Continuing Education Activity

Biofeedback is a versatile technique that enhances sensory feedback, enabling individuals to gain control over typically involuntary physiological functions. Widely used in physical therapy, neuromuscular rehabilitation, and stress management, biofeedback helps address conditions such as chronic pain, anxiety, incontinence, and motor dysfunction. This activity provides a comprehensive overview of biofeedback modalities, including biomechanical and physiological techniques, and explores their applications in managing diverse conditions. Participants learn biofeedback mechanisms, proper selection of modalities, and strategies for effective integration into treatment plans. Emphasis is placed on interprofessional collaboration, leveraging advanced technology, and optimizing patient outcomes through tailored care.

Objectives:

• Identify the appropriate biofeedback modality based on the patient’s condition, such as muscle activity, heart rate, or respiratory patterns.
• Implement biofeedback as part of a comprehensive treatment plan for conditions such as chronic pain, stress, anxiety, and neuromuscular disorders.
• Apply biofeedback techniques to manage symptoms effectively, such as muscle coordination or stress reduction, in patients with appropriate conditions.
• Collaborate with an interprofessional healthcare team, including physical therapists and psychiatric health nurses, to optimize biofeedback therapy outcomes.

Introduction

Biofeedback is a technique that enhances sensory feedback, enabling individuals to consciously modify bodily functions typically considered involuntary. This technique is commonly used for symptom management in chronic illnesses and as part of physical therapy for patients with motor dysfunction. The process begins by using noninvasive equipment to measure a selected physical parameter, which is then displayed directly or converted into a visual, auditory, or tactile feedback signal. The patient practices controlling the feedback signal by consciously adjusting the physical parameter. As biofeedback provides an additional form of feedback beyond the body’s intrinsic sensory system, it is also known as augmented or extrinsic feedback.

Biofeedback is classified into 2 main categories—biomechanical and physiological—based on the parameter being measured. Biomechanical techniques use simple inertial sensors or advanced video motion sensors to assess body activity and movement.[1] Several different modalities serve to measure physiological activity. Muscle activity, measured by electromyography, is one of the most common biofeedback parameters. Other options include cardiac activity (measured by heart rate and heart rate variability), breathing activity (measured by respiratory rate and depth), and electrodermal activity (measured by skin conductance).[2] 

Biofeedback has been used in physical therapy for over 50 years and has proven beneficial in managing neuromuscular disorders. These techniques are particularly effective as part of physical therapy programs for individuals with motor weakness or dysfunction following a stroke, orthopedic surgery, or due to other neuromuscular conditions. As technology advances, these methods are increasingly effective in training complex, task-oriented activities such as walking and grasping objects.[3]

In addition to neuromuscular retraining, biofeedback is commonly used for managing chronic symptoms such as anxiety, pain, and urinary or fecal incontinence. These techniques target the overactive sympathetic response and help coordinate muscle activity in the gastrointestinal and genitourinary tracts.[4][5] Biofeedback techniques are generally considered safe and free of adverse effects, so they are often included in treatment plans despite the lack of strong evidence supporting their benefits.[2]

Evidence suggests that biofeedback is an effective treatment for various pelvic pain syndromes, including anorectal disorders, chronic prostatitis, and pelvic pain in men, women, and children. Biofeedback has been shown to provide significant pain relief and improve quality of life. [6] Moderate evidence indicates that biofeedback can moderately reduce disability in the short- and intermediate-term, though it does not significantly affect pain levels or work capacity. Among biofeedback types, pressure biofeedback has shown more significant benefits for intermediate-term disability compared to EMG biofeedback.[7] Biofeedback is valuable in general and cancer-specific rehabilitation, as it can enhance patients' self-awareness and control over specific physiological responses, including muscle tension, heart rate, and pain.[8]

Integrating biofeedback with virtual reality, gaming, music, and relaxation techniques can effectively reduce anxiety in children, students, and patients with conditions such as Parkinson disease.[9] Real-time feedback and positive reinforcement from wearable device-based biofeedback rehabilitation can enhance dynamic balance and gait in patients with neurological disorders, including Parkinson disease and post-stroke.[10]

Biofeedback may reduce the time to fall asleep and the number of awakenings, but study results are inconsistent. No evidence supports that it significantly improves total sleep time or efficiency.[11]

