Biofeedback Therapy
K W Jung, D-H Yang, and S-J Myung, Asan Medical Center, Seoul, South Korea
ã 2012 Elsevier Inc. All rights reserved.
Glossary
Classical conditioning The formation of a
conditioned reflex through the temporal paring of an
unconditioned stimulus, which reflexively elicits a
response, and a neutral conditioned stimulus. After the
pairing, the formerly neutral conditioned stimulus
acquires the ability to elicit a response similar to
the one elicited by the unconditioned
stimulus.
Underlying Learning Theory and Biologic Mechanism
Learning Theory
Learning theories have traditionally distinguished between two
types of learning. One type, called classical conditioning, in-
volves the pairing of two stimuli in a close temporal proximity.
One of the two stimuli, known as the unconditioned stimulus,
normally elicits some reflex behavior such as salivation, eye
blink, or a change in skin conductance. The other stimulus,
known as the conditioned stimulus, is neutral prior to the
pairing but acquires the ability to elicit a response similar to
the unconditioned response after the pairing process. The sec-
ond type of learning recognized by learning theorists is known
as operant conditioning. In operant conditioning, the response
is generally thought of as emitted on a more or less voluntary
basis, rather than being reflexively elicited by any particular
stimulus. Also, the operant conditioning process involves the
pairing of the stimulus dependent on the occurrence of a
response. The paired stimulus leads to an increase in the fre-
quency or the magnitude of the response and it is known as a
negative reinforce if its removal leads to an increase in the
frequency or the magnitude of the response.
Between 1928, when the two types of learning were for-
mally distinguished, and the early 1960s, it was generally
assumed that operant and classical conditioning were mutu-
ally exclusive processes. All voluntary skeletal motor behaviors
were assumed to be subject to operant conditioning, while
visceral and glandular responses mediated by the autonomic
nervous system were assumed to be involuntary and modifi-
able only through classical conditioning. It was thought
impossible that salivation to a light stimulus could be oper-
antly reinforced by food. This view was retained until the early
1960s when groups of researchers in the Soviet Union,
Canada, and the United States began a series of experiments
designed to show that responses mediated by the autonomic
nervous system can, in fact, be brought under a voluntary
control through techniques that closely resemble operant
conditioning.
Since the first suggestion regarding instrumental learning
and operant conditioning, it demonstrated the medical poten-
tial of biofeedback by showing that the normally involuntary
344
Operant conditioning The presentation of a stimulus
dependent on the occurrence of a response for the purpose
of modifying the strength or the frequency of the response.
Reinforcer In operant conditioning, any stimulus when
presented or removed depending on the occurrence of a
response results in the modification of the response.
In a classical conditioning, the presentation of a conditioned
stimulus and an unconditioned stimulus is in a close
temporal proximity.
autonomic nervous system can be operantly conditioned with
the use of an appropriate feedback. By means of instruments,
patients acquire information about the status of involuntary
biological functions such as skin temperature and electrical
conductivity, muscle tension, blood pressure, heart rate, and
brain wave activity. Patients, then, learn to regulate one or
more of these biological states that affect symptoms.
Biological Mechanisms
Biofeedback makes physiologic change possible by means of
operant conditioning or trial-and-error learning, in which a
response is learned and performed depending on whether
that response is followed by reinforcement. For biofeedback
to be useful, four conditions must be satisfied. First, there must
be a readily detectable and measurable response such as the
bladder pressure or the pelvic floor muscle activity. Second,
there must be variability in that response with a detectable
change as opposed to total paralysis. Third, there must be a
perceptible cue such as the sensation of urgency that indicates
to the patient when control should be performed. Fourth,
because biofeedback is based on learning, it requires the active
involvement of a motivated patient.
Taking basketball as an example, the information about
where the ball went with each shot is called feedback. If both
the coach and the novice were blindfolded, there would be no
feedback, and the novice would not learn to improve. Some
tense patients may not be aware of the fact that certain muscles
are tense, and patients with neuromuscular disorders, or even
their therapists, may not be able to discriminate small increases
in the activity of paralyzed muscles or decreases in the contrac-
tions of spastic ones. They are like a blindfolded basketball
novice and coach. However, a display of the electrical activity
of the muscles (the EMG) can remove the blindfold and give
them a better feedback about what the muscles are doing. This
feedback might be in the form of a series of auditory clicks
that get faster when the muscle contracts more or a tracing of
the activity of one or more muscles as a dot draws the curve
of a graph on a TV screen. Feedback from a measuring instru-
ment that yields moment-to-moment information about a
biological function is called biofeedback.

