

effect of EMG biofeedback and conventional exercise in 21 children in comparison to 15 children who 

performed exercise alone. The biofeedback group showed significant improvements in tonus of the 

plantar flexor muscle and active range of motion of the ankle joints. While gait function improved in both 

groups, the improvement was greater in the biofeedback group. 

 One case study of adults with cerebral palsy showed biofeedback-assisted relaxation training 

decreased self-report of pain in two of three adults; however, these did not correspond with physiological 

changes (Engle, Jensen, & Schwartz, 2004). 

References 

Bolek, J.E. (2003). A preliminary study of modification of gait in real time using surface 

electromyography. Applied Psychophysiology and Biofeedback, 28(2), 129-138. 

Bolek, J.E. (2006). Use of multiple-site performance-contingent SEMG reward programming in pediatric 

rehabilitation: A retrospective review. Applied Psychophysiology and Biofeedback, 31(3), 263-272. 

Colborne, G.R., Wright, F.V., & Naumann, S. (1994). Feedback of triceps surae EMG in gait of children 

with cerebral palsy: A controlled study. Archives of Physical Medicine Rehabilitation, 75(1), 40-45. 

Dursun, E., Dursun, N., & Alican, D. (2004). Effects of biofeedback treatment on gait in children with 

cerebral palsy. Disability and Rehabilitation, 26(2), 116-120. 
 Page 24

Engel, J.M., Jensen, M.P., & Schwartz, L. (2004). Outcome of biofeedback-assisted relaxation for pain in 

adults with cerebral palsy: Preliminary findings. Applied Psychophysiology and Biofeedback, 29(2), 

135-140. 

Toner, L.V., Cook, K., & Elder, G.C. (1998). Improved ankle function in children with cerebral palsy 

after computer-assisted motor learning. Developmental Medicine and Child Neurology, 40(12), 829-835. 

Chronic Obstructive Pulmonary Disease (COPD) 

Level 2: Possibly Efficacious 

A small, randomized study demonstrated those persons receiving breathing-pattern training had a 

22% increase in forced expiratory volume (FEV1) and a 19% increase in forced vital capacity (FVC) but 

no significant increases in the control group (Esteve, Blanc-Gras, Gallego, & Benchetrit, 1996). Another 

uncontrolled study showed five sessions of HRV biofeedback and walking with pulse oximetry feedback 

improved the distance walked in six minutes and quality of life in patients with COPD (Giardino, Chan, 

& Borson, 2004). 

References 

Esteve, F., Blanc-Gras, N., Gallego, J., & Benchetrit, G. (1996). The effects of breathing-pattern training 

on ventilatory function in patients with COPD. Biofeedback and Self Regulation, 21(4), 311-321. 

Giardino, N.D., Chan, L., & Borson, S. (2004). Combined heart rate variability and pulse oximetry 

biofeedback for chronic obstructive pulmonary disease: Preliminary findings. Applied Psychophysiology 

and Biofeedback, 29(2), 121-133. 

Chronic Pain 

Level 4: Efficacious

Chronic pain can arise from just one or two sites, or it can be pervasive and widespread. Most 

research studies focus on pain from a particular site, but because chronic pain, regardless of its source, 

may involve nonspecific factors such as neural sensitization, altered neurotransmitter levels, 

inflammation, and muscle guarding, there is some logic to also treating chronic pain as a unitary condition 

regardless of its site and supposed generating mechanism. This section on Chronic Pain excludes specific 

categories that are presented in other sections for that disorder (e.g., headaches). Because some specific 

disorders have clearly demonstrated biofeedback effectiveness while others have only case studies and 

mixed results for the efficacy of specific disorders, it is necessary to generalize across various specific 

pain disorders. For specific disorders, review other sections of this document and other related, more 

detailed publications such as AAPB’s White Paper on chronic pain (Clinical Efficacy of 

Psychophysiological Assessments and Biofeedback Interventions for Chronic Pain Disorders Other Than 

Head-Area Pain, 2006). Most studies of biofeedback treatment are from studies where biofeedback is a 

part of a multiple modality program, so it is not possible at this time to ascertain the unique contributions 

biofeedback may provide for chronic pain patients. However, the studies presented below clearly 

demonstrate treatment programs that include biofeedback are as effective as standard (single treatment or 

medication alone) and more effective than no-control conditions. 
 Page 25

Flor and Birbaumer (1993) studied both EMG biofeedback and cognitive therapy for both back 

pain and temporomandibular joint pain. In this study, biofeedback had the strongest effect on many 

aspects of pain, and the effects were still present at a 24-month follow up. Vlaeyen, Haazen, Schuerman, 

Kole-Snijders, and van Eek (1995) studied the response to EMG biofeedback training in 71 chronic back 

pain patients in comparison with a cognitive-training group. The groups had comparable positive 

outcomes as compared to wait-list control and an operant conditioning–only treatment. Newton-John, 

Spence, and Schotte (1995) compared cognitive therapy with EMG biofeedback in chronic back patients 

and obtained similar beneficial effects with both as compared to a wait-list control group. Effects 

persisted at a six-month follow up. Humphreys and Gevirtz (2000) reported a study of recurrent 

abdominal pain in 64 children and teenagers that used thermal biofeedback alone or in combination with 

cognitive-behavioral treatment. Results for pain relief were significantly above an inactive treatment 

(fiber-only) control group. 

A comprehensive literature review of biopsychosocial approaches to chronic pain published in 

2001 (Nielson & Weir, 2001) examined many single and combined treatments and found EMG 

biofeedback had at least moderate support as a separate treatment. The bulk of the studies and the three 

systematic reviews covered mostly back pain, the most common focus for research at that time. 

Fifty chronic pain patients were evaluated pre- and post-treatment using the Wahler Physical 

Symptoms Checklist and the IPAT Anxiety Scale (Corrado, Gottlieb, & Abdelhamid, 2003). Participants 

were randomly assigned to a biofeedback-plus-relaxation-training group or a pain-education group. The 

biofeedback-plus-relaxation-training group reported significantly improved symptoms of anxiety and 

significantly reduced somatic complaints in comparison with the pain-education group. 

Hawkins and Hart (2003) used thermal biofeedback in the treatment of pain associated with 

endometriosis. A multiple case study design (n = 5) was employed. Four participants were able to 

demonstrate mastery over hand temperature through thermal biofeedback. Of those four participants, 

significant reductions in various aspects of pain were observed. Pulliam and Gatchel (2003) examined the 

literature with respect to biofeedback and chronic pain and summarized the current indications of this 

treatment modality for various disorders. 

Conditions reviewed included headaches, temporomandibular disorders, low back pain, 

fibromyalgia, irritable bowel syndrome, and Raynaud’s disease. The authors concluded biofeedback 

represents a useful adjunctive treatment technique for most chronic pain conditions. Its addition to 

standard treatment provides significant incremental validity for many disorders. 

A review article by Stinson (2003) reported only RCT trials comparing a clearly defined 

psychological treatment with a control condition (wait-list and self-monitoring) for chronic pain in 

children or adolescents. The main outcome was pain experience denoted as a Pain Index. A reduction in 

the Pain Index of ≥ 50% from baseline was equivalent to a clinically significant improvement with 

subsequent classification of the outcome as improved or unimproved. Thirteen of 18 RCTs that met the 

selection criteria were included in the meta-analysis. The 25 psychological treatments studied in these 

RCTs included relaxation (11 RCTs), relaxation with biofeedback (four RCTs), cognitive behavioral 

therapy (nine RCTs), and cognitive behavioral family intervention (one RCT). Twelve RCTs took place 

in clinic settings and six in school settings. More patients in the treatment group than in the control group 

had a ≥ 50% reduction in the Pain Index from baseline. 

A series of articles reported on the treatment of 52 consecutive patients with chronic myofascial 

pain who had failed to respond to physical, chiropractic, medical, surgical, and pharmacologic treatment 

with physical therapy combined with EMG biofeedback, counseling, medications, and trigger point 

injections (Sorrell & Flanagan, 2003; Sorrell, Flanagan, & McCall, 2003). They compared groups with 

clinically defined anxiety and depression or both with the group having neither. All patients with anxiety 

took anxiolytic medication during the study, and all but one with depression took antidepressants. Results 

were that anxiety alone had no effect on outcomes while depressed patients were less likely to improve. 
 Page 26

Engel, Jensen, and Schwartz (2004) studied three adults with cerebral palsy, using biofeedbackassisted relaxation training on self-reported pain and muscle tension. Two of three participants reported 

decreases in their pain experiences post-treatment. Their subjective reports, however, did not correspond 

with physiological changes. 

Ninety-two systemic lupus erythematosus (SLE) patients were assigned randomly to receive 

either biofeedback-assisted cognitive-behavioral treatment (biofeedback/CBT), a symptom-monitoring 

support (SMS) intervention, or usual medical care (UC) alone (Greco, Rudy, & Manzi, 2004). 

Biofeedback/CBT participants had significantly greater reductions in pain and psychological dysfunction 

compared with the SMS group and the UC group. Biofeedback/CBT had significantly greater 

improvement in perceived physical function compared with UC and improvement relative to SMS was 

marginally significant. At a nine-month follow-up evaluation, biofeedback/CBT continued to exhibit 

relative benefit compared with UC in psychological functioning. 

In a study of Complex Regional Pain Syndrome (CRPS), the effects of a multidisciplinary day 

treatment program were examined by McMenamy, Ralph, Auen, and Nelson (2004). Participants included 

11 adults with a history of CPRS of six months or longer. Multidisciplinary treatments used included 

physical therapy; occupational therapy; stress management; biofeedback; goal-oriented cognitively based 

individual, group, and family counseling; sympathetic blocks; medication management; behavioral 

modification; pain management; nutritional education; and case management. Variables assessed at 

admission and discharge included physical and occupational therapy ratings, thermal biofeedback levels, 

self-reported pain levels, depression and somatic distress levels, narcotic use, and vocation status. At postdischarge follow up, which ranged from six to 30 months, pain levels, vocational status, and narcotic use 

were assessed. Results support the hypothesis that multidisciplinary treatment of CPRS is effective in the 

improvement of symptomatology. 

Fifty women between 42 and 74 years old with the diagnosis of knee osteoarthritis participated in 

a study (Durmus, Alayli, & Canturk, 2005). Patients were randomized into two groups of biofeedbackassisted isometric exercise or electrical stimulation. For both groups, 20 minutes of therapy was applied 

five days a week for four weeks. Patients were evaluated before and after therapy. Both treatment groups 

showed significant improvements in pain and physical function scores and demonstrated significant 

improvements in anxiety and depression scores. 

Phantom limb pain (PLP) was studied in nine individuals (Harden et al. 2005). They received up 

to seven thermal/autogenic biofeedback sessions over the course of four to six weeks. Interrupted timeseries analytical models were created for each of the participants, allowing biofeedback sessions to be 

modeled as discrete interventions. Analyses revealed a 20% pain reduction was seen in five of the nine 

patients in the weeks after session four and at least a 30% pain reduction (range: 25 to 66%) was seen in 

six of the seven patients in the weeks following session six. 

In an illustrative case study, Masters (2006) describes how, after three years of various medical 

interventions, including exploratory surgery, an individual was referred for biofeedback training. After a 

course of seven sessions over five months that variously included heart rate variability and skin 

temperature feedback along with extensive home practice of paced breathing and hand warming, the 

patient achieved significant symptom reduction and improved coping abilities. 

A study of 50 chronic pain patients aged 18 to 65 who suffered for at least six months (23 patients 

with pain in the lumbar region and 27 patients with pain in the cervical and dorsal regions) was reported 

by Ferrari, Fipaldini, and Birbaumer (2006). The patients were assigned randomly to one of two treatment 

conditions: 12 sessions of 60 minutes of EMG biofeedback with the electrodes placed in the region of 

pain and 12 sessions of 80 minutes in a small group. At the end of both treatments, a reduction in the 

quantity of analgesics consumed, the subjective pain intensity, and the self-evaluations of pain were 

observed. These improvements continued at the one-month and the six-month follow ups. 
 Page 27

In a study by Qi and Ng (2007), an eight-week home program provided patellofemoral pain 

syndrome patients with a treatment with and without EMG biofeedback of the vastus medialis obliquus 

and vastus lateralis. Twenty-six subjects were randomly allocated into exercise-only or EMGbiofeedback-plus-exercise groups. Both groups performed the same exercise program lasting eight weeks. 

The intensity of the knee pain was recorded. The results reveal the incorporation of EMG biofeedback 

into a home exercise program significantly facilitated the activation of the vastus medialis obliquus 

muscle and the reduction of pain. 

In a study by Tsai, Chen, Lai, Lee, and Lin (2007), the effects of frontal EMG biofeedbackassisted relaxation on pain in patients with advanced cancer in a palliative care unit was assessed. 

Participants were randomly assigned to conditions. The experimental group (n = 12) received six EMG 

biofeedback-assisted relaxation sessions over a four-week period; whereas, the control group (n = 12) 

received conventional care. The primary efficacy measure was the level of pain, measured by the Brief 

Pain Inventory. Findings from this study showed frontal EMG biofeedback is effective in reducing 

cancer-related pain in advanced cancer patients. 

Voerman, Vollenbroek-Hutten, and Hermens (2006) studied changes in pain, disability, and 

muscle activation patterns in chronic whiplash (WAD) patients after four weeks of ambulant 

myofeedback training. Eleven WAD patients received ambulatory myofeedback training, during which 

upper trapezius muscle activation and relaxation were continuously recorded and processed for four 

weeks. Feedback was provided when muscle relaxation was insufficient. Pain in neck, shoulders, and 

upper back (Visual Analogue Scale), disability (Neck Disability Index), and muscle activation patterns 

during rest, typing, and stress tasks (surface electromyography) were assessed before and after the four 

weeks of training. Pain intensity decreased after training. Clinically relevant changes were found with 

regard to pain in the neck and upper back region and right and left shoulder. A trend for decreased 

disability was found that was clinically relevant in 36% of the patients. A remarkable reduction was found 

in the Neck Disability Index items concerning headache and lifting weights. 

In a review of studies that evaluated treatments for recurrent abdominal pain (RAP), Weydert, 

Ball, and Davis (2003) located 10 studies that met the inclusion criteria that the study involve children 

aged five to 18 years with a diagnosis of RAP, and subjects were randomly assigned to treatment or 

control groups. Studies that evaluated famotidine, pizotifen, cognitive-behavioral therapy, biofeedback, 

and peppermint oil enteric-coated capsules showed a decrease in measured pain compared to control 

groups. The studies that evaluated dietary interventions had conflicting results, in the case of fiber, or 

showed no efficacy, in the case of lactose avoidance. 

In a review of treatment of chronic pain, Singh (2005) reported the therapeutic response of 

pharmacotherapy in chronic pain at the present time remains unsatisfactory and refractory at best. 

Multidisciplinary pain management has not only brought new hope but has also increased the therapeutic 

response in general. The multidisciplinary management allows patient access to a complete 

armamentarium of pain therapies and includes relaxation therapy, physiotherapy, transcutaneous electrical 

nerve stimulation, exercise, biofeedback techniques, acupuncture, behavior modification, hypnosis, 

sympathetic nerve block, desensitization, and cognition therapy as well as the therapeutic benefit of 

pharmacotherapy. Multidisciplinary management of chronic pain syndrome has become the key for 

enhanced success and the route of holistic management. 

In a review of mind-body interventions for chronic pain in older adults, Morone and Greco (2007) reported 

on 20 trials. There was some support for the efficacy of progressive muscle relaxation plus guided 

imagery for osteoarthritis pain with limited support for meditation and tai chi for improving function or 

coping in older adults with low back pain or osteoarthritis. In an uncontrolled biofeedback trial that 

stratified by age group, both older and younger adults had significant reductions in pain following the 

intervention. 
 Page 28

 Bohm-Starke, Brodda-Jansen, Linder, and Danielsson (2007) provided 35 women with provoked 

vestibulodynia four months of treatment with either EMG biofeedback (n=17) or topical lidocaine (n=18). 

Assignment to conditions was randomized. Vestibular and general pressure pain thresholds (PPTs) were 

measured and the health survey Short Form-36 (SF-36) was filled out before treatment and at a six-month 

follow up. Subjective treatment outcome and bodily pain were analyzed. Thirty healthy women of the 

same age served as controls for general PPTs and SF-36. Three patients reported total cure, and 25 were 

improved. 

 The results of a comprehensive review by the National Institutes of Health Technology Panel are 

summarized by Lebovits (2007). He reports cognitive-behavioral approaches include hypnosis, relaxation 

(including guided imagery, progressive muscular relaxation, meditation, and music therapy), biofeedback, 

coping skills training, cognitive restructuring, supportive and group therapy, and stress-management 

techniques. The panel concluded the evidence is “strong” (its highest rating) for the effectiveness of 

relaxation in reducing chronic pain. Specific relaxation strategies that have been shown to reduce levels of 

pain include guided imagery, progressive muscle relaxation, and meditation. Yet despite the generally 

accepted efficacy of these methods with pain patients, their relative ease of implementation, and their 

very low side-effect profile, barriers still exist with the integration of psychological therapies into 

standard medical care. 

In a recent study utilizing EEG biofeedback for Complex Regional Pain Syndrome Type 1 

(CRPS-1), Jensen, Grierson, Tracy-Smith, Bacigalupi, and Othmer (2007) reported the results from 18 

participants. Pain was measured before and after each 30-minute EEG biofeedback treatment. The EEG 

biofeedback varied for each participant and across sessions. The authors report a substantial and 

significant reduction in pain from pre- to post-treatments with 50% reporting clinically meaningful 

reduction in pain. 

In summary, the category of Chronic Pain is a diffuse collection of pain-related, specific 

disorders, and their treatment with biofeedback techniques has a range of efficacy associated with them. 

For many chronic conditions, biofeedback has been shown to be effective in treating pain, especially 

when included in a multiple modality program. Therefore, the general conclusion is that biofeedback is 

efficacious in treating chronic pain, but its utilization for specific disorders needs to be determined from 

an in-depth review of the literature for that specific condition. 

References 

Bohm-Starke, N., Brodda-Jansen, G., Linder, J., & Danielsson, I. (2007). The result of treatment on 

vestibular and general pain thresholds in women with provoked vestibulodynia. The Clinical Journal of 

Pain, 23(7), 598-604. 

Corrado, P., Gottlieb, H., & Abdelhamid, M.H. (2003). The effect of biofeedback and relaxation training 

on anxiety and somatic complaints in chronic pain patients. American Journal of Pain Management, 

13(4), 133-139. 

Durmus, D., Alayli, G., & Canturk, F. (2005). Effects of biofeedback-assisted isometric exercise and 

electrical stimulation on pain, anxiety, and depression scores in knee osteoarthritis. Turkiye Fiziksel Tip 

ve Rehabilitasyon Dergisi, 51(4), 142-145. 

Engel, J.M., Jensen, M.P., & Schwartz, L. (2004). Outcome of biofeedback-assisted relaxation for pain in 

adults with cerebral palsy: Preliminary findings. Applied Psychophysiology and Biofeedback, 29(2), 

135-140. 

Ferrari, R., Fipaldini, E., & Birbaumer, N. (2006). Individual characteristics and results of biofeedback 

training and operant treatment in patients with chronic pain. Psicoterapia Cognitiva e Comportamentale, 

12(2), 161-179. 
 Page 29

Flor, H., & Birbaumer, N. (1993). Comparison of the efficacy of electromyographic biofeedback 

cognitive-behavioral therapy and conservative medical interventions in the treatment of chronic 

musculoskeletal pain. Journal of Consulting and Clinical Psychology, 61(4) 653-658. 

Greco, C.M., Rudy, T.E., & Manzi, S. (2004). Effects of a stress-reduction program on psychological 

function, pain, and physical function of systemic lupus erythematosus patients: A randomized controlled 

trial. Arthritis and Rheumatism, 51(4), 625-634. 

Harden, R.N., Houle, T.T., Green, S., Remble, T.A., Weinland, S.R., Colio, S., et al. (2005). Biofeedback 

in the treatment of phantom limb pain: A time-series analysis. Applied Psychophysiology and 

Biofeedback, 30(1), 83-93. 

Hawkins, R.S., & Hart, A.D. (2003). The use of thermal biofeedback in the treatment of pain associated 

with endometriosis: Preliminary findings. Applied Psychophysiology and Biofeedback, 28(4), 279-289. 

Humphreys, P.A., & Gevirtz, R. (2000). Treatment of recurrent abdominal pain: Components analysis of 

four treatment protocols. Journal of Pediatric Gastroenterological Nutrition, 31(1), 47-51. 

Jensen, M.P., Grierson, C., Tracy-Smith, V., Bacigalupi, S., & Othmer, S. (2007). Neurofeedback 

treatment for pain associated with complex regional pain syndrome type I. Journal of Neurotherapy, 

11(1), 45-53. 

Lebovits, A. (2007). Cognitive-behavioral approaches to chronic pain. Primary Psychiatry, 14(9), 48-54. 

Masters, K.S. (2006). Recurrent abdominal pain, medical intervention, and biofeedback: What happened 

to the biopsychosocial model? Applied Psychophysiology and Biofeedback, 31(2), 155-165. 

McMenamy, C., Ralph, N., Auen, E., & Nelson, L. (2004). Treatment of complex regional pain syndrome 

in a multidisciplinary chronic pain program. American Journal of Pain Management, 14(2), 56-62. 

Morone, N.E., & Greco, C.M. (2007). Mind-body interventions for chronic pain in older adults: A 

structured review. Pain Medicine (Malden, MA), 8(4), 359-375. 

Newton-John, T.R., Spence, S.H., & Schotte, D. (1995). Cognitive-behavioural therapy versus EMG 

biofeedback in the treatment of chronic low back pain. Behavioural Research & Therapy, 33(6), 691-697. 

Nielson, W.R., & Weir, R. (2001). Biopsychosocial approaches to the treatment of chronic pain. Clinical 

Journal of Pain, 17(4 Suppl.), S114-S127. 

Pulliam, C.B., & Gatchel, R.J. (2003). Biofeedback 2003: Its role in pain management. Critical Reviews 

in Physical and Rehabilitation Medicine, 15(1), 65-82. 

Qi, Z., & Ng, G.Y.F. (2007). EMG analysis of vastus medialis obliquus/vastus lateralis activities in 

subjects with patellofemoral pain syndrome before and after a home exercise program. Journal of 

Physical Therapy Science, 19(2), 131-137. 

Singh, A.N. (2005). Multidisciplinary management of chronic pain. International Medical Journal, 12(2), 

111-116. 

Sorrell, M.R., & Flanagan, W. (2003). Treatment of chronic resistant myofascial pain using a 

multidisciplinary protocol [the myofascial pain program]. Journal of Musculoskeletal Pain, 11(1), 5-9. 

Sorrell, M.R., Flanagan, W., & McCall, J.L. (2003). The effect of depression and anxiety on the success 

of multidisciplinary treatment of chronic resistant myofascial pain. Journal of Musculoskeletal Pain, 

11(1), 17-20. 

Stinson, J. (2003). Review: Psychological interventions reduce the severity and frequency of chronic pain 

in children and adolescents. Evidence-Based Nursing, 6(2), 45-45. 
 Page 30

Tsai, P.S., Chen, P.L., Lai, Y.L., Lee, M.B., & Lin, C.C. (2007). Effects of electromyography 

biofeedback-assisted relaxation on pain in patients with advanced cancer in a palliative care unit. Cancer 

Nursing, 30(5), 347-353. 

