PETITION FOR THE RECOGNITION OF A

PROFICIENCY IN PROFESSIONAL PSYCHOLOGY

AMERICAN PSYCHOLOGICAL ASSOCIATION

750 First Street, NE
Washington, D.C. 20002-4242
(202) 336-5500

PETITION PACKAGE

NOTE: Complete responses to all questions posed in each of the criteria are required. Appendix materials
should not be considered as substitutes for the completion of responses to questions in the criteria.

Proposed title of new proficiency: Biofeedback and Applied Psychophysiology

Definition: A proficiency is a circumscribed activity in the general practice of professional psychology or

one or more of its specialties that is represented by a distinct procedure, technique, or applied skill set used
in psychological assessment, treatment and/or intervention within which one develops competence.

In order to educate and protect the public, the profession has the responsibility to exercise authority over
the process of proficiency recognition. Organization (s) responsible for the proficiency will define how the
proficiency meets public need and how practitioners acquire the psychological knowledge and skills that
represent the bases for its practice. In addition, organization (s) that are responsible for the organized
development of the proficiency are responsible for collaborating with other organizations to ensure that
appropriate education and training is provided in a sequential and integrated nature. When education and
training in a proficiency can be achieved through interdisciplinary study, organization (s) responsible for
the proficiency will describe how the proficiency meets the criteria within the context of interdisciplinary
education and training.
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Petition Sponsor

Criterion I. Administrative Organizations. The proposed proficiency is represented by one or more

organizations that provide systems and structures that are sufficient to support the organized
development of the proficiency, in terms of effectiveness, quality improvement, and provider
identification and evaluation.

Commentary: In order to ensure the management of the proficiency, having the resources of
national organization(s) willing to assume responsibility is important, so that psychology's
scientific and professional integrity can be preserved. These organizations meet regularly to review
and describe the proficiency and appropriate policies for education and training in the proficiency.

1. Please provide the following information for the organization submitting the petition:

Name of organization: Association for Applied Psychophysiology and Biofeedback (AAPB)

Address: One Parkview Plaza, Suite 800

City/State/Zip: Oakbrook Terrace, IL 60181

Phone: 800-477-8892 Fax:

E-mail address: info@aapb.org

Website of organization: www.aapb.org

2. Please provide the following information for the President or Chair of the organization:

Name: Patrick R. Steffen, PhD, BCB APA membership status: member

Address: Brigham Young University, 284 TLRB

City/State/Zip: Provo, UT 84602

Phone: 801-422-7757 Fax: 801-422-0163

E-mail address: patrick_steffen@byu.edu

3. Please provide the following information for the organization submitting the petition:

Year organization founded: 1969

Organization incorporated: Yes__X___ No_____

In what state is the organization incorporated__Colorado____

Describe the purpose and objectives of the administrative organization.

The Association for Applied Psychophysiology and Biofeedback (AAPB) was founded in 1969 as the
Biofeedback Research Society. The goals of the association are to promote a scientific understanding of
biofeedback and advance the methods used in practice and application. AAPB is a non-profit organization as
defined in Section 501(c)(6) of the Internal Revenue Service Code.
It is the mission of AAPB to promote and represent the science and practice of self-regulation to enhance health
and performance. It is the Association’s vision to integrate self-regulation into everyday life.
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AAPB works to advance the development, dissemination and utilization of knowledge about applied
psychophysiology and biofeedback to improve health and the quality of life through research, education and
practice.
The Association is hard at work meeting these objectives:
• Encouragement of scientific research and expansion of clinical and educational applications of
biofeedback and applied psychophysiology
• Integration of biofeedback with other self-regulatory methods
• Promoting high standards of professional practice, ethics, and education
• Increasing member knowledge through events, publications, educational programs and special
interest sections
• Making the public aware of the benefits of biofeedback

Membership in AAPB is open to professionals interested in the investigation and application of applied
psychophysiology and biofeedback, and in the scientific and professional advancement of the field. In its
history, AAPB has grown to more than 2,000 members representing the fields of psychology, medicine, nursing,
social work, counseling, physical therapy, education and other healthcare areas. There are many state, regional,
and international chapters.

Please append the bylaws for the petitioning organization if bylaws are not provided on the website.

Please see Appendix A for a copy of our Bylaws. Bylaws are also present on our website at
https://www.aapb.org/i4a/pages/index.cfm?pageid=3303

. Please provide the following information for all officials in the organization, including the Executive Officer
or responsible petitioning staff person.

A. Name: Patrick R. Steffen, PhD, BCB

Title: President APA membership status: member
Address: Brigham Young University, 284 TLRB
City/State/Zip: Provo, UT 84602
Phone: 801-422-7757 FAX: 801-422-0163

B. Name: Ethan Benore, PhD, BCB, ABPP

Title: President-Elect APA membership status: member
Address: Cleveland Clinic, 2801 Martin Luther King Jr Drive
City/State/Zip: Cleveland, OH 44104
Phone: 216-448-6253 FAX: 216-448-6207

C. Name: Gabriel E. Sella, MD, MSc, MPH, PhD, BCB

Title: Past-President APA membership status: non-member
Address: G.E. Sella MD, Inc., 25 Reid Avenue
City/State/Zip: Wheeling, WV 26003
Phone: 704-633-4485 FAX: 704-633-4141

D. Name: Fredric B. Shaffer, PhD, BCB, BCB-HRV

Title: Treasurer APA membership status: non-member
Address: Truman State University, 4 Sunrise Lane
City/State/Zip: Kirksville, MO 63501-1820
Phone: (660) 349-9522 FAX: N/A

E. Name: Inna Khazan, PhD, BCB, BCB-HRV

Title: Board Member APA membership status: member
Address: Ten Post Office Square South, c/o Carr Workplaces, 8th Floor
City/State/Zip: Boston, MA 02109
Phone: 617-231-0011 FAX: N/A
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F. Name: Leah Lagos Wallach, PsyD, BCB
Title: Board Member APA membership status: member
Address: 505 Park Avenue, Suite 1904
City/State/Zip: New York, NY 10022
Phone: (732) 425-6573 FAX: N/A

G. Name: Christine S. Moravec, PhD

Title: Board Member APA membership status: non-member
Address: Cleveland Clinic, 9500 Euclid Ave, NE61
City/State/Zip: Cleveland, OH 44195
Phone: 216-445-9949 FAX: 216-445-9949

H. Name: Mari Swingle, PhD, BCN

Title: Board Member APA membership status: member
Address: 555 Jervis St. Suite 2502
City/State/Zip: Vancouver, BC V6E 4N1 Canada
Phone: (604) 602-7091 FAX: N/A

I. Name: OPEN (per AAPB bylaws, the Board has elected to keep this position vacant until the 2019 Board
of Directors election, scheduled for January 2019)

J. Name: OPEN (recently vacated by graduating student)

Title: Student Representative APA membership status: N/A
Address:
City/State/Zip:
Phone: N/A FAX: N/A

K. Name: Michelle Cunningham

Title: Executive Director APA membership status: non-member
Address: AAPB, One Parkview Plaza, Suite 800
City/State/Zip: Oakbrook Terrace, IL 60181
Phone: 303-422-8436 FAX: 720-881-6102

Outline the structure and functions of the administrative organization (frequency of meetings, number of
meetings per year, membership size, functions performed, how decisions are made, types of committees, dues
structure, publications, etc.). Provide samples of newsletters, journals, and other publications, etc.

The hierarchical organization of AAPB gives the Board of Directors final authority on all decisions of policy and
fiscal management – in accordance with membership ratified bylaws. Roles, power, and responsibilities are
delineated in Appendix A. Board officers include President (serves as president-elect and past president as part of a
three-year term), Past President, President-Elect and Treasurer. The Treasurer serves a three-year term. Five at-
large Board members are elected and a student representative is Board-appointed and voted on annually. Board
members are elected and serve on a volunteer basis.

The work flow process is contracted to an association management firm, Kellen Company, to provide
administration, staffing, process applications, software management, contracting, and other services as defined by a
periodically evaluated scope of work. Staffing is inclusive of a part-time Executive Director who serves the Board
in an ex-officio capacity. Additional shared staff includes an Associate Executive Director, Meetings Director,
Controller, Membership Coordinator, and Registration support staff.

Committees are charged with organizational capacity, building and program compliance, making recommendations
and developing initiatives with staff support and Board oversight. Committee leadership reports to the Board.

A managing editor is contracted independently, to work in concert with guest editors, to produce Biofeedback
Magazine, a non-scientific membership publication.