One of the advantages of biofeedback is that it allows small
changes in the correct direction to be noticed and rewarded
as success so that they gradually can be built up into larger
changes. Eventually, patients learn to perceive these changes
without the measuring instrument so that they can practice by
themselves. Biofeedback should be especially effective in those
cases where the patients cannot perceive their initial small
correct responses or even may have the wrong perception of
what they are doing.
Other advantages of biofeedback are that by making the
early signs of slight progress conspicuous, it can encourage
and motivate the patients, relieve their sense of helplessness,
and serve as a coping response to reduce symptoms of stress.
Instead of having something done to the patients, it teaches
them to do something for themselves, increasing their confi-
dence, or what has been called self-efficacy. This factor is
particularly important when biofeedback is being used to
treat symptoms that are elicited or aggravated by stress.
Early Development
Experiments on Humans
It was first shown that human subjects could learn to voluntar-
ily dilate blood vessels of the finger in order to avoid or escape
an electric shock if they were provided with visual information
about their vasomotor activity. Subjects provided with an
amplified auditory representation of their heart beat also were
trained to accelerate their heart rate to avoid an electric shock
to the ankle. Other responses generally considered involuntary
were brought under voluntary control by providing subjects
with feedback information about the targeted response and
some form of operant reinforcement. Studies conducted in
the 1960s also demonstrated operant conditioning of the skin
conductance response and brain wave activity. Voluntary con-
trol over the firing of single motor units was demonstrated by
providing subjects with auditory and visual displays of individ-
ual myoelectric potentials recorded from fine wire intramuscu-
lar electrodes.
Experiments on Animals
At about the same time that voluntary control of autonomically
mediated behavior was being demonstrated in humans, paral-
lel lines of research were in progress using various animal
species. For example, thirsty dogs were trained to increase and
decrease the flow of saliva using water as a reinforcer. Bidirec-
tional changes in heart rate and blood pressure were also shown
to be subject to operant conditioning in monkeys and rats.
Methods
The feedback instrument used depends on the patient and the
specific problem. The most effective instruments are the elec-
tromyogram (EMG), which measures the electrical potentials
of muscle fibers; the electroencephalogram (EEG), which mea-
sures alpha waves that occur in a relaxed state and the thermis-
tor, which measures skin temperature (which drops during
tension because of peripheral vasoconstriction). Recently,
Biofeedback Therapy 345
fMRI (functional magnetic resonance imaging) has been used
to identify both positive and negative emotional stimuli for
stress management (neurofeedback).
Patients are attached to one of the instruments that measure
a physiological function and translate the measurement into
an audible or visual signal that the patients use to gage their
responses. For example, in the treatment of bruxism, an EMG is
attached to the masseter muscle. The EMG emits a high tone
when the muscle is contracted and a low tone when at rest.
Patients can learn to alter the tone to indicate relaxation.
Patients receive feedback about the masseter muscle, the tone
reinforces the learning, and the condition ameliorates, with all
of these events interacting synergistically.
Many less specific clinical applications (e.g., treating insom-
nia, dysmenorrhea, and speech problems; improving athletic
performance; treating volitional disorders; achieving altered
states of consciousness; managing stress; and supplementing
psychotherapy for anxiety associated with somatoform disor-
ders) use a model, in which frontalis muscle EMG biofeedback
is combined with thermal biofeedback and verbal instructions
in progressive relaxation.
Relaxation Therapy
Learning relaxation, therefore, involves cultivating a muscle
sense. To develop the muscle sense further, patients are taught
to isolate and contract specific muscles or muscle groups, one
at a time. For example, patients flex the forearm while the
therapist holds it back to observe tenseness in the biceps mus-
cle. Patients are repeatedly reminded that relaxation involves
no effort. In fact ‘making an effort is being tense and therefore
is not to relax.’ As the session progresses, patients are instructed
to let go further and further, even past the point when the body
part seemed perfectly relaxed.
Patients would work in this fashion with different muscle
groups, often over more than 50 sessions. Patients were also
frequently left alone while the therapist attended to other
patients.
Neurofeedback
Neurofeedback allowed, for the first time, voluntary self-
regulation of brain activity through feedback and reward.
Expectancies ran high and many premature announcements
of clinical success based on single case studies or uncontrolled
observations discredited the field early on. In the 1970s,
Miller’s demonstrations of operant control of autonomic
(and central nervous system (CNS)) functions in curarized
rats, supposedly proving ‘voluntary’ operant regulation of
many bodily functions excluding mediation of the motor sys-
tem through curarization, turned out to be difficult to replicate.