EMG biofeedback has shown benefits in improving quadriceps strength and knee extension, with one study noting better balance. However, EMG biofeedback did not significantly impact pain levels or Lysholm scores. While the meta-analysis indicated some improvement in knee extension, this was not clinically meaningful, and pain relief results varied. Overall, EMG biofeedback shows promise for post-ACL surgery rehabilitation but requires further research to confirm its effectiveness and cost-effectiveness.[12]

Anatomy and Physiology

Clinicians can use biofeedback techniques to manage overall physiological responses or focus on specific muscle movements. Commonly targeted muscle groups include those in the upper and lower limbs and the muscles involved in gait. Muscles controlled by the autonomic nervous system, such as those involved in digestion, defecation, and urination, are also frequently selected.[13] For urinary incontinence, biofeedback targets the pelvic floor muscles, while for fecal incontinence, the focus is on the external anal sphincter. Biofeedback is also utilized for nonmusculoskeletal purposes, including reducing anxiety and stress. Additionally, it has been applied to regulate vascular function and decrease vasoconstriction.

Indications

Clinicians can incorporate biofeedback techniques into the overall treatment plan for various conditions. This technique is commonly used to manage stress and anxiety, whether as a primary illness or secondary to another cause. Specific evidence supports the use of biofeedback for specific ailments, including the following conditions:

• Constipation
• Fecal incontinence
• Urinary incontinence
• Chronic pain, including chronic low back pain, chronic pelvic pain, and other pain syndromes
• Chronic insomnia
• Migraine headaches
• Chronic fatigue
• Fibromyalgia
• Epilepsy
• Motion sickness
• Depression
• Anxiety
• Raynaud phenomenon [14]

Contraindications

Biofeedback is widely regarded as a safe procedure with no absolute contraindications and is suitable for individuals of all ages.[15] The technique relies on active patient participation, making it unsuitable for individuals unable to comprehend and follow commands or for those with complete paralysis. Additionally, biofeedback is not recommended as the sole treatment for severe hypertension and should be used with caution in patients with acute psychiatric conditions.[16] 

Equipment

Biofeedback techniques are categorized into 2 main types—physiological and biomechanical—based on the actions they target. Each approach utilizes specialized equipment to measure sensory parameters, convert them into feedback, and present the results to the patient.

• Physiological biofeedback uses electromyography to measure muscle activity. Autonomic functions can be monitored through heart rate, respiratory rate and depth, and electrodermal activity. Although electroencephalography (EEG) is an option, it is used less frequently.[17]

• Biomechanical biofeedback focuses on parameters related to movement and spatial orientation. These are measured using devices such as inertial motion detectors (eg, accelerometers or gyroscopes), force plate sensors, and real-time ultrasound. While endoscopy has been successfully utilized, it is not a commonly used technique.[18]

The sensor data is processed and converted into feedback, which can be visual (eg, changing graphics or patterns), auditory (eg, varying tones or music volume), or haptic (eg, vibrations from a wearable device).

Virtual reality leverages wearable motion detector sensors, advanced processing, and display technology to create interactive games incorporating rehabilitation techniques. This approach particularly benefits pediatric patients, enhancing engagement and therapy outcomes.[19] This technology enhances patient engagement, boosts motivation, and improves overall outcomes, especially in younger populations.

Personnel

Skilled physical therapists are crucial in the effective application of biofeedback therapies.[20] Experienced technicians are also essential for modalities such as EEG, skin conductance, and ultrasound. Certified biofeedback technicians and clinical certificants, accredited by the Association for Applied Psychophysiology and Biofeedback (AAPB), are qualified to administer biofeedback therapy. Finally, the supervising physician plays a crucial role in assessing the patient's overall progress and coordinating additional therapies to maximize their outcomes.

Preparation

Successful biofeedback training requires significant motivation and active participation from the patient. The individual must be able to communicate, comprehend, and follow instructions. The appropriate modality must be selected based on the specific condition. For instance, electromyography biofeedback is typically used for musculoskeletal conditions, while real-time ultrasound biofeedback is effective for pelvic floor dysfunction.[13] For headaches, blood volume pulse feedback has the strongest evidence for reducing both headache severity and frequency of episodes.[21] Depending on the indication, sensors are placed on different areas of the patient’s body to monitor the relevant physiological parameters.

