You help people cope with chronic pain. You’ve heard of biofeedback. You know the value of teaching various types of relaxation, and may have wondered whether biofeedback might help with that. But the idea of measuring things like muscle tension, breathing, heartbeat, and skin conductance sounds complicated, and you’re not sure how it would go over with your clients.
What is biofeedback, exactly? It’s simply the process of measuring some physiological variable, and then feeding that information, in real time, back to the person whose body it is—in principle, like a mirror. The feedback can be audio, visual, or numerical, or even vibration, but carries ongoing information for the person to consider. Biofeedback magnifies body awareness. Some people appreciate concrete data about themselves, seek more control, or don’t respond well to “psych talk” without concrete evidence. Engineers tend to like biofeedback.
EXAMPLE: Suppose you’re working with a man with chronic neck and shoulder pain. You could use biofeedback to compare his neck tension to norms; you could show him how the number goes up when shrugging, wincing, and even when talking about something disturbing, such as his neck pain. Have him imagine lying on a beach, enjoying the sun, and the muscles will begin to relax. Muscle tension sensations are vague, but a biofeedback reading like “5.8 microvolts” is pretty precise, so suddenly there’s some solid information. You might set a goal of 3 microvolts and help him relax enough to reach that number. The feedback helps him learn better muscle control and also improve his ability to discriminate muscle sensations before they become pain. Muscle tension can be a cause of pain, a response to pain, or both.
PSYCHOPHYSIOLOGY AND PAIN
In your work with people in chronic pain, you have probably seen all of these:
– Excess muscle tension from guarding and bracing against pain flares; chronic tightening around joints
– Rapid heart rate or cool, sweaty hands associated with emotions related to chronic pain
– G-I upset (abdominal cramps, pain, IBS) – can be both a cause and response to pain
– Hyper-vigilance, inability to relax, poor sleep
– Rapid, shallow, irregular breathing
These conditions may have emotional origins, but also have a biological side that can be monitored and reduced with biofeedback. Learning to lower over-arousal—reducing the body’s alarm response—is a big part of chronic pain management. Apprehension, obsessive worry, anger, and catastrophic thinking have measurable somatic correlates which can be soothed with biofeedback, giving the client a new tool to use.
MECHANISMS
We cannot measure pain directly, but the body/mind’s response to pain is measurable. When the reaction to pain feeds into the pain, a “vicious circle” (stress pain) develops. Damping down this resonating feedback loop reduces the suffering, including anxiety, catastrophic thinking, a sense of urgency, and ultimately, pain intensity. The “pain gate” concept explains this, but it’s hard to get across to people unfamiliar with descending inhibitory tracts, substance P, frontal lobe, insula, cingulate cortex, etc.
This “damping down” effect is enhanced and focused by relaxation, broadly defined. Feeding back heart rate, skin conductance, breathing, or skin temperature shows moment-to-moment changes in stress level, which is useful information. If pain serves as an alarm, then self-soothing muffles the alarm. No skill can be mastered without some kind of feedback about progress. You can use biofeedback to demonstrate the effectiveness of guided imagery, slow breathing, or meditation. You can try various relaxation methods to see which works best, guided by both biofeedback readings and subjective outcomes.
I spent many years running biofeedback groups in a chronic pain program at Kaiser Permanente. Participants used biofeedback to learn better self-regulation, and also learned to read their own body signals better – in effect, switching to internal biofeedback. The two most common benefits mentioned were feeling a greater sense of control over the pain and changing their attitude toward their pain. They learned to address their responses to pain rather than the pain itself. The group’s focus was mainly on reducing the suffering component, but as a bonus, the pain intensity usually dropped.
BIOFEEDBACK EQUIPMENT
The standard biofeedback setup used by specialist-practitioners includes a multi-channel computerized system with visual and audio feedback and medical/research-grade sensors and amplifiers. But there are also lower-cost devices that provide valid data, allowing a practitioner to begin in a small way.
