Clinical Issues in Using Biofeedback

Biofeedback can be abused if it used outside of the context of therapy. It cannot be used in the same manner that one would administer medication. Individual differences must be noted and addressed using an individualized protocol before biofeedback can be suc

Biofeedback cessful. Also, the individual should be closely monitored and changes recommended if problems arise. Biofeedback may be successful in the clinic, but patients may not be able to modify their responses in the natural environment without biofeedback. Thus the development of self-control should be included in the protocol.

Sometimes a person's baseline physiological responses are normal, but the individual may experience exaggeration of SNS responses when stressed. Biofeedback should be focused on helping these individuals decrease SNS arousal during stressful situations. Thus, in biofeedback therapy it is important to teach biofeedback skills in a variety of situations and intensities of stimuli.

Biofeedback allows for discrete control of a response system. For example, one component of auto-nomic nervous system (ANS) activity can be modified without other ANS systems being called into play. Specific EEG patterns can be modified and discrete muscle groups as small as a single motor unit can be trained independently with the use of feedback. However, for the ANS it appears that increases in arousallike activity are easier to obtain than decreases in arousal-like activity. Thus, researchers have more consistently demonstrated voluntary blood pressure and heart rate increases and skin temperature decreases than the opposite processes. This indicates that biofeedback may be more useful in lowering high levels of arousal such as those associated with clinical stress conditions or pathological states than normal or healthy states

The specific form and structure of the biofeedback training must depend largely on the individual characteristics of the patient, the physiological symptoms in question, the particular physiological system for which feedback is to be given, the nature of the disorder itself, and the goals of treatment. Through an accumulation of knowledge gained through basic and clinical research, including systematic case studies, certain generalizations may be possible. However, at this time generalization are made with caution. The biofeedback clinician must choose a specific procedure on the basis of all the facts in the case and his or her own understanding of the current technology and state of research knowledge. The astute clinician can proceed in a systematic manner through trial, error, and close observation of clinical outcomes as they occur for a given patient.

Compliance to the biofeedback practice may be difficult at times as positive effects usually do not always happen instantaneously. The patient must be prepared to expect that decreases in symptoms may not occur for several weeks. Patient motivation may be low because for some disorders there are no short-term aversive consequences such as in hypertension. Another motivation reducer is that the symptom itself may be reinforced in the natural environment. The patient may experience secondary gain. For example, a patient may use talking about her problem in social situations to gain attention. What will she do in social situations if she does not have a problem to discuss? The patient may also be a candidate for social skills training, so that as the symptom is reduced she will have acquired other skills to help her cope in social situations. Another possible area of motivational difficulty may arise from other behaviors strongly entrenched in the patient's repertoire that are in conflict with the aim of therapy. An example is a young man who has overextended himself in extracurricular activities and has poor time-management skills. This young man is quite able to learn the biofeedback skills but cannot find time to practice at home. This issue must be addressed by the therapist if treatment is to be successful.

If the patient is on medication that may effect the response that is being manipulated, consult with the patient's physician to determine if the medication can be kept at a constant level while biofeedback therapy is occurring. If during the biofeedback training the patient or physician wants to decrease or increase medication intake, ask that this be reported so that this information can be used to evaluate the success of the biofeedback therapy.

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