Applied Psychophysiology and Biofeedback is the official publication of AAPB and is produced, in partnership
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with Springer. The journal editor is contracted by Springer and reports to the publisher. Applied Psychophysiology
and Biofeedback is an international, interdisciplinary journal which explores the interrelationship of physiological
systems, cognition, social and environmental parameters, and health. Priority coverage is devoted to original
research, basic and applied, which contributes to the theory, practice, and evaluation of applied psychophysiology
and biofeedback.

Board:
Direct and Set Policy

Committees: Staff:
Develop and Implements,
Recommend Sets Process

For complete Committee charters outlining committee roles, meetings, membership and responsibilities,
visit https://www.aapb.org/i4a/pages/index.cfm?pageid=3888.

Chapters: AAPB also leads a multi-organizational Council of Chapters with regional, like-minded entities that
qualify through an application process to be recognized as an AAPB chapter. No fees are paid to AAPB for
inclusion. Chapters qualify by Board approval. Chapters operate independent from each other. However, all
chapters support the larger mission, goals and objectives of AAPB (see Bylaws, Appendix A). Further, Chapters
inform and make recommendations to the Board for topics such as conference programming and publications.

Sections: In addition, AAPB manages and is supported by several special interest sections, each with topic specific
goals to support members and the community at large. Sections are funded by additional membership fees,
restricted to the section. Non-members are not eligible for section participation.

o Allied Professionals Section

o Applied Respiratory Psychophysiology Section
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o Child and Adolescent Health Section
o Education Section
o International Section
o ISMA-USA Stress Management Section
o Mind-Body Medicine Section
o Neurofeedback Section
o Optimal Performance Section
o Performing Arts Psychophysiology Section
o SEMG/SESNA Section

Board Meetings: The Board meets monthly and serves the membership by setting policy, directing strategy,
adhering to bylaws, establishing committees and other ad hoc workgroups for targeted objectives, and financial
management. Motions are forwarded to the Board and discussed by board members. For those actions approved in
the Bylaws, resolutions are approved by a majority. AAPB follows Robert’s Rules of Order for procedural
authority. Issues affecting the full membership or those actions not under the stated direction of the Board (e.g.,
revisions to Bylaws, elections) are ratified by membership vote.

Current Membership Size: 724 (as of October 31, 2018)

Dues Structure: Membership dues reflect the level of engagement with AAPB and the associated benefits and
privileges, as stated in the Bylaws (Appendix A). Membership is available year-round and renewable on an anniversary
basis. Categories include Regular, Early Career, Retired, Hardship, Associate Member, Student Member, and
Honorary Member, as delineated in Article III of the Bylaws. Dues are priced as follows:

o Regular: $195.00
o Early Career: $129.00
o Retired (Partial or Full): $149.00 partial/$49.00 full
o Hardship: $95.00
o Associate Member: $225.00
o Student Member: $59.00
o Lifetime Member: $0.00 – case by case Board decision
o Honorary Member: $0.00 – case by case Board decision

The dues and association benefits are stated on our website at

https://www.aapb.org/i4a/pages/index.cfm?pageID=3277.

Publications: AAPB serves its members with the publication, Biofeedback Magazine, a non-scientific membership
publication (an example is found in Appendix B).

AAPB serves its members and the larger community with the publication Applied Psychophysiology and Biofeedback,
a peer-reviewed research journal (an example is found in Appendix C).

In addition, AAPB publishes a number of books for education, clinical training, and research purposes. A reference list
of AAPB publications in the last 10 years follows and can be found in Appendix D:

Peper, E. (2009). Biofeedback mastery - An experiential teaching and self-training manual. Wheat Ridge,
CO: Association for Applied Psychophysiology and Biofeedback.

Strack, B., Linden, M. & Wilson, V. (2011). Biofeedback & neurofeedback applications in sport
psychology. Wheat Ridge, CO: Association for Applied Psychophysiology and Biofeedback.

Sherman, R. (2012). Pain: Assessment & intervention from a psychophysiological perspective, 2nd
ed. Wheat Ridge, CO: Association for Applied Psychophysiology and Biofeedback.

Thompson, M. & Thompson, L. (2015). Functional neuroanatomy. Wheat Ridge, CO: Association for
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Applied Psychophysiology and Biofeedback.

Thompson, M. & Thompson, L. (2015). The neurofeedback book, 2nd ed. Wheat Ridge, CO: Association
for Applied Psychophysiology and Biofeedback.

Tan, G., Shaffer, F., Lyle, R. & Teo, I. (2016). Evidence-based practice in biofeedback and
neurofeedback, 3rd ed. Wheat Ridge, CO: Association for Applied Psychophysiology and Biofeedback.

Moss. D. & Shaffer, F. (2016). Foundations of heart rate variability biofeedback: A book of readings.
Wheat Ridge, CO: Association for Applied Psychophysiology and Biofeedback.

Education: As an approved provider of continuing education credits through the American Psychological Association,
AAPB is active in the ongoing live delivery of education in applied psychophysiology and biofeedback, in compliance
with approved standards.

4. Present a rationale that describes how your organization provides systems and structures which make a
significant contribution to the organized development of the proficiency. Describe the role of your organization
in collaborating with other organization/s to ensure the organized development of the proficiency. Describe the
role of your organization in providing oversight to ensure a core of psychological knowledge and training is
offered in a sequential and integrated nature. Describe the role of your organization in providing oversight if the
proficiency is obtained in the context of interdisciplinary education and training.

As the oldest established, pioneering association for this modality, AAPB serves as a leader in advocating for and
developing resources toward the advancement of the science and application of biofeedback. We support the
development and maintenance of biofeedback as a proficiency of the APA through several mechanisms:

1) Facilitating an environment for the exchange of information, concepts, clinical outcomes, and scientific
data by creating a central support and resource community—to the benefit of psychologists, physicians,
educators, researchers, clinicians, academics, brain and behavioral science and health experts, and
other qualified professionals involved with safe and efficacious delivery of biofeedback. This is
accomplished in large part through education, resource development, and professional mentorship:

a. The AAPB Annual Scientific Meeting provides continuing education and networking opportunities
for over 400 professionals and students through an inclusive call for abstracts with blind review
process. Submissions are sought in the subject matter areas of:

o Peripheral Biofeedback (HRV/Resp)

o Peripheral Biofeedback (EMG/Temp/GSR)
o Neurofeedback (EEG)
o Optimal Performance
o Heart Rate Variability (ECG, RESP)
o Stress Management
o Practice Management
o Mindfulness
o Technology and Innovations
o High-level science from aligned disciplines
o Evidence-based practice
o Hypothesis-driven scientific research
o Ethical Standards
o Case Studies
o Debates
o Successful Clinical Outcomes (Depression, Epilepsy, Behavior, Diabetes)
o VA Whole Health Initiative
o Historical Foundations
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The program schedule of our most recent 2018 Annual Scientific Meeting is presented in
Appendix E. Details of our upcoming Annual Scientific Meeting can be found at
https://www.aapb.org/i4a/pages/index.cfm?pageID=3749.

b. AAPB provides live and recorded webinars on a variety of topics, offered at discounted rates to
members and at other price points to all other attendees. The last 3 years of webinars sponsored by
AAPB are listed in Appendix F.

c. AAPB provides support for biofeedback chapters throughout the country and the world. Chapters can
address local issues, learn from the activity of other chapters, and together forward larger concerns to
be addressed by the Council of Chapters or AAPB. An updated list of chapters is located at
https://www.aapb.org/i4a/pages/index.cfm?pageid=3301.

d. AAPB maintains positive liaison relationships with other modality-related organizations, including
the Biofeedback Certification International Alliance (BCIA; www.bcia.org), the Biofeedback
Federation of Europe (BFE; www.bfe.org), and the International Society for Neurofeedback and
Research (ISNR; www.isnr.org).

e. AAPB board members serve other organizations and present on biofeedback and applied
psychophysiology at other organizational meetings (See Appendix G).

2) Providing oversight of training and dissemination of knowledge regarding biofeedback.

a. AAPB publishes several scientific publications and academic resources to educate and improve the
standards of proficiency in biofeedback. Most recently, this includes the 2016 publication
“Evidenced-based Practice in Biofeedback and Neurofeedback: 3rd Edition” (See Appendix D for
other citations). We also support and promote the publication “Biofeedback: A Practitioner’s Guide:
Fourth Edition” (published by Guilford Press) to our membership.

b. AAPB supports ongoing education for student development through the Foundation for Education
and Research in Biofeedback and Related Sciences (FERB)
(https://www.aapb.org/i4a/pages/index.cfm?pageid=3280).

c. AAPB provides interdisciplinary training opportunities through sponsored webinars

(https://www.aapb.org/i4a/pages/index.cfm?pageid=3653).