Vlaeyen, J.W., Haazen, I.W., Schuerman, J.A., Kole-Snijders, A.M., & van Eek, H. (1995). Behavioural 

rehabilitation of chronic low back pain: Comparison of an operant treatment, an operant-cognitive 

treatment, and an operant-respondent treatment. Clinical Psychology, 34(Pt 1), 95-118. 

Voerman, G.E., Vollenbroek-Hutten, M.M., & Hermens, H.J. (2006). Changes in pain, disability, and 

muscle activation patterns in chronic whiplash patients after ambulant myofeedback training. The Clinical 

Journal of Pain, 22(7), 656-663. 

Weydert, J.A., Ball, T.M., & Davis, M.F. (2003). Systematic review of treatments for recurrent abdominal 

pain. Pediatrics, 111(1), e1-11. 

Coronary Artery Disease 

Level 2: Possibly Efficacious 

Diminished heart rate variability (HRV) in patients with coronary artery disease is associated with 

increased cardiac morbidity and mortality. In patients with coronary artery disease, some HRV timedomain indices were improved in treatment versus control groups by EMG biofeedback (Wang, Zhang, 

Liu, & Lu, 2006) and HRV biofeedback (Nolan et al. 2005; Del Pozo, Gevirtz, Scher, & Guarneri, 2004). 

Survivors of out-of-hospital ventricular fibrillation or asystole were randomized into two groups, 

a control group and a group receiving psychosocial therapy consisting of physiological relaxation with 

biofeedback focused on altering autonomic tone, cognitive behavioral therapy, and cardiovascular health 

education. Risk of cardiovascular death was significantly reduced by 86%, and all-cause mortality was 

reduced by 62% in those receiving psychosocial therapy (Cowan, Pike, & Budzynski, 2001). 

References 

Cowan, M.J., Pike, K.C., & Budzynski, H.K. (2001). Psychosocial nursing therapy following sudden 

cardiac arrest: Impact on two-year survival. Nursing Research, 50(2), 68-76. 

Del Pozo, J.M., Gevirtz, R.N., Scher, B., & Guarneri, E. (2004). Biofeedback treatment increases heart 

rate variability in patients with known coronary artery disease. American Heart Journal, 147(3), E11. 

Nolan, R.P., Kamath, M.V., Floras, J.S., Stanley, J., Pang, C., Picton, P., et al. (2005). Heart rate 

variability biofeedback as a behavioral neurocardiac intervention to enhance vagal heart rate control.

American Heart Journal, 149(6), 1137. 

Wang, L., Zhang, F., Liu, H., & Lu, X. (2006). Influence of the biofeedback relaxation training on the 

heart rate variability of patients with coronary heart disease. Chinese Journal of Clinical Rehabilitation,

10(6), 13-15. 
 Page 31

Cystic Fibrosis 

Level 2: Possibly Efficacious

Respiratory muscle biofeedback coupled with breathing retraining produced significant 

improvement in forced expiratory volume (FEV1) and forced vital capacity (FVC) in comparison to a 

control group that received biofeedback-assisted (hand warming) relaxation training (Delk, Gevirtz, 

Hicks, Carden, & Rucker, 1994). This single study was included in a Cochrane Review evaluating 

psychological interventions for cystic fibrosis (Glasscoe & Quittner, 2003). The Cochrane Review found 

high-quality efficacy trials for psychological interventions for cystic fibrosis are rare and was unable to 

conclude anything about biofeedback efficacy. 

References

Delk, K.K., Gevirtz, R., Hicks, D.A., Carden, F., & Rucker, R. (1994). The effects of biofeedbackassisted breathing retraining on lung functions in patients with cystic fibrosis. Chest, 105(1), 23-28. 

Glasscoe, C.A., & Quittner, A.L. (2003). Psychological interventions for cystic fibrosis. Cochrane 

Database of Systematic Reviews (Online), 3(3), CD003148. 

Depressive Disorders 

Level 2: Possibly Efficacious

Preliminary case studies (Kumano et al. 1996; Rosenfeld, 2000) and pilot studies (Waldkoetter & 

Sanders, 1997) show neurofeedback may decrease depressive symptoms. One study compared 

biofeedback-assisted relaxation to a wait-list control on depression in chronic pain patients and found 

improved scores on the Beck depression index (Corrado & Gottlieb, 1999). 

Baehr, Rosenfeld, and Baehr (2001) presented a follow-up study of three of six patients who had 

completed an average of 27 EEG biofeedback sessions using a patented alpha asymmetry protocol for the 

treatment of depression. The follow-up data, from one to five years post-therapy, were derived from a 

single session re-test using the same alpha asymmetry protocol and the Beck Depression Inventory. The 

three patients originally diagnosed as having unipolar depression reached the training criteria for the 

nondepressed range by the end of their initial training, and they had maintained their normal scores for 

right hemisphere alpha asymmetry training over time. The follow-up Beck Depression Inventory scores 

were also within the normal range. While some patients reported mood changes with life’s vicissitudes, 

none experienced clinical depression since they terminated therapy. 

In a study conducted by Raymond, Varney, Parkinson, and Gruzelier (2005), 12 participants with 

high scores for withdrawal (as measured by the PSQ) were given either alpha/theta EEG biofeedback or 

mock feedback, and their personality and mood were assessed. Withdrawal scores on the PSQ-80 were 

not found to change in either group, but significant effects were found for the Profile of Mood States 

(POMS) with real feedback producing higher overall scores than mock feedback. Real feedback caused 

participants to feel significantly more energetic than did mock feedback. Sessions of real feedback made 

participants feel more composed, agreeable, elevated, and confident while sessions of mock feedback 

made participants feel more tired yet composed. 

Fifty women between 42 and 74 years old with the diagnosis of knee osteoarthritis participated in 

a study by Durmus, Alayli, and Canturk (2005). The patients were randomized into two groups of 

biofeedback-assisted isometric exercise or electrical stimulation. For both groups, 20 minutes of therapy 

was applied five days a week for four weeks. Patients were evaluated before and after therapy. Both 
 Page 32

treatment groups showed significant improvements in pain and physical function scores and demonstrated 

significant improvements in anxiety and depression scores. 

In a study by Karavidas et al. (2007) using Heart Rate Variability (HRV) as a treatment for major 

depressive disorder (MDD), all 11 participants received the 10 weekly treatments. Significant 

improvements were noted in the Hamilton Depression Scale (HAM-D) and the Beck Depression 

Inventory (BDI-II) by session four. Clinically and statistically significant improvement in depression 

persisted for the duration of the study. 

References 

Baehr, E., Rosenfeld, J.P., & Baehr, R. (2004). Clinical use of an alpha asymmetry neurofeedback 

protocol in the treatment of mood disorders: Follow-up study one to five years post therapy. Journal of 

Neurotherapy, 4(4), 11-18.

Corrado, P., & Gottlieb, H. (1999). The effect of biofeedback and relaxation training on depression in 

chronic pain patients. American Journal of Alternative Medicine, 9, 18-21. 

Durmus, D., Alayli, G., & Canturk, F. (2005). Effects of biofeedback-assisted isometric exercise and 

electrical stimulation on pain, anxiety, and depression scores in knee osteoarthritis. Turkiye Fiziksel Tip 

ve Rehabilitasyon Dergisi, 51(4), 142-145. 

Karavidas, M.K., Lehrer, P.M., Vaschillo, E., Vaschillo, B., Marin, H., Buyske, S., et al. (2007). 

Preliminary results of an open-label study of heart rate variability biofeedback for the treatment of major 

depression. Applied Psychophysiology and Biofeedback, 32(1), 19-30. 

Kumano, H., Horie, H., Shidara, T., Kuboki, T., Suematsu, H., & Yasushi, M. (1996). Treatment of a 

depressive disorder patient with EEG-driven photic stimulation. Biofeedback and Self Regulation, 21(4), 

323-334. 

Raymond, J., Varney, C., Parkinson, L.A., & Gruzelier, J.H. (2005). The effects of alpha/theta 

neurofeedback on personality and mood. Brain Research. Cognitive Brain Research, 23(2-3), 287-292. 

Rosenfeld, J.P. (2000). An EEG biofeedback protocol for affective disorders. Clinical 

Electroencephalography, 31(1), 7-12. 

Waldkoetter, R.O., & Sanders, G.O. (1997). Auditory brainwave stimulation in treating alcoholic 

depression. Perceptual and Motor Skills, 84(1), 226. 

Diabetes Mellitus 

Level 3: Probably Efficacious

Earlier studies showed biofeedback-assisted relaxation training had no effect on diabetic control 

as measured by glucose tolerance, fasting blood glucose, two-hour postprandial blood glucose, and 

fructosamine (Jablon, Naliboff, Gilmore, & Rosenthal, 1997) or on glycosylated hemoglobin (Lane, 

McCaskill, Ross, Feinglos, & Surwit, 1993). Mood (e.g., depression, anxiety) may impact this lack of 

response (McGrady & Horner, 1999). Later studies on those with noninsulin-dependent diabetes showed 

comprehensive intervention, including education and biofeedback, were associated with significant 

decreases in average blood glucose and HbA1C (McGinnis, McGrady, Cox, & Grower-Dowling, 2005). 

 On the other hand, thermal biofeedback to increase peripheral blood flow improved healing to 

foot ulcers in a randomized controlled study of 32 patients with chronic nonhealing ulcers; 87.5% of 

ulcers healed in the experimental group in contrast to 43.8% in the control group (Rice, Kalker, Schindler, 
 Page 33

& Dixon, 2001). Another study supported the ability of those with diabetes mellitus to increase foot 

temperature despite mild-to-moderate neuropathy; 41% of the variance in foot warming was explained by 

lower-extremity sympathetic-autonomic and sensory nerve function tests (Fiero, Galper, Cox, Phillips, & 

Fryburg, 2003). Biofeedback of body center of gravity was shown to reduce the number of falls and force 

of the fall in elderly patients with diabetic sensory neuropathy in comparison to those who did not receive 

the biofeedback training (Wu, 1997). Finally, audio biofeedback on weight bearing of persons with 

transtibial amputation may help patients learn to ambulate correctly using a prosthesis (Chow & 

Cheng, 2000). 

References 

Chow, D.H., & Cheng, C.T. (2000). Quantitative analysis of the effects of audio biofeedback on weightbearing characteristics of persons with transtibial amputation during early prosthetic ambulation. Journal 

of Rehabilitation Research Development, 37(3), 255-260. 

Fiero, P.L., Galper, D.I., Cox, D.J., Phillips, L.H.,2nd, & Fryburg, D.A. (2003). Thermal biofeedback and 

lower extremity blood flow in adults with diabetes: Is neuropathy a limiting factor? Applied 

Psychophysiology and Biofeedback, 28(3), 193-203. 

Jablon, S.L., Naliboff, B.D., Gilmore, S.L., & Rosenthal, M.J. (1997). Effects of relaxation training on 

glucose tolerance and diabetic control in type II diabetes. Applied Psychophysiology and Biofeedback,

22(3), 155-169. 

Lane, J.D., McCaskill, C.C., Ross, S.L., Feinglos, M.N., & Surwit, R.S. (1993). Relaxation training for 

NIDDM: Predicting who may benefit. Diabetes Care, 16(8), 1087-1094. 

McGinnis, R.A., McGrady, A., Cox, S.A., & Grower-Dowling, K.A. (2005). Biofeedback-assisted 

relaxation in type 2 diabetes. Diabetes Care, 28(9), 2145-2149. 

McGrady, A., & Horner, J. (1999). Role of mood in outcome of biofeedback-assisted relaxation therapy 

in insulin-dependent diabetes mellitus. Applied Psychophysiology and Biofeedback, 24(1), 79-88. 

Rice, B., Kalker, A.J., Schindler, J.V., & Dixon, R.M. (2001). Effect of biofeedback-assisted relaxation 

training on foot ulcer healing. Journal of the American Podiatric Medical Association, 91(3), 132-141. 

Wu, G. (1997). Real-time feedback of body center of gravity for postural training of elderly patients with 

peripheral neuropathy. Institute of Electrical and Electronics Engineers Transactions on Rehabilitation 

Engineering, 5(4), 399-402. 

Eating Disorders 

Level 1: Not Empirically Supported

 One study of 76 obese and 27 anorexic girls showed benefits of a multimodal program including 

biofeedback relaxation based on electrodermal response (EDR), with better results for anorectic girls (Pop 

Jordanova, 2000). This study also examined multimodal psychological assessment and manner of coping 

with stress and found anorexia nervosa and hyperphagia were associated with stress. 

Reference 

Pop Jordanova, N. (2000). Psychological characteristics and biofeedback mitigation in preadolescents 

with eating disorders. Pediatrics International Official Journal of the Japan Pediatric Society, 42(1), 

76-81. 
 Page 34

Epilepsy 

Level 4: Efficacious

Early studies testing EEG biofeedback for epilepsy showed promise in reducing seizure activity, 

utilizing some form of the technique to increase the abundance of SMR (typically defined at 12-15 Hz) 

and often to simultaneously decrease the EEG in the typical low-frequency range of 4-8 Hz. In the first 

case study published in 1972, Sterman demonstrated a complete cessation of seizures in a woman who 

had a seven-year history of medically uncontrolled generalized tonic-clonic seizures. After becoming 

seizure-free, she was issued a state driver’s license. This research was an extension of studies with 

animals that demonstrated they could be operant-conditioned to increase SMR, and this increase was 

associated with an increase in seizure threshold. 

Recent studies built on these findings demonstrate self-regulation of slow cortical potentials using 

EEG feedback decreases seizure activity in drug-resistant epilepsy when compared to pre-training 

(Kotchoubey, Schneider, et al. 1996; Kotchoubey et al. 1999; Sterman, 1986; Swingle, 1998). This effect 

was sustained for at least six months after therapy (Kotchoubey, Blankenhorn, Froscher, Strehl, & 

Birbaumer, 1997). A five consecutive–day neurobehavioral treatment protocol resulted in 79% of patients 

being able to achieve seizure control (Joy Andrews, Reiter, Schonfeld, Kastl, & Denning, 2000). 

Kotchoubey et al. (2001) studied patients with refractory epilepsy in a controlled clinical trial comparing 

an anticonvulsive drug plus psychosocial counseling (drug), a group that learned to control breathing 

(control), and a group learning self-regulation of slow cortical potentials (experimental). The 

experimental and drug groups showed a significant decrease of seizure frequency, but the control group 

did not. 

In a review of the EEG biofeedback treatment for seizures, Sterman (2000) reviewed 18 studies 

published between 1981 and 1996 in peer-reviewed journals. Most studies used pre-treatment baselines 

for comparisons, but 10 used appropriate controls such as another biofeedback modality or noncontingent 

feedback. These trials treated 174 patients with 142 of them (82%) showing clinically significant 

improvements and 115 of them (66%) demonstrating significant increases in SMR activity. There were no 

reports of increased seizure activity in those treated with biofeedback. Unfortunately, because none of the 

studies were designed to be RCTs, this led a Cochrane Database Systematic Review to conclude there is 

no reliable evidence to support the use of EEG biofeedback in the treatment of epilepsy because of 

methodological deficiencies and limited number of patients studied (Ramaratnam, Baker, & Goldstein, 

2005). However, because most of the subjects were refractory seizure victims, in spite of medication 

usage, and the biofeedback was shown to clinically reduce the seizure, this technique appears to be 

effective and safe. 

 In a recent review by Marson and Ramaratnam (2003), which looked at only RCT studies, one 

controlled trial was found, and that trial reported significant reductions in median seizure activity. 

Another review of biofeedback treatment of seizures (Sheth, Stafstrom, & Hsu, 2005) reported a review 

from 16 studies. Subjects in all studies were designated as having refractory epilepsy. Sample size for 

most studies was relatively small (n = 1 – 8), but one larger sample size study was found (n = 83). When 

all studies were combined, 82% of those treated with biofeedback showed clinical improvement. This 

review also presented studies with two other biofeedback techniques, and these are Contingent Negative 

Variation (CNV) or Slow Cortical Potential (SCP) and Galvanic Skin Response (GSR). Both techniques 

had positive outcomes with reduction in seizure activity being clinically significant. 

Pop-Jordanova, Zorcec, and Demerdzieva (2005) report a case study of biofeedback treatment of 

a 13-year-old girl with psychogenic nonepileptic seizures (PNS). The treatment was electrodermal (EDR) 

biofeedback combined with cognitive-behavioral therapy. After 10 sessions of 45 minutes per day, they 

observed cessation of attacks, stabilization of neurotic tendencies, progression of the maturational 

process, and good academic results. 
 Page 35

In conclusion, based on more than 30 years of clinical trials with EEG biofeedback based on EEG 

waveform characteristics for the treatment of seizures, several independent investigators have 

demonstrated EEG biofeedback is effective in reducing seizure activity, often in refractory patients. There 

is no evidence this treatment has been linked to an increase in seizures. Other biofeedback techniques 

(SCP and GSR) have been tried with some success. 

References 

Joy Andrews, D., Reiter, J.M., Schonfeld, W., Kastl, A., & Denning, P. (2000). A neurobehavioral 

treatment for unilateral complex partial seizure disorders: A comparison of right- and left-hemisphere 

patients. Seizure, 9(3) 189-197. 

Kotchoubey, B., Blankenhorn, V., Froscher, W., Strehl, U., & Birbaumer, N. (1997). Stability of cortical 

self-regulation in epilepsy patients. Neuroreport, 27(8), 1867-1870. 

Kotchoubey, B., Schneider, D., Schleichert, H., Strehl, U., Uhlmann, C., Blankenhorn, V., et al. (1996). 

Self-regulation of slow cortical potentials in epilepsy: A retrial with analysis of influencing factors. 

Epilepsy Research, 25(3), 269-276. 

Kotchoubey, B., Strehl, U., Holzapfel, S., Blankenhorn, V., Froscher, W., & Birbaumer, N. (1999). 

Negative potential shifts and the prediction of the outcome of neurofeedback therapy in epilepsy. Clinical 

Neurophysiology, 110(4), 683-686. 

Kotchoubey, B., Strehl, U., Uhlmann, C., Holzapfel, S., Konig, M., Froscher, W., et al. (2001). 

Modification of slow cortical potentials in patients with refractory epilepsy: A controlled outcome study. 

Epilepsia, 42(3), 406-416. 

Marson, A., & Ramaratnam, S. (2003). Epilepsy. Clinical Evidence, 9(9), 1403-1420. 

Pop-Jordanova, N., Zorcec, T., & Demerdzieva, A. (2005). Electrodermal biofeedback in treating 

psychogenic nonepileptic seizures. Prilozi / Makedonska akademija na naukite i umetnostite, Oddelenie 

za bioloski i medicinski nauki = Contributions / Macedonian Academy of Sciences and Arts, Section of 

Biological and Medical Sciences, 26(2), 43-51. 

Sheth, R.D., Stafstrom, C.E., & Hsu, D. (2005). Nonpharmacological treatment options for epilepsy. 

Seminars in Pediatric Neurology, 12(2), 106-113. 

Sterman, M.B. (1986). Epilepsy and its treatment with EEG feedback therapy. Annals of Behavioral 

Medicine, 8(1), 21-25. 

Sterman, M.B. (2000). Basic concepts and clinical findings in the treatment of seizure disorders with EEG 

operant conditioning. Clinical Electroencephalography, 31(1), 45-55. 

Sterman, M.B., & Friar, L. (1972). Suppression of seizures in an epileptic following sensorimotor EEG 

feedback training. Electroencephalography Clinical Neurophysiology, 33(1), 89-95. 

Swingle, P.G. (1998). Neurofeedback treatment of pseudoseizure disorder. Biological Psychiatry, 44(11), 

1196-1199. 

Erectile Dysfunction 

Level 2 Efficacy – Possibly Efficacious 

 Erectile dysfunction is a new area for biofeedback and is beginning to show some promise. Pelvic 

floor exercises, biofeedback, and electrical stimulation resulted in normal erection for almost half of those 
 Page 36

treated; its effect was most favorable in those with venous-occlusive dysfunction (Van Kampen et al. 

2003). An RCT of 55 men treated with pelvic floor exercises, biofeedback, and suggestions for lifestyle 

changes versus those treated with lifestyle changes alone (and later transferred to the active treatment) 

revealed those in the treatment group showed significant mean increases in anal pressure and digital anal 

grades (Dorey et al. 2004). After four months, 40% of participants had achieved normal erectile function, 

35.5% had improved erectile function, and 24.5% failed to improve (Dorey, Speakman, Feneley, 

Swinkels, & Dunn, 2005). 

References 

Dorey, G., Speakman, M., Feneley, R., Swinkels, A., Dunn, C., & Ewings, P. (2004). Randomised 

controlled trial of pelvic floor muscle exercises and manometric biofeedback for erectile dysfunction. The 

British Journal of General Practice: The Journal of the Royal College of General Practitioners, 54(508), 

819-825. 

Dorey, G., Speakman, M.J., Feneley, R.C., Swinkels, A., & Dunn, C.D. (2005). Pelvic floor exercises for 

erectile dysfunction. BJU International, 96(4), 595-597. 

Van Kampen, M., De Weerdt, W., Claes, H., Feys, H., De Maeyer, M., & Van Poppel, H. (2003). 

Treatment of erectile dysfunction by perineal exercise, electromyographic biofeedback, and electrical 

stimulation. Physical Therapy, 83(6), 536-543. 

Fecal Disorders

Literature on biofeedback for fecal incontinence and constipation is difficult to interpret. Most 

studies include patients with a variety of conditions and lack control groups. A critical review of the 

literature concluded that biofeedback results in 67 – 74% success in treating fecal incontinence but states 

quality control is lacking in many of the studies reviewed (Heymen, Jones, Ringel, Scarlett, & Whitehead, 

2001). A more recent efficacy review of 74 qualified studies showed a 67.2% success rate in those being 

treated for fecal incontinence and 62.4% success rate in those treated for constipation (Palsson, Heymen, 

& Whitehead, 2004); only 20% of studies were controlled outcome studies. In those with multiple 

sclerosis, biofeedback retraining appears to be an effective treatment for constipation and fecal 

incontinence (Wiesel et al. 2000). Biofeedback may be more useful in patients with milder disability and 

manometric alternations (Munteis et al. 2007). 

Fecal Disorders in Children 

Level 3: Probably Efficacious

Biofeedback has been used for fecal incontinence in children and for that occurring after surgery 

for anorectal malformations and results in clinical improvement in children with fecal incontinence (Iwai, 

Iwata, Kimura, & Yanagihara, 1997; van Ginkel et al. 2000; Hibi, Iwai, Kimura, Sasaki, & Tsuda, 2003; 

Leung et al. 2006). In contrast to numerous uncontrolled studies showing efficacy in children, a Cochrane 

Systematic Review (Brazzelli & Griffiths, 2006) concluded there is no evidence biofeedback training 

adds any benefit to conventional treatment. 

 Biofeedback has also improved constipation (encopresis) in 44 – 80% of children studied (Iwai et 

al. 1997; van Ginkel et al. 2000). The addition of home biofeedback does not enhance the effect of 

laboratory biofeedback (Croffie et al. 2005). A controlled study of biofeedback versus conventional 

therapy in 49 children with chronic idiopathic constipation (Sunic-Omejc et al. 2002) reported 
 Page 37

biofeedback was an effective method of treatment for childhood constipation because rectal sensation 

threshold, critical volume, and recto-anal inhibitory reflex volume were significantly higher, and the 

prevalence of abnormal defecation dynamics was significantly lower after treatment in those receiving 

biofeedback training. 