Together with the clinical overstatements in the field of bio-
feedback, this historic incident virtually halted funding from
the public sources and blocked large controlled clinical studies
despite some indications of its efficiency. However, more recent
studies suggested that some patients with drug-resistant epilepsy
(mostly with secondarily generalized seizures) experienced a
reduction in the number of ictal events during and after training
consisting of self-regulation of slow cortical potentials (SCPs),
an effect also reported using biofeedback of skin conductance
346 Biofeedback Therapy
responses (GSR). Nagai et al. showed that learned increase in
autonomic arousal through reduction of skin conductance
decreased negative SCPs at the cortical level and thus increased
seizures thresholds confirming earlier reports.
The clinical target populations for brain–machine interface
(BMI) treatment consist primarily of patients with amyo-
trophic lateral sclerosis (ALS) and severe CNS damage includ-
ing spinal cord injuries and stroke, resulting in substantial
deficits in communication and motor function. However, an
extensive body of literature started in the 1970s using neuro-
feedback training. Such training implemented to control vari-
ous EEG-measures provided solid evidence of positive effects
in patients with otherwise pharmacologically intractable epi-
lepsy, attention deficit disorder, and hyperactivity ADHD.
More recently, the successful introduction and testing of real-
time fMRI and a near-infrared spectroscopy (NIRS)-BMI has
opened an exciting field of interest in patients with psycho-
pathological conditions.
Clinical Applications
Gastrointestinal Diseases
In the field of gastroenterology, an initial study focused on
biofeedback applications in patients with fecal incontinence.
Later, biofeedback applications for the treatment of chronic
constipation due to pelvic floor dyssynergia (anismus, spastic
pelvic floor syndrome, and puborectalis paradox), had been
widely performed by pediatric and adult doctors. The goal of
biofeedback training in gastroenterology is to restore a normal
pattern of defecation. In patients with dyssynergic defecation,
the goal of neuromuscular training is twofold: to correct the
dyssynergia in coordination of the abdominal, rectal, and anal
sphincter muscles to achieve a normal and complete evacua-
tion; and to enhance rectal sensory perception in patients with
impaired rectal sensation. This training consisted of improving
the abdominal push efforts (diaphragmatic muscle training)
together with manometric-guided pelvic floor relaxation fol-
lowed by simulated defecation training.
The symptomatic improvement rate has varied between
44% and 100% in recent randomized controlled trials of
adults with dyssynergic defecation. All of these studies have
concluded, however, that biofeedback therapy is superior to
controlled treatment approaches, such as diet, exercise, and
laxatives, or use of polyethylene glycol, diazepam, or placebo,
balloon defecation therapy, or sham feedback therapy.
Recently published meta-analysis showed that biofeedback
in fecal incontinence was equally effective as nonbiofeed-
back therapy. For constipation, more than threefold superior-
ity of biofeedback to nonbiofeedback, but equal efficacy of
EMG biofeedback to other applications was shown. Other
indications, including chronic proctalgia, irritable bowel syn-
drome, and functional dyspepsia, still need more data with
prospectively designed randomized controlled studies.
Urinary Diseases
Biofeedback is a very specific treatment that can restore bladder
control by teaching patients to modulate the mechanisms of
continence using a pelvic perineal reeducation technique,
which uses a signal that is usually visual, but may be auditory,
which allows the patient with an anorectal or perineal func-
tional anomaly to understand and correct the trouble. Bio-
feedback has now gained several potential applications for
urologic conditions, having been successfully used for patients
with urologic disorders such as detrusor instability, detrusor
sphincter dyssynergia, and enuresis. In a randomized trial
involving older women with urgent urinary incontinence,
the percent reduction in incontinence episodes was similar
after 8 weeks of behavioral therapy with biofeedback ther-
apy, after 8 weeks of behavioral therapy without biofeedback
therapy, and after self-administered behavioral treatment
according to a self-help booklet.
Enuresis describes intermittent incontinence at night and
refers to any discrete leakage of urine at night. Therefore,
dysfunctional voiding has been used as a broad term. The
reason of dysfunctional voiding in children could include
hyperactive pelvic floor, overactive bladder, incontinence, or
lazy bladder syndrome. For children with hyperactive pelvic
floor, biofeedback therapy focuses on the relaxation and a
return of normal flow. For children with overactive bladder
and incontinence, use of the guarding reflex of the pelvic floor
musculature can maintain continence during uninhibited con-
tractions. In addition, biofeedback can be used for these
children to void optimally and ensure that there is no decom-
pensation of the detrusor muscle that occurs with the lazy
bladder syndrome.
