Biofeedback: Information for Pain Management
Biofeedback1 and hypnosis2 are increasing in popularity as modalities for the treatment of chronic, non-cancer pain. Although biofeedback rarely provides a “cure” for chronic, non-cancer pain, it can be used to help patients self-regulate and influence their pain perception.3
The earliest case reports describing hypnotic strategies for chronic pain management originally were published in the 1950’s,4,5 a time that also witnessed the release of biofeedback technology that helped individuals attain similar physiologic states.6
Knowledge about the stress response and its effects on an individual’s physiology greatly increased. As a result, a large number of studies were conducted investigating the efficacy of hypnosis and biofeedback in the treatment of several pain conditions, including chronic pelvic pain,7 fibromyalgia,8-11 headaches,12,13 irritable bowel syndrome/gastrointestinal conditions,14-16 lower back pain,17 multiple sclerosis,18 and temporomandibular pain.19
What is Biofeedback?
The term biofeedback alludes to the function of this modality. “Bio” means body, and “feedback” means having information fed back to the patient. Thus, biofeedback is the use of instrumentation to mirror psychophysiologic processes that an individual is not normally aware of but may be able to bring under voluntary control.
The “fight or flight” response involves all parts of the nervous system, including the sympathetic nervous system, which is also responsible for adrenaline secretion. The response occurs when an individual is subjected to severe stress. When the response is activated by a stressor (such as a pain flare-up), the nervous system increases sympathetic activity, including increased heart rate, sweating, and muscular strength, which prepares the individual to face or avoid the stressor (face the pain or avoid it). Most people who benefit from biofeedback have conditions that are brought on or made worse by stress, which makes internal processes become overactive.
The biofeedback instruments give patients immediate information about their own biological conditions, including brainwaves, heart function, breathing, muscle tension, temperature, and galvanic skin response (or sweat). This feedback enables an individual to become an active participant in the process of health maintenance.20 Over time, these changes can endure without continued use of the instruments.6
Providers may recommend biofeedback for several reasons. Biofeedback training may be able to reduce, or even eliminate, the need for medication management of disease states. Biofeedback also may help patients take an active role in their own healing, which is consistent with the self-management model of chronic pain.
What types of biofeedback are available?
Most individuals have come into contact with common types of biofeedback. For example, people use thermometers, bathroom scales, and mirrors at home to become more aware of their physiology, and they use the information they obtain to make changes and gain control. In addition, patients are familiar with blood pressure and heart rate monitors, which provide information about cardiovascular functioning that can be altered.
There are several types of instruments that typically are used in biofeedback training (Table).
Perhaps the most common is the thermistor, a skin probe taped on a finger to measure temperature. The photoplethysmograph, or heart rate variability (HRV) monitor, also involves taping onto the index finger a probe that detects the flushing of the skin that occurs with each cardiac contraction. Patients, at times, will have a sensor placed around their abdomen, the pnuemograph, which measures breath rate, rhythm, volume, and location.
Another sensor, the electrodermograph, can be placed on the palmar surface of the fingers to measure sweat gland activity. The most widely used of all biofeedback instruments is the electromyograph (EMG), which monitors muscle tension, body relaxation, and muscle dysfunction. Typically, the EMG sensors are attached to the area of tension, but the most basic placement for training is on the forehead. The electroencephalograph, which measures electrical activity in the brain using sensors on a scalp cap,20 is used in “neurofeedback,” the most complicated form of biofeedback.
Biofeedback instruments do not change or influence bodily processes; they merely monitor or measure bodily functions. The implementation of mental exercises is the key! In a typical biofeedback training session, sensors are attached to the skin at the different locations of the body after the therapist has asked for the patient’s permission. The area of the skin where the sensor is going to be attached usually is cleaned with an alcohol wipe, or a tiny dab of electrode gel is applied to each sensor.
The biofeedback therapist then leads the patient in mental exercises. These techniques can range from listening to prerecorded audio or other media, to mindfulness (the calm awareness of one’s body functions, feelings, and content of consciousness), to formal relaxation techniques (such as diaphragmatic breathing, guided imagery, progressive muscle relaxation, and autogenics), to prescribed self-hypnosis practice.
When successful, the feedback signals from these instruments reflect accomplishment and act as affirmation and encouragement for the patient’s continued efforts.
How does biofeedback help patients cope with chronic pain?
There are 3 stages that occur during the biofeedback training.
- During the first stage, the patient gains awareness of his/her problematic physical response. Individuals identify how their bodies respond to a variety of stressors and determine their ability to overcome the undesired physical reactions.
- During the second stage, the patient uses the signals from the biofeedback to control his/her physical responses. The individual is coached by the therapist to reach certain goals related to managing a specific physical response.
- At the final stage, the patient transfers control from the biofeedback equipment to themselves. Individuals learn through trial and error to identify triggers that alert them to implement the self-regulation skills they learned. At the conclusion of treatment, patients are typically encouraged to practice the mental exercises daily.
Biofeedback should be conducted only by trained health care professionals, such as licensed psychologists or masters’ level clinicians. There are some contraindications for biofeedback that one must keep in mind. Certain cases are discouraged to pursue biofeedback therapy, including people with severe psychosis or neurosis, individuals with a pacemaker or other implantable electrical device, debilitated patients, and patients with psychopathic personalities.