Fecal Incontinence: Adults 

Level 3: Probably Efficacious

In adults, biofeedback has been used to treat chronic fecal incontinence and that following 

childbirth and anorectal surgery. It has resulted in improvement in fecal incontinence in 60 – 92% of 

those studied (Chiarioni et al. 2002; Ko et al. 1997; Ryn, Morren, Hallbook, & Sjodahl, 2000; MartinezPuente, Pascual-Montero, & Garcia-Olmo, 2004; Beddy et al. 2004; Terra et al. 2006). In Solomon, 

Pager, Rex, Roberts, and Manning (2003), 120 randomly assigned patients in three biofeedback treatment 

groups — biofeedback with anal manometry, biofeedback with transanal ultrasound, and pelvic floor 

exercises with feedback from digital examination — showed a 70% improvement in continence with no 

difference between groups. The addition of cholestyramine to biofeedback treatment led to additional 

benefits in terms of stool frequency and consistency and the number of incontinent episodes (RemesTroche, Ozturk, Philips, Stessman, & Rao, 2007). Another RCT compared biofeedback to standard care, 

standard care plus sphincter exercises, sphincter-pressure biofeedback, and biofeedback plus home EMG 

biofeedback in 171 patients with fecal incontinence; they reported biofeedback was no better than 

standard care (Norton, Chelvanayagam, Wilson-Barnett, Redfern, & Kamm, 2003). 

Fecal incontinence was also improved with biofeedback after obstetric trauma (Fynes et al. 1999). 

Two RCTs comparing EMG biofeedback with EMG biofeedback and electrical stimulation after delivery 

showed conflicting results. Mahony et al. (2004) reported both groups had improved continence scores, 

and the addition of electrical stimulations did not enhance outcome. In contrast, Naimey et al. (2007) 

reported neither treatment showed improvement in continence scores. This contrast could be related to the 

type of fecal incontinence. Shafik, El Sibai, Shafik, and Shafik (2007) showed that while biofeedback was 

effective in 53% of patients with urge incontinence and 67% of patients with stress incontinence, it was 

not effective in mixed types. 

 Long-term efficacy of biofeedback for fecal incontinence has been demonstrated (Enck, Daublin, 

Lubke, & Strohmeyer, 1994; Guillomot et al. 1995; Ryn et al. 2000; Ozturk, Niazi, Stessman, & Rao, 

2004). Despite all of these studies, a Cochrane Systematic Review concluded the limited number of 

controlled numbers together with their methodological weaknesses do not provide evidence of 

biofeedback enhancing the outcome of treatment for fecal incontinence compared to other conservative 

methods (Norton, Cody, & Hosker, 2006). 

 Biofeedback has also been used after anal sphincter repair (Davis, Kumar, & Poloniecki, 2004) 

and surgery/radiation for colorectal cancer (Allgayer, Dietrich, Rohde, Koch, & Tuschhoff, 2005). 

Neither of these studies found biofeedback to be effective in reducing post-treatment incontinence. 

 Two recent studies have attempted to identify those patients most likely to be successful in 

treating their incontinence with biofeedback. Predictors of positive response included older age and 

abnormal defecatory maneuver (Fernandez-Fraga, Azpiroz, Aparici, Casaus, & Malagelada, 2003; Byrne, 

Solomon, Young, Rex, & Merlino, 2007). Finally, comparison of clinic-based biofeedback with 

telephone-assisted biofeedback showed a 54% mean improvement in the patients’ rating of incontinence 

with no significant differences in outcome between the groups (Byrne et al. 2005). 
 Page 38

Constipation: Adults 

Level 4: Efficacious

A critical review of 38 studies of biofeedback treatment for constipation reported most studies 

report positive results (Heymen, Jones, Scarlett, & Whitehead, 2003). Success rate for pressure 

biofeedback (78%) was greater than for EMG biofeedback (70%), but there was no difference in outcome 

using intra-anal or perianal EMG sensors. These findings are consistent with another review showing a 

62.4% success rate in those treated for constipation (Palsson et al. 2004). 

 Biofeedback has led to significant improvement in those with constipation (Heymen et al. 1999; 

Ko et al. 1997; Pucciani et al. 1998). A number of controlled trials have shown EMG biofeedback and 

manometry biofeedback had similar effects (Wang, Luo, Qi, & Dong, 2003), biofeedback and electrical 

stimulation were comparable (Chang et al. 2003), EMG biofeedback was better than medical treatment 

with diazepam or a placebo (Heymen et al. 2007), EMG biofeedback was better than sham biofeedback or 

standard care (Rao et al. 2007), and biofeedback was better than laxatives (Chiarioni, Whitehead, Pezza, 

Morelli, & Bassotti, 2006). It appears to be more effective for those with pelvic floor dyssynergia than for 

those with slow-transit constipation (Bassotti et al. 2004; Battaglia et al. 2004; Chiarioni, Salandini, & 

Whitehead, 2005). 

 Biofeedback has also been used after surgery for rectal disorders. In uncontrolled studies, 

biofeedback was shown to be of benefit after surgery (Kairaluoma et al. 2004; Hwang et al. 2005; Hwang 

et al. 2006). 

References 

Allgayer, H., Dietrich, C.F., Rohde, W., Koch, G.F., & Tuschhoff, T. (2005). Prospective comparison of 

short- and long-term effects of pelvic floor exercise/biofeedback training in patients with fecal 

incontinence after surgery plus irradiation versus surgery alone for colorectal cancer: Clinical, functional 

and endoscopic/endosonographic findings. Scandinavian Journal of Gastroenterology, 40(10), 

1168-1175. 

Bassotti, G., Chistolini, F., Sietchiping-Nzepa, F., de Roberto, G., Morelli, A., & Chiarioni, G. (2004). 

Biofeedback for pelvic floor dysfunction in constipation. BMJ, 14, 328(7436), 393-396. 

Battaglia, E., Serra, A.M., Buonafede, G., Dughera, L., Chistolini, F., Morelli, A., et al. (2004). Longterm study on the effects of visual biofeedback and muscle training as a therapeutic modality in pelvic 

floor dyssynergia and slow-transit constipation. Diseases of the Colon and Rectum, 47(1), 90-95. 

Beddy, P., Neary, P., Eguare, E.I., McCollum, R., Crosbie, J., Conlon, K.C., & Keane, F.B. (2004). 

Electromyographic biofeedback can improve subjective and objective measures of fecal incontinence in 

the short term. Journal of Gastrointestinal Surgery, 8(1), 64-72. 

Brazzelli, M., & Griffiths, P. (2006). Behavioural and cognitive interventions with or without other 

treatments for the management of faecal incontinence in children. Cochrane Database of Systematic 

Reviews (Online), 2(2), CD002240. 

Byrne, C.M., Solomon, M.J., Rex, J., Young, J.M., Heggie, D., & Merlino, C. (2005). Telephone vs. faceto-face biofeedback for fecal incontinence: Comparison of two techniques in 239 patients. Diseases of the 

Colon and Rectum, 48(12), 2281-2288. 

Byrne, C.M., Solomon, M.J., Young, J.M., Rex, J., & Merlino, C.L. (2007). Biofeedback for fecal 

incontinence: Short-term outcomes of 513 consecutive patients and predictors of successful treatment.

Diseases of the Colon and Rectum, 50(4), 417-427. 
 Page 39

Chang, H.S., Myung, S.J., Yang, S.K., Jung, H.Y., Kim, T.H., Yoon, I.J., et al. (2003). Effect of electrical 

stimulation in constipated patients with impaired rectal sensation. International Journal of Colorectal 

Disease, 18(5), 433-438. 

Chiarioni, G., Bassotti, G., Stanganini, S., Vantini, I., Whitehead, W.E., & Stagagnini, S. (2002). Sensory 

retraining is key to biofeedback therapy for formed stool fecal incontinence. American Journal of 

Gastroenterology, 97(1), 109-117. 

Chiarioni, G., Salandini, L., & Whitehead, W.E. (2005). Biofeedback benefits only patients with outlet 

dysfunction, not patients with isolated slow-transit constipation. Gastroenterology, 129(1), 86-97. 

Chiarioni, G., Whitehead, W.E., Pezza, V., Morelli, A., & Bassotti, G. (2006). Biofeedback is superior to 

laxatives for normal transit constipation due to pelvic floor dyssynergia. Gastroenterology, 130(3), 

657-664. 

Croffie, J.M., Ammar, M.S., Pfefferkorn, M.D., Horn, D., Klipsch, A., Fitzgerald, J.F., et al. (2005). 

Assessment of the effectiveness of biofeedback in children with dyssynergic defecation and recalcitrant 

constipation/encopresis: Does home biofeedback improve long-term outcomes. Clinical Pediatrics, 44(1), 

63-71. 

Davis, K.J., Kumar, D., & Poloniecki, J. (2004). Adjuvant biofeedback following anal sphincter repair: A 

randomized study. Alimentary Pharmacology & Therapeutics, 20(5), 539-549. 

Enck, P., Daublin, G., Lubke, H.J., & Strohmeyer, G. (1994). Long-term efficacy of biofeedback training 

for fecal incontinence. Diseases of the Colon and Rectum, 37(10), 997-1001. 

Fernandez-Fraga, X., Azpiroz, F., Aparici, A., Casaus, M., & Malagelada, J.R. (2003). Predictors of 

response to biofeedback treatment in anal incontinence. Diseases of the Colon and Rectum, 46(9), 

1218-1225. 

Fynes, M.M., Marshall, K., Cassidy, M., Behan, M., Walsh, D., O’Connell, P.R., et al. (1999). A 

prospective, randomized study comparing the effect of augmented biofeedback with sensory biofeedback 

alone on fecal incontinence after obstetric trauma. Diseases of the Colon and Rectum, 42(6), 753-761. 

Guillomot, F., Bouche, B., Gower-Rousseau, C., Chartier, M., Wolschies, E., Lamblin, M.D., et al. 

(1995). Biofeedback for the treatment of fecal incontinence: Long-term clinical results. Diseases of the 

Colon and Rectum, 38(4), 393-397. 

Heymen, S., Jones, K.R., Ringel, Y., Scarlett, Y., & Whitehead, W.E. (2001). Biofeedback treatment of 

fecal incontinence: A critical review. Diseases of the Colon and Rectum, 44(5), 728-736. 

Heymen, S., Jones, K.R., Scarlett, Y., & Whitehead, W.E. (2003). Biofeedback treatment of constipation: 

A critical review. Diseases of the Colon and Rectum, 46(9), 1208-1217. 

Heymen, S., Scarlett, Y., Jones, K., Ringel, Y., Drossman, D., & Whitehead, W.E. (2007). Randomized, 

controlled trial shows biofeedback to be superior to alternative treatments for patients with pelvic floor 

dyssynergia-type constipation. Diseases of the Colon and Rectum, 50(4), 428-441. 

Heymen, S., Wexner, S.D., Vickers, D., Nogueras, J.J., Weiss, E.G., & Pikarsky, A.J. (1999). 

Prospective, randomized trial comparing four biofeedback techniques for patients with constipation. 

Diseases of the Colon and Rectum, 42(11), 1388-1393. 

Hibi, M., Iwai, N., Kimura, O., Sasaki, Y., & Tsuda, T. (2003). Results of biofeedback therapy for fecal 

incontinence in children with encopresis and following surgery for anorectal malformations. Diseases of 

the Colon and Rectum, 46(10 Suppl), S54-8. 

Hwang, Y.H., Choi, J.S., Nam, Y.S., Salum, M.R., Weiss, E.G., Nogueras, J.J., et al. (2005). Biofeedback 

therapy after perineal rectosigmoidectomy or J pouch procedure. Surgical Innovation, 12(2), 135-138. 
 Page 40

Hwang, Y.H., Person, B., Choi, J.S., Nam, Y.S., Singh, J.J., Weiss, E.G., et al. (2006). Biofeedback 

therapy for rectal intussusception. Techniques in Coloproctology, 10(1), 11-16. 

Iwai, N., Iwata, G., Kimura, O., & Yanagihara, J. (1997). Is a new biofeedback therapy effective for fecal 

incontinence in patients who have anorectal malformations? Journal of Pediatric Surgery, 32(11), 

1626-1629. 

Kairaluoma, M., Raivio, P., Kupila, J., Aarnio, M., & Kellokumpu, I. (2004). The role of biofeedback 

therapy in functional proctologic disorders. Scandinavian Journal of Surgery, 93(3), 184-190. 

Ko, C.Y., Tong, J., Lehman, R.E., Shelton, A.A., Schrock, T.R. & Welton, M.L. (1997). Biofeedback is 

effective therapy for fecal incontinence and constipation. Archives of Surgery, 132(8), 829-834. 

Leung, M.W., Wong, B.P., Leung, A.K., Cho, J.S., Leung, E.T., Chao, N.S., et al. (2006). Electrical 

stimulation and biofeedback exercise of pelvic floor muscle for children with faecal incontinence after 

surgery for anorectal malformation. Pediatric Surgery International, 22(12), 975-978. 

Mahony, R.T., Malone, P.A., Nalty, J., Behan, M., O’Connell, P.R., & O’Herlihy, C. (2004). Randomized 

clinical trial of intraanal electromyographic biofeedback physiotherapy with intraanal electromyographic 

biofeedback augmented with electrical stimulation of the anal sphincter in the early treatment of 

postpartum fecal incontinence. American Journal of Obstetrics and Gynecology, 191(3), 885-890. 

Martinez-Puente, M.C., Pascual-Montero, J.A., & Garcia-Olmo, D. (2004). Customized biofeedback 

therapy improves results in fecal incontinence. International Journal of Colorectal Disease, 19(3), 

210-214. 

Munteis, E., Andreu, M., Martinez-Rodriguez, J.E., Ois, A., Bory, F., & Roquer, J. (2007). Manometric 

correlations of anorectal dysfunction and biofeedback outcome in patients with multiple sclerosis.

Multiple Sclerosis, (Epub, ahead of print). 

Naimy, N., Lindam, A.T., Bakka, A., Faerden, A.E., Wiik, P., Carlsen, E., et al. (2007). Biofeedback vs. 

electrostimulation in the treatment of postdelivery anal incontinence: A randomized, clinical trial.

Diseases of the Colon and Rectum, 50(12), 2040-2046. 

Norton, C., Chelvanayagam, S., Wilson-Barnett, J., Redfern, S., & Kamm, M.A. (2003). Randomized 

controlled trial of biofeedback for fecal incontinence. Gastroenterology, 125(5), 1320-1329. 

Norton, C., Cody, J.D., & Hosker, G. (2006). Biofeedback and/or sphincter exercises for the treatment of 

faecal incontinence in adults. Cochrane Database of Systematic Reviews (Online), 3, CD002111. 

Ozturk, R., Niazi, S., Stessman, M., & Rao, S.S. (2004). Long-term outcome and objective changes of 

anorectal function after biofeedback therapy for faecal incontinence. Alimentary Pharmacology & 

Therapeutics, 20(6), 667-674. 

Palsson, O.S., Heymen, S., & Whitehead, W.E. (2004). Biofeedback treatment for functional anorectal 

disorders: A comprehensive efficacy review. Applied Psychophysiology and Biofeedback, 29(3), 153-174. 

Pucciani, F., Rottoli, M.L., Bologna, A., Coanchi, F., Forconi, S., Cutelle, M., et al. (1998). Pelvic floor 

dyssynergia and bimodal rehabilitation: Results of combined pelviperineal kinesitherapy and biofeedback 

training. International Journal of Colorectal Disease, 13(3), 124-130. 

Rao, S.S., Seaton, K., Miller, M., Brown, K., Nygaard, I., Stumbo, P., et al. (2007). Randomized 

controlled trial of biofeedback, sham feedback, and standard therapy for dyssynergic defecation. Clinical 

Gastroenterology and Hepatology, 5(3), 331-338. 

Remes-Troche, J.M., Ozturk, R., Philips, C., Stessman, M., & Rao, S.S. (2007). Cholestyramine: A useful 

adjunct for the treatment of patients with fecal incontinence. International Journal of Colorectal Disease, 

23(2), 189-194. 
 Page 41

Ryn, A.K., Morren, G.L., Hallbook, O., & Sjodahl, R. (2000). Long-term results of electromyographic 

biofeedback training for fecal incontinence. Diseases of the Colon and Rectum, 43(9), 1262-1266. 

Shafik, A., El Sibai, O., Shafik, I.A., & Shafik, A.A. (2007). Stress, urge, and mixed types of partial fecal 

incontinence: Pathogenesis, clinical presentation, and treatment. The American Surgeon, 73(1), 6-9. 

Solomon, M.J., Pager, C.K., Rex, J., Roberts, R., & Manning, J. (2003). Randomized, controlled trial of 

biofeedback with anal manometry, transanal ultrasound, or pelvic floor retraining with digital guidance 

alone in the treatment of mild to moderate fecal incontinence. Diseases of the Colon and Rectum, 46(6), 

703-710. 

Sunic-Omejc, M., Mihanovic, M., Bilic, A., Jurcic, D., Restek-Petrovic, B., Maric, N., Dujsin, M., & 

Bilic, A. (2002). Efficiency of biofeedback therapy for chronic constipation in children. Collegium 

Antropologicum, 6 (Suppl), 93-101. 

Terra, M.P., Dobben, A.C., Berghmans, B., Deutekom, M., Baeten, C.G., Janssen, L.W., Boeckxstaens, 

G.E., Engel, A.F., Felt-Bersma, R.J., Slors, J.F., Gerhards, M.F., Bijnen, A.B., Everhardt, E., Schouten, 

W.R., Bossuyt, P.M., & Stoker, J. (2006). Electrical stimulation and pelvic floor muscle training with 

biofeedback in patients with fecal incontinence: A cohort study of 281 patients. Dis Colon Rectum, 49(8), 

1149-1159. 

van Ginkel, R., Benninga, M.A., Blommaart, P.J., van der Plas, R.N., Boeckxstaens, G.E., Buller, H.A., et 

al. (2000). Lack of benefit of laxatives as adjunctive therapy for functional nonretentive fecal soiling in 

children. Journal of Pediatrics, 137(6), 808-813. 

Wang, J., Luo, M.H., Qi, Q.H., & Dong, Z.L. (2003). Prospective study of biofeedback retraining in 

patients with chronic idiopathic functional constipation. World Journal of Gastroenterology, 9(9), 

2109-2113. 

Wiesel, P.H., Norton, C., Roy, A.J., Storrie, J.B., Bowers, J., Kamm, M.A. (2000). Gut focused 

behavioural treatment (biofeedback) for constipation and faecal incontinence in multiple sclerosis. 

Journal of Neurology, Neurosurgery, and Psychiatry, 69(2), 240-243. 

Fibromyalgia/Chronic Fatigue Syndrome 

Level 2: Possibly Efficacious 

 This poorly understood disorder has often been the subject of clinical trials involving several 

simultaneous interventions. The rationale for this scattershot approach is usually that it is a 

multidimensional disorder and therefore calls for multiple approaches in combination. Biofeedback is 

often included as part of a treatment package including physical exercise and cognitive-behavioral 

therapy. EMG is the most common modality, but EEG feedback has been used also. Separate reviews 

(Hadhazy, Ezzo, Creamer, & Berman, 2000; Sim & Adams, 1999; Yousefi & Coffey, 2005; Sarzi-Puttini, 

Buskila, Carrabba, Doria, & Atzeni, 2007) of mind-body approaches to fibromyalgia, examining mostly 

randomized controlled studies, concluded there was no clear superiority of any mind-body approach 

including biofeedback but that collectively they seemed to help in conjunction with physical exercise. 

Berman and Swyers (1999) concluded, “The strongest data exist for the use of mind-body techniques 

(e.g., biofeedback, hypnosis, cognitive behavioural therapy), particularly when utilized as part of a 

multidisciplinary approach to treatment.” Several uncontrolled trials have shown improvement from EMG 

biofeedback alone (Mur, Drexler, Gruber, Hartig, & Gunther, 1999; Sarnoch, Adler, & Scholz, 1997). 

Improvement may include quality of sleep, self-efficacy, pain threshold, and emotional adjustment. 
 Page 42

Donaldson, Sella, and Mueller (1998) included biofeedback with other therapies and found 

improvement in symptoms along with normalization of the EEG. Mueller, Donaldson, Nelson, and 

Layman (2001) improved fibromyalgia symptoms using EEG-driven stimulation; in contrast, Kravitz, 

Esty, Katz, and Fawcett (2006) did not observe an effect of EEG vs. sham feedback. EMG biofeedback 

showed some positive effects when used alone (Babu, Mathew, Danda, & Prakash, 2007) or in 

combination with cognitive behavioral therapy (Al-Haggar, Al-Naggar, & Abdel-Salam, 2006). A onegroup study of HRV biofeedback, wherein 12 women were taught to breathe at their resonant frequency, 

showed decreases in depression and pain and improvement in functioning (Hassett et al. 2007). 

Taken together, these studies do not show biofeedback efficacy in treating this challenging 

disorder, probably because the etiology remains unclear. Mitani et al. (2006) used physiological 

monitoring techniques to monitor differences between the right and left sides of the body. They found 

marked asymmetries of surface EMG, temperature, and skin conductance levels in those with 

fibromyalgia compared to healthy subjects and suggested these might be related to nervous system 

dysfunction. 

References 

Al-Haggar, M.S., Al-Naggar, Z.A., & Abdel-Salam, M.A. (2006). Biofeedback and cognitive behavioral 

therapy for Egyptian adolescents suffering from chronic fatigue syndrome. Journal of Pediatric 

Neurology, 4(3), 161-169. 

Babu, A.S., Mathew, E., Danda, D., & Prakash, H. (2007). Management of patients with fibromyalgia 

using biofeedback: A randomized control trial. Indian Journal of Medical Sciences, 61(8), 455-461. 

Berman, B.M., & Swyers, J.P. (1999). Complementary medicine treatments for fibromyalgia syndrome. 

Baillieres Best Practice & Research. Clinical Rheumatology, 13(3), 487-92. 

Donaldson, C.C., Sella, G., & Mueller, H.H. (1998). Fibromyalgia: A retrospective study of 252 

consecutive referrals. Canadian Journal of Clinical Medicine, 5(6), 116-127. 

Hadhazy, V.A., Ezzo, J., Creamer, P., & Berman, B.M. (2000). Mind-body therapies for the treatment of 

fibromyalgia: A systematic review. Journal of Rheumatology, 27(12), 2911-2918. 

Hassett, A.L., Radvanski, D.C., Vaschillo, E.G., Vaschillo, B., Sigal, L.H., Karavidas, M.K., et al. (2007). 

A pilot study of the efficacy of heart rate variability (HRV) biofeedback in patients with fibromyalgia.

Applied Psychophysiology and Biofeedback, 32(1), 1-10. 

Kravitz, H.M., Esty, M.L., Katz, R.S., & Fawcett, J. (2006). Treatment of fibromyalgia syndrome using 

low-intensity neurofeedback with the flexyx neurotherapy system: A randomized controlled clinical trial.

Journal of Neurotherapy, 10(2-3), 41-58. 

Mitani, Y., Fukunaga, M., Kanbara, K., Takebayashi, N., Ishino, S., & Nakai, Y. (2006). Evaluation of 

psychophysiological asymmetry in patients with fibromyalgia syndrome. Applied Psychophysiology and 

Biofeedback, 31(3), 217-225. 

Mueller, H.H., Donaldson, C.C., Nelson, D.V., & Layman, M. (2001). Treatment of fibromyalgia 

incorporating EEG-driven stimulation: A clinical outcomes study. Journal of Clinical Psychology, 57(7), 

933-952. 

Mur, E., Drexler, A., Gruber, J., Hartig, F., & Gunther, V. (1999). Electromyography biofeedback therapy 

in fibromyalgia [article in German]. Wiener Medizinische Wochenschrift, 149(19-20), 561-563. 