3) Supporting relationships with industry to support innovation and scientist development to elevate the public
awareness of biofeedback-related devices and technology, with regard to optimal public health and safety.

a. AAPB has implemented a Standards and Professional Practices Standing Committee with the
objective to set minimum standards for performing biofeedback services, as well as appropriate use
of technology.

b. AAPB has implemented a standing Innovation Committee which has objectives to support the
understanding of emerging technology, standardize data collection and reporting, and set standards
for the use/evaluation of emerging technology safely and effectively.

5. List other organizations that are associated with, that promote, or that certify practitioners in this
psychological proficiency. Please provide letters of support these other organizations supporting your
petition.

Letters of support from the following organizations included in Appendix H:

o Biofeedback Certification International Alliance (BCIA) - The internationally and nationally recognized
standard bearer of certification for the modality. They have been an ongoing supporter of Biofeedback and
Applied Psychophysiology as a proficiency recognized by the APA. This organization has been instrumental
to the education of professional and maintenance of this proficiency. Portions of their work are referenced in
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support of this application.

6. Signature of official (s) representing the organization submitting the petition:

name title date

President-Elect 12/28/2018
_____________________________ ______________________ _______________
Ethan Benore, PhD, BCB, ABPP President-Elect

_____________________________ ______________________ _______________

Michelle Cunningham Executive Director

Need and Distinctiveness

Criterion II. Public Need for Proficiency Practice. The services of a proficiency are responsive to
identifiable public needs

Commentary: Proficiencies may evolve from the profession’s recognition that there is a particular
public need. Proficiencies may also develop from advances in scientific psychology from which
applications to serve the public may be derived.

1. Describe with relevant references the public needs the proficiency fulfills and how the proficiency meets those
needs?

Biofeedback has become a popular term in public discussions of health and wellness. However, there is a
significant limit in public awareness (and awareness of practicing mental and medical care professionals) of the
specifics regarding training, clinical application, standards for operation, and evidence base for biofeedback.

Given the increasing need for self-management of health and wellness (e.g.,(Howard & Williams, 2018; Mezuk et
al., 2017; Pandey, Hale, Goddings, Blakemore, & Viner, 2017; Shields, Moons, & Slavich, 2017), the growing
interest in technology for healthcare (Deng et al., 2018; Duking, Holmberg, & Sperlich, 2017; Gordt, Gerhardy,
Najafi, & Schwenk, 2018; Havelka, Havelka, & Delimar, 2009; Nogueira et al., 2018; Peake, Kerr, & Sullivan,
2018; Shull, Jirattigalachote, Hunt, Cutkosky, & Delp, 2014; Stubberud & Linde, 2018; Tao & Or, 2013), and the
growing understanding of psychophysiology or “mind-body” medicine (Gok Metin et al., 2018; Helgason &
Sarris, 2013; Matos et al., 2015; Morgan, Irwin, Chung, & Wang, 2014; Morone & Greco, 2007; Senders,
Wahbeh, Spain, & Shinto, 2012; Ventegodt & Merrick, 2009; Wang et al., 2014; Wickramasekera, 1999; Younge,
Gotink, Baena, Roos-Hesselink, & Hunink, 2015) beyond medications or surgery alone as treatment (Ramirez,
Desantis, & Opler, 2001), there is a public need for a specific clinical proficiency in biofeedback and applied
psychophysiology. The public needs addressed by this proficiency include:

a) Awareness and control of physiological metrics

b) Reduction of symptoms in known medical/psychological conditions
c) Performance enhancement
d) Health and wellness and prevention of negative health outcomes

There are a number of physical and psychological conditions which respond favorably to biofeedback. AAPB has
previously supported a publication outlining the standards for biofeedback and strategies to evaluate the efficacy
of this therapy (LaVaque et al., 2002). Most recently, AAPB published a 3rd edition of a text summarizing up-to-
date evidence supporting biofeedback interventions for medical and psychological conditions, including: ADHD,
alcoholism, anxiety, asthma, autism, chronic pain, constipation, depression, diabetes, epilepsy, erectile
dysfunction, incontinence (urinary and fecal), fibromyalgia, headache, hypertension, insomnia, irritable bowel
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syndrome, preeclampsia, PTSD, Raynaud’s disease, TMJ pain, tinnitus, traumatic brain injury (Tan, Shaffer, Lyle,
& Teo, 2016). A copy of this publication is provided with this application, with references included. (Appendix I)

There is a further public need beyond remission of symptoms or ailments. Biofeedback and applied
psychophysiology also addresses the field of performance enhancement (Aritzeta et al., 2017; Jimenez Morgan &
Molina Mora, 2017; Markovska-Simoska, Pop-Jordanova, & Georgiev, 2008; Rijken et al., 2016; Sutarto, Wahab,
& Zin, 2013). While research in this field is growing, there continues to be a public need to understand the process
of performance enhancement. Finally, there is a trend in healthcare to increase our attention to optimizing wellness
and the prevention of negative health outcomes, especially in the light of population-based care models—
biofeedback has the potential to empower the public to maintain healthy states with effective monitoring and self-
regulation.

2. Describe any regulatory, professional privileging, and/or educational statute or regulation of this
proficiency of which you are aware.

State Law: The following states are known to reference biofeedback as a specific skill or competency in the
practice of psychology under state law, statues, or regulations: Alaska, Arkansas, California, Delaware,
Florida, Hawaii, Illinois, Maine, Maryland, Massachusetts, Michigan, Missouri, Montana, Nebraska, Nevada,
New Jersey, New Mexico, North Carolina, Ohio, Oklahoma, Pennsylvania, Tennessee, Texas, Virginia, West
Virginia, and Wisconsin.

Insurance Coverage: In some states, Biofeedback Certification International Alliance (BCIA) certification is
required as proof of competency needed for Medicaid or Workmen’s Compensation reimbursement.

Hospital privileges: Many healthcare organizations and hospitals require specialized training or BCIA
certification in biofeedback before they grant a health care provider with this clinical privilege. The Cleveland
Clinic is one such example.

AAPB recommends all those practicing biofeedback to demonstrate and maintain competency, maintain
certification (i.e., BCIA certification) where applicable, and seek appropriate state licensure. AAPB has also
provided additional support to those regulatory agencies by publishing recommended standards for performing
biofeedback as a clinical competency (http://www.aapb.org/i4a/pages/index.cfm?pageid=3678). BCIA
certification is widely supported as demonstration of competency in biofeedback and applied
psychophysiology (M. S. Schwartz & F. Andrasik, 2016a) and has provided additional standards and ethical
principles (See Appendix B, pages 64-68).

3. Describe how the recognition of this proficiency will increase the availability and quality of services that
professional psychologists provide without reducing access to needed services.

Given the above stated public need for accurate knowledge and access to effective interventions utilizing
biofeedback, it is paramount that APA and AAPB support a standard of biofeedback and applied
psychophysiology which protects the public while still providing them with the information and services they
need. Recognition of biofeedback and applied psychophysiology as a proficiency will:

a) Encourage interested clinicians to seek advanced training relevant to standards of practice. There exists a
specialized set of knowledge and clinical competencies to perform biofeedback. These include:
a. Basic training in a related healthcare field
b. Up-to-date education on anatomy and physiology
c. Detailed understanding of the physiological, clinical, and technical aspects of biofeedback
d. Advanced and mentored training in proper use of the equipment

b) Encourage and support advanced training opportunities for new and existing clinicians to maintain high
standards of clinical proficiency.

c) Encourage and support the efforts of regulatory agencies and state boards to monitor the competency of
clinicians who are using the modality and seeking licensure or license renewal.
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d) Encourage and support the efforts of health care organizations to monitor the competency of clinicians
seeking clinical privileges.

e) Encourage healthcare agencies to acknowledge this specific proficiency and develop healthcare service lines
related to biofeedback and applied psychophysiology, potentially increasing future access to these services.

There continues to be multiple avenues for advanced training in this field (e.g., coursework, training and
certification processes), as well as access to mentoring, continuing education, and regular revision of standards,
ethics, and clinical effectiveness of biofeedback. Therefore, recognition of biofeedback and applied
psychophysiology is not anticipated to limit the availability/access to qualified care providers. In contrast, this
recognition may increase the continuing education and research in this area, increasing the quality of care and
likely the quantity of skilled clinicians.

