Publications
APS Bulletin • Volume 14, Number 4, 2004
Pain Clinic Perspectives
Steven Sanders, PhD, Department Editor
Biofeedback as an Adjunctive Treatment Modality in Pain Management
Robert J. Gatchel, PhD ABPP
Editor’s Note:
This is the third in a series of summaries of articles published in Seminars in Pain Medicine, Volume 1, 2003, edited by Allen Lebovits, PhD. This issue of the journal reviewed most of the mainstream psychological/behavioral interventions used with pain patients today, with an emphasis on critiquing the scientific evidence supporting their use. Application of these methods to children and as part of an interdisciplinary pain treatment program also is critically reviewed. As Dr. Lebovits highlighted in his introduction, “Only through an evidence-based approach can the specialty of pain psychology be advanced, and, more significantly, patients suffering from pain can be helped.”
In keeping with the increasing demand for empirical documentation on the efficacy of treatments across disciplines that treat pain patients, psychological/behavioral interventions also must be subject to scrutiny. The articles in Seminars in Pain Medicine, Volume 1, summarized here and in future APS Bulletin issues, provide up-to-date information that reviews and critiques the empirical science behind psychological/behavioral treatment for pain patients. The APS Bulletin editorial staff extends thanks to Dr. Lebovits for his help in arranging for the publication of these summaries and to Elsevier, the publisher of Seminars in Pain Medicine, for giving permission to do so.
As always, comments and thoughts are encouraged and welcomed. Please send your correspondence to ssanders@siskinrehab.org.
Introduction
Biofeedback involves developing patients’ ability to alter a particular physiological response by providing them with feedback about the response they are attempting to control. Electromyograph (EMG) is one of the most common types of biofeedback, which involves feedback of muscle tension. Other types of biofeedback include thermal biofeedback, which provides information on skin temperature; electroencephalograph (EEG), which provides information on brain wave activity; and electrodermal response (EDR), which provides information on sweat gland activity. Often, patients will receive biofeedback information from more than one of the above modalities (Green & Shellenberger, 1999).
In early reviews of research on the application of biofeedback for the regulation of pain, it was concluded that biofeedback was effective, but no better than other less expensive and less instrument-oriented treatments such as progressive muscle relaxation training and coping skills training. This status has not dramatically changed much, although some subsequent studies have found that biofeedback is useful in reducing pain. Indeed, since the earlier pessimistic view of biofeedback, biofeedback training does provide subjects with information that enables them to control voluntarily some aspect of their physiology that may contribute to the pain experience. However, because pain is a complex behavior and not merely a pure sensory experience, biofeedback is most beneficial for patients when used as one adjunctive component of an interdisciplinary pain management program (Gatchel et al., 2003). In this context, a true biopsychosocial approach to the patient can be undertaken, and an interdisciplinary team can address the “whole person,” rather than just the pathophysiology. Further, biofeedback is then performed not only within the larger context of the interdisciplinary pain clinic, but also in the context of cognitive behavioral therapy (CBT). Biofeedback in combination with CBT can provide powerful evidence of the relationship among thoughts, feelings, and physiological functioning. Further, CBT with biofeedback increases the patient’s sense of self-efficacy by providing clear unequivocal feedback about a person’s ability to gain control over certain physiological responses.
Specific Pain Disorders
Below, recent research is briefly summarized that examines the effectiveness of biofeedback with various pain conditions. Of note, most of these conditions were treated from a biopsychosocial perspective in an interdisciplinary setting.
Upper extremity disorders. A growing problem in occupational settings is work-related upper extremity disorders (e.g., carpal tunnel syndrome). Although there have been few well-controlled studies in this area, those that exist suggest that biofeedback can aid in treatment effectiveness.