Sarnoch, H., Adler, F., & Scholz, O.B. (1997). Relevance of muscular sensitivity, muscular activity, and 

cognitive variables for pain reduction associated with EMG biofeedback in fibromyalgia. Perceptual and 

Motor Skills, 84(3 Pt. 1), 1043-1050. 
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Sarzi-Puttini, P., Buskila, D., Carrabba, M., Doria, A., & Atzeni, F. (2007). Treatment strategy in 

fibromyalgia syndrome: Where are we now? Seminars in Arthritis and Rheumatism, Epub-ahead of print. 

Sim, J., & Adams, N. (1999). Physical and other nonpharmacological interventions for fibromyalgia. 

Baillieres Best Practice Research Clinical Rheumatology, 13(3), 507-523. 

Yousefi, P., & Coffey, J. (2005). For fibromyalgia, which treatments are the most effective? Journal of 

Family Practice, 54(12), 1094-1095. 

Hand Dystonia 

Level 2: Possibly Efficacious 

 EMG biofeedback from the proximal large muscles of the hand was provided to 10 patients with 

hand dystonia (writer’s cramp) (Deepak & Behari, 1999). Nine patients showed improvement from 37 to 

93% in handwriting, alleviation of discomfort, and pain. 

Reference 

Deepak, K.K., & Behari, M. (1999). Specific muscle EMG biofeedback for hand dystonia. Applied 

Psychophysiology and Biofeedback, 24(4), 267-80. 

Headache – Pediatric 

Level 3: Probably Efficacious

Research support for migraine in children is stronger than that for mixed and tension-type 

headache. A recent review article (Hermann & Blanchard, 2002) summarized headache/biofeedback 

research to date in children and concluded thermal biofeedback is effective in alleviating headache 

activity in children; most studies showed more than two-thirds of the children had a 50% symptom 

reduction. Two recent meta-analyses examining psychological treatment of headache, and not specifically 

biofeedback, reported overall improvement with relaxation training in comparison to wait-list controls for 

children and adolescents with both migraine and tension-type headache (Trautmann, Lackschewitz, & 

Kroner-Herwig, 2006). A second meta-analysis, limited to tension-type headache, found no evidence for 

or against biofeedback effectiveness (Verhagen et al. 2005). 

 A minority of studies used EMG biofeedback from the frontal area instead of or in addition to 

hand-warming biofeedback. Most protocols used 10 sessions or fewer and included home practice; some 

involved the parents also. For example, five children with tension-type headaches (Arndorfer & Allen, 

2001) participated in a multiple-baseline, time-lagged, within-subject design using thermal biofeedback. 

All learned the hand-warming technique and showed significant clinical improvement, and six months 

afterward, 80% were headache-free. Labbe (1995) compared thermal biofeedback-assisted autogenic 

training to autogenic training only with a wait-list control group in 30 migrainous children; 80% of the 

first group had significant improvement, 50% of the second group, and none in the third group. Finally, 

Damen et al. (2006) conducted a systematic review of 19 studies of nonpharmacological treatment in 

children; they reported biofeedback with relaxation was more effective than wait-list controls or placebo. 
 Page 44

Headache – Adult 

Level 4: Efficacious 

Adult headache, whether tension, migraine, or mixed, has been the focus of much research. For 

example, Arena, Bruno, Hannah, and Meader (1995) compared biofeedback training from the forehead 

and trapezius muscles with a nonfeedback progressive muscle relaxation control group in 26 tensionheadache patients; clinical improvement was strongest for the trapezius group. McGrady, Wauquier, 

McNeil, and Gerard (1994) and Vasudeva, Claggett, Tietjen, and McGrady (2003) found superior clinical 

results for biofeedback-assisted relaxation as compared to self-directed relaxation; this conclusion was 

supported by measurement of cerebral flood flow using transcranial Doppler monitoring. An RCT 

comparing temporal pulse amplitude biofeedback with cognitive behavioral therapy and wait list showed 

68% headache reduction in the CBT group compared to 56% in the biofeedback group and 20% in the 

control group (Martin, Forsyth, & Reece, 2007). Thermal and EMG biofeedback coupled with relaxation 

training was found to be just as effective as propranolol in treating migraine headache but more effective 

during the first year post-treatment (Kaushik, Kaushik, Mahajan, & Rajesh, 2005). 

Rokicki et al. (1997) found a significant drop in headaches following a six-session EMG 

biofeedback protocol compared with a control group that showed no improvement. Improvement 

correlated most with a greater sense of self-efficacy rather than with EMG levels. Later work by this same 

investigator suggests EMG variance, rather than just mean EMG level, may provide a more complete 

measure of physiological changes responsible for headache reduction following EMG biofeedback 

training (Rokicki et al. 2003). 

Silberstein (2000) published a review of migraine treatment on behalf of the American Academy 

of Neurology – U.S. Consortium and concluded thermal and muscle biofeedback, in a general context of 

relaxation training, was generally effective and recommended as a treatment option. Isolating biofeedback 

as the active element from factors such as general relaxation, emotional improvement, and enhanced selfefficacy has not been very successful so far because most studies offer combined treatment approaches. 

But a very recent and specific meta-analysis of 55 studies examining the efficacy of biofeedback for 

migraine showed a medium effect size for all biofeedback interventions that was stable over 17 months; 

they also reported BVP biofeedback had higher effect sizes than thermal or EMG biofeedback (Nestoriuc 

& Martin, 2007). Andrasik (2007) reviewed meta-analyses and evidenced-based reviews of behavioral 

treatments for headaches in adults. After considering all meta-analyses to date, he concluded the effects of 

behavioral treatments are superior to various control conditions and similar to current medications for 

both migraine and tension-type headache. Combining behavioral and pharmacological treatments may 

increase effectiveness even further. 

A recent study explored the effect of biofeedback on oxidative stress as measured by peroxides, 

nitric oxide, and superoxide dismutase in patients with migraine (Ciancarelli, Tozzi-Ciancarelli, Spacca, 

Di Massimo, & Carolei, 2007). They suggested the effect of biofeedback may be related to muscle 

relaxation associated with decreased oxidative stress. 

Biofeedback is also effective for treatment of migraine in pregnancy and menstrually related 

headache. Conner and Rideout (2005) reported 72% of those receiving thermal biofeedback, relaxation 

training, and physical therapy exercise improved compared to 29% of the attention control group. In an 

uncontrolled study, Blanchard and Kim (2005) provided thermal biofeedback to women with menstrually 

related headache; those with vascular headache showed a reduction in headache and use of related 

medications while those with tension-type headache did not respond to training. Because many studies 

include a combination of treatments, it is not possible to separate out the specific effects of biofeedback. 

Many patients are not able to access therapy sites. Therefore, Devineni and Blanchard (2005) 

tested an internet-based treatment for chronic headache composed of relaxation, limited biofeedback with 

autogenic training, and stress management versus a wait-list control. They found 39% of treated 
 Page 45

participants improved post-treatment, and this rose to 47% two months post-treatment with a 35% 

reduction in medication usage. 

References 

Andrasik, F. (2007). What does the evidence show? Efficacy of behavioural treatments for recurrent 

headaches in adults. Neurological Sciences, 28, Suppl 2, S70-7. 

Arena, J.G., Bruno, G.M., Hannah, S.L., & Meader, K.J. (1995). Comparison of frontal 

electromyographic biofeedback training, trapezius electromyographic biofeedback training, and 

progressive muscle relaxation therapy in the treatment of tension headache. Headache, 35(7), 411-419. 

Arndorfer, R.E., & Allen, K.D. (2001). Extending the efficacy of a thermal biofeedback treatment 

package to the management of tension-type headaches in children. Headache, 41(2), 183-92. 

Blanchard, E.B., & Kim, M. (2005). The effect of the definition of menstrually related headache on the 

response to biofeedback treatment. Applied Psychophysiology and Biofeedback, 30(1), 53-63. 

Ciancarelli, I., Tozzi-Ciancarelli, M.G., Spacca, G., Di Massimo, C., & Carolei, A. (2007). Relationship 

between biofeedback and oxidative stress in patients with chronic migraine. Cephalalgia, 27(10), 

1136-1141. 

Conner, S.J., & Rideout, S. (2005). What are the best therapies for acute migraine in pregnancy? Journal 

of Family Practice, 54(11), 992-5. 

Damen, L., Bruijn, J., Koes, B.W., Berger, M.Y., Passchier, J., & Verhagen, A.P. (2006). Prophylactic 

treatment of migraine in children: Part 1. A systematic review of nonpharmacological trials. Cephalalgia,

26(4), 373-383. 

Devineni, T., & Blanchard, E.B. (2005). A randomized controlled trial of an internet-based treatment for 

chronic headache. Behaviour Research and Therapy, 43(3), 277-292. 

Hermann, C., & Blanchard, E.B. (2002). Biofeedback in the treatment of headache and other childhood 

pain. Applied Psychophysiology & Biofeedback, 27(2), 143-162. 

Kaushik, R., Kaushik, R.M., Mahajan, S.K., & Rajesh, V. (2005). Biofeedback-assisted diaphragmatic 

breathing and systematic relaxation versus propranolol in long term prophylaxis of migraine.

Complementary Therapies in Medicine, 13(3), 165-174. 

Labbe, E.E. (1995). Treatment of childhood migraine with autogenic training and skin temperature 

biofeedback: A component analysis. Headache, 35(1), 10-13. 

Martin, P.R., Forsyth, M.R., & Reece, J. (2007). Cognitive-behavioral therapy versus temporal pulse 

amplitude biofeedback training for recurrent headache. Behavior Therapy, 38(4), 350-363. 

McGrady, A., Wauquier, A., McNeil, A., & Gerard, C. (1994). Effect of biofeedback-assisted relaxation 

on migraine headache and changes in cerebral blood flow velocity in the middle cerebral artery. 

Headache, 34(7), 424-428. 

Nestoriuc, Y., & Martin, A. (2007). Efficacy of biofeedback for migraine: A meta-analysis. Pain, 128(1-

2), 111-127. 

Rokicki, L.A., Holroyd, K.A., France, C.R., Lipchik, G.L., France, J.L., & Kvaal, S.A. (1997). Change 

mechanisms associated with combined relaxation/EMG biofeedback training for chronic tension 

headache. Applied Psychophysiology & Biofeedback, 22(1), 21-41. 

Rokicki, L.A., Houle, T.T., Dhingra, L.K., Weinland, S.R., Urban, A.M., & Bhalla, R.K. (2003). A 

preliminary analysis of EMG variance as an index of change in EMG biofeedback treatment of tensiontype headache. Applied Psychophysiology and Biofeedback, 28(3), 205-215. 
 Page 46

Silberstein, S.D. (2000). Practice parameter: Evidence-based guidelines for migraine headache (an 

evidence-based review): Report of the quality standards subcommittee of the American Academy of 

Neurology. Neurology, 55, 754-762. 

Trautmann, E., Lackschewitz, H., & Kroner-Herwig, B. (2006). Psychological treatment of recurrent 

headache in children and adolescents — a meta-analysis. Cephalalgia, 26(12), 1411-1426. 

Vasudeva, S., Claggett, A.L., Tietjen, G.E., & McGrady, A.V. (2003). Biofeedback-assisted relaxation in 

migraine headache: Relationship to cerebral blood flow velocity in the middle cerebral artery. Headache, 

43(3), 245-50. 

Verhagen, A.P., Damen, L., Berger, M.Y., Passchier, J., Merlijn, V., & Koes, B.W. (2005). Conservative 

treatments of children with episodic tension-type headache: A systematic review. Journal of Neurology,

252(10), 1147-1154. 

Hypertension 

Level 4: Efficacious

 A meta-analysis of 23 studies completed between 1975 and 1996 compared biofeedback-based 

training with active interventions (those thought to be effective, such as relaxation and meditation) and 

with inactive interventions (those representing a control group, such as clinic BP measurement or sham 

biofeedback). While both biofeedback and other active treatments resulted in a reduction in BP, there 

were no differences in the magnitude of the reduction in either systolic blood pressure (SBP) or diastolic 

blood pressure (DBP) when biofeedback was compared with active treatment. However, when 

biofeedback was compared to inactive control treatments, there was a significantly greater reduction in 

both SBP (6.7 mmHg) and DBP (4.8 mmHg) (Yucha et al. 2001). 

 A second meta-analysis of 22 randomized controlled studies (comprising a total of 905 essential 

hypertensive persons) published between 1966 and 2001 supported these findings (Nakao, Yano, 

Nomura, & Kuboki, 2003). In comparison with nonintervention controls, biofeedback resulted in 

significantly greater reductions in SBP (7.3 mmHg) and DBP (5.8 mmHg). Compared with other 

behavioral interventions, the net reductions in SBP and DBP were not statistically different. A very recent 

review of more than one hundred randomized controlled trials showed that behavioral treatments reduce 

BP to a modest degree (but as much as 14 mmHg for SBP and 11 mmHg for DBP), and this change is 

greater than that seen in wait-list or other inactive controls (Linden & Moseley, 2006). 

 Biofeedback appears to work just as well for those with white-coat hypertension as those with 

essential hypertension (Nakao, Nomura, Shimosawa, Fujita, & Kuboki, 2000) and for those with and 

without organ damage secondary to their hypertension (Nakao, Nomura, Shimosawa, Fujita, & Kuboki, 

1999). Laboratory training followed by home training appears to be particularly effective (Henderson, 

Hart, Lal, & Hunyor, 1998), as do workplace stress reduction programs for hypertensive employees 

(McCraty, Atkinson, & Tomasino, 2003). 

 It is not clear exactly how biofeedback exerts its BP-lowering effect. Thermal biofeedback seems 

to work by helping patients to dilate peripheral blood vessels, thereby lowering total peripheral resistance. 

Because baroreceptor sensitivity is reduced in hypertension, two recent studies have shown that 

increasing baroreceptor sensitivity with baroreceptor feedback (Overhaus, Ruddel, Curio, Mussgay, & 

Scholz, 2003) or respiratory training (Reyes del Paso et al. 2006) may result in BP reduction. 

Unfortunately, the degree of response to biofeedback training has varied widely for hypertension. 

This may be because of the starting level of BP (the higher the initial level, the better the response), the 
 Page 47

variety of modalities used (thermal, EMG, heart rate, BP biofeedback), the length of the training (four to 

20 sessions), and the ability of the subject to actually learn and incorporate the techniques into his or her 

lifestyle (Yucha, 2002; Linden & Moseley, 2006). Current literature shows thermal and EDR biofeedback 

are more effective than EMG or direct BP feedback (Linden & Moseley, 2006). While it is difficult to 

predict which hypertensives will be helped to reduce or even eliminate their antihypertensive medications 

with training, those with high resting sympathetic activity (low skin temperature, high heart rate, high BP) 

appear to benefit more with biofeedback-assisted relaxation training (Weaver & McGrady, 1995). 

References 

Henderson, R.J., Hart, M.G., Lal, S.K., & Hunyor, S.N. (1998). The effect of home training with direct 

blood pressure biofeedback of hypertensives: A placebo-controlled study. Journal of Hypertension, 16(6), 

771-778. 

Linden, W., & Moseley, J.V. (2006). The efficacy of behavioral treatments for hypertension. Applied 

Psychophysiology and Biofeedback, 31(1), 51-63. 

McCraty, R., Atkinson, M., & Tomasino, D. (2003). Impact of a workplace stress reduction program on 

blood pressure and emotional health in hypertensive employees. Journal of Alternative & Complementary 

Medicine, 9(3), 355-369. 

Nakao, M., Nomura, S., Shimosawa, T., Fujita, T., & Kuboki, T. (1999). Blood pressure biofeedback 

treatment, organ damage, and sympathetic activity in mild hypertension. Psychotherapy and 

Psychosomatics, 68(6), 341-347. 

Nakao, M., Nomura, S., Shimosawa, T., Fujita, T., & Kuboki, T. (2000). Blood pressure biofeedback 

treatment of white-coat hypertension. Journal of Psychosomatic Research, 48(2), 161-169. 

Nakao, M., Yano, E., Nomura, S., & Kuboki, T. (2003). Blood pressure-lowering effects of biofeedback 

treatment in hypertension: A meta-analysis of randomized controlled trials. Hypertension Research, 

26(1), 37-46. 

Overhaus, S., Ruddel, H., Curio, I., Mussgay, L., & Scholz, O.B. (2003). Biofeedback of baroreflex 

sensitivity in patients with mild essential hypertension. International Journal of Behavioral Medicine,

10(1), 66-78. 

Reyes del Paso, G.A., Cea, J.I., Gonzalez-Pinto, A., Cabo, O.M., Caso, R., Brazal, J., et al. (2006). Shortterm effects of a brief respiratory training on baroreceptor cardiac reflex function in normotensive and 

mild hypertensive subjects. Applied Psychophysiology and Biofeedback, 31(1), 37-49. 

Weaver, M.T., & McGrady, A. (1995). A provisional model to predict blood pressure response to 

biofeedback-assisted relaxation. Biofeedback and Self Regulation, 20(3), 229-240. 

Yucha, C.B. (2002). Problems inherent in assessing biofeedback efficacy studies. Applied 

Psychophysiology and Biofeedback, 27(1), 99-106, 113-114. 

Yucha, C.B., Clark, L., Smith, M., Uris, P., Lafleur, B., & Duval, S. (2001). The effect of biofeedback in 

hypertension. Applied Nursing Research, 14(1), 29-35. 

Immune Function 

Level 1: Not empirically supported 

 A small study (Gruber et al. 1993) of 13 stage-one breast cancer postmastectomy patients showed 

improvements in immune function (natural killer cell activity, mixed lymphocyte responsiveness, 
 Page 48

cancavalin A responsiveness, and the number of peripheral blood lymphocytes). Another small study 

(n=10) examining the effects of relaxation training, including EMG biofeedback in HIV-positive men, 

showed significant improvement in anxiety, mood, self-esteem, and T-cell count in comparison to a 

control group (Taylor, 1995). A study of 42 HIV patients showed no treatment effects on immune 

function, but those treated with massage and biofeedback showed significant differences in quality of 

life assessment in health care utilization and health perceptions (Birk, McGrady, MacArthur, & 

Khuder, 2000). 

References 

Birk, T.J., McGrady, A., MacArthur, R.D., & Khuder, S. (2000). The effects of massage therapy alone 

and in combination with other complementary therapies on immune system measures and quality of life 

in human immunodeficiency virus. Journal of Alternative and Complementary Medicine, 6(5), 405-414. 

Gruber, B.L., Hersh, S.P., Hall, N.R., Waletzky, L.R., Kunz, J.F., Carpenter, et al. (1993). Immunological 

responses of breast cancer patients to behavioral interventions. Biofeedback and Self Regulation, 18(1), 

1-22. 

Taylor, D.N. (1995). Effects of a behavioral stress-management program on anxiety, mood, self-esteem, 

and T-cell count in HIV positive men. Psychological Reports, 76(2), 451-457. 

Insomnia 

Level 3: Probably Efficacious

In 1996, an NIH Technology Assessment Panel examined existing research and concluded 

several nonpharmacological techniques, particularly relaxation and biofeedback, produced improvements 

in some aspects of sleep but questioned whether the magnitude of the improvement in sleep onset and 

total sleep time were clinically significant. 

In 1998, the American Academy of Sleep Medicine recommended biofeedback along with 

progressive muscle relaxation for insomnia after reviewing the quality of research, using American 

Psychological Association research criteria. Biofeedback was rated “probably efficacious” along with 

sleep restriction and cognitive-behavioral therapy (Morin et al. 1998). (Progressive muscle relaxation, 

stimulus control, and paradoxical intent were rated even higher.) 

The assignment of specific biofeedback procedures to particular subjects based on personal 

characteristics such as presence of tension and anxiety was examined by Hauri, Percy, Hellekson, 

Hartmann, and Russ (1982), using theta and SMR EEG. Nicassio, Boylan, and McCabe (1982) 

highlighted the importance of expectancy and found no correlation between achieved muscle relaxation 

and quality of sleep. 

In an update by the American Sleep Disorders Association in 2006, a task force of content experts 

was appointed by the American Academy of Sleep Medicine to perform a comprehensive review of the 

scientific literature since 1999 and to grade the evidence regarding nonpharmacological treatments of 

insomnia (Morgenthaler et al. 2006). Recommendations were developed based on this review using 

evidence-based methods. Psychological and behavioral interventions are effective in the treatment of both 

chronic primary insomnia (standard) and secondary insomnia (guideline). Stimulus control therapy, 

relaxation training, and cognitive behavior therapy are individually effective therapies in the treatment of 

chronic insomnia (standard) and sleep-restriction therapy, multicomponent therapy (without cognitive 

therapy), biofeedback, and paradoxical intention are individually effective therapies in the treatment of 

chronic insomnia (guideline). 
 Page 49

In a later but similar review by Morin, Jarvis, and Lynch (2007), therapeutic options for sleepmaintenance and sleep-onset insomnia published between January 1996 and January 2006 were 

evaluated. Nonpharmacologic options include stimulus control, sleep hygiene education, sleep restriction, 

paradoxical intention, relaxation therapy, biofeedback, and cognitive behavioral therapy. They concluded 

behavioral strategies, which often include biofeedback, have been demonstrated in numerous studies. 

These strategies are recommended when medications are not indicated, as an augmentation to medication, 

or as individual therapy in short-term mild insomnia. 

References 

Hauri, P.J., Percy, L., Hellekson, C., Hartmann, E., & Russ, D. (1982). The treatment of 

psychophysiologic insomnia with biofeedback: A replication study. Biofeedback and Self Regulation, 

7(2), 223-235. 

Morgenthaler, T., Kramer, M., Alessi, C., Friedman, L., Boehlecke, B., Brown, T., et al. (2006). Practice 

parameters for the psychological and behavioral treatment of insomnia: An update. An American 

Academy of Sleep Medicine Report. Sleep, 29(11), 1415-1419. 

Morin, A.K., Jarvis, C.I., & Lynch, A.M. (2007). Therapeutic options for sleep-maintenance and sleeponset insomnia. Pharmacotherapy, 27(1), 89-110. 

Morin, C.M., Hauri, P.J., Espie, C.A., Spielman, A.J., Buysse, D.J., & Bootzin, R.R. (1998). 

Nonpharmacologic treatment of chronic insomnia. An American Academy of Sleep Medicine Review.

Neuroscience and Behavior Physiology, 28(3), 330-335. 

Nicassio, P.M., Boylan, M.B., & McCabe, T.G. (1982). Progressive relaxation, EMG biofeedback and 

biofeedback placebo in the treatment of sleep-onset insomnia. British Journal of Medical Psychology, 

55(Pt. 2), 159-166. 

NIH Technology Assessment Panel on Integration of Behavioral and Relaxation Approaches into the 

Treatment of Chronic Pain and Insomnia. (1996). Integration of behavioral and relaxation approaches into 

the treatment of chronic pain and insomnia. Journal of the American Medical Association, 276(4), 

313-318. 

Standards of Practice Committee of the American Academy of Sleep Medicine. (1999). An American 

Academy of Sleep Medicine Report. Practice parameters for the non-pharmacologic treatment of chronic 

insomnia. Sleep, 22(8), 1134-1156. 