References for Criterion II

Aritzeta, A., Soroa, G., Balluerka, N., Muela, A., Gorostiaga, A., & Aliri, J. (2017). Reducing anxiety and
improving academic performance through a biofeedback relaxation training program. Appl Psychophysiol
Biofeedback, 42(3), 193-202. doi:10.1007/s10484-017-9367-z
10.1007/s10484-017-9367-z [pii]
Deng, W., Papavasileiou, I., Qiao, Z., Zhang, W., Lam, K. Y., & Han, S. (2018). Advances in automation
technologies for lower extremity neurorehabilitation: A review and future challenges. IEEE Rev Biomed
Eng, 11, 289-305. doi:10.1109/RBME.2018.2830805
Duking, P., Holmberg, H. C., & Sperlich, B. (2017). Instant biofeedback provided by wearable sensor technology
can help to optimize exercise and prevent injury and overuse. Front Physiol, 8, 167. doi:
10.3389/fphys.2017.00167
Gok Metin, Z., Ejem, D., Dionne-Odom, J. N., Turkman, Y., Salvador, C., Pamboukian, S., & Bakitas, M. (2018).
Mind-body interventions for individuals with heart failure: A systematic review of randomized trials. J
Card Fail, 24(3), 186-201. doi:S1071-9164(17)31213-7 [pii]
10.1016/j.cardfail.2017.09.008
Gordt, K., Gerhardy, T., Najafi, B., & Schwenk, M. (2018). Effects of wearable sensor-based balance and gait
training on balance, gait, and functional performance in healthy and patient populations: A systematic
review and meta-analysis of randomized controlled trials. Gerontology, 64(1), 74-89.
doi:10.1159/000481454
000481454 [pii]
Havelka, M., Havelka, J., & Delimar, M. (2009). PhysioSoft--an approach in applying computer technology in
biofeedback procedures. Coll Antropol, 33(3), 823-830.
Helgason, C., & Sarris, J. (2013). Mind-body medicine for schizophrenia and psychotic disorders: A review of the
evidence. Clin Schizophr Relat Psychoses, 7(3), 138-148. doi:10.3371/CSRP.HESA.020813
Y7563L0717267R62 [pii]
Howard, S. J., & Williams, K. E. (2018). Early self-regulation, early self-regulatory change, and their longitudinal
relations to adolescents' academic, health, and mental well-being outcomes. J Dev Behav Pediatr, 39(6),
489-496. doi: 10.1097/DBP.0000000000000578
Jimenez Morgan, S., & Molina Mora, J. A. (2017). Effect of heart rate variability biofeedback on sport
performance, a systematic review. Appl Psychophysiol Biofeedback, 42(3), 235-245. doi:10.1007/s10484-
017-9364-2
10.1007/s10484-017-9364-2 [pii]
LaVaque, T. J., Hammond, D. C., Trudeau, D., Monastra, V., Perry, J., Lehrer, P., . . . Sherman, R. (2002).
Template for developing guidelines for the evaluation of the clinical efficacy of psychophysiological
evaluations. Applied Psychophysiology and Biofeedback, 27(4), 273-281.
Markovska-Simoska, S., Pop-Jordanova, N., & Georgiev, D. (2008). Simultaneous EEG and EMG biofeedback for
peak performance in musicians. Prilozi, 29(1), 239-252.
Matos, L. C., Sousa, C. M., Goncalves, M., Gabriel, J., Machado, J., & Greten, H. J. (2015). Qigong as a
traditional vegetative biofeedback therapy: Long-term conditioning of physiological mind-body effects.
Biomed Res Int, 2015, 531789. doi:10.1155/2015/531789
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Criterion III. Diversity. The organization (s) responsible for the proficiency demonstrates
recognition of the importance of cultural and individual differences and diversity in education and
training in the proficiency.

Commentary: The proficiency provides trainees with relevant knowledge and experiences about
the role of cultural and individual differences and diversity in psychological phenomena as it
relates to the science and practice of the proficiency in each of the following areas: i) development
of a proficiency-specific scientific and theoretical knowledge; ii) preparation for practice; iii)
education and training; iv) continuing education and professional development; and v) evaluation
of effectiveness.

1. Describe how education and training of cultural and individual differences and diversity are integrated into the
curriculum. Include information on coursework and training experiences.

All AAPB-approved symposia, webinars, workshop presenters, and panelists are required to answer the following
questions during the submission process for approval consideration:

1) Describe how your proposal addresses the issues of cultural diversity, cultural competence, and
multicultural issues?

2) How does your research serve the target audience to improve the practice and/or delivery of
health services in terms of competency, performance and/or patient outcomes? Knowledge
translation describes any activity or process that facilitates the transfer of high-quality evidence from
research into effective changes in practice, policy or products. This increasingly important discipline
attempts to combine elements of research, education, quality improvement, and electronic systems
development to create a seamless linkage between interventions that improve patient care and their
routine implementation in daily clinical practice. A practice “gap” is the difference between ‘desired’
practice and ‘actual’ practice using sources such as national/state data, registries, surveys, journal
publications.

Response options include: Patient Care, Medical/Psychological Knowledge, Practice based Learning and
Improvement, Interpersonal Communication skills, Professionalism, Systems-based Practice, Other.

3) How the session will teach the target audience that will potentially improve or correct this gap?

AAPB actively selects instructors who both promote participant mastery of specific strategies and behaviors that
enhance inclusion of diverse populations (including those from underserved populations) and creates a professional
environment that promotes diversity – institutionally.

AAPB periodically offers a free webinar to AAPB members and referred guests that addresses diversity, entitled:
Multi-Cultural and Diversity Considerations for Organizations and Practitioners, presented by Rick Harvey,
PhD. This is an encore presentation of a live conference 60-minute session—the recording is offered at no charge
at least twice per year. AAPB continues to give ongoing consideration to developing additional resources.

In addition, AAPB collects and assesses AMA GAP Analysis on all presentation submissions. These are published
on the website – to ensure awareness and understanding of cultural and individual differences relevant in our
proficiency.

AAPB literature on efficacy in biofeedback and related white papers address the current state of knowledge in cultural
differences, as well as the need for ongoing research and development in this area (e.g., (Harvey, Lin, & Booiman,
2015).

2. Describe how knowledge of cultural and individual differences and diversity are applied in practice.
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Each AAPB member attests to adhere to the organization’s Ethical Principles when joining and renewing their
membership which includes the following statements:

“AAPB and its membership are committed to the protection of human rights. AAPB members strive to
maintain the dignity and worth of the individual while rendering service, conducting research, and
training others.”

“AAPB members do not discriminate against or refuse services to anyone on the basis of gender,
ethnicity, race, sexual orientation, age, disability, socioeconomic status, language spoken, religion or
national origin.”

We additionally present the AAPB-endorsed APA Authoritative Diversity/Inclusivity Guidance Framework as part
of our volunteer opportunities information at https://www.aapb.org/i4a/pages/index.cfm?pageid=3885. AAPB
recently published a Special Issue of Biofeedback Magazine, exclusively dedicated to diversity and cultural
competency (Biofeedback, volume 45, Issue 3, see Appendix B), including among other resources an annotated
bibliography of updated cultural competency (Wei & Quigley, 2017). The issue includes a reprint of the APA
Guidelines and AAPB’s endorsement.

Should a member demonstrate behavior that is grossly incongruous with AAPB policy, the Board of Directors may
revoke membership or remove any individual from a live event.

We are in the process of translating two AAPB-published books – “Evidence-Based Practice in Biofeedback and
Neurofeedback” and “Foundations of HRV Biofeedback” - into French and Spanish, respectively. We will help
sell the books on our website and retain only 10% of the proceeds - to help our international partners build income
to help them grow and develop resources.

The AAPB Code of Ethics (Appendix J) as well as the BCIA’s Professional Standards and Ethics (Appendix K, also
embedded in Appendix B) outline how knowledge of cultural and individual differences and diversity are intended to
be applied in practice.

AAPB Code of Ethics (excerpt)

Multiculturalism and Diversity

A. AAPB members are encouraged to recognize that, as cultural beings, they may hold attitudes and beliefs that
can detrimentally influence their perceptions of and interactions with individuals who are different from
themselves in terms of race, color, religion, creed, sex, sexual orientation, gender identity, national origin,
ancestry, age, veteran status, disability unrelated to job requirements, genetic information, military service, socio-
economic class, and other cultural categories.

B. AAPB members are encouraged to recognize the importance of multicultural sensitivity/responsiveness to,
knowledge of, and understanding about individuals who are different in terms of race, color, religion, creed, sex,
sexual orientation, gender identity, national origin, ancestry, age, veteran status, disability unrelated to job
requirements, genetic information, military service, socioeconomic class, and other cultural categories.

