Master your mind , Master your life

Biofeedback and neurofeedback

role in physical therapy

Applied psychophysiology

[Link] Abdelazem Gad

Introduction
The brain is using 10% only of its capacity( true or false)
Percentage of active cells at once 1% to 16% (conscious work )
The rest percentage is working subconsciously to save energy with
focal transfer between the states of conscious according to level of
alertness and task performance
The brain represent 2% of body mass and uses 20% of body glucose.
About 86 billion neuron uses 34 (18 zero ) ATP per minute
Neural plasticity : rewiring and building new connections in learning
new skills which require repeated stimulation .
Brain levels( floors)

Basement : brain stem control the vital signs

(HR/RESP/Digestion) subconscious control

1st floor : limbic system : control feelings and emotions

( Amygdala is the center of fear and anxiety )

2nd floor the cortex : synchronize all activity ( for fast and accurate

reactions)
The question here : Can we control of vital signs and subconscious

physiological signs or not ? ( heart rate , BP , respiration ,

temperature , sweat gland activity , muscle tone and brain
activities)
Control stages

 Awareness : improved awareness of physiological,

cognitive, and emotional processes which is crucial in

creating change.
 Change : ability to self- regulate depends on the ability
to create helpful changes by training and repetitions .
 Generalization : long - lasting improvement is only
possible when the skills learned in the therapist office
are generalized to every day environment
Biofeedback
Biofeedback is a way to help people develop greater


awareness and ability to regulate their physiological

functions by using signals from their own bodies with the
goal of improving their well - being, health, and performance.
Biofeedback instruments measure muscle activity , skin


temperature, electrodermal activity (sweat gland activity),

respiration, heart rate, heart rate variability, blood pressure,
brain electrical activity, oxygen saturation and blood flow
and transfer data into visual , auditory and tactile stimulus
graded according to level of original physiological function .
Neurofeedback
Neurofeedback is EEG biofeedback , which is devoted to

training people to gain control over electro-

physiological processes in the human brain . 
Neurofeedback uses information from the

electroencephalogram (EEG) to show the trainee

current patterns in his or her cortex.
Many neurological and medical disorders are

accompanied by abnormal patterns of cortical activity .

Neurofeedback
Neurofeedback assessment uses a baseline EEG,
and sometimes a multi-site quantitative EEG
(QEEG), to identify abnormal patterns .
Clinical training with EEG feedback then enables the
individual to modify those patterns, normalizing or
optimizing brain activity.
Neurofeedback practice is growing rapidly with the
widest acceptance for applications for attention
deficit hyperactivity disorder (ADHD), learning
disabilities, seizures, depression,OCD, acquired
brain injuries, substance abuse, anxiety and peak
performance .
Advantages of biofeedback

1) give the individual a more active role in his or her

own health care,
2) involve a holistic emphasis on body, mind, and
spirit,
3) noninvasive .
4) elicit the body’s own healing response .
* Biofeedback and neurofeedback emphasize training
individuals to self-regulate, gain awareness, increase
control over their bodies, brains, and nervous systems,
and improve flexibility in physiologic responding.
professional standards and guidelines