Here are some simple biofeedback devices to consider, often used for home practice:
- Digital thermometer to measure small changes in blood flow in the fingers. Stress constricts peripheral blood vessels, making the skin cooler. This often reflects worry, anxiety, and traumatic memories, and usually autonomic imbalance (excess sympathetic activity) Available: from $1 for a simple glass tube model to $4 -$25 for a digital display (sensitive to 1/10-degree, visual feedback only).
- Heart rate monitor to measure speed and regularity of the heartbeat, which usually speeds up with anxiety or pain flares and reflects emotional response to pain. Available: Fingertip pulse monitors combined with oximeter, under $50; measures both pulse and blood oxygen saturation (related to hyperventilation). Also many free cell-phone apps.
- Skin conductance monitor (GSR) to measure changes in sweat gland activity in the hands. GSR is especially sensitive to anxiety; lowering this indicator correlates with relaxation, safety, and comfort. Available: GSR2 – Usually $75, battery-powered, adjustable sensitivity and audio feedback volume. Also, Mindfield GSR for tablet or phone.
- Heart rate variability (HRV) to monitor synchrony between breathing and heart rate. Breathing phase (inhaling vs exhaling) correlates with the heart speeding up and slowing down. This synchrony is disrupted by emotional tension and improved by relaxation and feelings of comfort. Available: Inner Balance, emWave2, or emWave Pro ($100-$300, Heartmath). Also, cellphone apps.
- Muscle monitor (EMG) to measure muscle tension. Bracing and guarding are common responses to pain, and releasing this tension often brings some relief. MyoTrac: single channel, for monitoring any muscle near the body surface. Visual and audio feedback. $500. Antense (forehead tension, with headphones): $160.
- Multi-modal: eVu TPS sensor monitors heart rate/HRV, GSR, and hand temperature. Bluetooth connection to Android phone or tablet. $395.
Professional biofeedback systems monitor and display all of the above and more through a computer-linked console and a broad array of sensors, displays, assessments, and games. The major systems are from Mind Media, Thought Technology, and Somatic Vision. Price range: from $800 to $6000.
Source for biofeedback instruments and systems: The main vendor for most biofeedback products in the U.S. is Bio-medical.com. Others can be found by web search.
TRAINING RESOURCES
Understanding and learning to use biofeedback includes basic information about psychophysiology. Two recommended books:
Biofeedback Mastery by Erik Peper et al, 2008, published by AAPB.
The Clinical Handbook of Biofeedback by Inna Khazan, 2013, Wiley-Blackwell.
Both books are both excellent and practical, providing the details of using biofeedback with clients. You can learn enough from them to get started, though they’re not interactive and offer no opportunity for hands-on learning. Attending a basic biofeedback course is helpful if you want to know more. The main training organization is STENS in San Rafael, CA. They give very good introductory training with hands-on experience. One-to three-day workshops and seminars are held in many locations.
A good way to “start small” is to acquire a simple biofeedback device and practice with yourself and friends and relatives who are willing to let you try things. You can include a biofeedback demonstration as part of a pain management treatment session to see if it’s useful – it need not dominate the whole session.
Research support
Applications of biofeedback to many pain conditions have been fairly well studied and found effective. The complex effects of pain on behavior, cognition, and emotion are typically targeted rather than the pain sensation itself. Outcomes vary, depending on client engagement and extent of home practice; biofeedback is as much training as treatment, and people learn at different rates and in different ways. AAPB publishes a thorough compilation of research support for a large number of disorders, including chronic pain. (“Evidence-based Biofeedback in Biofeedback and Neurofeedback”).
These are the main organizations devoted to biofeedback:
Association for Applied Psychophysiology & Biofeedback
Biofeedback Foundation of Europe
For practitioner certification: Biofeedback Certification International Alliance. The fact that specialty certification is available does not mean that it’s required for practice. Starting small and remaining within your skill limits should not violate your discipline’s ethical standards.
My own small biofeedback-focused website has sample screen traces and simple explanations of various types of biofeedback.
Final word
The devices by themselves are only inert hardware with no power to educate, and are best used by a clinician with some skill in teaching techniques of relaxation and self-regulation. A bathroom scale does not lose weight for you, and a mirror will not teach you how to do your hair, but they are both handy biofeedback tools for learning to do those things.