Biofeedback Applications for the Management of Medical, Psychiatric, and Neurocognitive Conditions in the Primary Care Setting

Amir Ramezani, PhD

Mark Johnson, PhD

Christopher Gilbert, PhD

Ravi Prasad, MD

FAST FACTS

Biofeedback is the process by which an individual’s physiological activity, such as muscle tension or brain activity, is presented to the individual in the form of a computerized game, graphic, auditory, tactile, or visual display in real time.
In chronic conditions, biofeedback training can increase patients’ sense of control over their condition, instilling greater confidence in their ability to self-regulate and gain better control over their symptoms.
Cognitive-, mindfulness-, compassion-, and acceptance-based therapies teach individuals skills to develop healthy, realistic, value-based and compassionate ways of mentally relating to their pain.

INTRODUCTION

Biofeedback is one of the longest established, nonpharmacological treatments available since the1960s. Biofeedback makes invisible stress-related physiological activity visible.¹ With advances in wireless technology and wearable devices, biofeedback has become easier to implement in a fast-paced environment, such as the primary care setting.

Biofeedback is the process by which an individual’s physiological activity, such as muscle tension or brain activity, is presented to the individual in the form of a computerized game, graphic, auditory, tactile, or visual display in real time. This process helps the individual to “see” their body’s activity, moment-to-moment, to learn how to change their physiological activities through trial-and-error learning (e.g., operant conditioning). This leads to increased self-regulation of the physiological activity that is being recorded² and “fed back” to the individual. This leads to better self-management of medical and psychiatric conditions.

Leading biofeedback, psychophysiology, and neuroscience organizations representing the field of biofeedback have developed the following standard definition:

“Biofeedback is a process that enables an individual to learn how to change physiological activity for the purposes of improving health and performance. Precise instruments measure physiological activity such as brainwaves, heart function, breathing, muscle activity, and skin temperature. These instruments rapidly and accurately ‘feed back’ information to the user. The presentation of this information—often in conjunction with changes in thinking, emotions, and behavior—supports desired physiological changes. Over time, these changes can endure without continued use of an instrument”³ (Association for Applied Psychophysiology and Biofeedback [AAPB], Biofeedback Certification International Alliance [BCIA], International Society for Neurofeedback and Research [ISNR]).

This chapter discusses the significance of biofeedback for pain management and comorbid psychological and emotional conditions; the importance of integrating biofeedback treatment with adjunctive psychological modalities; restoration of functional impairment to improve activities of daily living/quality of life, and a summary of the research and evidential support for the application of biofeedback for pain. Case approach methods/protocols will also be presented to demonstrate practical applications in a primary care environment.

BIOFEEDBACK APPLICATIONS

Yucha and Montgomery (2008) outlined the criteria for levels of efficacy of psychophysiological interventions⁴ and categorized them as “not empirically supported” (level 1), “possibly efficacious” (level 2), “probably efficacious” (level 3), “efficacious” (level 4), and “efficacious and specific” (level 5).⁴ The term “efficacy levels” refers to outcome studies with higher standards of research (e.g., randomization, placebo/sham control groups). It should be noted that a categorical rating of less than efficacious does not necessarily mean the intervention is not effective, but rather that there may be insufficient evidence to make such a determination at the time.⁵ See Table 28-1 for a list of evidence-based applications of biofeedback.

Primary care medical settings have great potential for biofeedback given that many patients in these settings have poorly understood conditions.⁶ Patients who overutilize health services are sometimes labeled as “difficult” or psychosomatic. Newer diagnoses have reconceptualized medically unexplained disorders as functional disorders that include fibromyalgia, chronic fatigue syndrome, irritable bowel syndrome, chemical sensitivity, chronic pain disorder, and anxiety with somatic symptoms.⁶ These disorders are also gradually being remedicalized as central sensitivity syndromes and autonomic dysregulation syndromes (i.e., disorders of the central and peripheral nervous system where persistent pain and other overlapping symptoms are prominent features) in which biofeedback has good potential to effect autonomic and central response and treat these symptoms.