Irritable Bowel Syndrome 

Level 2: Possibly Efficacious 

 Studies of biofeedback to reduce irritable bowel syndrome (IBS) symptomatology are mixed. Earlier 

studies showed benefits with effects lasting four years post-treatment (Schwarz, Taylor, Scharff, & 

Blanchard, 1990). Two controlled comparisons of a previously validated multicomponent (relaxation, 

thermal biofeedback, and cognitive therapy) treatment for IBS showed no difference in comparison to an 

attention-placebo control group or a symptom monitoring control group (Blanchard et al. 1992). A recent 

study tested the effect of computerized biofeedback games for teaching relaxation (monitored by 

electrodermal activity) to patients with IBS. Training reduced the global and bowel symptom score, and 

50% of patients continued to use the technique to induce relaxation (Leahy, Clayman, Mason, Lloyd, & 

Epstein, 1998). 
 Page 50

References 

Blanchard, E.B., Schwarz, S.P., Suls, J.M., Gerardi, M.A., Scharff, L., Greene, B., et al. (1992). Two 

controlled evaluations of multicomponent psychological treatment of irritable bowel syndrome. 

Behavioral Research and Therapy, 30(2), 175-189. 

Leahy, A., Clayman, C., Mason, I., Lloyd, G., & Epstein, O. (1998). Computerized biofeedback games: A 

new method for teaching stress management and its use in irritable bowel syndrome. Journal of the Royal 

College of Physicians of London, 32(6), 552-556. 

Schwarz, S.P., Taylor, A.C., Scharff, L., & Blanchard, E.B. (1990). Behaviorally treated irritable bowel 

syndrome patients: A four-year follow-up. Behavioral Research and Therapy, 28(4), 331-335. 

Motion Sickness 

Level 4: Efficacious

The rationale for biofeedback relies on an assumed correlation between ability to control the 

autonomic precursors of motion sickness (rise in skin conductance, drop in skin temperature, high heart 

rate) and resistance to sickness resulting from induced motion, such as a chair movable in three directions, 

as is done with NASA research. 

Promethazine is commonly prescribed for motion sickness in astronauts with variable 

effectiveness. The strongest study on this application was by Cowings and Toscano (2000), where 

promethazine injections were compared to autogenic feedback training, including skin temperature and 

conductance with superior results for the latter. Control groups included a saline-placebo injection and no 

treatment. Four 30-minute sessions of autogenic training resulted in significantly more tolerance of the 

rotating chair in comparison with the two levels of intramuscular promethazine and placebo. Decreased 

variability of skin conductance plus lower HR was evident in the autogenic feedback groups. 

 Several studies were reviewed showing the impact of self-regulation training on motion sickness 

tolerance in virtually every motion sickness–inducing stimuli on the surface of a planet (Cowings, 1990), 

and research in space indicates this training is also effective in microgravity (Cowings et al. 1985; 1988; 

Toscano & Cowings, 1994). Scattered studies in the past 25 years have tried autogenic training assisted 

by biofeedback of temperature, skin conductance, and heart rate, sometimes including cognitive therapy. 

Two studies with negative results investigated the correlation between physiological change and 

success in reducing symptoms of motion sickness (Graybiel & Lackner, 1980; Jozsvai & Pigeau, 1996). 

These showed little correlation. It was later demonstrated by Cowings that this finding was due to a 

procedural error. Graybiel manually measured heart rate, blood pressure, and temperature before the onset 

of the motion sickness stimulus and again when the stimulus ended. By continuously monitoring 

physiological changes on more than 140 people, Cowings et al. (1986) showed there are distinct patterns 

associated with motion sickness susceptibility. Subsequent studies further demonstrated there are 

individually specific response patterns that are stable over repeated exposures to a motion sickness 

stimulus (Cowings, Naifeh, & Toscano, 1990; Stout, Toscano, & Cowings, 1995). 

Both NASA and military laboratories have demonstrated the effectiveness of training for control 

of airsickness in high performance aircraft (Levy, Jones, & Carlson, 1981; Jones et al. 1985; Cowings et 

al. 2001; Cowings et al. 2005). Desensitization in vivo has been the basic clinical model for intervention. 

Yet it is difficult to reproduce the conditions of a spaceship free of gravity. Also, the stimulus context of a 

chair spinning in three dimensions is more drastic than the usual context of a moving vehicle or boat. So 

generalizing from this experimental context to a more universal, nonastronaut situation is open to 
 Page 51

question in spite of the study’s design, so far unreplicated. The best approach, based on the research to 

date, seems to be training GSR control, first in isolation and then while exposed to a condition expected 

to induce motion sickness. 

References 

Cowings, P.S. (1977). Combined use of autogenic therapy and biofeedback in training effective control of 

heart rate by humans. Therapy in Psychosomatic Medicine, 4, 167-173. 

Cowings, P.S. (1977). Observed differences in learning ability of heart rate self-regulation as a function 

of hypnotic susceptibility. Therapy in Psychosomatic Medicine, 4, 221-226. 

Cowings, P.S. (1990). Autogenic-feedback training: A preventive method for motion and space motion 

sickness. In G. Crampton (Ed.), Motion and Space Sickness (pp. 354-372), Boca Raton, FL: CRC Press. 

Cowings, P.S., Billingham, J., & Toscano, W.B. (1977). Learned control of multiple autonomic responses 

to compensate for the debilitating effects of motion sickness. Therapy in Psychosomatic Medicine, 4, 

318-323. 

Cowings, P.S., Keller M.A., Folen, R.A., Toscano, W.B., Burge, J.D. (2001). Autogenic-feedback 

training exercise pilot performance: Enhanced functioning under search and rescue flying conditions. 

International Journal of Aviation Psychology, 11(3), 305-315. 

Cowings, P.S., Naifeh, K.H., & Toscano, W.B. (1990) The stability of individual patterns of autonomic 

responses to motion sickness stimulation. Aviation Space and Environmental Medicine, 61(5), 399-405. 

Cowings, P.S., Suter, S., Toscano, W.B., Kamiya, J., & Naifeh, K. (1986). General autonomic 

components of motion sickness. Psychophysiology, 23(5), 542-551. 

Cowings, P.S., & Toscano, W.B. (1977). Psychosomatic health: Simultaneous control of multiple 

autonomic responses by humans — a training method. Therapy in Psychosomatic Medicine, 4, 184-190. 

Cowings, P.S., & Toscano, W.B. (1982). The relationship of motion sickness susceptibility to learned 

autonomic control for symptom suppression. Aviation, Space and Environmental Medicine, 53(6), 

570-575. 

Cowings, P.S., & Toscano, W.B. (2000). Autogenic-feedback training exercise is superior to 

promethazine for control of motion sickness symptoms. Journal of Clinical Pharmacology, 40(10), 1154-

1165. 

Cowings, P.S., Toscano, W.B., Kamiya, J., Miller, N.E., & Sharp, J.C. (1985). Autogenic-feedback 

training as a preventive method for space adaptation syndrome. NASA Flight Experiment #3AFT23. 

Spacelab-3. Progress Report I. NASA Conference Publication #2429: Spacelab 3 Mission Science Review. 

pp. 84-89. 

Cowings, P.S., Toscano, W.B., Kamiya, J., Miller, N.E., & Sharp, J.C. (1988). Final Report. Spacelab-3 

Flight Experiment #3AFT23: Autogenic-feedback training as a preventive method for space adaptation 

syndrome. NASA Technical Memorandum #89412. National Aeronautics and Space Administration, 

Ames Research Center, Moffett Field, CA. 

Cowings, P.S., Toscano, W.B., Timbers, A., Casey, C., Hufnagel, J. (2005). Autogenic feedback training 

exercise: A treatment for airsickness in military pilots. The International Journal of Aviation Psychology, 

15(4), 395-412. 

Graybiel, A., & Lackner, J.R. (1980). Evaluation of the relationship between motion sickness 

symptomatology and blood pressure, heart rate, and body temperature. Aviation, Space, and Environment 

Medicine, 51(3), 211-214. 
 Page 52

Jones, D.R., Levy, R.A., Gardner, L., Marsh, R.W., & Patterson, J.C. (1985). Self-control of 

psychophysiologic responses to motion stress: Using biofeedback to treat airsickness. Aviation, Space, 

and Environmental Medicine, 56, 1152-1157. 

Jozsvai, E.E., & Pigeau, R.A. (1996). The effect of autogenic training and biofeedback on motion 

sickness tolerance. Aviation, Space, and Environment Medicine, 67(10), 963-968. 

Levy, R.A., Jones, D.R., & Carlson, F.H. (1981). Biofeedback rehabilitation of airsick crew. Aviation, 

Space, and Environmental Medicine, 52, 118-121. 

Stout, C.S., Toscano, W., & Cowings, P.S. (1995). Reliability of psychophysiological responses across 

multiple motion sickness stimulation tests. Journal of Vestibular Research, 5(1), 25-33. 

Toscano, W.B., & Cowings, P.S. (1982). Reducing motion sickness: Autogenic-feedback training 

compared to an alternative cognitive task. Aviation, Space and Environmental Medicine. 53(5), 449-453. 

Toscano, W.B., & Cowings, P. (1994). The effects of autogenic-feedback training on motion sickness 

severity and heart rate variability in astronauts, NASA Technical Memorandum #108840. 

Post-Traumatic Stress Disorder 

Level 2: Possibly Efficacious

 Several small studies incorporating biofeedback into multicomponent therapy, including eye 

movement desensitization and reprocessing (EMDR), reveal some improvement in self-report, 

psychometric, and standardized interview measures after therapy (Carlson, Chemtob, Rusnak, Hedlund, & 

Muraoka, 1998; Silver, Brooks, & Obenchain, 1995). A study of Vietnam veterans with combat-related 

post-traumatic stress disorder compared traditional medical treatment with 30 sessions of alpha-theta 

brainwave neurofeedback (Peniston & Kulkosky, 1991). Neurofeedback resulted in decreases in MMPI 

scores on clinical scales labeled hypochondriasis, depression, hysteria, psychopathic deviate, masculinityfemininity, paranoia, psychasthenia, schizophrenia, hypomania, and social introversion-extraversion in 

comparison to the traditional care group who showed decreases only on the scale labeled schizophrenia. A 

30-month follow up showed all traditional-care patients had relapsed, in contrast to only three of 15 

neurofeedback patients. 

Pop-Jordanova and Zorcec (2004) selected a group of 10 children manifesting post-traumatic 

stress disorder (PTSD) diagnosed by ICD-10. The mean age of the patients was nine ± 3.05 years, from 

both sexes (girls three, boys seven). Mothers and children were examined by a battery of psychometric 

instruments (MMPI), CBCL, Eysenck (EPQ), and STAI. In addition to the classical psychotherapeutic 

methods (supportive, behavior, and play therapy), a multimodal computerized biofeedback technique was 

introduced for both assessment and therapy. The results showed a high level of anxiety and stress, 

somatization, and behavioral problems (aggressiveness, impulsivity, nonobedience, and nightmares), 

complemented by hypersensitive and depressive mothers and miss-attachment in the early period of 

infancy. The therapeutic results obtained with biofeedback techniques were very encouraging. 

References 

Carlson, J.G., Chemtob, C.M., Rusnak, K., Hedlund, N.L., & Muraoka, M.Y. (1998). Eye movement 

desensitization and reprocessing (EDMR) treatment for combat-related post-traumatic stress disorder. 

Journal of Traumatic Stress, 11(1), 3-24. 

Peniston, E.G., & Kulkosky, P.J. (1991). Alpha-theta brainwave neurofeedback therapy for Vietnam 

veterans with combat-related post-traumatic stress disorder. Medical Psychotherapy, 4, 47-60. 
 Page 53

Pop-Jordanova, N., & Zorcec, T. (2004). Child trauma, attachment, and biofeedback mitigation. Prilozi / 

Makedonska akademija na naukite i umetnostite, Oddelenie za bioloski i medicinski nauki = 

Contributions / Macedonian Academy of Sciences and Arts, Section of Biological and Medical Sciences, 

25(1-2), 103-114. 

Silver, S.M., Brooks, A., & Obenchain, J. (1995). Treatment of Vietnam War veterans with PTSD: A 

comparison of eye movement desensitization and reprocessing, biofeedback, and relaxation training. 

Journal of Traumatic Stress, 8(2), 337-342. 

Raynaud’s Disease 

Level 4: Efficacious

There were several brief, relatively uncontrolled studies published in the 1970s that confirmed the 

rationale underlying temperature biofeedback (TBF) treatment of primary Raynaud’s disease (RP). 

Peterson and Vorhies (1983) studied thermal biofeedback-trained Raynaud’s patients, observing the speed 

of hand temperature return to baseline after hand immersion in ice water, which was six to seven times as 

fast after biofeedback training (six minutes average after training versus 40 minutes before). Jobe, 

Sampson, Roberts, and Kelly (1986) compared hand temperature responses to whole-body chilling before 

and after biofeedback training and found it to be effective. When Guglielmi, Roberts, and Patterson 

(1982) compared thermal biofeedback with EMG biofeedback and controls with a double-blind 

procedure, all three groups had comparable improvements, suggesting a role of nonspecific factors. The 

results of this study have limited generalization to clinical practice because the participants could not have 

adequate instructions about how to perform the physiological changes, when and how to utilize the 

training, and any motivational guidelines for incorporating the training daily to enhance the clinical 

training. Keefe, Surwit, and Pilon (1980) found similar results, in which other behavioral control methods 

performed as well as thermal biofeedback. However, Freedman et al. (1988) compared simple thermal 

biofeedback with autogenic training and found the former to be more effective. 

The largest study to date of Raynaud’s involving biofeedback compared use of a calcium-channel 

blocker (nifedipine) with thermal biofeedback, EMG feedback, and a placebo (Raynaud’s Treatment 

Study Investigators, 2000). In this study of 313 subjects with primary Raynaud’s disease, nifedipine 

seemed to be the superior agent for reducing symptoms. Problems with training the thermal biofeedback 

subjects to an adequate level of skill, however, mitigated the final results (Middaugh et al. 2001). 

A recent review of finger temperature training in primary Raynaud’s phenomenon that focused on 

whether subjects were adequately trained to increase finger temperature found eight RCT, one nonRCT, 

and two follow-up studies (Karavidas, Tsai, Yucha, McGrady, & Lehrer, 2006). The authors concluded 

the level of evidence for TBF efficacy is categorized as Level IV: efficacious. The rationale was based on 

three randomized controlled trials conducted in independent laboratories that demonstrated “superiority or 

equivalence” of treatments that include TBF. 

References 

Freedman, R.R., Sabharwal, S.C., Ianni, P., Desai, N., Wenig, P., & Mayes, M. (1988). Nonneural betaadrenergic vasodilating mechanism in temperature biofeedback. Psychosomatic Medicine, 50(4), 

394-401. 

Guglielmi, R.S., Roberts, A.H., & Patterson, R. (1982). Skin temperature biofeedback for Raynaud’s 

disease: A double-blind study. Biofeedback & Self-Regulation, 7(1), 99-120. 
 Page 54

Jobe, J.B., Sampson, J.B., Roberts, D.E., & Kelly, J.A. (1986). Comparison of behavioral treatments for 

Raynaud’s disease. Journal of Behavioral Medicine, 9(1), 89-96. 

Karavidas, M.K., Tsai, P.S., Yucha, C., McGrady, A., & Lehrer, P.M. (2006). Thermal biofeedback for 

primary Raynaud’s phenomenon: A review of the literature. Applied Psychophysiology and Biofeedback,

31(3), 203-216. 

Keefe, F.J., Surwit, R.S., & Pilon, R.N. (1980). Biofeedback, autogenic training, and progressive 

relaxation in the treatment of Raynaud’s disease: A comparative study. Journal of Applied Behavior 

Analysis, 13(1), 3-11. 

Middaugh, S.J., Haythornthwaite, J.A., Thompson, B., Hill, R., Brown, K.M., Freedman, R.R., et al. 

(2001). The Raynaud’s Treatment Study: Biofeedback protocols and acquisition of temperature 

biofeedback skills. Applied Psychophysiology and Biofeedback, 26(4), 251-278. 

Peterson, L.L., & Vorhies, C. (1983). Raynaud’s syndrome: Treatment with sublingual administration of 

nitroglycerin, swinging arm maneuver, and biofeedback training. Archives of Dermatology, 119(5), 

396-399. 

Raynaud’s Treatment Study Investigators. (2000). Comparison of sustained-release nifedipine and 

temperature biofeedback for treatment of primary Raynaud’s phenomenon. Results from a randomized 

clinical trial with one-year follow up. Archives of Internal Medicine, 160(8), 1101-1108. 

Repetitive Strain Injury 

Level 2: Possibly Efficacious

 A randomized controlled study of 30 patients with upper extremity repetitive strain injury showed 

those receiving thermal biofeedback and autogenic relaxation had significantly higher reductions in pain 

in comparison to the waiting-list condition (Moore & Wiesner, 1996). Group training in ergonomic 

principles and psychophysiological awareness, coupled with EMG practice, may reduce body symptoms 

associated with computer work, thereby preventing injury (Peper, Gibney, & Wilson, 2004). 

References 

Moore, L.E., & Wiesner, S.L. (1996). Hypnotically induced vasodilation in the treatment of repetitive 

strain injuries. American Journal of Clinical Hypnosis, 39(2), 97-104. 

Peper, E., Gibney, K.H., & Wilson, V.E. (2004). Group training with healthy computing practices to 

prevent repetitive strain injury (RSI): A preliminary study. Applied Psychophysiology and Biofeedback,

29(4), 279-87. 

Respiratory Failure: Mechanical Ventilation 

Level 2: Possibly Efficacious 

 Relaxation training using EMG biofeedback and breathing retraining using tidal volume 

biofeedback may help patients to be weaned from mechanical ventilation (Jacovone & Young, 1998). 

Only one randomized trial showed those receiving biofeedback were weaned from their ventilator in 20.6 

days in comparison to those in the control group who were weaned in 32.6 days (Holliday & Hyers, 
 Page 55

1990). Respiratory relaxation feedback of expired CO2 showed decreases in respiratory parameters 

reflecting neural respiratory drive (such as occlusion pressure, minute inspiratory volume, mean 

inspiratory flow, and selected EEG parameters) may contribute to the effectiveness of biofeedback in 

reducing weaning time (Holliday & Lippmann, 2003). 

References 

Holliday, J.E., & Hyers, T.M. (1990). The reduction of weaning time from mechanical ventilation using 

tidal volume and relaxation biofeedback. American Review of Respiratory Disease, 141(5 Pt. 1), 

1214-1220. 

Holliday, J.E., & Lippmann, M. (2003). Reduction in ventilatory response to CO2 with relaxation 

feedback during CO2 rebreathing for ventilator patients. Chest, 124(4), 1500-1511. 

Jacavone, J., & Young, J. (1998). Use of pulmonary rehabilitation strategies to wean a difficult-to-wean 

patient: Case study. Critical Care Nurse, 18(6), 29-37. 

Spinal Cord Injury 

Level 1: Not Empirically Supported

 There are limited studies on biofeedback post-spinal cord injury, and they involve different 

treatment protocols and outcome measures. However, there was a significant increase in triceps EMG 

activity in one hundred patients with long-term cervical spine injury after one biofeedback treatment, and 

further increases occurred after additional treatment sessions (Brucker & Bulaeva, 1996). A small study 

(n=10), studied patients in a daily therapy program lasting two months, including muscle strengthening 

and gait training. Half the subjects received biofeedback for 30 minutes a day; half used an ambulatory 

device to receive continuous biofeedback every time they walked. After two months, those undergoing 

clinical therapy showed a 50% reduction in hip drop; those using the home training device showed almost 

normal gait (Petrofsky, 2001). 

References 

Brucker, B.S., & Bulaeva, N.V. (1996). Biofeedback effect on electromyography responses in patients 

with spinal cord injury. Archives of Physical Medical Rehabilitation, 77(2), 133-137. 

Petrofsky, J.S. (2001). The use of electromyogram biofeedback to reduce trendelenburg gait. European 

Journal of Applied Physiology, 85(5), 491-495. 

Stroke (Cardiovascular Accident) 

Level 2: Possibly Efficacious 

 Four meta-analyses on the effect of biofeedback for rehabilitation after stroke show conflicting 

results. The first included eight studies (total of 192 patients) and examined functional outcome of EMG 

biofeedback. They found a significant effect size (0.81), concluding EMG biofeedback is useful for 

neuromuscular reeducation in the hemiplegic stroke patient (Schleenbaker & Mainous, 1993). The second 

meta-analysis compared the effects of EMG biofeedback and physical therapy on upper extremity 

function and found no significant differences (Moreland & Thomson, 1994). The third meta-analysis 
 Page 56

included studies with an outcome of change in range of joint motion of a paretic limb. The results of 

pooling eight studies did not support the efficacy of biofeedback in restoring upper or lower extremity 

range of motion of hemiparetic joints (Glanz et al. 1995). The fourth meta-analysis examined the efficacy 

of EMG biofeedback compared with conventional physical therapy for improving lower extremity 

function. EMG biofeedback was superior to physical therapy for improving ankle dorsiflexion muscle 

strength but not for improving gait quality, ankle range of motion, ankle angle during gait, stride length, 

or gait speed (Moreland, Thomson, & Fuoco, 1998). Thus it appears that when functional measures 

related to lower extremity are the outcome, biofeedback is effective; when functional measures related to 

the upper extremity or change in range of joint motion is the outcome, biofeedback is not effective. 

 A more recent Cochrane Review (Woodford & Price, 2006) of 13 studies of 269 persons 

concluded, “Despite evidence from a small number of individual studies to suggest that EMG 

biofeedback plus standard physiotherapy produces improvements in motor power, functional recovery, 

and gait quality when compared to standard physiotherapy alone, combination of all the identified studies 

did not find a treatment benefit.” 

 Finally, the use of biofeedback to treat urinary incontinence after stroke has not been sufficiently 

studied to demonstrate efficacy (Thomas et al. 2005). 

References 

Glanz, M., Klawansky, S., Stason, W., Berkey, C., Shah, N., Phan, H., et al. (1995). Biofeedback therapy 

in post-stroke rehabilitation: A meta-analysis of the randomized controlled trials. Archives of Physical 

Medical Rehabilitation, 76(6), 508-515. 

Moreland, J., & Thomson, M.A. (1994). Efficacy of electromyographic biofeedback compared with 

conventional physical therapy for upper-extremity function in patients following stroke: A research 

overview and meta-analysis. Physical Therapy, 74(6), 534-547. 

Moreland, J.D., Thomson, M.A., & Fuoco, A.R. (1998). Electromyographic biofeedback to improve 

lower extremity function after stroke: A meta-analysis. Archives of Physical Medical Rehabilitation,

79(2), 134-140. 

Schleenbaker, R.E., & Mainous, A.G. (1993). Electromyographic biofeedback for neuromuscular 

reeducation in the hemiplegic stroke patient: A meta-analysis. Archives of Physical Medical 

Rehabilitation, 74(12), 1301-1304. 

Thomas, L.H., Barrett, J., Cross, S., French, B., Leathley, M., Sutton, C., et al. (2005). Prevention and 

treatment of urinary incontinence after stroke in adults. Cochrane Database of Systematic Reviews 

(Online), 3(3), CD004462. 

Woodford, H., & Price, C. (2006). EMG biofeedback for the recovery of motor function after stroke. 

Cochrane Database of Systematic Reviews, (2), CD004585. 

Syncope (Neurocardiogenic) 

Level 1: Not Empirically Supported

 Ten patients with neurocardiogenic syncope were treated with EMG and thermal biofeedback, 

coupled with progressive muscle relaxation; six showed a major decrease in symptoms (McGrady, Bush, 

& Grubb, 1997). A later controlled pilot study on 22 patients with neurocardiogenic syncope showed 

biofeedback-assisted relaxation training led to significant improvement in headache index and loss of 

consciousness in the treatment group (McGrady et al. 2003). 
 Page 57

References 

McGrady, A.V., Kern-Buell, C., Bush, E., Devonshire, R., Claggett, A.L., & Grubb, B.P. (2003). 