Headache. Despite the numerous precipitants of tension-type headaches, studies have found successful outcomes using EMG to reduce pain in these disorders. Moreover, headaches come in many “types and sizes,” and individuals presenting with headaches often suffer from more than one variety, making treatment and debates regarding etiology difficult. However, research suggests that temperature/ thermal biofeedback is more effective than no treatment when combined with autogenic/relaxation training for migraine headache. In addition, these treatments may be superior to placebo treatments. For tension/muscle contraction headaches, EMG biofeedback effects may exceed those of medication placebo, biofeedback placebo, and psychotherapy procedures. Furthermore, while research suggests that biofeedback and relaxation produce similar levels of improvement for this type of headache, biofeedback may offer greater benefits for a subset of patients.
Back pain. Low back pain is one of the most costly of the musculoskeletal disorders. Flor, Birbaumer, and Turk (1990) developed a diathesis-stress model of chronic musculoskeletal pain. Using a respondent conditioning model, they assumed that pain leads to reflex muscle spasm and to sympathetic activation that, over time, become classically conditioned to otherwise harmless stimuli, resulting in pain where it might not otherwise be expected (Flor & Birbaumer, 1994). These authors provided some support for this model by demonstrating that EMG biofeedback was more effective than CBT or conservative medical therapy with individuals suffering from temporomandibular pain and chronic back pain.
Temporomandibular disorders (TMD). The use of biofeedback techniques to cultivate lower arousal in TMD patients also appears to be effective. EMG and other biofeedback techniques can be used both to improve the comprehension of individual patient issues, as well as to improve functioning. EMG, in particular, is often used to evaluate appliances for particular individuals, re-educate the masticatory, facial, postural and potentially respiratory muscles, and aid in proprioceptive deficits and psychophysiologic problems. Overall, a considerable number of studies attest to the efficacy of biofeedback training, especially when accompanied by relaxation or general stress management training.
Fibromyalgia syndrome. Widespread musculoskeletal pain, fatigue, and multiple tender points characterize fibromyalgia syndrome. With regard to biofeedback training, many practitioners use multiple muscle sites and simultaneous EMG channels while patients are in multiple postures, positions, and office stressor conditions. While muscle-relaxation therapies and EMG biofeedback are logical parts of the recommended multicomponent treatments, to date there is very little research on the topic.
Conclusions
Although past research has been mixed with regard to biofeedback’s ability to decrease pain, when used within the context of an interdisciplinary approach, the results are promising. The biopsychosocial model of pain, which is now accepted as the most heuristic approach to the understanding and treatment of pain disorders, views physical disorders such as pain as a result of a complex and dynamic interaction among physiologic, psychologic, and social factors, which perpetuates and may worsen the clinical presentation. Each individual experiences pain uniquely. The range of psychological, social, and economic factors can interact with physical pathology to modulate a patient’s report of symptoms and subsequent disability. Indeed, the treatment efficacy of a biopsychosocial approach to pain has consistently demonstrated the value of this model. Biofeedback can serve as one important modality in this comprehensive approach.
References
Flor, H., & Birbaumer, N. (1994). Psychophysiological methods in the assessment and treatment of chronic musculoskeletal pain. In J. G. Carlson, A.R. Seifert & N. Birbaumer (Eds.), Clinical applied psychophysiology. New York: Plenum.Flor, H., Birbaumer, N., & Turk, D.C. (1990). The psychobiology of chronic pain. Advances in Behavior Research Therapy, 12, 47–84.
Gatchel, R.J., Robinson, R. C., Pulliam, C., & Maddrey, A.M. (2003). Biofeedback with pain patients: Evidence for its effectiveness. Seminars in Pain Medicine, 1, 55–66.
Green, J.A., & Shellenberger, R. (1999). Biofeedback therapy. In W. B. Jonas & J. S. Levin (Eds.), Essentials of complementary and alternative medicine (pp. 410–425). Baltimore, MD: Lippincott Williams & Wilkins.
This research was supported in part by grants No. 3R01 MH046452 and 5R01 DE010713 (from the National Institutes of Health) and grant No. DAMD17-03-1-0055 (from the Department of Defense).
Robert J. Gatchel, PhD ABPP, is at the University of Texas Southwestern Medical Center at Dallas.