Cardiovascular Diseases
Since the beginning of biofeedback in the 1970s, biofeedback
was used to control heart rate and blood pressure in patients
diagnosed with cardiovascular diseases. It remains unclear
whether the biofeedback regarding heart rate variability has
more or less potential than other types of biofeedback in
patients with cardiovascular disease, but these preliminary
observations suggest that it may be useful in improving symp-
toms and the quality of life. Regarding hypertension, blood
pressure can be lowered by 6–10 mmHg when biofeedback is
effective, which is less of an effect than what is observed with
most antihypertensive medications. Thus, although biofeed-
back has a potential in hypertension, its efficacy is not well
proven and the systemic trials are lacking.
Neurologic Diseases
Biofeedback methods in the treatment of migraine are based on
the concept that various relaxation skills, including diaphrag-
matic breathing or visualization, were helpful to induce the
relaxation response, which includes relaxation of the sympa-
thetic nervous system and activation of the parasympathetic
nervous system. Recently published meta-analysis showed
that biofeedback can be supported as an efficacious treatment
option for migraine and tension-type headache according to
the Association for Applied Psychophysiology and Biofeedback
and the International Society for Neurofeedback and Research
criteria.
Epileptic patients who were refractory to anticonvulsant
medications have been treated with biofeedback therapy
based on EEG. Several positive outcomes were reported

especially regarding complex-partial seizures, an extremely
difficult-to-treat seizure type. However, it still needs a rando-
mized, controlled study to prove its efficacy.
Others
Early studies in patients with Raynaud’s syndrome demon-
strated that biofeedback alone or in combination with various
procedures reduced the occurrence of vasospastic episodes,
based on the concept that cold hands and cold feet are frequent
concomitants of anxiety and also occur in Raynaud’s syn-
drome. Exposure to cold during temperature biofeedback
may enhance the effects of biofeedback alone.
Fibromyalgia syndrome and other myofacial pain had been
treated with biofeedback therapy. Recently randomized con-
trolled study regarding fibromyalgia based on EEG showed the
significant efficacy by a significantly decreased theta/sensory
motor rhythm ratio by EEG waves compared to baseline.
Biofeedback therapy based on EMG was also tried in treat-
ing bronchial asthma. Children who were instructed to reduce
frontalis muscle tension via biofeedback and continue their
strategies in the home setting showed improvement in pulmo-
nary function testing compared with children who were
instructed to maintain frontalis tension.
Biofeedback Therapy 347
Further Reading
Ballek NK and McKenna PH (2010) Lower urinary tract dysfunction in childhood.
The Urologic Clinics of North America 37(2): 215–228.
Basmajian JV (1989) Biofeedback: Principles and Practice for Clinicians, 3rd edn.
Baltimore: Williams & Wilkins.
Birbaumer N, Ramos Murgialday A, Weber C, and Montoya P (2009) Neurofeedback
and brain-computer interface clinical applications. International Review of
Neurobiology 86: 107–117.
Chiarioni G and Whitehead WE (2008) The role of biofeedback in the treatment of
gastrointestinal disorders. Nature Clinical Practice. Gastroenterology & Hepatology
5: 371–382.
Enck P, Van Der Voort IR, and Klosterhalfen S (2009) Biofeedback therapy in fecal
incontinence and constipation. Neurogastroenterology and Motility 21: 1133–1141.
Miller NE (1978) Biofeedback and visceral learning. Annual Review of Psychology
29: 373–404.
Moravec CS (2008) Biofeedback therapy in cardiovascular disease: Rationale and
research overview. Cleveland Clinic Journal of Medicine 75: S35–S38.
Nestoriuc Y, Martin A, Rief W, and Andrasik F (2008) Biofeedback treatment for
headache disorders: A comprehensive efficacy review. Applied Psychophysiology
and Biofeedback 33: 125–140.
Nygaard I (2010) Clinical practice. Idiopathic urgency urinary incontinence.
New England Journal of Medicine 363(12): 1156–1162.
Peters TE and Fritz GK (2010) Psychological considerations of the child with asthma.
Child and Adolescent Psychiatric Clinics of North America 19(2): 319–333.
Rao SC (2008) Dyssynergic defecation and biofeedback therapy. Gastroenterology
Clinics of North America 37: 569–586.
Sterman MB (2010) Biofeedback in the treatment of epilepsy. Cleveland Clinic Journal
of Medicine 77: S60–S67.