Biofeedback-assisted relaxation therapy in neurocardiogenic syncope: A pilot study. Applied 

Psychophysiology and Biofeedback, 28(3), 183-192. 

McGrady, A.V., Bush, E.G., & Grubb, B.P. (1997). Outcome of biofeedback-assisted relaxation for 

neurocardiogenic syncope and headache: A clinical replication series. Applied Psychophysiology and 

Biofeedback, 22(1), 63-72. 

Temporomandibular Disorder (TMD) 

Level 4: Efficacious 

Used alone, biofeedback improves pain, pain-related disability, and mandibular functioning 

(Gardea, Gatchel, & Mishara, 2001). When used in combination with other treatments, such as intraoral 

applications (Turk, Zaki, & Rudy, 1993), and in cognitive-behavioral skills training (Gardea et al. 2001), 

the effect is enhanced (Turk, Rudy, Kubinski, Zaki, & Greco, 1996). A meta-analysis of 13 studies of 

EMG biofeedback treatment showed biofeedback was superior to no treatment or psychological placebo 

control for patient pain reports, clinical exam findings, and/or ratings of global improvement (Crider & 

Glaros, 1999). 

Gatchel, Stowell, Wildenstein, Riggs, and Ellis (2006) conducted a randomized clinical trial to 

evaluate the efficacy of a biopsychosocial intervention for patients who were at high risk (HR) of 

progressing from acute to chronic TMD-related pain. The authors assessed pain and psychosocial 

measures at intake and at one-year follow up. Two conditions were studied: standard care and standard 

care plus CBT and biofeedback comprised of frontal EMG and finger temperature training. Of 101 

subjects who started the study, 98 completed the one-year follow-up study. Subjects’ self-reported pain 

levels were measured on an analog scale and as a response to palpation. At one year, the treatment group 

subjects had significantly lower levels of self-reported pain and depression. The normal treatment group 

subjects had utilized more health care for jaw-related pain. The normal treatment group subjects were 

12.5 times as likely to have a somatoform disorder, more than seven times as likely to have an anxiety 

disorder, and 2.7 times more likely to have an affective disorder at one year compared with treatment 

group subjects. 

In a recent review of the literature, Crider, Glaros, and Gevirtz (2005) report on 14 controlled and 

uncontrolled outcome evaluations of biofeedback-based treatments for TMD published since 1978. This 

literature includes RCTs of three types of biofeedback treatment: 1) surface electromyographic (SEMG) 

training of the masticatory muscles, 2) SEMG training combined with adjunctive cognitive-behavioral 

therapy (CBT) techniques, and 3) biofeedback-assisted relaxation training (BART). Based on a detailed 

review of RCTs supplemented with information from nonRCT findings, the authors concluded SEMG 

training with adjunctive CBT is an efficacious treatment for TMD, and both SEMG training as the sole 

intervention and BART are probably efficacious treatments. 

Medlicott and Harris (2006) reported the results of a systematic review of the effectiveness of 

exercise, manual therapy, electrotherapy, relaxation training, and biofeedback in the management of 

TMD. Thirty studies met four criteria: 1) subjects were from one of three groups identified in the first axis 

of the Research Diagnostic Criteria for TMD, 2) the intervention was within the realm of physical therapy 

practice, 3) an experimental design was used, and 4) outcome measures assessed one or more primary 

presenting symptoms were found. Among other recommendations, the authors state combinations of 
 Page 58

active exercises, manual therapy, postural correction, and relaxation techniques often combined with 

biofeedback may be effective. 

In another recent systematic review, Turp et al. (2007) found 11 RCTs that met the criteria of at 

least four weeks of interventions where simple therapy was compared to multimodal interventions. Their 

conclusions were that with patients with no psychological disturbances simple treatment is effective, but 

for those with comorbid conditions a multimodal program is needed. 

Myers (2007) reported on a systematic review to TMD treatments and, based on a collection of previously 

reviewed studies and yet-to-be-reviewed studies, concludes biofeedback has been shown to be 

consistently superior to placebo or no-treatment controls. However, when compared to other treatments, 

biofeedback had mixed results: sometimes superior, sometimes equivalent, and sometimes less effective. 

References 

Crider, A.B., & Glaros, A.G. (1999). A meta-analysis of EMG biofeedback treatment of 

temporomandibular disorders. Journal of Orofacial Pain, 13(1), 29-37. 

Crider, A., Glaros, A.G., & Gevirtz, R.N. (2005). Efficacy of biofeedback-based treatments for 

temporomandibular disorders. Applied Psychophysiology and Biofeedback, 30(4), 333-345. 

Gardea, M.A., Gatchel, R.J., Mishra, K.D. (2001). Long-term efficacy of biobehavioral treatment of 

temporomandibular disorders. Journal of Behavioral Medicine, 24(4), 341-59. 

Gatchel, R.J., Stowell, A.W., Wildenstein, L., Riggs, R., & Ellis, E., 3rd. (2006). Efficacy of an early 

intervention for patients with acute temporomandibular disorder-related pain: A one-year outcome study.

Journal of the American Dental Association, (1939), 137(3), 339-347. 

Medlicott, M.S., & Harris, S.R. (2006). A systematic review of the effectiveness of exercise, manual 

therapy, electrotherapy, relaxation training, and biofeedback in the management of temporomandibular 

disorder. Physical Therapy, 86(7), 955-973. 

Myers, C.D. (2007). Complementary and alternative medicine for persistent facial pain. Dental Clinics 

North America, 51(1), 263-274. 

Turk, D.C., Rudy, T.E., Kubinski, J.A., Zaki, H.S., & Greco, C.M. (1996). Dysfunctional patients with 

temporomandibular disorders: Evaluating the efficacy of a tailored treatment protocol. Journal of 

Consulting Clinical Psychology, 64(1), 139-46. 

Turk, D.C., Zaki, H.S., & Rudy, T.E. (1993). Effects of intraoral appliance and biofeedback/stress 

management alone and in combination in treating pain and depression in patients with 

temporomandibular disorders. Journal of Prosthetic Dentistry, 70(2), 158-64. 

Turp, J.C., Jokstad, A., Motschall, E., Schindler, H.J., Windecker-Getaz, I., Ettlin, D.A. (2007). Is there a 

superiority of multimodal as opposed to simple therapy in patients with temporomandibular disorders? A 

qualitive systematic review of the literature. Clinical Oral Implications Research, 18(Suppl. 3), 138-150. 

Tinnitus 

Level 2: Possibly Efficacious 

 EMG biofeedback and neurofeedback have been used in the treatment of tinnitus. Biofeedback 

appears to be of greatest benefit in reducing tinnitus for certain subgroups of patients (Erlandsson, 

Rubinstein, & Carlsson, 1991). For example, EMG biofeedback is most effective when muscle tension 

and mental distress accompany the tinnitus (Ogata, Sekitani, Moriya, & Watanabe, 1993). Another 
 Page 59

showed tinnitus patients reported a greater amount of psychological stress than healthy controls but not 

physiological arousal (Heinecke, Weise, Schwarz, & Rief, 2008), supporting the need for relaxation 

training. Flor, Hoffmann, Struve, and Diesch (2007) showed patients (n=12) who engaged in regular 

auditory discrimination training as compared to those who practiced irregularly were significantly more 

successful in reducing tinnitus severity independent of the trained frequencies. One German study showed 

EEG biofeedback to upregulate the amplitude of alpha activity and downregulate the amplitude of betaactivity during muscle relaxation and acoustic orientation, which led to a significant reduction in the score 

on a tinnitus questionnaire in comparison to a control group that did not receive neurofeedback 

(Gosepath, Nafe, Ziegler, & Mann, 2001). A second German study comparing EEG-alpha and EEG-beta 

training showed both groups reported a significant reduction of subjective tinnitus annoyance (Schenk, 

Lamm, Gundel, & Ladwig, 2005). Finally, enhancing tau activity (oscillatory activity produced in 

perisylvian regions within the alpha frequency range (8-12 Hz) and concomitant reduction in delta power 

range (0.5-4 Hz) to alter the tau-to-delta ratio significantly reduces tinnitus intensity (Dohrmann, Weisz, 

et al. 2007). Comparison of neurofeedback-treated patients (n=21) with a group trained with a frequency 

discrimination task (n=27), showed the tinnitus relief in the neurofeedback group was significantly 

stronger (Dohrmann, Elbert, et al. 2007). 

References 

Dohrmann, K., Elbert, T., Schlee, W., & Weisz, N. (2007). Tuning the tinnitus percept by modification of 

synchronous brain activity. Restor Neurol Neuroscience, 25(3-4), 371-378. 

Dohrmann, K., Weisz, N., Schlee, W., Hartmann, T., & Elbert, T. (2007). Neurofeedback for treating 

tinnitus. Prog Brain Res, 166, 473-485. 

Erlandsson, S.I., & Rubinstein, B., & Carlsson, S.G. (1991). Tinnitus: Evaluation of biofeedback and 

stomatognathic treatment. British Journal of Audiology, 25(3), 151-161. 

Flor, H., Hoffmann, D., Struve, M., & Diesch, E. (2004). Auditory discrimination training for the 

treatment of tinnitus. Applied Psychophysiology and Biofeedback, 29(2), 113-120. 

Gosepath, K., Nafe, B., Ziegler, E., & Mann, W.J. (2001). Neurofeedback in therapy of tinnitus. HalsNasen-Ohrenärzte, 49(1), 29-35. 

Heinecke, K., Weise, C., Schwarz, K., & Rief, W. (2008). Physiological and psychological stress 

reactivity in chronic tinnitus. Journal of Behavioral Medicine, Epub ahead of print. 

Ogata, Y., Sekitani, T., Moriya, K., & Watanabe, K. (1993). Biofeedback therapy in the treatment of 

tinnitus. Auris, Nasus, Laryn, 20(2), 95-101. 

Schenk, S., Lamm, K., Gundel, H., & Ladwig, K. (2005). Effects of neurofeedback-based EEG alpha and 

EEG beta training in patients with chronically decompensated tinnitus. HNO, 53(1), 29-37. 

Traumatic Brain Injury (TBI) 

Level 3: Probably Efficacious

EEG biofeedback appears to improve memory in persons with brain injury (Thornton, 2000). It 

also improves attention and response accuracy of a performance task and decreases errors in a problemsolving task (Tinius & Tinius, 2000). Walker, Norman, and Weber (2002) found 88% of mild head injury 

patients showed more than 50% improvement in EEG coherence scores, and all patients who had been 

employed prior to injury reported being able to return to work following the treatment. One small 

controlled study (n=12) demonstrated EEG-based therapy results in improvement of some measures of 
 Page 60

cognitive function as well as participants’ reports of depression and fatigue (Schoenberger, Shif, Esty, 

Ochs, & Matheis, 2001). Another controlled study demonstrated significant improvement in attention 

deficits in those receiving feedback of beta activity in comparison with a matched control group 

(Keller, 2001). 

In a review of the literature of EEG biofeedback treatment with TBI individuals, Thornton and 

Carmody (2005) provided a theoretical justification for EEG biofeedback based on a series of findings by 

several independent investigators (Miller, Tabano, Thatcher, Thornton, and Trudeau) that the EEG pattern 

is different between normals and TBIs. This difference is primarily the result of decreased posterior alpha, 

increased posterior beta, frontal connection abnormalities, and long cortico-cortico connection deviations. 

Recent results support the sensitivity of measures of coherence being approximately 90% when 

identifying TBI. The authors present a series of single case studies by other investigators and six of their 

own, demonstrating improvements in reading skills during and after EEG biofeedback. They also 

reviewed studies that used EEG amplitude feedback, coherence feedback, and audio/visual dominant 

frequency feedback. These studies employed minimal control conditions or none, but did demonstrate 

positive outcome on a variety of measures with follow-up assessment up to one year. 

A recent study that used the low energy neurofeedback system (LENS) method with one hundred 

TBI patients (ages six to 80) with the outcome being assessed by session-by-session subjective symptom 

ratings reported average symptom ratings across 15 major problem areas (e.g., anxiety, mood disturbance, 

attentional problems, fatigue, pain, sleep problems, etc.) to show significant improvements (Larsen, 

Harrington, & Hicks, 2006). Equally significant was the drop in EEG amplitude at the highest amplitude 

electrode site (HAS) as well as a lesser but still significant decrease at Cz. In another article using the 

LENS technique, Hammond (2007) reported on a multiple case study with two individuals who suffered 

loss or reduction of olfactory acuity (anosmia) due to acceleration-deceleration traumatic brain injury 

(TBI). Both participants reported a complete reversal of long-term anosmia following neurofeedback 

treatment. 

Hartelius, Theodoros, and Murdoch (2005) used electropalatography (EPG) as a biofeedback tool 

in a case study of a 30-year-old male with disordered articulation following TBI. Therapy was 

administered three times a week for five weeks. Results showed word and sentence intelligibility 

increased approximately 10%, and error patterns for lingual articulation indicated fricative errors 

decreased considerably. The authors concluded that as a part of an intervention program visual EPG 

biofeedback therapy appears to have a definite role in assisting dysarthric speakers exhibiting difficulties 

with lingual articulation in understanding their errors, learning how to exploit kinesthetic and acoustic 

sources of feedback, and how to make appropriate adjustments in tongue articulation to increase the level 

of speech intelligibility. 

Based on these studies, it can be concluded the EEG biofeedback and the LENS technique are 

probably efficacious. Further research is needed, with appropriate controls and random assignment to 

conditions, to further clarify the applications of biofeedback with individuals who have suffered loss due 

to traumatic brain injury. 

References 

Hammond, D.C. (2007). Can LENS neurofeedback treat anosmia resulting from a head injury? Journal of 

Neurotherapy, 11(1), 57-62. 

Hartelius, L., Theodoros, D., & Murdoch, B. (2005). Use of electropalatography in the treatment of 

disordered articulation following traumatic brain injury: A case study. Journal of Medical SpeechLanguage Pathology, 13(3), 189-204. 

Keller, I. (2001). Neurofeedback therapy of attention deficits in patients with traumatic brain injury. 

Journal of Neurotherapy, 5(1-2), 19-32. 
 Page 61

Larsen, S., Harrington, K., & Hicks, S. (2006). The LENS (low energy neurofeedback system): A clinical 

outcomes study on one hundred patients at Stone Mountain Center, New York. Journal of Neurotherapy, 

10(2-3), 69-78. 

Schoenberger, N.E., Shif, S.C., Esty, M.L., Ochs, L., & Matheis, R.J. (2001). Flexyx Neurotherapy 

System in the treatment of traumatic brain injury: An initial evaluation. Journal of Head Trauma 

Rehabilitation, 16(3), 260-274. 

Thornton, K. (2000). Improvement/rehabilitation of memory functioning with neurotherapy/QEEG 

biofeedback. Journal of Head Trauma Rehabilitation, 15(6), 1285-1296. 

Thornton, K.E., & Carmody, D.P. (2005). Electroencephalogram biofeedback for reading disability and 

traumatic brain injury. Child and Adolescent Psychiatric Clinics of North America, 14(1), 137-162. 

Tinius, T.P., & Tinius, K.A. (2000). Changes after EEG biofeedback and cognitive retraining in adults 

with mild traumatic brain injury and attention deficit hyperactivity disorder. Journal of Neurotherapy, 

4(2), 27-44. 

Walker, J.E., Norman, C.A., Weber, R.K. (2002). Impact of qEEG-guided coherence training for patients 

with a mild closed head injury. Journal of Neurotherapy, 6(2), 31-43. 

Urinary Incontinence in Females 

Level 5: Efficacious and Specific

Numerous within-subject studies have demonstrated biofeedback efficacy at the lower levels of 

efficacy (Dannecker, Wolf, Raab, Hepp, & Anthuber, 2005; Rett et al. 2007); all of these have not been 

reported here. Rather, only RCTs and systematic reviews are included that show levels four and five 

efficacy of biofeedback for urinary incontinence in females. It is better than no treatment (i.e., control) 

(Burgio et al. 1998; Burns et al. 1993; Dougherty et al. 2002; McDowell et al. 1999), better than or equal 

to other behavioral treatments (e.g., pelvic floor exercises, bladder training) (Burns et al. 1993; Glavind, 

Nohr, & Walter, 1996; Sherman, Davis, & Wong, 1997; Sung, Hong, Choi, Baik, & Yoon, 2000; 

Weatherall, 1999; Wyman, Fantl, McClish, & Bump, 1998; Wallace, Roe, Williams, & Palmer, 2004), as 

effective as pelvic floor electrical stimulation (Goode et al. 2003; Wang, Wang, & Chen, 2004) and 

vaginal cone (Seo, Yoon, & Kim, 2004), and better than drug (i.e., oxybutynin chloride) treatment 

(Burgio et al. 1998; Goode, 2004). The benefit of biofeedback over drug therapy was supported by a 

systematic review (Teunissen, de Jonge, van Weel, & Lagro-Janssen, 2004). Combining drug and 

behavioral therapy in a stepped program can produce added benefit for those not satisfied with the 

outcome of single treatment (Burgio, Locher, & Goode, 2000). 

Biofeedback is also effective for reducing urinary incontinence in older women (Tadic et al. 

2007). In comparison to drug treatment with oxybutynin, biofeedback reduced incontinence (Goode, 

2004) and nocturia in older women (Johnson, Burgio, Redden, Wright, & Goode, 2005). Exploring the 

effect of pelvic floor muscle exercises on urinary incontinence following childbirth is more complicated. 

Studies where it is administered prenatally include women who are both continent and incontinent 

postnatally; this diminishes the results, and the effect is not different from that seen in control groups. 

However, in studies in which this training is provided to only those who are incontinent after childbirth, 

there is a significant effect on reducing or resolving urinary incontinence (Haddow, Watts, & 

Robertson, 2005). 
 Page 62

 In those with multiple sclerosis, EMG biofeedback for lower urinary tract dysfunction, especially 

in combination with neuromuscular electrical stimulation, decreased incontinence episodes (McClurg, 

Ashe, & Lowe-Strong, 2007). 

A number of systematic reviews are now available reporting efficacy for pelvic floor muscle 

training (Bø, 2003; Neumann, Grimmer, & Deenadayalan, 2006; Hay-Smith & Dumoulin, 2006). In a 

Cochrane Review, Alhasso, McKinlay, Patrick, and Stewart (2006) found symptomatic improvement was 

more common among those on anticholinergic drugs compared with bladder training (with and without 

biofeedback). In contrast, a more specific review of pelvic floor muscle biofeedback reported the overall 

mean treatment improvement was 72.6% and that in 60% of paired comparisons, biofeedback 

demonstrated superior symptomatic outcome to control or alternate treatment groups, including 

oxubutynin (Glazer & Laine, 2006). 

Recent studies have explored variations in biofeedback therapy. Home biofeedback for 12 weeks 

resulted in an increase in pelvic floor muscle activity and a decrease in leakage index (Aukee et al. 2004). 

A telemedicine continence program (including biofeedback-assisted pelvic floor training) was as effective 

as a clinic-based program (Hui, Lee, & Woo, 2006). Position during training (supine vs supine and 

upright) does not differentially affect treatment outcomes (France, Zyczynski, Downey, Rause, & 

Wister, 2006). 

References 

Alhasso, A.A., McKinlay, J., Patrick, K., & Stewart, L. (2006). Anticholinergic drugs versus non-drug 

active therapies for overactive bladder syndrome in adults. Cochrane Database of Systematic Reviews 

(Online), 4(4), CD003193. 

Aukee, P., Immonen, P., Laaksonen, D.E., Laippala, P., Penttinen, J., & Airaksinen, O. (2004). The effect 

of home biofeedback training on stress incontinence. Acta Obstetricia et Gynecologica Scandinavica,

83(10), 973-977. 

Bø, K. (2003). Is there still a place for physiotherapy in the treatment of female incontinence? EAU 

Update Series, 1(3), 145-153. 

Burgio, K.L., Locher, J.L., & Goode, P.S. (2000). Combines behavioral and drug therapy for urge 

incontinence in older women. Journal of the American Geriatric Society, 48(4), 370-374. 

Burgio, K.L., Locher, J.L., Goode, P.S., Hardin, J.M., McDowell, B.J., Dombrowski, M., et al. (1998). 

Behavioral vs. drug treatment for urge urinary incontinence in older women: A randomized controlled 

trial. Journal of the American Medical Association, 280(23), 1995-2000. 

Burns, P.A., Pranikoff, K., Nochajski, T.H., Hadley, E.C., Levy, K.J., & Ory, M.G. (1993). A comparison 

of effectiveness of biofeedback and pelvic muscle exercise treatment of stress incontinence in older 

community-dwelling women. Journal of Gerontology, 48(4), M167-174. 

Dannecker, C., Wolf, V., Raab, R., Hepp, H., & Anthuber, C. (2005). EMG-biofeedback assisted pelvic 

floor muscle training is an effective therapy of stress urinary or mixed incontinence: A seven-year 

experience with 390 patients. Archives of Gynecology and Obstetrics, 273(2), 93-97. 

Dougherty, M.C., Dwyer, J.W., Pendergast, J.F., Boyington, A.R., Tomlinson, B.U., Coward, et al. 

(2002). A randomized trial of behavioral management for continence with older rural women. Research in 

Nursing and Health, 25(1), 3-13. 

France, D.F., Zyczynski, H.M., Downey, P.A., Rause, C.R., & Wister, J.A. (2006). Effect of pelvic-floor 

muscle exercise position on continence and quality-of-life outcomes in women with stress urinary 

incontinence. Physical Therapy, 86(7), 974-986. 
 Page 63

Glavind, K., Nohr, S.B., & Walter, S. (1996) Biofeedback and physiotherapy versus physiotherapy alone 

in the treatment of genuine stress urinary incontinence. International Urogynecologic Journal of Pelvic 

Floor Dysfunction, 7(6), 339-343. 

Glazer, H.I., & Laine, C.D. (2006). Pelvic floor muscle biofeedback in the treatment of urinary 

incontinence: A literature review. Applied Psychophysiology and Biofeedback, 31(3),187-201. 

Goode, P.S., Burgio, K.L., Locher, J.L., Roth, D.L., Umlauf, M.G., Richter, H.E., et al. (2003). Effect of 

behavioral training with or without pelvic floor electrical stimulation on stress incontinence in women: A 

randomized controlled trial. JAMA, 290(3), 345-352. 

Goode, P.S. (2004). Behavioral and drug therapy for urinary incontinence. Urology, 63(3 Suppl. 1), 

58-64. 

Haddow, G., Watts, R., & Robertson, J. (2005). Effectiveness of a pelvic floor muscle exercise program 

on urinary incontinence following childbirth. International Journal of Evidence-Based Healthcare, 3(5), 

103-146. 

Hay-Smith, E.J., & Dumoulin, C. (2006). Pelvic floor muscle training versus no treatment, or inactive 

control treatments, for urinary incontinence in women. Cochrane Database of Systematic Reviews 

(Online), 1(1), CD005654. 

Hui, E., Lee, P.S., & Woo, J. (2006). Management of urinary incontinence in older women using 

videoconferencing versus conventional management: A randomized controlled trial. Journal of 

Telemedicine and Telecare, 12(7), 343-347. 

Johnson, T.M.I., Burgio, K.L., Redden, D.T., Wright, K.C., & Goode, P.S. (2005). Effects of behavioral 

and drug therapy on nocturia in older incontinent women. Journal of the American Geriatric Society,

53(5), 846-850. 

McClurg, D., Ashe, R.G., & Lowe-Strong, A.S. (2007). Neuromuscular electrical stimulation and the 

treatment of lower urinary tract dysfunction in multiple sclerosis: A double-blind, placebo-controlled, 

randomised clinical trial. Neurourology and Urodynamics, (Epub, ahead of print). 