Technique or Treatment

The biofeedback process is essentially a form of operant conditioning, using positive feedback to reinforce desired actions or behaviors and negative feedback to discourage undesired ones. The first step involves selecting the appropriate modality and establishing a baseline parameter. The next step is learning to control the parameter and practicing until the action becomes ingrained in memory. An example of this is using biofeedback to manage hypertension.

In thermal biofeedback, a temperature probe is attached to a patient's finger or toe, and the patient is instructed to increase or decrease the temperature in response to the feedback. Warming the digit involves reducing sympathetic vasoconstriction, which increases blood flow to the area.[22] This training aims to reduce neural-mediated vasoconstriction systemically, lowering total peripheral resistance and subsequently decreasing blood pressure.[22] 

Another common use of biofeedback is treating urinary incontinence and enuresis in children. Electrodes are placed near the anus and on the leg of the patient while a urotherapist guides the child through pelvic floor exercises.[23] These exercises are incorporated into a video game where the child controls a caterpillar and is instructed to contract their pelvic floor muscles to avoid obstacles. The child is also taught to continue these exercises at home to improve pelvic floor strength and reduce urinary incontinence.[23]

Complications

Biofeedback is a safe and well-tolerated procedure with minimal complications. However, if used continuously throughout therapy, performance may decline once the equipment is discontinued. Therefore, it is beneficial for patients to practice the techniques without the biofeedback equipment as part of their overall treatment plan to maintain sustained improvement.[24] If patients do not practice the techniques regularly, the results may diminish over time, necessitating retraining.

Clinical Significance

Biofeedback techniques offer a safe and effective way to relieve symptoms and enhance quality of life without significant adverse effects. By empowering patients to take control of their condition, these methods play a vital role in promoting self-efficacy and overall well-being.[25] With sufficient training, patients can achieve lasting changes without continued reliance on biofeedback instruments. Additionally, biofeedback may reduce the need for medications, helping to minimize the risks associated with polypharmacy and limiting the potential adverse effects of other treatments. 

Enhancing Healthcare Team Outcomes

Biofeedback techniques are recommended for managing symptoms such as chronic pain, fatigue, and insomnia, but they are most effective when integrated into a comprehensive rehabilitation plan. Individual outcomes may vary, with the greatest benefits often achieved when biofeedback is combined with cognitive-behavioral therapy, physical therapy, or other relaxation techniques.[26][27]

Several smaller studies and systematic reviews have examined biofeedback measures, but the results are conflicting and likely influenced by publication bias. Issues such as poor randomization and comparisons against no treatment rather than standard physical therapy have been noted in some studies.[13][28] Long-term research is needed to determine whether positive outcomes can be sustained.

An interprofessional healthcare team comprising primary care providers, pain specialists, neurologists, physical therapists, and psychiatric health nurses can significantly enhance the effectiveness of biofeedback procedures by assisting clinicians and tracking patient progress. Nurses and therapists play a key role by educating patients, monitoring their responses to treatment, and providing valuable updates about patient progress to the healthcare team. Open communication among the various clinicians involved in a case is essential. Effective collaboration within an interprofessional healthcare team improves patient outcomes with biofeedback.

Nursing, Allied Health, and Interprofessional Team Interventions

Nurses are often the first to identify symptoms of anxiety or gait abnormalities. Recognizing when biofeedback may be beneficial and appropriate as a supplemental treatment can enhance patient care. Given the wide range of indications biofeedback can address, nurses should remain attentive to presenting symptoms and consider its potential use. In some states, healthcare providers such as psychologists may be restricted from physically touching patients to apply sensors, requiring a healthcare provider, such as a nurse, to act as a chaperone or handle sensor applications. Nurses also play a vital role in patient education, as they can guide patients with urinary incontinence on strategies to reduce accidents, such as adhering to scheduled voiding times. 

Nursing, Allied Health, and Interprofessional Team Monitoring

During biofeedback therapy, primary monitoring focuses on fatigue, which may be exacerbated by the ongoing treatment. Depending on the modality, nurses also check for discomfort that some patients may experience, such as in cases of fecal incontinence, where probes and balloons are inserted into the rectum to stimulate defecation. Additionally, nurses observe for complications, such as reactions to sensor tape.[29]

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References

1.

Kos A, Tomažič S, Umek A. Suitability of Smartphone Inertial Sensors for Real-Time Biofeedback Applications. Sensors (Basel). 2016 Feb 27;16(3):301. [PMC free article: PMC4813876] [PubMed: 26927125]

2.