Biofeedback and neurofeedback are also approaches

that rely on well-developed professional standards
and guidelines for competent practice.
A national certification organization, the Biofeedback
Certification Institute of America, has established a
blueprint of necessary knowledge and skills and
conducts examinations qualifying individuals for
certification .
Biofeedback is no longer an “alternative” treatment
modality but a clear first choice for some conditions
and an excellent adjunctive treatment for others.
Professional associations
Two professional associations in this
practice area :
The Association for Applied
Psychophysiology and Biofeedback
(AAPB)
The International Society for Neuronal
Regulation, now known as the
International Society for Neurofeedback
and Research (ISNR),
modalities of biofeedback
Peripheral training techniques :
Respiratory – measuring rate and pattern of breathing, as
well as carbon dioxide levels in the blood
Cardiovascular – measuring heart rate, heart rate variability
(H RV) , respiratory sinus arrhythmia ( RSA ), and blood
volume pulse , HRV stands for heart rate variability.
The term RSA predates the term HRV, and refers to the rise
and fall of heart rate ( beat to beat ) synchronized with each
breath (faster on the inhale, slower on the exhale).
The magnitude of this systematic variability seems to reflect
a healthy cardiovascular system . By calming one’s
emotional state and by making the breathing slower and
more regular, the HRV can be increased, at least temporarily.
 Neuromuscular – measuring muscle tension with surface
electromyography( sEMG ) to provide the learner with
enhanced information about his or her muscle tension,
hoping this will facilitate learning control of the muscle.
- Relaxation of excess tension and reinforcement of weak
muscle are the usual goals.
 Skin conductance – measuring sweat gland activity that
provides information about sympathetic nervous system
activity.
 Peripheral skin temperature – measuring finger and/or
toe temperature to teach the learner to warm his or her
peripheral extremities.
- While core temperature is (37.0 C), skin temperature is
much lower, In order to raise skin temperature, one must
relax skeletal muscles as well as the muscles within the
walls of the blood vessels.
: Central training

Central nervous system (brain) – measuring brain

wave signals
The goal of neurofeedback is to teach learners to
modify their EEG. One of these includes teaching
the learner to maintain a relaxed, alert, and focused
mental state while carrying out cognitive tasks.
Another application of EEG training includes
teaching the learner to increase slower-frequency
brainwaves to achieve deeper levels of
psychophysiological relaxation or to access calmer
mental states.
Research Findings

Mindfulness - Based Stress Reduction program ( MBSR )
training , revealed that
1. activation of the left frontal region of the brain, which is
responsible for producing positive emotions.
2. more antibodies , meaning that their immune system
function was higher . 
3. increased quality of life and positive changes in the function
of the hypothalamic – pituitary – adrenal ( HPA ) axis.  
4. decrease in the levels of interleukin - 6, an inflammatory
protein. promoting a decrease of inflammation in the body. 
5. produces both structural and functional changes using
functional magnetic resonance imaging (fMRI) and
compared them with the brains of people with no MBSR
training. The results showed that some parts of the brain
became larger (increased gray matter), some became
smaller, and others became more active.
Role of biofeedback in physical
therapy
( evidence based studies)
Used in assessment and treatment in
all of physiotherapy fields
 Neurology

 Bell's palsy : EMG biofeedback was shown to be more

effective than kinesitherapy with showed better clinical
recovery and minor synkinesis than kinesitherapy patients.
 Fibromyalgia : Biofeedback is often included as part of a
treatment package including physical exercise and cognitive-
behavioral therapy .
 Spinal cord injury : a significant increase in EMG activity and
improve gait .
 Stroke : EMG biofeedback plus standard physiotherapy
produces improvements in motor power, functional recovery,
and gait quality when compared to standard physiotherapy
alone.
Orthopaedic

