When you are having an especially hectic day or haven’t had a lot of down time, your pain may worsen. Stress often can make arthritis pain worse. When you’re under stress, your body will show it. Blood pressure may increase, and muscles may tense. For those with pain, the added inflammation that accompanies stress can make joint pain worse. But stress, and the physiologic changes that result, often can be managed. One method for managing stress is with biofeedback.
Biofeedback can help you learn to control the changes that cause pain by directly controlling muscle tension as well as physiologic responses previously thought to be outside of conscious control, including breathing, blood pressure, heart rate, skin temperature and perspiration.
While the National Institutes of Health (NIH) has reported that biofeedback is an effective treatment for chronic pain, some controversy persists about its success. Biofeedback techniques are being used to help treat numerous pain-related conditions including:
– rheumatoid arthritis;
– Raynaud’s Syndrome (a circulatory disorder that causes uncomfortably cold hands);
– tension and migraine headaches;
– pediatric ADHD;
– back pain;
– irritable bowel syndrome;
– TMD (jaw pain);
– peripheral neuropathy; and
– Complex Regional Pain Syndrome.
Generally, biofeedback works when a person can learn to directly control his or her physiologic responses to relieve stress. The idea is that once you relieve stress and tension in your body, your pain will lessen. Although many people have had success with biofeedback, there are many gaps in the research. The pain conditions for which the research is strongest are migraine and tension headaches, TMD and Raynaud’s Syndrome.
As with many complementary alternative medicine practices, biofeedback may be a helpful additional treatment. However, it is best used under a physician’s care.
How Does Biofeedback Work?
Biofeedback techniques use sensitive electronic instruments to monitor specific bodily responses and then “feed back” that information to the person. The feedback is in the form of an audible tone or a light that changes in intensity as the bodily response increases or decreases or other auditory and visual feedback that change with the person’s physiology.
Mastering control of bodily processes takes time and practice. Biofeedback requires patience and commitment. Each person comes to the learning process with a different level of knowledge and skill, so some people find the process more challenging than others. But the rewards can be great: You can take back control of your body and your health.
Before starting a program to learn biofeedback techniques that may or may not work for you, consider whether you are able to make the required time commitment.
Practitioners use different types of biofeedback to treat different conditions. The most common type is EMG (electromyographic) biofeedback, which provides information about muscle tension. EMG biofeedback has been used in two ways. First, the technique has been used to assist with muscle strengthening, which can help patients move more easily with less pain. Patients have surface electrodes placed on relevant muscle groups, and an electromyograph measures muscle contraction strength. The information on muscle contraction is fed back, often with an audible tone, to the patient, who tries to change the intensity of the tone in the desired direction. By trying to maximize the signal (e.g., make the tone louder) while exercising, the patient learns to alter muscle contractions to get stronger.
Second, EMG biofeedback more frequently is used to teach muscle relaxation. Chronic muscle tension can cause pain or make pain more intense. Biofeedback that teaches the muscles to relax can ease pain and give people a certain sense of control over their pain. EMG electrodes are placed on large muscles that stiffen or spasm when a person is under stress (e.g., the large muscles of the back or the muscles of the forehead). Patients are instructed to try to maximize the period of time the signal from the EMG machine is indicating their muscles are relaxed. With practice, patients can relax their muscles at will without the help of the machine. Temperature biofeedback has been used to help patients raise their hand and foot temperature, to increase blood flow to those areas and possibly help diminish inflammatory factors that cause pain and stiffness. Hand and foot temperature also is an indicator of the level of stress, so temperature biofeedback can be used to teach relaxation.
But the use of biofeedback for stress reduction and muscle control in managing arthritis pain and other chronic pain conditions has not been fully investigated. According to Mark Litt, Ph.D., a researcher at the University of Connecticut School of Medicine, “The use of biofeedback to help people with arthritis is not very common. It requires an experienced practitioner who has the right equipment to conduct biofeedback. Usually, biofeedback is not covered by insurance. Finally, there are a great many rheumatologists who do not believe biofeedback will be effective for their patients. This skepticism has some basis in fact. The results of most controlled studies of biofeedback for arthritis show at best only modest effects on pain, anxiety and quality of life.”
Another type of biofeedback, EEG Biofeedback, also known as neurofeedback, is based on electrical brain activity, the electroencephalogram. Put simply, it is biofeedback applied directly to the brain. Self-regulation is a necessary part of good brain function. EEG biofeedback has been used most frequently to treat children with attention-deficit/hyperactivity disorder (ADHD). It is a learning strategy that helps children alter their brain waves. An EEG biofeedback practitioner places sensors on the scalp to monitor brain waves. A computer processes the signal and uses a video game to show the child what is happening in his or her brain. The biofeedback practitioner teaches the child that when a desirable signal increases, the video game will move faster. As an undesirable signal increases, the video game is stopped. Gradually, the child’s brain responds to the cues that it is given, and a mapping of new brain wave patterns occurs that helps the child control his or her behavior and attention.