C. As educators, AAPB members are encouraged to employ the constructs of multiculturalism and diversity in
education.

D. Culturally-sensitive researchers are encouraged to recognize the importance of conducting culture-centered

and ethical research among persons from diverse race, color, religion, creed, sex, sexual orientation, gender
identity, national origin, ancestry, age, veteran status, disability unrelated to job requirements, genetic information,
military service, socioeconomic class, and other cultural categories.

E. AAPB members are encouraged to apply culturally appropriate skills in clinical and other biofeedback
practices.

F. AAPB members are encouraged to use positive motivational change processes to support culturally informed
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organizational (policy) development and practices.

G. AAPB members regularly engage in professional reading and education (both online and face-to-face) on
multiculturalism and diversity, keeping up-to-date on current standards and research.

BCIA document on Professional Standards and Ethics (excerpt)

(http://www.bcia.org/files/public/ProfessionalStandardsAndEthicalPrinciplesofBiofeedback.pdf):

D. Multiculturalism and Diversity

1. BCIA professionals are encouraged to recognize that, as cultural beings, they may hold attitudes and
beliefs that can detrimentally influence their perceptions of and interactions with individuals who are
different from themselves ethnically, racially, in sexual orientation, or gender identity.

2. BCIA professionals are encouraged to recognize the importance of multicultural

sensitivity/responsiveness to, knowledge of, and understanding about individuals who are different
ethnically, racially, in sexual orientation, or gender identity.

3. As educators, BCIA professionals are encouraged to employ the constructs of multiculturalism and
diversity in education.

4. Culturally sensitive researchers are encouraged to recognize the importance of conducting culture-
centered and ethical research among persons from diverse ethnic, linguistic, racial, sexual orientation, or
gender identity backgrounds.

5. BCIA professionals are encouraged to apply culturally appropriate skills in clinical and other biofeedback
practices.

6. BCIA professionals are encouraged to use positive motivational change processes to support culturally
informed organizational (policy) development and practices.

7. BCIA professionals regularly engage in professional reading and education (both online and face to face)
on multiculturalism and diversity, keeping up to date on current standards and research.

3. Describe the opportunities for continuing professional development and education related to cultural and
individual differences in diversity.

Overall, organizationally, the AAPB Board of Directors has formally endorsed and adopted the APA's Guidelines
on Multicultural Education, Training, Research, Practice and Organizational Change for Psychologists with the
following modifications:

Guideline #1: Psychologists are encouraged to recognize that, as cultural beings, they may hold attitudes
and beliefs that can detrimentally influence their perceptions of and interactions with individuals who are
ethnically and racially different from themselves.

Guideline #2: Psychologists are encouraged to recognize the importance of multicultural

sensitivity/responsiveness, knowledge, and understanding about ethnically and racially different
individuals.

Guideline #3: As educators, psychologists are encouraged to employ the constructs of multiculturalism
and diversity in psychological education.

Guideline #4: Culturally sensitive psychological researchers are encouraged to recognize the importance
of conducting culture–centered and ethical psychological research among persons from ethnic, linguistic,
and racial minority backgrounds.

Guideline #5: Psychologists strive to apply culturally–appropriate skills in clinical and other applied
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psychological practices.

Guideline #6: Psychologists are encouraged to use organizational change processes to support culturally
informed organizational (policy) development and practices.

These guidelines are shared with committee leadership, members and staff. While we do blind peer review for the
selection, we do seek out a handful of invited presenters from the international community. We also work with
several sister or like-minded regional organizations in Africa, Spain, Poland, and Australia to help develop content
or offer recommendations and perspectives - and offer support to these organizations in understanding US
standards and share evidence-based information at no charge, upon request.

AAPB has made efforts to review and regularly highlight the application of cultural and individual differences and
diversity through webinars and professional presentations.

4. Describe how students are evaluated. How is competency measured? Please include samples of evaluation tools
related to an understanding of cultural and individual differences and diversity.

AAPB is not an educational program provider that directly evaluates students on competencies. However, the
accredited educational programs that train students in biofeedback also take great effort to address cultural
competency. As an example:

• The neurofeedback program at the University of Texas at San Antonio is under the auspices of the Counseling
Department and the courses involved are part of the degree curricula for master and doctoral program in that
they are taken as electives. As such, students in the neurofeedback program are pursuing a degree in
counseling. The program is CACREP accredited, which includes a standard for "cultural factors relevant to
clinical mental health counseling" (Section 5.C.2.j). The program meets this standard by including required
coursework in cultural competency, specifically COU 5283 Counseling in a Multicultural Setting (master
level) and COU 7283 Advanced Multicultural Counseling (doctoral level). In the coursework for
Neurofeedback, cultural issues are emphasized in regard to professional ethics, clinical practice, and
sensitivity to social-economic factors (Dr. Mark Jones, personal communication, June 27, 2018).

• Alliant University offers an APA-approved Clinical Psychology PhD program. A portion of the Health
Psychology Emphasis focuses on Applied Psychophysiology and Biofeedback. At Alliant, all courses must
include a multi-cultural component, indicated in their syllabi. In addition, all students take multi-cultural
competence courses (Dr. Richard Gevirtz, personal communication, June 28, 2018).

Because AAPB has implemented practice gap correction identification, we maintain minimum compliance with
most academic program syllabi diversity requirements. Topics of cultural competency are required to be embedded
in education submissions in regard to professional ethics, clinical practice, and sensitivity to social-economic
factors.

Each AAPB session attendee (inclusive of students) receives an email with a link to an online evaluation form.
Evaluations are tabulated electronically with the quantitative scores and comments provided for each session.
Completion of an evaluation is required before issuance of a CE certificate of attendance.

We assess how much a learner learned as a result of this program, with the following question:

Please describe what changes you will make in your clinical practice as a result of having attended this
educational activity?

Upon completion of the participant evaluation data, the information is shared with the Chair of the Education and
Program Planning Committees. The evaluation data is then shared with the appropriate committee members to
assess the level of learning that was achieved by the participants resulting from the CE program. Both qualitative
data and comments are reviewed carefully extracting information useful in developing future CE program
offerings, including potential topics, research data/findings, empirical data related to the use of biofeedback and/or
neurofeedback equipment, speakers and/or knowledgeable contacts pertinent to various topics, specific content
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areas either missed in the presentation or needing expansion for future events, and potential gaps in programming
needs.

Upon completion of the post tests, the exam items and responses are reviewed by the Education Committee to
determine whether the testing instrument was a good evaluation of the material presented and additionally whether
the learning objectives were met.

The AAPB Education Committee is currently evaluating additional mechanisms to assess competency in this area.
It has been determined that a question will be added to all continuing education attendee evaluations and begin
collecting data in this area in a more organized fashion to determine deficiencies and areas for improvement.

References for Criteria III:

Biofeedback Certification International Alliance. (2016). Professional standards and ethical principles of
biofeedback.
Harvey, R. , Lin, I., & Booiman, A. (2015). Multicultural and diversity training considerations for biofeedback
practitioners. Biofeedback, 43(3), 163-167.
Schwartz, M. S., & Andrasik, Fr. (2016). Biofeedback: A practitioner's guide (4th ed.). New York: Guilford Press.
Wei, X & Quigley, D. (2017). Cultural competence: Annotated bibliography 2009-2014. Biofeedback, 45(3), 64-
68.

Criterion IV. Distinctiveness. A proficiency is represented by a distinct procedure, technique, or

applied skill set used in psychological assessment and/or treatment within which one develops
competence.

Commentary: A proficiency typically reflects the development of a competence in a circumscribed

activity beyond broad and general doctoral training. While it is recognized that there may be
overlap among the knowledge and skill bases of various psychological applications (i.e. procedure,
technique, or applied skill set), the proficiency does not overlap completely with any other
psychological applications.

1. Provide a brief description of the proficiency by responding to the questions below (limit 400
words total; reading level should be approximately 8th grade). This provides the foundation for
what will appear on the APA website upon recognition of the proficiency and should be
understandable to the general public. Descriptions will be edited for consistency to conform to the
CRSPPP website standards.

a. Provide a brief (2-3 sentences) definition of the proficiency.

Biofeedback is a process that enables an individual to learn how to change physiological activity for the
purposes of improving health and performance. Precise instruments measure physiological activity such as
brainwaves, heart function, breathing, muscle activity, and skin temperature. These instruments rapidly and
accurately "feed back" information to the user. The presentation of this information — often in conjunction
with changes in thinking, emotions, and behavior — supports desired physiological changes. Over time, these
changes can endure without continued use of an instrument.