 Arthritis : Both thermal and EMG biofeedback have been

used to teach relaxation techniques to adults with chronic
arthritis.
 A significant effect sizes post-intervention for pain,
functional disability, psychological status and rheumatoid
factor titer (a measure of disease activity) with reduction
clinic visits and days hospitalized, thereby decreasing
medical costs
 TMJ problems : biofeedback has been shown to be
consistently superior to placebo or no-treatment controls.
 Repetitive strain injuries : Receiving thermal biofeedback
and autogenic relaxation had significantly higher
reductions in pain and reduce body symptoms associated
with computer work, thereby preventing injury .
Chronic pain
Studies clearly demonstrate treatment programs that include
biofeedback ( EMG,TEMP,EEG) are as effective as standard and more
effective than no-control conditions in
Chronic back pain patients
Knee osteoarthritis
Phantom limb pain (PLP)
Patellofemoral pain syndrome cancer-related pain in advanced
cancer patients.
Chronic whiplash (WAD)
Headache
Complex Regional Pain Syndrome
Recurrent abdominal pain , endometriosis , Systemic lupus
erythematosus (SLE)
Sports medicine
Peak performance : Training programs for professional athletes
have evolved considerably over the years.
There was a time when athletes simply trained for their sport.
Today, training is much more complex and includes both a
physical and mental component.
Every moment for the athlete must become automatic, from the
focusing on the ball, to pushing out all negative self-talk, to
mastering breathing for maximum recovery before the next
round, in order to ensure maximum success in their sport.
Peak performance through mental conditioning is now
recognized as an integral part of performance enhancement.
Furthermore, although designed for use with athletes, many
optimizing performance methods transfer well into the non-
athletic field with executives, performers and other individuals
who want to improve focus, minimize distractions and reduce
stress.
Pediatric
Cerebral palsy : Studies examining the efficacy of EMG biofeedback
to improve :
1. Posture and walking in children with cerebral palsy
2. Gait symmetry in comparison to physical therapy alone
3. Ankle movement and tonus of the plantar flexor muscle
4. Motor control during standing or sitting .
 
Dystonia : EMG biofeedback for the proximal large muscles of the
hand was provided to patients with hand dystonia (writer’s
cramp) patients showed improvement in handwriting, alleviation
of discomfort, and pain.

ADHD :EEG biofeedback ( neurofeedback) .

Chest

Asthma :
A significant difference is reported in forced expiratory volume (FEV1)
with biofeedback.
changes in neutrophils and basophils, suggestive of reduced inflammation.
reductions in respiratory impedance .
Less medication than those in the control groups
 improved level of asthma severity and decrease of symptoms.
Raise end-tidal pCO2
COPD :
o Persons receiving breathing-pattern training had a significant increase in
forced expiratory volume (FEV1) and forced vital capacity (FVC) compared
to control group.
o HRV biofeedback and walking with pulse oximetry feedback improved the
distance walked in six minutes and quality of life in patients with COPD . 
Cystic fibrosis : Respiratory muscle biofeedback coupled with breathing
retraining produced significant improvement in forced expiratory volume
(FEV1) and forced vital capacity (FVC) in cystic fibrosis
Internal medicine

Diabetes Mellitus :
decreases in average blood glucose and HbA1C .
Increase peripheral blood flow improved healing to foot ulcers chronic
nonhealing ulcers .
Reduce the number of falls and force of the fall in elderly patients with
diabetic sensory neuropathy
Audio biofeedback on weight bearing of persons with transtibial
amputation may help patients learn to ambulate correctly using a
prosthesis  
Hypertension : Thermal biofeedback seems to work by helping patients
to dilate peripheral blood vessels, thereby lowering total peripheral
resistance.
Increasing baroreceptor sensitivity with feedback or respiratory training
may result in BP reduction.
Raynauds disease : Studies demonstrated “superiority or equivalence” of
treatments that include TBF with medications .
Cardiology and ICU

 Coronary artery disease : Diminished heart rate

variability (HRV) in patients with coronary artery
disease is associated with increased cardiac
morbidity and mortality , Risk of cardiovascular
death was significantly reduced by BF .
 Waning from mechanical ventilation: Relaxation
training using EMG biofeedback and breathing
retraining using tidal volume biofeedback may help
patients to be weaned from mechanical ventilation
and contribute to reducing weaning time .
Gynacology
 Urinary incontence : Recent studies have explored
variations in biofeedback therapy, an increase in
pelvic floor muscle activity and a decrease in leakage
index
 A telemedicine continence program (including
biofeedback-assisted pelvic floor training) was as
effective as a clinic-based program .
 Fecal incontinence : Biofeedback has been used for
fecal incontinence that occurring after surgery and
results in clinical improvement
Other general applications
Irritable bowel syndrome
Insomnia
Erectile dysfunction
Constipation
Anxiety
Depression
Epilepsy
Headache .
THANKS