Windthorst P, Veit R, Enck P, Smolka R, Zipfel S, Teufel M. [Biofeedback and neurofeedback: applications in psychosomatic medicine and psychotherapy]. Psychother Psychosom Med Psychol. 2015 Mar;65(3-4):146-58. [PubMed: 25798668]

3.

Cheung EYY, Yu KKK, Kwan RLC, Ng CKM, Chau RMW, Cheing GLY. Effect of EMG-biofeedback robotic-assisted body weight supported treadmill training on walking ability and cardiopulmonary function on people with subacute spinal cord injuries - a randomized controlled trial. BMC Neurol. 2019 Jun 24;19(1):140. [PMC free article: PMC6591819] [PubMed: 31234791]

4.

American Gastroenterological Association. Bharucha AE, Dorn SD, Lembo A, Pressman A. American Gastroenterological Association medical position statement on constipation. Gastroenterology. 2013 Jan;144(1):211-7. [PubMed: 23261064]

5.

Costilla VC, Foxx-Orenstein AE, Mayer AP, Crowell MD. Office-based management of fecal incontinence. Gastroenterol Hepatol (N Y). 2013 Jul;9(7):423-33. [PMC free article: PMC3736779] [PubMed: 23935551]

6.

Wagner B, Steiner M, Huber DFX, Crevenna R. The effect of biofeedback interventions on pain, overall symptoms, quality of life and physiological parameters in patients with pelvic pain : A systematic review. Wien Klin Wochenschr. 2022 Jan;134(Suppl 1):11-48. [PMC free article: PMC8825385] [PubMed: 33751183]

7.

Campo M, Zadro JR, Pappas E, Monticone M, Secci C, Scalzitti D, Findley JL, Graham PL. The effectiveness of biofeedback for improving pain, disability and work ability in adults with neck pain: A systematic review and meta-analysis. Musculoskelet Sci Pract. 2021 Apr;52:102317. [PubMed: 33461043]

8.

Crevenna R. Biofeedback in medicine with a focus on cancer rehabilitation. Wien Klin Wochenschr. 2022 Jan;134(Suppl 1):1-2. [PubMed: 35133476]

9.

Alneyadi M, Drissi N, Almeqbaali M, Ouhbi S. Biofeedback-Based Connected Mental Health Interventions for Anxiety: Systematic Literature Review. JMIR Mhealth Uhealth. 2021 Apr 22;9(4):e26038. [PMC free article: PMC8103295] [PubMed: 33792548]

10.

Bowman T, Gervasoni E, Arienti C, Lazzarini SG, Negrini S, Crea S, Cattaneo D, Carrozza MC. Wearable Devices for Biofeedback Rehabilitation: A Systematic Review and Meta-Analysis to Design Application Rules and Estimate the Effectiveness on Balance and Gait Outcomes in Neurological Diseases. Sensors (Basel). 2021 May 15;21(10) [PMC free article: PMC8156914] [PubMed: 34063355]

11.

Melo DLM, Carvalho LBC, Prado LBF, Prado GF. Biofeedback Therapies for Chronic Insomnia: A Systematic Review. Appl Psychophysiol Biofeedback. 2019 Dec;44(4):259-269. [PubMed: 31123938]

12.

Ananías J, Vidal C, Ortiz-Muñoz L, Irarrázaval S, Besa P. Use of electromyographic biofeedback in rehabilitation following anterior cruciate ligament reconstruction: a systematic review and meta-analysis. Physiotherapy. 2024 Jun;123:19-29. [PubMed: 38244487]

13.

Giggins OM, Persson UM, Caulfield B. Biofeedback in rehabilitation. J Neuroeng Rehabil. 2013 Jun 18;10:60. [PMC free article: PMC3687555] [PubMed: 23777436]

14.

Frank DL, Khorshid L, Kiffer JF, Moravec CS, McKee MG. Biofeedback in medicine: who, when, why and how? Ment Health Fam Med. 2010 Jun;7(2):85-91. [PMC free article: PMC2939454] [PubMed: 22477926]

15.