--Definition approved May 18, 2008 by the Association for Applied Psychophysiology and Biofeedback
(AAPB), Biofeedback Certification International Alliance (BCIA), & International Society for Neurofeedback
and Research (ISNR) (Schwartz & Andrasik, 2016)

b. What specialized knowledge is key to the proficiency?

A clinician will have specialized knowledge in several key domains:

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• Anatomy and Physiology

• Principles related to psychophysiology, including changes in physiology through self-regulation and
learning theories
• Biopsychosocial model of health and illness
• Terminology of biofeedback and psychophysiological recording
• Biofeedback instrumentation, including signal processing, data computation, and audio-visual
representation
• Evidence of effectiveness of biofeedback for specific medical and psychological conditions
• Evidence of effectiveness of biofeedback for performance enhancement
• Ethical and professional behavior utilizing biofeedback procedures

A more detailed example of BCIA Blueprint of Knowledge Statements for Board Certification in Biofeedback and
Neurofeedback, utilized by BCIA, are provided in Appendices L & M)

c. What are the essential skills and procedures associated with the proficiency?

A clinician will have the following essential skills and procedures:

• Interpersonal skills for clinical care

• Clinical skills specific to client/patient interfacing with biofeedback (sensor application, patient education,
clinically useful feedback/representation of psychophysiological data)
• Technical skill in the use of biofeedback hardware and software
• Data interpretation
• Treatment planning and ongoing assessment
• Application of principles related to psychophysiology, skill development, and clinical intervention
• Ethical and professional behavior utilizing biofeedback procedures
A more detailed description the essential skills necessary for practice in biofeedback and neurofeedback, utilized
by BCIA, is provided in Appendices N & O)

2. Provide a detailed description of how this proposed proficiency differs from and is similar to
existing proficiency practices. Provide a detailed description of how one develops and is evaluated
for competency to practice the proficiency. The comparison and differentiation must address the
distinct procedure, technique or skill set used in the practice of the proficiency. In addition, the
comparison and differentiation must address how a knowledge base and competency in the
proficiency is gained beyond broad and general doctoral training.
Proficiencies such as sports psychology, psychopharmacology, and assessment and treatment of serious mental
illness were all reviewed. At the most basic level, biofeedback and applied psychophysiology shares with other
proficiencies a goal of providing effective psychological care. Similar to these proficiencies, biofeedback and
applied psychophysiology addresses a specific subset of knowledge which is not taught in most standard
undergraduate and graduate courses or required for a degree. Some concepts of ethics, research methodology,
psychopathology, the role of medication and its influence on physiology, and the role of behavior and learning in
health may overlap to a small extent with the proficiency of biofeedback and applied psychophysiology. In contrast
to these proficiencies, biofeedback and applied psychophysiology specifically addresses the knowledge regarding
psychophysiological measurement, self-regulation, and clinical application of biofeedback methodology. Further,
there is likely some overlap with existing proficiencies in regard to skills and procedures. While biofeedback and
applied psychophysiology also employ skills such as psychoeducation, psychotherapy, especially behavioral and
cognitive behavioral therapy, this proficiency addresses the specific application of physiological monitoring
devices, interface with computer for data interpretation and feedback, and interpersonal skills to facilitate learning
and physiological change.

In addition, unlike sports psychology or assessment and treatment of serious mental illness, biofeedback does not
address a specific subpopulation. Similar to psychopharmacology, biofeedback as a proficiency applies to all
individuals, and as such, differences across subgroups may influence the practice and research.
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Biofeedback is similar to those proficiencies that provide specialized types of healthcare to those it has benefited
such as psychopharmacology, treatment of substance use disorders, assessment and treatment of serious mental
illness, personality assessment.

As the field of biofeedback and applied psychophysiology grows further, we will better understand the unique
differences needed in assessment, medical intervention, and research.

Biofeedback is not included as a core component of doctoral training in psychology. The knowledge and skills
used in biofeedback is voluntarily sought by those professionals who had interest in increasing the breadth of their
clinical skill set or in developing advanced research and psychophysiology. While there are some universities who
offer biofeedback education and clinical training (e.g., Alliant International University/California School of
Professional Psychology, Saybrook University, Truman State University, Widener University, and Brigham Young
University), as an elective. Individuals interested in advanced education typically seek this training from
institutions approved to provide training which is recognized by BCIA. After documenting completion of course
requirements and mentor training hours, individuals pursuing certification must pass a psychometrically
standardized certification exam. BCIA has stratified this process for general biofeedback, neurofeedback, pelvic
muscle dysfunction biofeedback, and HRV biofeedback (https://www.bcia.org/i4a/pages/index.cfm?pageid=3277).

References for Criteria IV:

Schwartz, M. S., & Andrasik, F.. (2016). Biofeedback: A practitioner's guide (4th ed.). New York: Guilford Press.

Criterion V. Parameters of practice. A proficiency may be described by a circumscribed set of

activities that may be applied to specific populations, settings, and biopsychosocial problems.

Commentary: This parameter consists of the descriptions of specific procedures and techniques
utilized in the proficiency and to the populations to which they apply. This includes assessment
techniques, intervention strategies, consultative methods, diagnostic procedures, ecological
strategies, and applications from the psychological laboratory to serve a public need for
psychological assistance.

1. Provide a description of the procedures and techniques utilized in the practice of the proficiency.
The narrative should include a description of the assessment techniques, intervention strategies,
consultative methods, diagnostic procedures and ecological strategies used in the practice of the
proficiency. In addition, the description should describe the settings in which the techniques and
strategies are applied, the specific populations served by those practicing in the proficiency, and
the biopsychosocial problems the proficiency addresses.
Biofeedback is a process that enables an individual to learn how to change physiological activity for the purposes
of improving health and performance. Precise instruments measure physiological activity such as brainwaves, heart
function, breathing, muscle activity, and skin temperature. These instruments rapidly and accurately "feed back"
information to the user. The presentation of this information — often in conjunction with changes in thinking,
emotions, and behavior — supports desired physiological changes. Over time, these changes can endure without
continued use of an instrument. (Approved May 18, 2008 by the Association for Applied Psychophysiology and
Biofeedback (AAPB), Biofeedback Certification International Alliance (BCIA), & International Society for
Neurofeedback and Research (ISNR)) (M. S. Schwartz & F. Andrasik, 2016a).

From the Foreword of the recent AAPB publication Evidence-based practice in Biofeedback and Neurofeedback, 3rd
Edition (Tan, et al., 2016), “This feedback of information about physiological processes assists the individual to
increase awareness of these processes and to gain voluntary control over body and mind. … Biofeedback therapies
teach the individual to take a more active role in maintaining personal health and achieving higher level mind-body
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health and performance. A primary goal of biofeedback therapies is the acquisition of self-regulation skills and the
generalization of these skills to everyday life outside the clinic. … Neurofeedback is a specialty field within
biofeedback that is devoted to training people to gain control over electrophysiological processes in the human brain.”
(Moss & Shaffer, 2016)

Below is a description of biofeedback modalities and common training goals (for further descriptions, see (Khazan,
2016; Peek, 2016; Shaffer, 2015; Yucha & Montgomery, 2008):

Modality Sensor Measures Training Goal

Muscle sEMG Superficial measure of electrical Raising OR lowering tension in
Tension Surface electrode activity by action potential of specific muscle fibers. Often
sensors muscle fibers. Signal is filtered lowering below 4Hz.
and reported as microvolts.

Respiration Strain gauge Relative breathing movements of Control rate, rhythm, mechanics of
abdomen or thorax, used to breath cycle. Often slow even
evaluate breathing quality. paced abdominal breathing around
6 breaths/minute.
sEMG (right Relative breathing movements of Typically, more relaxed thoracic
trapezius) thorax, used to evaluate breathing breathing to increase abdominal
quality. breathing.
Temperature Thermistor Relative temperature in the Raising OR lowering temperature
periphery, a proxy measure of in targeted area. Often raising to
increased blood flow (i.e., above 92 degrees.
vasodilatation/vasoconstriction).
Measures in Fahrenheit or Celsius.
Heart Rate Electrocardiogram Electrical activity by action Lower HR
(HR) (ECG) potential of cardiac fibers. Time Increase HRV (MaxHR-MinHR)
Surface electrode (ms) between R-R spikes gives Increase HRV (LF power%)
sensors HR. Increase HRV (SDNN)
Blood Volume Relative change in blood volume. Increase coherence with
Pulse (BVP) Time (ms) between N-N spikes respirations
gives HR.