McDowell, B.J., Engberg, S., Sereika, S., Donovan, N., Jubeck, M.E., Weber, E., et al. (1999). 

Effectiveness of behavioral therapy to treat incontinence in homebound older adults. Journal of the 

American Geriatric Society, 47(3), 309-318. 

Neumann, P.B., Grimmer, K.A., & Deenadayalan, Y. (2006). Pelvic floor muscle training and adjunctive 

therapies for the treatment of stress urinary incontinence in women: A systematic review. BMC Women’s 

Health, 6, 11. 

Rett, M.T., Simoes, J.A., Herrmann, V., Pinto, C.L., Marques, A.A., & Morais, S.S. (2007). Management 

of stress urinary incontinence with surface electromyography-assisted biofeedback in women of 

reproductive age. Physical Therapy, 87(2), 136-142. 

Seo, J.T., Yoon, H., & Kim, Y.H. (2004). A randomized prospective study comparing new vaginal cone 

and FES-biofeedback. Yonsei Medical Journal, 45(5), 879-884. 

Sherman, R.A., Davis, G.D., & Wong, M.F. (1997). Behavioral treatment of exercise-induced urinary 

incontinence among female soldiers. Military Medicine, 162(10), 690-704. 

Sung, M.S., Hong, J.Y., Choi, Y.H., Baik, S.H., Yoon, H. (2000). FES-biofeedback versus intensive 

pelvic floor muscle exercise for the prevention and treatment of genuine stress incontinence. Journal of 

Korean Medical Science, 15(3), 303-308. 

Tadic, S.D., Zdaniuk, B., Griffiths, D., Rosenberg, L., Schafer, W., & Resnick, N.M. (2007). Effect of 

biofeedback on psychological burden and symptoms in older women with urge urinary incontinence.

Journal of the American Geriatric Society, 55(12), 2010-2005. 
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Teunissen, T.A., de Jonge, A., van Weel, C., & Lagro-Janssen, A.L. (2004). Treating urinary incontinence 

in the elderly — conservative therapies that work: A systematic review. The Journal of Family Practice,

53(1), 25-30, 32. 

Wallace, S.A., Roe, B., Williams, K., & Palmer, M. (2004). Bladder training for urinary incontinence in 

adults. Cochrane Database of Systematic Reviews (Online), 1(1), CD001308. 

Wang, A.C., Wang, Y.Y., & Chen, M.C. (2004). Single-blind, randomized trial of pelvic floor muscle 

training, biofeedback-assisted pelvic floor muscle training, and electrical stimulation in the management 

of overactive bladder. Urology, 63(1), 61-66. 

Weatherall, M. (1999). Biofeedback or pelvic floor muscle exercise for female genuine stress 

incontinence: A meta-analysis of trials identified in a systematic review. British Journal of Urology, 

International, 83(9), 1015-1016. 

Wyman, J.F., Fantl, J.A., McClish, D.K., & Bump, R.C. (1998). Comparative efficacy of behavioral 

interventions in the management of female urinary incontinence. Continence Program for Women 

Research Group. American Journal of Obstetrics and Gynecology, 179(4), 999-1007. 

Urinary Incontinence in Males 

Level 3: Probably Efficacious

Most studies testing the effect of biofeedback on male incontinence have been done on males 

after prostatectomy. Two systematic reviews for urinary incontinence after prostatectomy show mixed 

results. MacDonald, Fink, Huckabay, Monga, and Wilt (2007) found men receiving biofeedbackenhanced pelvic floor training were more likely to achieve continence than those with no training. In 

contrast, Hunter, Glazener, and Moore (2007) concluded the value of pelvic floor muscle training with or 

without biofeedback remains uncertain, whether the training started pre-operatively or post-operatively. 

Two studies involved pre-operative biofeedback-enhanced pelvic floor training; both showed such 

training prior to radical prostatectomy hastens the recovery of urine control and decreases the severity of 

incontinence after surgery (Parekh et al. 2003; Burgio et al. 2006). One problem with past studies is that 

many of the men included were not incontinent; this decreases the ability to see an effect of treatment. For 

example, Wille, Sobottka, Heidenreich, and Hofmann (2003) showed the continence rate increased from 

21.4% one day after catheter removal to 59.2% at three months and 85.9% at 12 months, but there was no 

difference among groups treated with instruction, biofeedback, or electrical stimulation. In studies 

including all prostatectomy patients, rather than those who were incontinent, biofeedback was not 

effective (Bales et al. 2000; Franke et al. 2000; Mathewson-Chapman, 1997). However, studies in men 

who were incontinent after prostatectomy demonstrate biofeedback was better than no treatment (control) 

(Van Kampen et al. 2000; Zhang, Strauss, & Siminoff, 2007) and equal to pelvic floor exercises (Floratos 

et al. 2002). It has also been shown to be effective for treatment post-micturition dribble in men with 

erectile dysfunction (Dorey et al. 2004). 

References 

Bales, G.T., Gerber, G.S., Minor, T.X., Mhoon, D.A., McFarland, J.M., Kim, H.L., et al. (2000). Effect of 

preoperative biofeedback/pelvic floor training on continence in men undergoing radical prostatectomy. 

Urology, 56(4), 627-630. 

Burgio, K.L., Goode, P.S., Urban, D.A., Umlauf, M.G., Locher, J.L., Bueschen, A., et al. (2006). 

Preoperative biofeedback-assisted behavioral training to decrease post-prostatectomy incontinence: A 

randomized, controlled trial. The Journal of Urology, 175(1), 196-201. 
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Dorey, G., Speakman, M., Feneley, R., Swinkels, A., Dunn, C., & Ewings, P. (2004). Pelvic floor 

exercises for treating post-micturition dribble in men with erectile dysfunction: A randomized controlled 

trial. Urologic Nursing: Official Journal of the American Urological Association Allied, 24(6), 

490-497, 512. 

Floratos, D.L., Sonke, G.S., Rapidou, C.A., Alivizatos, G.J., Deliveliotis, C., Constantinides, C.A., et al. 

(2002). Biofeedback vs. verbal feedback as learning tools for pelvic muscle exercises in the early 

management of urinary incontinence after radical prostatectomy. British Journal of Urology, 

International, 89(7), 714-719. 

Franke, J.J., Gilbert, W.B., Grier, J., Koch, M.O., Shyr, Y., & Smith, J.A., Jr. (2000). Early postprostatectomy pelvic floor biofeedback. Journal of Urology, 163(1), 191-193. 

Hunter, K.F., Glazener, C.M., & Moore, K.N. (2007). Conservative management for postprostatectomy 

urinary incontinence. Cochrane Database of Systematic Reviews (Online), 2(2), CD001843. 

MacDonald, R., Fink, H.A., Huckabay, C., Monga, M., & Wilt, T.J. (2007). Pelvic floor muscle training 

to improve urinary incontinence after radical prostatectomy: A systematic review of effectiveness. BJU 

International, 100(1), 76-81. 

Mathewson-Chapman, M. (1997). Pelvic muscle exercise/biofeedback for urinary incontinence after 

prostatectomy: An education program. Journal of Cancer Education, 12(4), 218-223. 

Parekh, A.R., Feng, M.I., Kirages, D., Bremner, H., Kaswick, J., & Aboseif, S. (2003). The role of pelvic 

floor exercises on post-prostatectomy incontinence. The Journal of Urology, 170(1), 130-133. 

Wille, S., Sobottka, A., Heidenreich, A., & Hofmann, R. (2003). Pelvic floor exercises, electrical 

stimulation, and biofeedback after radical prostatectomy: Results of a prospective randomized trial. The 

Journal of Urology, 170(2 Pt. 1), 490-493. 

Van Kampen, M., De Weerdt, W., Van Poppel, H., De Ridder, D., Feys, H., & Baert, L. (2000). Effect of 

pelvic-floor re-education on duration and degree of incontinence after radical prostatectomy: A 

randomized controlled trial. Lancet, 355(9198), 98-102. 

Zhang, A.Y., Strauss, G.J., & Siminoff, L.A. (2007). Effects of combined pelvic floor muscle exercise 

and a support group on urinary incontinence and quality of life of postprostatectomy patients. Oncology 

Nursing Forum, 34(1), 47-53. 

Urinary Incontinence in Children 

Level 2: Possibly Efficacious

Studies of biofeedback efficacy in children who suffer from urinary incontinence lack control 

groups. In general, these studies show improvement in urinary incontinence in 60 to 90% of children 

treated (Combs, Glassberg, Gerdes, & Horowitz, 1998; Hoekx, Wyndaele, & Vermandel, 1998; 

McKenna, Herndon, Connery, & Ferrer, 1999; Barroso et al. 2006; Khen-Dunlop, Van Egroo, Bouteiller, 

Biserte, & Besson, 2006; Yagci et al. 2005; Shei Dei Yang & Wang, 2005). One five-year follow-up 

study of biofeedback for nocturnal enuresis showed 79% were still dry at night (Hoekx, Vermandel, & 

Wyndaele, 2003). 

 The lack of control groups is particularly problematic in this population because of the maturation 

factor. A systematic review of five studies concluded that no intervention tested in a trial has been shown 

to be of benefit (Sureshkumar, Bower, Craig, & Knight, 2003). A nonrandomized study comparing 

biofeedback to alpha blocker therapy showed comparable reduction in post-void residual urine volume 
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(Yucel et al. 2005). In two behavioral voiding programs delivered over 24 sessions, one with the addition 

of biofeedback, both led to improvement in urinary continence; those in the biofeedback group also 

showed a significant decrease in post-void residual urine (Vasconcelos et al. 2006). 

References 

Barroso, U., Jr., Lordelo, P., Lopes, A.A., Andrade, J., Macedo, A., Jr., & Ortiz, V. (2006). 

Nonpharmacological treatment of lower urinary tract dysfunction using biofeedback and transcutaneous 

electrical stimulation: A pilot study. BJU International, 98(1), 166-171. 

Combs, A.J., Glassberg, A.D., Gerdes, D., & Horowitz, M. (1998). Biofeedback therapy for children with 

dysfunctional voiding. Urology, 52(2), 312-315. 

Hoekx, L., Wyndaele, J.J., & Vermandel, A. (1998). The role of bladder biofeedback in the treatment of 

children with refractory nocturnal enuresis associated with idiopathic detrusor instability and small 

bladder capacity. Journal of Urology, 160(3 pt. 1), 858-860. 

Hoekx, L., Vermandel, A., & Wyndaele, J.J. (2003). Functional bladder capacity after bladder 

biofeedback predicts long-term outcome in children with nocturnal enuresis. Scandinavian Journal of 

Urology and Nephrology, 37(2), 120-123. 

Khen-Dunlop, N., Van Egroo, A., Bouteiller, C., Biserte, J., & Besson, R. (2006). Biofeedback therapy in 

the treatment of bladder overactivity, vesico-ureteral reflux, and urinary tract infection. Journal of 

Pediatric Urology, 2(5), 424-429. 

McKenna, P.H., Herndon, C.D., Connery, S., & Ferrer, F.A. (1999). Pelvic floor muscle retraining for 

pediatric voiding dysfunction using interactive computer games. Journal of Urology, 162(3 pt. 2), 

1056-1063. 

Shei Dei Yang, S., & Wang, C.C. (2005). Outpatient biofeedback relaxation of the pelvic floor in treating 

pediatric dysfunctional voiding: A short-course program is effective. Urologia Internationalis, 74(2), 

118-122. 

Sureshkumar, P., Bower, W., Craig, J.C., & Knight, J.F. (2003). Treatment of daytime urinary 

incontinence in children: A systematic review of randomized controlled trials. The Journal of Urology,

170(1), 196-200. 

Vasconcelos, M., Lima, E., Caiafa, L., Noronha, A., Cangussu, R., Gomes, S., et al. (2006). Voiding 

dysfunction in children. Pelvic-floor exercises or biofeedback therapy: A randomized study. Pediatric 

Nephrology (Berlin, Germany), 21(12), 1858-1864. 

Yagci, S., Kibar, Y., Akay, O., Kilic, S., Erdemir, F., Gok, F., et al. (2005). The effect of biofeedback 

treatment on voiding and urodynamic parameters in children with voiding dysfunction. The Journal of 

Urology, 174(5), 1994-1998. 

Yucel, S., Akkaya, E., Guntekin, E., Kukul, E., Akman, S., Melikoglu, M., et al. (2005). Can alphablocker therapy be an alternative to biofeedback for dysfunctional voiding and urinary retention? A 

prospective study. The Journal of Urology, 174(4 pt. 2), 1612-1615. 

Vulvar Vestibulitis (Vulvodynia) 

Level 3: Probably Efficacious

 EMG biofeedback and pelvic floor exercises have been used to treat women with vulvar 

vestibulitis. A randomized study comparing biofeedback with cognitive behavioral therapy and with 
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vestibulectomy demonstrated that all three groups reported statistically significant reductions in pain and 

improvements in sexual function and psychological adjustment (Bergeron et al. 2001). Although the 

vestibulectomy group was more successful than the two other groups in regard to pain reduction, some 

patients assigned to this group refused the intervention. The benefit of EMG biofeedback and pelvic floor 

exercises has also been demonstrated in two uncontrolled studies with patients showing reductions in pain 

and approximately 70% able to resume sexual activity without discomfort (Glazer, Rodke, Swencionis, 

Hertz, & Young, 1995; McKay et al. 2001). 

Intrapelvic sEMG biofeedback has also been demonstrated effective in treatment of the second 

subset of vulvodynia, dysesthetic vulvodynia (Glazer, 2000). Via chart review and patient follow up, 88% 

of patients responding stated they were pain free after EMG-assisted pelvic floor muscle rehabilitation 

(mean 39 months). Thus this treatment was shown to be an effective and long-term cure for dysesthetic 

vulvodynia. 

 Retrospectively, Jantos (2008) studied the psychophysiological profile of 529 women with 

vulvodynia. EMG data collected using a vaginal sensor were positively associated with pelvic muscle 

dysfunction and negatively associated with duration of pain. Patients practiced EMG-assisted pelvic 

muscle exercises and cognitive therapy for varying lengths of time until their pain decreased, and they 

were able to resume sexual activity. Compared to pre-training, EMG readings showed decreases in 

muscle resting baseline and instability and increases in phasic and tonic contraction amplitudes. Together 

these changes reflect more relaxed pelvic muscles and improved muscle tone. 

References 

Bergeron, S., Binik, Y.M., Khalife, S., Pagidas, K., Glazer, H.I., Meana,.M., et al. (2001). A randomized 

comparison of group cognitive-behavioral therapy, surface electromyographic biofeedback, and 

vestibulectomy in the treatment of dyspareunia resulting from vulvar vestibulitis. Pain, 91(3), 297-306. 

Glazer, H.I., Rodke, G., Swencionis, C., Hertz, R., & Young, A.W. (1995). Treatment of vulvar 

vestibulitis syndrome with electromyographic biofeedback of pelvic floor musculature. Journal of 

Reproductive Medicine, 40(4), 283-290. 

Glazer, H.I. (2000). Dysesthetic vulvodynia: Long-term follow up after treatment with surface 

electromyography-assisted pelvic floor muscle rehabilitation. Journal of Reproductive Medicine, 45, 

798-802. 

Jantos, M. (2008). Vulvodynia: A psychophysiological profile based on electromyographic assessment. 

Applied Psychophysiology and Biofeedback, 33(1). 

McKay, E., Kaufman, R.H., Doctor, U., Berkova, Z., Glazer, H., & Redko, V. (2001). Treating vulvar 

vestibulitis with electromyographic biofeedback of pelvic floor musculature. Journal of Reproductive 

Medicine, 46(4), 337-342. 

Emerging Applications 

Level 1: Not Empirically Supported

Birbaumer, Hinterberger, Kubler, and Neumann (2003) utilized a thought-translation device 

(TTD) consisting of a training device and spelling program for the completely paralyzed using slowcortical brain potentials (SCP). During the training phase, the self-regulation of SCPs is learned through 

visual-auditory feedback and positive reinforcement of SCPs; during the spelling phase, patients select 

letters or words with their SCPs. The neurophysiological and anatomical basis of SCP-regulation was 
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investigated by recording of BOLD-response in functional magnetic resonance imaging. The clinical 

outcome of 11 paralyzed patients using the TTD and quality of life of severely paralyzed patients were 

successful. 

The results of a study by Block, Onslow, Roberts, and White (2004) on the control of stuttering 

with EMG feedback is reported. Participants were 12 children and adolescents. Two experienced 

clinicians and two student clinicians presented the treatment as outlined in the Craig manual for six hours 

per day over five consecutive days. Subjects showed a reduction of 48.9% of their stuttering during 

reading conditions after the treatment and a reduction of 36.7% of stuttering after the treatment during 

conversation. During the post-treatment period participants were speaking at a mean of 111 syllables per 

minute, which is around half the expected speech rate for Australians in this age group. 

A study to evaluate the immediate, long-term, and carry-over effects of nasopharyngoscopic 

biofeedback therapy in patients with cleft palate who exhibit velopharyngeal dysfunction (VPD) was 

reported by Brunner, Stellzig-Eisenhauer, Proschel, Verres, and Komposch (2005). The study was 

completed at the Heidelberg University Hospital, Heidelberg, Germany. The participants were 11 patients 

with VPD who had received conventional speech therapy without showing significant improvement. The 

intervention was a four-stage feedback procedure. The patients watched and evaluated their 

velopharyngeal (VP) valving during speech by an endoscopic image displayed on a video monitor. Two 

feedback sessions took place for every target sound. Significant improvement and stability of VP closure 

was noted. Mean occurrence of VP closure was 5% before therapy, 91% after two biofeedback sessions, 

and 86% in the follow up after six months. Velopharyngeal dysfunction associated with compensatory 

articulation proved to be equally well trained as VPD on sounds with good articulatory placement. No 

significant difference was observed in the degree of improvement between phoneme-specific VPD and 

generalized VPD. The transfer to the level of words and sentences was successful and showed significant 

stability. The stability of VP closure for vowels was less than the stability for fricatives and stop sounds. 

Patients also gained improved auditory and kinesthetic self-perception of their articulation. 

Earles, Kerr, and Kellar (2003) reported a study of the effects of EMG biofeedback for the 

treatment of vocal cord dysfunction (VCD), which is an obstructive upper airway syndrome that 

frequently mimics asthma and for which there is no empirical treatment of choice. Two military service 

members experiencing VCD were treated. Both cases were active-duty military members with VCD 

confirmed by laryngoscopy. They each received biofeedback self-regulation training to decrease tension 

in the extrinsic laryngeal musculature. Both patients responded to the treatment, denied the presence of 

dyspnea, and resumed military physical training. 

 An outcome study of laryngeal and velopharyngeal biofeedback treatment in children and young 

adults was reported by Lierde, Claeys, De Bodt, and Van Cauwenberge (2004). Four subjects were 

studied pretreatment (one week before LB or VB treatment) and posttreatment (one week after the LB or 

VB treatment). To measure and compare the effect of LB and VB, objective and subjective assessment 

techniques were used. Perceptual voice assessment included a perceptual rating of the voice using the 

GRBAS scale. Furthermore, the vocal quality in this population is modeled by means of the Dysphonia 

Severity Index. For the objective assessment of nasal resonance, the Nasometer and the Glatzel test were 

used. A perceptual evaluation of speech, the Gutzmann test, and the tests from Bzoch were used as 

subjective assessment techniques. Both patients selected for LB and VB treatment showed improvement 

of their performances. The resulting improvement, as measured by means of an objective approach, is in 

agreement with the perceived (auditory) improvement of voice and resonance. 

A study to evaluate the effect of a six-session biofeedback intervention program on cognitive 

aspects of patients with somatoform disorders was reported by Moss et al. (2003). The treatment 

consisted of psychophysiological demonstrations of how mental processes can influence biological 

functions. Patients were assessed using a structured interview to diagnose somatization syndrome (SSI-8) 

and comorbidity according to DSM-IV criteria. Fifty patients were recruited and randomly assigned to 
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biofeedback treatment or control relaxation group. Participants completed a questionnaire battery 

assessing cognitive characteristics, causal attributions, and controllability before and after intervention. 

The results suggest biofeedback modified the patients’ cognitive schemata: Patients with somatization 

syndrome of the biofeedback group showed a greater reduction of catastrophizing of somatic sensations 

and higher acceptance of psychosocial causal attributions than the control group. Both groups improved 

significantly in the conviction of self-efficacy. 

In a study to improve cognitive functioning in the elderly using peak alpha frequency (PAF), 

which has been shown to correlate positively with cognitive performance and to correlate negatively with 

age after childhood, a new EEG biofeedback protocol was utilized (Angelakis et al. 2007). The study used 

a double-blind, controlled design to investigate whether training older individuals to increase PAF would 

result in improved cognitive performance. The results demonstrate PAF EEG biofeedback improved 

cognitive processing speed and executive function but had no clear effect on memory. 

Becerra et al. (2006) reported a two-year follow up from a previous study describing positive 

behavioral changes and a spurt of EEG maturation with theta/alpha EEG biofeedback training in a group 

of learning disabled (LD) children. In a control-paired group treated with placebo, behavioral changes 

were not observed, and the smaller maturational EEG changes observed were easily explained by 

increased age. Two years later, the EEG maturational lag in the control group increased, reaching 

abnormally high theta Relative Power values; the absence of positive behavioral changes continued, and 

the neurological diagnosis remained. In contrast, after two years, EEG maturation did continue in children 

who belonged to the treatment group; this was accompanied by positive behavioral changes, which were 

reflected in remission of LD symptoms. 

In a study of LD children, Fernandez et al. (2003) used 10 children with higher-than-normal 

ratios of theta to alpha absolute power (theta/alpha ratio). The children were divided into two groups in 

order to maintain similar IQ values. EEG biofeedback was applied in the region with the highest ratio, 

triggering a sound each time the ratio fell below a threshold value. Noncontingent reinforcement was 

given to the other group. Twenty twice-weekly half-hour sessions were provided. Before and after 20 

sessions, TOVA, WISC, and EEG were obtained. There was significant improvement in performance on 

the outcome measures in the treatment group that was not observed in the noncontingent reinforcement 

group. EEG absolute power decreased in delta, theta, alpha, and beta bands in the treatment group. The 

noncontingent reinforcement group only showed a decrease in relative power in the delta band. 

References 

Angelakis, E., Stathopoulou, S., Frymiare, J.L., Green, D.L., Lubar, J.F., & Kounios, J. (2007). EEG NF: 

A brief overview and an example of peak alpha frequency training for cognitive enhancement in the 

elderly. The Clinical Neuropsychologist, 21(1), 110-129. 

Becerra, J., Fernandez, T., Harmony, T., Caballero, M.I., Garcia, F., Fernandez-Bouzas, A., et al. (2006). 

Follow-up study of learning-disabled children treated with EEG biofeedback or placebo. Clinical EEG 

and Neuroscience: Official Journal of the EEG and Clinical Neuroscience Society (ENCS), 37(3), 

198-203. 

Birbaumer, N., Hinterberger, T., Kubler, A., & Neumann, N. (2003). The thought-translation device 

(TTD): Neurobehavioral mechanisms and clinical outcome. IEEE Transactions on Neural Systems and 

Rehabilitation Engineering: A Publication of the IEEE Engineering in Medicine and Biology Society,

11(2), 120-123. 

Block, S., Onslow, M., Roberts, R., & White, S. (2004). Control of stuttering with EMG feedback.