Venkatesan T, Levinthal DJ, Tarbell SE, Jaradeh SS, Hasler WL, Issenman RM, Adams KA, Sarosiek I, Stave CD, Sharaf RN, Sultan S, Li BUK. Guidelines on management of cyclic vomiting syndrome in adults by the American Neurogastroenterology and Motility Society and the Cyclic Vomiting Syndrome Association. Neurogastroenterol Motil. 2019 Jun;31 Suppl 2(Suppl 2):e13604. [PMC free article: PMC6899751] [PubMed: 31241819]

16.

Greenhalgh J, Dickson R, Dundar Y. Biofeedback for hypertension: a systematic review. J Hypertens. 2010 Apr;28(4):644-52. [PubMed: 20090553]

17.

Nagai Y. [Biofeedback treatment for epilepsy]. Nihon Rinsho. 2014 May;72(5):887-93. [PubMed: 24912291]

18.

Imada M, Kagaya H, Ishiguro Y, Kato M, Inamoto Y, Tanaka T, Shibata S, Saitoh E. Effect of visual biofeedback to acquire supraglottic swallow in healthy individuals: a randomized-controlled trial. Int J Rehabil Res. 2016 Jun;39(2):181-4. [PubMed: 26795716]

19.

Yoo JW, Lee DR, Cha YJ, You SH. Augmented effects of EMG biofeedback interfaced with virtual reality on neuromuscular control and movement coordination during reaching in children with cerebral palsy. NeuroRehabilitation. 2017;40(2):175-185. [PubMed: 28222541]

20.

Afzal MR, Lee H, Eizad A, Lee CH, Oh MK, Yoon J. Effects of Vibrotactile Biofeedback Coding Schemes on Gait Symmetry Training of Individuals With Stroke. IEEE Trans Neural Syst Rehabil Eng. 2019 Aug;27(8):1617-1625. [PubMed: 31247557]

21.

Andrasik F. Biofeedback in headache: an overview of approaches and evidence. Cleve Clin J Med. 2010 Jul;77 Suppl 3:S72-6. [PubMed: 20622082]

22.

Greenhalgh J, Dickson R, Dundar Y. The effects of biofeedback for the treatment of essential hypertension: a systematic review. Health Technol Assess. 2009 Oct;13(46):1-104. [PubMed: 19822104]

23.

Sancak EB, Akbaş A, Kurt Ö, Alan C, Ersay AR. The effectiveness of biofeedback therapy in children with monosymptomatic enuresis resistant to desmopressin treatment. Turk J Urol. 2016 Dec;42(4):278-284. [PMC free article: PMC5125743] [PubMed: 27909622]

24.

Tate JJ, Milner CE. Real-time kinematic, temporospatial, and kinetic biofeedback during gait retraining in patients: a systematic review. Phys Ther. 2010 Aug;90(8):1123-34. [PubMed: 20558567]

25.

Martic-Biocina S, Zivoder I, Kozina G. Biofeedback and neurofeedback application in the treatment of migraine. Psychiatr Danub. 2017 Sep;29(Suppl 3):575-577. [PubMed: 28953832]

26.

John M. Eisenberg Center for Clinical Decisions and Communications Science. Comparative Effectiveness Review Summary Guides for Clinicians [Internet]. Agency for Healthcare Research and Quality (US); Rockville (MD): Apr 16, 2012. Effectiveness of Treatments for Noncyclic Chronic Pelvic Pain in Adult Women. [PubMed: 22624166]

27.

Qaseem A, Wilt TJ, McLean RM, Forciea MA, Clinical Guidelines Committee of the American College of Physicians. Denberg TD, Barry MJ, Boyd C, Chow RD, Fitterman N, Harris RP, Humphrey LL, Vijan S. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2017 Apr 04;166(7):514-530. [PubMed: 28192789]

28.

Huang H, Wolf SL, He J. Recent developments in biofeedback for neuromotor rehabilitation. J Neuroeng Rehabil. 2006 Jun 21;3:11. [PMC free article: PMC1550406] [PubMed: 16790060]

29.

Chiarioni G, Ferri B, Morelli A, Iantorno G, Bassotti G. Bio-feedback treatment of fecal incontinence: where are we, and where are we going? World J Gastroenterol. 2005 Aug 21;11(31):4771-5. [PMC free article: PMC4398720] [PubMed: 16097042]

Disclosure: Kashif Malik declares no relevant financial relationships with ineligible companies.

Disclosure: Anterpreet Dua declares no relevant financial relationships with ineligible companies.