Skin Sweat Surface electrode Activity of eccrine sweat glands Lower skin conductance overall
or sensors on (i.e., electrical conductivity of Reduce response to stimuli OR
electrodermal fingers/hands skin). Measured in microsiemens. reduce time to recover from
activity activity.
(EDA)

Assessment Techniques:

Before biofeedback techniques are used, or a patient or client (hereafter “patient”) is referred to a biofeedback
practitioner, patients are assessed using techniques standard to any health care professional. Biofeedback
professionals will assess history of the presenting problem, along with medical, developmental, social, and
psychological history. The assessment may include additional data (labs, radiology, psychological instruments)
acquired through chart review, collaboration with another provider, or conducted by the practitioner if within the
scope of practice.

Dr. Schwartz has prepared a solid overview of intake procedures in the updated handbook Biofeedback: A
Practitioner’s Guide (4th ed.) (Schwartz, 2016). He reviews the following components of assessment and
preparation for intervention using biofeedback:
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• Understanding conditions appropriate for biofeedback, including contraindications for biofeedback
• Using a stepped care model of interventions and consideration of alternative modes of intervention
• Reviewing baseline biofeedback data
• Introducing the patient to biofeedback procedures
• Conducting the history review/intake interview

Biofeedback may be used for assessment purposes. Commonly, the individual will have biofeedback
instrumentation to conduct a baseline measure of physiological functioning. The individual sits quietly in a
temperature-controlled room without any data directly presented to him/her. Concepts to be attended to during
assessment include understating of autonomic balance, response stereotypy, orienting and defensive responses,
carryover effects, and temporal stability of measures (Arena & Schwartz, 2016). Some examples of baseline data
collections included (Bartlett, Sloots, Nowak, & Ho, 2011; Jorgensen, 2014; Lehrer et al., 2004; Nada, 2009; Peper
et al., 2003). Alternatively, assessment using biofeedback for other purposes may have an alternate protocol, given
the purpose of training (e.g., (Arena & Schwartz, 2016; Khazan, 2009, 2013).

Biofeedback can be used to “facilitate diagnostic determination and protocol determination” (Yucha &
Montgomery 2008, p. 19). Diagnosis of a specific disease or disorder is usually determined before the biofeedback
practitioner sees a patient, and biofeedback serves to confirm or challenge a diagnosis. Biofeedback may also be
used directly for assessment purposes. For example, biofeedback may be used to support assessment of
hyperventilation or ADHD. Testing of the value of these activities has also been accomplished. For example,
ADHD children were diagnosed, and then the EEG diagnostic accuracy was calculated. The diagnostic sensitivity
of EEG on ADHD was 83.58%, the specificity was 82.61%, and misdiagnosis was 16.4%. These results compare
favorably with the diagnostic accuracy of the Intermediate Visual and Auditory test (IVA).” (Yucha &
Montgomery 2008, p. 30)

Assessment of the level of any individual’s response to biofeedback treatment and training includes the patient’s
success in modifying patterns displayed with biofeedback instruments, and often involves having the patient keep a
log of symptoms.

Intervention: Intervention procedures are based upon existing clinical research, expert knowledge, and the
individual’s clinical presentation and baseline performance. At the basic level, determining the intervention
involves deciding:

• Which biofeedback modality to display to the individual

• Which training protocol to use
• What level to set feedback thresholds
• What form of feedback to use
o Audio/visual/both/neither
o Analog/digital
o Graphic data/graphic representation of data

Here is an example of a procedure preparing an individual for biofeedback treatment from Sherman, R. (2012).
Pain: Assessment & intervention from a psychophysiological perspective, 2nd ed. Wheat Ridge, CO: Association
for Applied Psychophysiology and Biofeedback:

• At least the following processes need to be accomplished during an initial interview:

1. Be sure the patient meets the selection criteria for treatment.

2. Explain the goals of the treatment and how they will be reached.

3. Discuss the concept of a coaching relationship with the patient as opposed to a typical therapist-
patient relationship. If the patient does not want to accept responsibility for learning to control
pain, there is little use proceeding.

4. Check motivation and secondary pain problems.

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5. Give the patient all of the required information and consent forms which inform the patient about
psychophysiological interventions including biofeedback, relaxation training, etc.

• In addition to discussing the coaching relationship, two additional important points in the initial interview
differ from many standard clinical interviews. They involve (1) helping patients understand and remember
what the interviewer said about the applied psychophysiology process and (2) the use of biofeedback
machines.

• Applied psychophysiological interventions cannot work effectively unless the patient is fully involved in
the treatment. Patients need to begin therapy with (1) an understanding of what their participation will be
and (2) how the treatment is related to their problem. Everyone has problems remembering the details of
an explanation of something not familiar to them. This is especially true when there is no previous
framework for incorporating the details, and when the patient is already under considerable stress due to
the situation.

Intervention may include the use of the following techniques and instruments (from Yucha, C. &
Montgomery D. (2008). Evidence-based practice in biofeedback and neurofeedback. pp 71-73)

• EMG (Electromyography): The principle of EMG training is normally to provide the learner with enhanced
information about his or her muscle tension in a particular area, hoping this will facilitate learning control of
the muscle. Relaxation of excess and inappropriate tension is the usual goal. Sensors are attached to the skin
over the muscle being targeted for change. Muscles may be targeted anywhere on the body, including the
forehead, neck, shoulders, back, jaws, arms, or legs. Insertable pelvic sensors are used to target pelvic
muscles. Tiny electrical signals emitted by muscles, proportional to degree of contraction, are amplified and
fed to a visual display or an audio signal. The visual display may be digits, polygraph-style lines, or changes
in colors or patterns. The audio tone may indicate changes in muscle tension by a rising or falling tone, or by a
change in frequency of a beep. Most biofeedback systems allow for recording average muscle tension over a
specified time interval.

After some instruction, the learner is allowed quiet practice time during which he or she attempts to lower the
measured muscle tension, using the biofeedback signal as an external guide. The trainer suggests various ways
to relax, helps deal with obstacles to learning, keeps track of progress, and generally facilitates the learning
process. Home practice is usually prescribed because the goal is to learn better control of the muscles without
the aid of biofeedback monitoring. One or more criteria are usually set as goals of training: for instance,
staying below two microvolts for the upper shoulder. Speed of recovery from contraction is another common
criterion and also keeping muscle tension lower during movement.

 Thermal: The goal of temperature training is to teach the learner to warm his or her peripheral extremities.
While core temperature is 98.6oF (37.0oC), skin temperature is much lower, ranging from 75-95oF. In order to
raise skin temperature, one must relax skeletal muscles as well as the muscles within the walls of the blood
vessels. This latter effect is believed to result in better blood flow to the skin and, therefore, a rise in skin
temperature.

A thermal sensor, called a thermistor, is taped to the skin, usually on the palmar surface of one of the fingers.
The temperature of the skin changes the resistance of the thermistor, thereby altering the electrical signal in
proportion to the temperature. The signal is displayed visually and/or through a tone that changes in response
to changes in temperature. The visual display may be digits, polygraph-style lines, or changes in colors or
patterns. Commonly, the learner’s skin temperature is displayed on a thermometer.

After some instruction, the learner is allowed quiet practice time during which he or she attempts to raise the
skin temperature. The trainer suggests various ways to do this, using the biofeedback signal as a guide. For
example, training in slow, deep breathing usually helps the learner to relax. The learner may repeat autogenic
phrases, such as “My hands feel warm and heavy,” or imagine lying on the beach feeling the sun’s warmth on
the hands. Home practice is prescribed, and the learner may be given a simple, handheld thermometer to
monitor progress. On subsequent training sessions, the thermistor may be moved from one hand to the other or
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to a foot. This helps the learner to generalize the skin temperature warming to areas beyond the hands. One or
more criteria are set as goals of training. Typically, learners are asked to raise hand temperature to 90 – 95oF
and foot temperature to 90oF.

 Skin conductance: Skin conductance feedback provides information about sweat gland activity on the hand,
which is closely correlated with sympathetic nervous system activity. This variable is called SCA (skin
conductance activity), EDA (electrodermal activity), or the more classic term GSR (galvanic skin response).
Sensors are attached to two fingers or two sites on the palm, and feedback is provided in various ways: a
changing audio tone, changes in colors on a display, numerical change, meter deflection, or a moving line via
video feedback. Response time is less than 2 seconds, making it very sensitive to transient changes in emotion.