EEG biofeedback also has shown some promising results in treating fibromyalgia, complex regional pain syndrome and treatment resistant migraines and insomnia.
In addition, EEG has been shown to be successful in helping people control their anxiety. Although there are many kinds of anxiety disorders, including phobias, stage fright, panic attacks and performance anxiety, a common thread exists among them. The cycle of anxiety is created by a rise in adrenaline and other stress hormones in the body that trigger what is called the fight-or-flight response, even if there is no real threat to one’s well-being. Anxiety is caused by a cycle of thoughts and physiologic responses that usually feel like this: You have a worried thought, you have a physiological response, you want to stop the thoughts but you observe more worried thoughts, you begin to panic. Biofeedback can help control anxiety symptoms or at least make them less overwhelming.
Biofeedback therapy can help you learn to control anxiety symptoms such as an increase in heart rate, rapid or shallow breathing, sweating and muscle tension. It also can help you learn to identify when your brain is showing higher activity, an increase in beta waves when the mind is stressed. A practitioner will use meditation techniques and visualization to help you learn to maintain the proper brainwave levels to become calmer and more relaxed.
EMG biofeedback and temperature biofeedback are used to treat both tension headaches and migraine headaches. For this treatment, electrodes are attached to the facial muscles and/or neck and shoulder muscles. The degree to which the patient is experiencing muscle tension is fed back using an audible sound or visual cue. The practitioner will help reduce tension by suggesting relaxation techniques to the patient such as visualizing an event or something relaxing or by engaging the patient in deep breathing or controlled breathing to relax.
“Of all conditions treated with biofeedback, practitioners have had the most success treating headaches,” said Cindy Perlin, a Licensed Clinical Social Worker and biofeedback practitioner certified by the Biofeedback Certification International Alliance (BCIA). “Patients with rheumatoid arthritis have tissue damage that needs to go through a healing process. Therefore, RA patients typically feel some improvement in the short term from muscle relaxation, but longer term application of the techniques will yield the best results.”
Numerous studies have shown biofeedback therapy can help with a wide variety of mental and emotional conditions, Perlin said. “The combination of biofeedback with learning relaxation skills provides the most benefit because, one, biofeedback provides information about how you are doing and helps you learn what is working and what is not working, and two, patients can see quickly they are getting some results and that motivates them to keep practicing the techniques so they get better.”
Two additional types of biofeedback are Galvanic Skin Response (GSA) biofeedback, which measures skin moisture and is used to relieve pain and anxiety; and heart rate variability (HRV), which measures the relationship between breathing and heart rate and is used to treat anxiety, asthma and chronic obstructive pulmonary disease (COPD). During a biofeedback session, a practitioner will monitor biofeedback activity and may use the following techniques to help patients learn to relax and control their physiology:
– diaphragmatic breathing;
– progressive muscle relaxation—alternately tightening and then relaxing different muscle groups;
– guided imagery—concentrating on images that promote relaxation and healing; and
– mindfulness meditation—focusing thoughts and letting go of negative emotions.
Once control of physiology is mastered with the aid of biofeedback, you will be able to control your body without the equipment or the practitioner. Going forward, you will be more skilled in listening to and responding appropriately to the changes taking place in your body.
How do I find a biofeedback practitioner?
Biofeedback sessions typically take place in a therapist’s office, but once the procedure is learned, people can practice the techniques in their own homes using portable monitors, or biofeedback “trainers,” some of which can connect to a home computer. Many different health-care providers offer biofeedback therapy, including psychiatrists, psychologists, social workers, physical therapists and general physicians. Choose a practitioner for biofeedback just as you would any other provider—seek referrals from your doctor. Practitioners should be members of a professional society such as the Association for Applied Psychophysiology & Biofeedback. They also may be BCIA (Biofeedback Certification International Alliance) certified, although providers with these credentials are scarce. If you are unable to find one, look for a psychologist with pain management experience who lists biofeedback as a treatment option.
Once you find a biofeedback practitioner, you may have a therapy session for 30 to 60 minutes, once or twice a week, for several weeks. The benefits of biofeedback are not always immediate; it may take a few sessions to start to feel them. The practitioner will work with you to help you learn how to use these skills at home to continue to lessen pain or discomfort. If you are not having success with biofeedback after a sufficient amount of time, you may want to try other treatments.
Keep in mind that biofeedback typically is an out-of-pocket expense not covered by most insurance. Sessions can be costly, ranging from $75 to $200 each, depending on where you live, so it is best to keep your physician informed if you are not making significant improvements.
To find a biofeedback provider, visit the Biofeedback Certification International Alliance website and search its Practitioner Directory, in which you can find providers by location or conditions treated.
Learn more about biofeedback and find additional resources at the Association for Applied Psychophysiology and Biofeedback’s website.
The Truth About Chronic Pain Treatments: The Best and Worst Strategies for Becoming Pain Free by Cindy Perlin reviews the evidence for safety and efficacy of dozens of chronic pain treatments and discusses the barriers to patients’ access to safe and effective treatments.
EEG Neurofeedback for Anxiety and Pain