Advances in Speech Language Pathology, 6(2), 100-106. 
 Page 70

Brunner, M., Stellzig-Eisenhauer, A., Proschel, U., Verres, R., & Komposch, G. (2005). The effect of 

nasopharyngoscopic biofeedback in patients with cleft palate and velopharyngeal dysfunction. The Cleft 

Palate-Craniofacial Journal: Official Publication of the American Cleft Palate-Craniofacial Association,

42(6), 649-657. 

Earles, J., Kerr, B., & Kellar, M. (2003). Psychophysiologic treatment of vocal cord dysfunction. Annals 

of Allergy, Asthma & Immunology: Official Publication of the American College of Allergy, Asthma, & 

Immunology, 90(6), 669-671. 

Fernandez, T., Herrera, W., Harmony, T., Diaz-Comas, L., Santiago, E., Sanchez, L., et al. (2003). EEG 

and behavioral changes following EEG biofeedback treatment in learning-disabled children. Clinical EEG 

(Electroencephalography), 34(3), 145-152. 

Lierde, K.M., Claeys, S., De Bodt, M., & Van Cauwenberge, P. (2004). Outcome of laryngeal and 

velopharyngeal biofeedback treatment in children and young adults: A pilot study. Journal of Voice,

18(1), 97-106. 

Moss, D., Sella, G.E., Andrasik, F., Donaldson, S., Lehrer, P., Palsson, O., et al. (2003). Current 

applications of biofeedback to physical medicine and rehabilitation. Europa Medicophysica, 39(4), 

165-170. 
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Sample Protocols 

General EMG Training 

 The principle of EMG training is normally to provide the learner with enhanced information 

about his or her muscle tension in a particular area, hoping this will facilitate learning control of the 

muscle. Relaxation of excess and inappropriate tension is the usual goal. Sensors are attached to the skin 

over the muscle being targeted for change. Muscles may be targeted anywhere on the body, including the 

forehead, neck, shoulders, back, jaws, arms, or legs. Insertable pelvic sensors are used to target pelvic 

muscles. Tiny electrical signals emitted by muscles, proportional to degree of contraction, are amplified 

and fed to a visual display or an audio signal. The visual display may be digits, polygraph-style lines, or 

changes in colors or patterns. The audio tone may indicate changes in muscle tension by a rising or falling 

tone, or by a change in frequency of a beep. Most biofeedback systems allow for recording average 

muscle tension over a specified time interval. 

After some instruction, the learner is allowed quiet practice time during which he or she attempts 

to lower the measured muscle tension, using the biofeedback signal as an external guide. The trainer 

suggests various ways to relax, helps deal with obstacles to learning, keeps track of progress, and 

generally facilitates the learning process. Home practice is usually prescribed because the goal is to learn 

better control of the muscles without the aid of biofeedback monitoring. One or more criteria are usually 

set as goals of training: for instance, staying below two microvolts for the upper shoulder. Speed of 

recovery from contraction is another common criterion and also keeping muscle tension lower during 

movement. 

Frequency of sessions varies, and may be twice per week or less often. The biofeedback is 

considered a temporary learning aid, and as the learner becomes more sensitive to internal sensations and 

learns to read his or her body better, the biofeedback becomes less necessary. The duration of this 

learning process varies from person to person but might typically take one to three months. Duration is 

best determined by achieving the criteria rather than by number of sessions. Symptoms are usually 

tracked with home diaries, and this helps the learner understand which activities and situations increase 

muscle tension. Self-regulation eventually begins to become habitual; goals such as keeping the shoulders 

low or the jaw loose require less and less conscious involvement. 

Temperature Training 

 The goal of temperature training is to teach the learner to warm his or her peripheral extremities. 

While core temperature is 98.6o

F (37.0oC), skin temperature is much lower, ranging from 75-95oF. In 

order to raise skin temperature, one must relax skeletal muscles as well as the muscles within the walls of 

the blood vessels. This latter effect is believed to result in better blood flow to the skin and, therefore, a 

rise in skin temperature. 

A thermal sensor, called a thermistor, is taped to the skin, usually on the palmar surface of one of 

the fingers. The temperature of the skin changes the resistance of the thermistor, thereby altering the 

electrical signal in proportion to the temperature. The signal is displayed visually and/or through a tone 

that changes in response to changes in temperature. The visual display may be digits, polygraph-style 

lines, or changes in colors or patterns. Commonly, the learner’s skin temperature is displayed on a 

thermometer. 

After some instruction, the learner is allowed quiet practice time during which he or she attempts 

to raise the skin temperature. The trainer suggests various ways to do this, using the biofeedback signal as 

a guide. For example, training in slow, deep breathing usually helps the learner to relax. The learner may 

repeat autogenic phrases, such as “My hands feel warm and heavy,” or imagine lying on the beach feeling 
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the sun’s warmth on the hands. Home practice is prescribed, and the learner may be given a simple, 

handheld thermometer to monitor progress. On subsequent training sessions, the thermistor may be 

moved from one hand to the other or to a foot. This helps the learner to generalize the skin temperature 

warming to areas beyond the hands. One or more criteria are set as goals of training. Typically learners 

are asked to raise hand temperature to 90 – 95o

F and foot temperature to 90oF. 

Thermal training sessions are typically held weekly. The biofeedback is considered a temporary 

learning aid, and as the learner becomes more sensitive to internal sensations of stress, the biofeedback 

becomes less necessary. The duration of this learning process varies from person to person but typically 

requires four to eight sessions accompanied by home practice. 

Thermal training is typically combined with other biofeedback modalities to train learners in 

general relaxation. It is also used in a number of disorders such as Raynaud’s disease, hypertension, 

migraine headaches, and anxiety. More recently, it has been used to increase blood flow to wounds, 

thereby promoting healing. 

Skin Conductance Training 

Skin conductance feedback provides information about sweat gland activity on the hand, which is 

closely correlated with sympathetic nervous system activity. This variable is called SCA (skin 

conductance activity), EDA (electrodermal activity), or the more classic term GSR (galvanic skin 

response). Sensors are attached to two fingers or two sites on the palm, and feedback is provided in 

various ways: a changing audio tone, changes in colors on a display, numerical change, meter deflection, 

or a moving line via video feedback. Response time is less than two seconds, making it very sensitive to 

transient changes in emotion. 

Self-calming by physical or cognitive means tends to lower skin conductance, while negative 

emotions such as fear, worry, or anger usually raise it, as will a startle response. Any disorder that would 

benefit from emotional calming may respond to GSR biofeedback, provided the learner is able to 

generalize from the feedback situation to real life. For example, GSR feedback is often employed in 

treatment of phobias and anxiety attacks, and has been used as one element in modifying hypertension 

and bowel disorders, which are exacerbated by emotional upset. 

In learning to reliably lower one’s GSR, one learns to resist distractions, which disrupt attention, 

and to maintain a state of mind that is neutral or pleasant. Relaxation techniques such as slow breathing, 

imagery, or meditation can help keep the attention steady and the emotions calm. This tends to stabilize 

the autonomic nervous system. Time needed to learn the skill varies from days to months. Practice 

between biofeedback sessions facilitates mastery of the skill and is practical since home-trainer GSR 

devices are available for less than a hundred dollars. 

EEG Training or Neurofeedback 

The goal of neurofeedback is to teach learners to modify their EEG. There are many applications 

of EEG training. One of these includes teaching the learner to maintain a relaxed, alert, and focused 

mental state while carrying out cognitive tasks. Another application of EEG training includes teaching the 

learner to increase slower-frequency brainwaves to achieve deeper levels of psychophysiological 

relaxation or to access calmer mental states. Other applications use EEG training to treat such disorders as 

depression, anxiety, epilepsy, sleep disorders, fibromyalgia, pain, alcoholism, and other addictions. EEG 

training is also used in the rehabilitation of brain injury and stroke. 

These applications are done by training learners to alter their brainwaves. Historically, there are 

four types of brainwaves identified according to their frequency or bandwidth. They are known as delta 
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(0.5-4 Hertz), theta (4-8 Hertz), alpha (8-12 Hertz), and beta (13-20+ Hertz), differing according to their 

frequency. Each person has an individual pattern of brainwave activity, but there are certain “signatures” 

of brainwave frequencies that are associated with specific symptoms or dysfunction. For example, people 

with Attention Deficit Disorder tend to have greater ratios of slower EEG activity (delta, theta, or even 

alpha) compared to faster beta activity. In this example, the goal of training for individuals with ADD is 

to decrease the amplitude of slow-wave activity (delta, theta, and/or alpha) while increasing the amplitude 

of faster wave activity (beta). 

In neurofeedback training, surface sensors are placed on selected areas of the head and ears. The 

number and location of these sensors is determined by the specific application and goal of the EEG 

training. Typically, the number of sensors used varies between three and six. The EEG signal is displayed 

visually and/or through auditory tones that vary as the EEG changes. Brainwave changes in the desired 

direction are rewarded with visual and/or auditory feedback. The visual signal may be graphs, digits, 

waveforms, changes in colors or patterns, or even animations. 

Neurofeedback training typically requires 40 or more 50-minute sessions, usually held twice or 

more weekly. EEG training may be accompanied by cognitive or other therapies. For example, those with 

ADD may receive coaching in learning strategies while those with alcoholism may receive coaching in 

alcohol avoidance. 

Neurofeedback may be combined with other biofeedback modalities such as EMG, EDR, 

temperature, HRV, or other biofeedback modalities to train learners in general relaxation. 

Heart Rate Variability 

HRV stands for heart rate variability. The term RSA (Respiratory Sinus Arrhythmia) predates the 

term HRV, and refers to the rise and fall of heart rate synchronized with each breath (faster on the inhale, 

slower on the exhale). The magnitude of this systematic variability seems to reflect a healthy alternation 

between two autonomic influences on the heartbeat: sympathetic and parasympathetic. Lack of this 

variation reflects an imbalance between the two aspects of the ANS, most likely deficient 

parasympathetic influence, and is a sign of poor cardiovascular health. By calming one’s emotional state 

and by making the breathing slower and more regular, the HRV can be increased, at least temporarily. 

The biofeedback setup for HRV involves monitoring either heart rate alone or heart rate plus 

respiration. Heart rate may be detected from plethysmographic sensors on the finger or earlobe, or via 

EKG monitors. Most commonly, a trace reflecting cyclic variations in heart rate is displayed on a video 

screen. The mean heart rate per minute is not important; the variability of heart rate is the variable of 

interest. The trainee observes the trace (or a derived graphic display) and uses it as feedback for 

regulating the breath and/or the emotional state. The heartbeat variability is maximized at a particular 

“resonant frequency” (breathing rate per minute), and this rate, usually around six per minute, can be 

determined for each individual by observation and experimentation. 

The time to achieve an improved HRV while assisted by biofeedback might average four to 10 

sessions. Learning time varies as with any biofeedback procedure. Generalization to the everyday 

environment, away from the biofeedback monitoring, takes longer than achieving success within the 

biofeedback context. Practicing with HRV biofeedback provides a model for real-life self-regulation; the 

goal is to develop awareness of one’s breathing and of one’s emotional state, both of which interact and 

influence the autonomic balance. This balance, in turn, has been found to be helpful for several disorders 

involving chronic maladjustment of the autonomic nervous system. 
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Biofeedback Foundation of Europe 

The Biofeedback Foundation of Europe (BFE) was founded to promote a greater awareness of 

biofeedback among European health professionals and, through training workshops, to educate clinicians 

in the use of biofeedback techniques and technology. BFE has compiled a series of clinical protocols 

developed by major contributors in the field of biofeedback and physical therapy in an effort to improve 

knowledge in the use of electromyography as an effective tool for physiotherapy. These describe 

assessment and biofeedback training technique. Protocols for the following conditions can be found on 

the Website (http://www.bfe.org/library.html, click on BFE protocols). 

Patella Femoral Pain Syndrome 

The Unstable Shoulder 

Post Operative Knee 

Urinary and Fecal Incontinence 

Phantom Limb Pain 

Oral Pharyngeal Dysphagia 

Myofacial Pain and TMJ 

Chronic Tension Headache 

Repetitive Strain Injury 

Effortless Diaphragmatic Breathing 

Vulvovaginal Pain Disorders 

Peak Performance Training with Electrodermal Biofeedback 

Towards an Integrated Approach of sEMG Utilization: Quantitative Protocols of Assessment and 

Biofeedback 

Protocol for use of EMG and Tactile Biofeedback in Treatment of Temporomandibular Disorders 

and Myofacial Pain
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The Biofeedback Certification Institute of America 

The Biofeedback Certification Institute of America (BCIA) is an autonomous nonprofit 

corporation that was created in January 1981 to establish and oversee standards for practitioners who use 

biofeedback, to certify those who meet these standards, and to progressively recertify those who advance 

their knowledge through continuing education. BCIA policies and procedures are set by an independent 

board of directors, which is comprised of a rotating group of distinguished biofeedback clinicians, 

researchers, and educators. Three certification programs are currently offered: 1) General Biofeedback 

(providing the basics of biofeedback, including GSR, EMG, HRV, thermal, and an introduction to EEG), 

2) EEG Biofeedback (for those who wish to specialize in EEG biofeedback/neurofeedback), and 3) Pelvic 

Muscle Dysfunction Biofeedback (built specifically for licensed health care professionals who use 

biofeedback and behavioral interventions to treat incontinence and pelvic pain syndromes). 

BCIA certification is the mark of distinction for providers of biofeedback services. Names of 

certified practitioners may be found in the “Find a Practitioner” area of our Website at www.bcia.org. A 

BCIA-certified practitioner must meet the following qualifications: 

1. Prerequisite educational degree of a BA/BS or higher from a regionally accredited academic 

institution in a BCIA-accepted clinical health care field such as counseling, medicine, nursing, 

psychology, rehabilitation, or social work. Credentialed special education teachers and counselors 

may also become certified in EEG biofeedback to work in school environments. 

2. Didactic training by completing a three semester-hour university course or its equivalent or 

completing a BCIA-accredited training program covering the relevant Blueprint of Knowledge 

statements specific to that certification program. 

3. Evidence of a human anatomy, human physiology, or human biology course from a regionally 

accredited academic institution or from a BCIA-accredited program. 

4. Practical training to teach the application of clinical skills provided by a BCIA-approved mentor 

using contact hours to review personal biofeedback, case conference, and patient/client treatment 

sessions. 

5. Successful completion of a written certification exam covering all relevant blueprint areas. 

6. Adherence to the BCIA Ethical Principles, including working within the scope of one’s 

profession. When working with a medical or psychological disorder, BCIA certificants are 

required to carry a state-issued license (or other comparable credential), which allows 

independent practice in a BCIA-approved health care field or to work under legal supervision. 

Though BCIA certification assures that an individual has met entry-level education and training 

requirements for the clinical practice of biofeedback, this certification is not a substitute for a statesanctioned license or other credential to practice one’s profession. 

Please visit www.bcia.org, where the public or other interested professionals may read about 

certification requirements or search for a practitioner. 

10200 W. 44th Avenue, Suite 310,Wheat Ridge, CO 80033 

(303) 420-2902 ▪ Fax: (303) 422-8894 ▪ Email: BCIA@resourcenter.com 
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Association for Applied Psychophysiology and Biofeedback (AAPB) 

Code of Ethics 

Members of the Association for Applied Psychophysiology and Biofeedback are expected to 

comply with the organization’s Ethical Principles. These principles cover such areas as 

responsibility, competence, standards, public statements, confidentiality, protection of client 

rights and welfare, professional relationships, and research with humans and animals. A copy of 

these can be found on the organization’s Website at www.aapb.org. 
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Answers to Common Questions about Biofeedback Treatment 

What is a normal amount of time for a visit? If it takes longer, is it customary to bill per quarterhour increments, or is it usually one lump sum? 

Biofeedback sessions commonly range from 45 to 90 minutes. Shorter or longer sessions may be 

justified under unusual situations (e.g., shorter for a brief, uncomplicated follow up or practice session; 

longer for EEG training for epilepsy or treatment of a multiplicity of symptoms). It is customary to bill 

either by length of session in quarter-hour increments or a fixed amount per session regardless of length, 

depending on the profession and setting or the person doing the therapy. 

What are general guidelines for number of sessions for major diagnoses of migraine headaches, 

hypertension, tension headaches, Raynaud’s disease, anxiety, or irritable bowel syndrome? 

Eight to 20 sessions is a reasonable length of treatment for each of the disorders listed when there 

is good patient adherence and no other disorder is present. Follow-up interviews are advisable at three, 

six, and nine months after the end of treatment. 

What are reasonable fees for biofeedback therapy? 

Fees vary among professions (psychologist, physician, master’s level counselor, nurse, social 

worker, physical or occupational therapist, etc.) and between geographical regions but are not dependent 

on the physiological system being addressed in biofeedback therapy. Fees range from $50 to $200 per 

hour for biofeedback therapy. There should be little difference in fees between modalities of biofeedback 

therapy except that EEG therapy will customarily be higher because further specialized training is 

required. 

Is it customary to break down the psychotherapy bill separately? 

Although some biofeedback providers bill separately for biofeedback therapy and psychotherapy 

in the same session, it may not be necessary to do so. In addition to the use of biofeedback 

instrumentation, the clinical protocols in biofeedback therapies customarily involve two or three 

modalities of biofeedback and a variety of therapeutic procedures. Examples are autogenic training, 

imagery, symptom charting, assessment of life stressors, cognitive behavior therapies, strategies for 

generalization from the clinic to everyday life and application of skills outside the therapy session, 

assignment and review of homework, and adherence management. 

In some cases, biofeedback therapy may be considered a subcategory of psychotherapy, as is 

done by the World Health Organization in ICD-9CM. The factor that defines biofeedback therapy is 

the use of instrumentation for teaching physiological self-regulation. When biofeedback instrumentation 

is not part of assessment or treatment, the procedure is not biofeedback therapy and should not be billed 

as such. 

In some states, biofeedback therapy is not considered a form of psychotherapy and is not billed as 

such. Biofeedback providers should check with the ethical codes of regulatory and professional agencies 

in their local region for the appropriate diagnostic code. Suggested CPT codes are provided on page 81. 

For what diagnoses is biofeedback a treatment of choice? 

Biofeedback therapy is a treatment of choice for certain types of fecal incontinence and urinary 

incontinence. It is a treatment of choice for tension-type headaches, migraine headaches, other chronic pain 

syndromes, irritable bowel syndrome, essential hypertension, asthma, Raynaud’s disease/syndrome, and a 

variety of neuromuscular disorders, especially during rehabilitation. EEG biofeedback therapy is a treatment 

of choice for certain selected patients with epilepsy or attention deficit disorder. 
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What treatments should be tried prior to biofeedback? 

We recommend a behavioral “step-care” approach to treatment prior to biofeedback therapy. This 

approach would include, for example, diet change, exercise, or environmental restructuring. If a disorder is 

life-threatening, it must be stabilized before biofeedback therapy is initiated. For example, the treatment of 

essential hypertension might include medication to bring blood pressure down and to maintain it at a safe 

level until the person develops self-regulation skills with biofeedback therapy. Also, when a person has 

psychological issues that interfere with learning self-regulation or with changing or eliminating a symptom, 

then psychotherapy may be needed before biofeedback therapy can be effective. 

Please list any suggestions or ideas on why extended periods of time longer than 15 to 20 sessions 

might be necessary? 

Many factors may contribute to an extended period of biofeedback therapy. Examples are the 

number and chronicity of symptoms, the number and type of additional medical or psychological diagnoses, 

the amount and type of medication and psychosocial factors such as motivation, multiplicity of life stressors, 

secondary gains, and intrafamily dynamics. Chronic pain of long duration, seizure disorders, and 

neuromuscular rehabilitation customarily take longer than 20 sessions. 

Where can I get more information about biofeedback? 

 The Association for Applied Psychophysiology and Biofeedback has a Website with further upto-date information at www.aapb.org. 
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Conclusion 

The diversity of applications of biofeedback therapies reflects the commonality of 

underlying factors in many behavioral and psychophysiologic disorders such as emotional and 

cognitive stressors, the stress response, and failure to maintain healthy homeostasis. That 

biofeedback therapies are effective with a variety of symptoms is no mystery. Theoretically, any 

physiological process that responds to stress will respond to stress reduction. Biofeedback 

therapies incorporate a solid core of behavioral, cognitive, and physiological self-regulation 

techniques that are used by the patient to alleviate the underlying causes of the disorder. 

Biofeedback therapies have broad applications because they give the patient skills that facilitate 

the natural tendency of the body to return to healthy homeostasis as well as skills for enhanced 

well-being and prevention of disease. 
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Treatment Codes 

(compiled by Robert P. Whitehouse, Ed.D., and Ronald L. Rosenthal, Ph.D.) 

The treatment codes for biofeedback therapy used by practitioners and third party 

payors in the United States are established by the Current Procedural Treatment (CPT) Code 

committee of the American Medical Association. 

Health and Behavior Assessment/Intervention: These codes describe services to patients 

who present with established illnesses or symptoms, who are not diagnosed with mental 

illnesses, and may benefit from evaluations that focus on the biopsychosocial factors 

related to the patient’s physical health status. 

96150 Health & behavior assessment (e.g., health-focused clinical interview, behavioral 

observations, psychophysiological monitoring, health-oriented questionnaires), each 

15 minutes face-to-face with the patient; initial assessment 

96151 Re-assessment 

96152 Health & behavioral intervention, each 15 minutes, face-to-face; 

individual 

96153 Health & behavioral intervention, each 15 minutes, face-to-face; 

group (2 or more patients) 

96154 Health & behavioral intervention, each 15 minutes, face-to-face; 

family (with the patient present) 

96155 Health & behavioral intervention, each 15 minutes, face-to-face; 

family (without the patient present) 

Biofeedback 

90901 Biofeedback training by any modality 

90911 Biofeedback training, perineal muscles, anorectal or urethral sphincter, including 

EMG and/or manometry 

Psychiatric Therapeutic Procedures 

90875 Individual psychophysiology therapy incorporating biofeedback training by any 

modality (face-to-face with the patient), with psychotherapy (e.g., insight oriented, 

behavior modifying or supportive psychotherapy); 

approximately 20-30 minutes 

90876 Individual psychophysiology therapy incorporating biofeedback training by any 

modality (face-to-face with the patient), with psychotherapy (e.g., insight oriented, 

behavior modifying or supportive psychotherapy); 

approximately 40-45 minutes 

Other codes that might be useable, if approved by third party payors 

94010 Spirometry, including graphic record, total & timed vital capacity, expiratory flow 

rate measurement(s), with or without maximal voluntary ventilation 

94400 Breathing response to CO2 (CO2 response curve) 

96002 Dynamic surface electromyography, during walking or other functional activities, 1-

12 muscles 

95957 Digital analysis of electroencephalogram (EEG) (e.g., for epileptic spike analysis) 
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90806 Individual psychotherapy. Insight oriented, behavior modifying and/or supportive, in 

an office or outpatient facility, approximately 45-50 minutes, face-to-face with the 

patient 

Neurofeedback Evaluation Codes 

95816 Digital EEG Recording 

95957 Digital EEG Analysis 

99090 Reference EEG database access 

Alternative Codes for Biofeedback 

97112 Neuromuscular reeducation of movement, balance, kinesthetic sense, posture, and/or 

proprioception for sitting and/or standing activities 

97532 Development of cognitive skills to improve attention, memory, problem solving 

(includes compensatory training) (Formerly 97770) 

ABC CAM Codes 

Five character codes have been developed by the Alternative Link for more than 4,000 

procedures “that describe the patient encounter with nursing, complementary and alternative 

medicine (CAM), and indigenous medicine services. Laws governing such providers differ by 

state and are available at 877-621-LINK. 

CDAAP Biofeedback, counseling, mental health services, practice specialties. 

Assisting the client to modify a body function using feedback from instrumentation.