COST-EFFECTIVENESS

Behavioral treatments such as biofeedback are front-loaded. After a number of initial self-regulation training sessions, treatment benefits last for years. For example, in the management of chronic headaches, over the course of a one-year period of treatment, minimal contact treatment (i.e., training in biofeedback with home practice) cost $500 less than pharmacological treatment.⁷ Biofeedback is considered a cost-effective treatment for reducing symptoms and symptom severity of irritable bowel syndrome⁸^,⁹ and for reducing stress, anxiety and depression.¹⁰^,¹¹ A review of multicomponent behavioral medicine studies in the treatment of psychosomatic illness and pain suggested that biofeedback and relaxation training were cost-effective in the majority of dimensions of healthcare costs including reductions in physician visits and/or use of medication, reduced medical costs to patients, reduced hospital stays and/or rehospitalizations, reduced mortality, and enhanced quality of life.¹²

TABLE 28-1 Evidence-Based Applications of Biofeedback⁴^,³⁰

Comorbid Physical and Psychiatric Condition in Pain (Efficacy levels 4 and 5)

Fecal incontinence (balloon manometer, rectal EMG, ultrasound sensor)
Erectile dysfunction (pelvic floor EMG)
Attention and attention deficit disorders (ADHD) (EEG)
Major depressive disorder (EEG: alpha asymmetry, fMRI upregulation, HRV)
Epileptic seizures: (EEG: sensorimotor rhythm, slow cortical potential)
Glycemic control (forehead EMG, hand temperature)
Anxiety disorders (EMG, HRV, breathing)
Essential hypertension—including preeclampsia (thermal, breathing, HRV)
Raynaud’s disease (thermal)

Pain Primarily (efficacy levels 3, 4, and 5)

Adult and pediatric headache, migraine and tension-type (EEG, EMG, thermal, BVP)
Pain related to the following (fMRI, EEG, EMG, breathing, HRV): Level 4: jaw and facial pain, noncardiac chest pain, posture-related pain, chronic and experimentally induced pain; Level 3: low-back, pelvic, phantom limb, patellofemoral, cancer pain
Irritable bowel syndrome (HRV)
TMJ dysfunction (EMG, hand temperature)
Arthritis (EMG, breathing, thermal, GSR)
Fibromyalgia (EMG)

Note: BVP, blood volume pulse; EEG, electroencephalography; EMG, electromyography; fMRI, functional magnetic resonance imaging; HRV, heart rate variability; GSR, galvanic skin response.

Clinical judgment should be exercised when making decision and may override the above suggestions.

Although biofeedback is cost-effective for a number of disorders, access to services is often a barrier. Reimbursement for biofeedback is inconsistent and unpredictable. It is recommended that a consultation with a board-certified biofeedback specialist be undertaken to appropriately bill services (e.g., CPT codes for medical coverage include health and behavior codes while mental health coverage has stand-alone biofeedback and biofeedback and therapy procedures codes).

REASONS FOR REFERRAL AND ASSESSING SUITABILITY

Patients in primary care settings may be referred for biofeedback as an alternative or adjunctive treatment for a variety of presenting issues. Reasons for referral may include a lack of positive response to current treatment, disinterest in medication, pharmaceutical contraindication (e.g., pregnancy, breast-feeding), or stress being a major component of the patient’s presentation.¹³ In chronic conditions, biofeedback training can increase patients’ sense of control over their condition, instilling greater confidence in their ability to self-regulate and gain better control over their symptoms. Before initiating biofeedback or psychophysiological monitoring/training or a referral, it is important to recognize clear contraindications and to determine if the individual is a suitable biofeedback candidate (see Table 28-2).

STAGES OF TRAINING

There are four general stages of training (see Figure 28-1). These include