Self-calming by physical or cognitive means tends to lower skin conductance, while negative emotions such as
fear, worry, or anger usually raise it, as will a startle response. Any disorder that would benefit from emotional
calming may respond to GSR biofeedback, provided the learner is able to generalize from the feedback
situation to real life. For example, GSR feedback is often employed in treatment of phobias and anxiety
attacks, and has been used as one element in modifying hypertension and bowel disorders, which are
exacerbated by emotional upset.

In learning to reliably lower one’s GSR, one learns to resist distractions, which disrupt attention, and to
maintain a state of mind that is neutral or pleasant. Relaxation techniques such as slow breathing, imagery, or
meditation can help keep the attention steady and the emotions calm. This tends to stabilize the autonomic
nervous system. Time needed to learn the skill varies from days to months. Practice between biofeedback
sessions facilitates mastery of the skill and is practical since home-trainer GSR devices are available for less
than a hundred dollars.

 EEG (Electroencephalogram), or Neurofeedback: The goal of neurofeedback is to teach learners to modify

their EEG. There are many applications of EEG training. 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. Other applications use EEG training to
treat such disorders as depression, anxiety, epilepsy, sleep disorders, fibromyalgia, pain, alcoholism, and other
addictions. EEG training is also used in the rehabilitation of brain injury and stroke.

These applications are done by training learners to alter their brainwaves. Historically, there are four types of
brainwaves identified according to their frequency or bandwidth. They are known as delta (0.5 – 4Hz), theta
(4-8 Hz), alpha (8-12 Hz), and beta (13-20 Hz), differing according to their frequency. Each person has an
individual pattern of brainwave activity, but there are certain “signatures” of brainwave frequencies that are
associated with specific symptoms or dysfunction.

In neurofeedback training, surface sensors are placed on selected areas of the head and ears. The number and
location of these sensors is determined by the specific application and goal of the EEG training. Typically, the
number of sensors used varies between three and six. The EEG signal is displayed visually and/or through
auditory tones that vary as the EEG changes. Brainwave changes in the desired direction are rewarded with
visual and/or auditory feedback. The visual signal may be graphs, digits, waveforms, changes in colors or
patterns, or even animations.

 HRV (Heart Rate Variability): The term RSA (Respiratory Sinus Arrhythmia) predates the term HRV, and
refers to the rise and fall of heart rate synchronized with each breath (faster on the inhale, slower on the
exhale). The magnitude of this systematic variability seems to reflect a healthy alternation between two
autonomic influences on the heartbeat: sympathetic and parasympathetic. Lack of this variation reflects an
imbalance between the two aspects of the ANS, most likely deficient parasympathetic influence, and is a sign
of poor cardiovascular health. By calming one’s emotional state and by making the breathing slower and more
regular, the HRV can be increased, at least temporarily.
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The biofeedback setup for HRV involves monitoring either heart rate alone or heart rate plus respiration. Heart
rate may be detected from photoplethysmographic sensors on the finger or earlobe, or via EKG sensors. Most
commonly, a trace reflecting cyclic variations in heart rate is displayed on a video screen. The mean heart rate
per minute is not important; the variability of heart rate is the variable of interest. The trainee observes the
trace (or a derived graphic display) and uses it as feedback for regulating the breath and/or the emotional state.
The heartbeat variability is maximized at a particular “resonance frequency” (breathing rate per minute), and
this rate, usually around six per minute, can be determined for each individual by observation and
experimentation.

Settings applied:

Biofeedback treatment/training is generally applied in a professional office, clinic or hospital setting. Given the growth
of technology, handheld units, smartphone applications, and home devices allow the continued practice of biofeedback
in the home setting or other naturalistic environments.

Populations served:

Biofeedback is not limited by age, but by capacity to learn and benefit from the procedures. Very young children may
benefit from biofeedback procedures (Culbert & Banez, 2016). Research is ongoing for biofeedback in the elderly
population (Alhasan, Hood, & Mainwaring, 2017; Cherniack, 2006; Simon & Bueno, 2017). However, there are special
considerations or precautions to take with certain populations (Sherman, 2012), which include:

• Persons with severe psychiatric disorders.

• Persons using medications including insulin, oral hypoglycemics, thyroid replacement, anticonvulsants and
antihypertensive medication.

• Patients maintained on antihypertensive medication, vasodilators, antidepressants, diuretics or any other

medication with a potential side effect of postural hypotension should avoid any sudden changes in posture
such as standing abruptly from a sitting position. This practice should especially be observed while practicing
biofeedback/relaxation training.

• Biofeedback assisted relaxation and other relaxation procedures may result in a need for adjustment in dosage
of the above mentioned medications. The adjustments needed, if any, are usually very gradual. The
prescribing provider should be informed of the patient's participation in biofeedback/relaxation treatment.

Psychosocial problems addressed:

AAPB and BCIA are responsibly forwarding the evidence base for both psychosocial and physical problems
addressed by biofeedback. This began with an AAPB Task Force to identify a standard for evaluating evidence to
treat conditions (La Vaque et al., 2002), which identified the following levels of efficacy:

Level 1: Not empirically supported. Supported only by anecdotal reports and/or case studies in nonpeer
reviewed venues.

Level 2: Possibly Efficacious. At least one study of sufficient statistical power with well identified outcome
measures, but lacking randomized assignment to a control condition internal to the study.

Level 3: Probably Efficacious. Multiple observational studies, clinical studies, wait-list controlled studies, and
within-subject and intrasubject replication studies that demonstrate efficacy.

Level 4: Efficacious.
a) In a comparison with a no-treatment control group, alternative treatment group, or sham
(placebo) control utilizing randomized assignment, the investigational treatment is shown to be
statistically significantly superior to the control condition or the investigational treatment is
equivalent to a treatment of established efficacy in a study with sufficient power to detect
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moderate differences,

b) The studies have been conducted with a population treated for a specific problem, for whom
inclusion criteria are delineated in a reliable, operationally defined manner,

c) The study used valid and clearly specified outcome measures related to the problem being
treated,

d) The data are subjected to appropriate data analysis,

e) The diagnostic and treatment variables and procedures are clearly defined in a manner that
permits replication of the study by independent researchers, and

f) The superiority or equivalence of the investigational treatment have been shown in at least two
independent research settings.

Level 5: Efficacious and Specific. The investigational treatment has been shown to be statistically superior to
credible sham therapy, pill, or alternative bona fide treatment in at least two independent research settings.

Below are those conditions currently with supporting evidence and summarized in the Evidence-Based Practice in
Biofeedback and Neurofeedback, 3rd Edition (Tan, et al., 2016):

Condition Level of Efficacy

Adult Headache Level 4: Efficacious
Attention Deficit Hyperactivity Disorder (ADHD) Level 5: Efficacious and Specific
Alcohol/substance Use Disorders Level 3: Probably Efficacious
Anxiety and Anxiety Disorders Level 4: Efficacious
Arthritis Level 3: Probably Efficacious
Asthma Level 3: Probably Efficacious
Autism Level 3: Probably Efficacious
Cerebral Palsy Level 2: Possibly Efficacious
Cognitive decline after chemotherapy Level 3: Probably Efficacious
Chronic Pain (orofacial pain, noncardiac chest pain, posture- Level 4: Efficacious
related pain)
Chronic Pain (muscle-related low-back pain, phantom limb pain, Level 3: Probably Efficacious
pelvic floor pain, subluxation of the patella and patellofemoral
pain, cancer pain)
Chronic Pain (carpal tunnel pain, myofascial pain, whiplash, Level 2: Possibly Efficacious
dysmenorrhea, muscle spasms)
Chronic Pain (overuse of muscles, reflex sympathetic dystrophy Level 1: Not Empirically Supported
or complex regional pain syndrome, trigeminal neuralgia)
Constipation Level 4: Efficacious
Coronary Artery Disease Level 2: Possibly Efficacious
Depressive Disorders Level 4: Efficacious
Diabetes (Glycemic Control) Level 4: Efficacious
Diabetes (Intermittent Claudication) Level 2: Possibly Efficacious
Diabetes (Diabetic ulcers) Level 3: Probably Efficacious
Epilepsy Level 4: Efficacious
Erectile Dysfunction Level 4: Efficacious
Facial Palsy Level 3: Probably Efficacious
Fecal Incontinence Level 4: Efficacious
Fibromyalgia Level 3: Probably Efficacious
Functional/Recurrent Abdominal Pain Level 2: Possibly Efficacious
Hyperhidrosis Level 2: Possibly Efficacious
Hypertension Level 4: Efficacious
Immune Function Level 2: Possibly Efficacious
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Insomnia Level 3: Probably Efficacious
Irritable Bowel Syndrome Level 4: Efficacious
Motion Sickness Level 3: Probably Efficacious
Performance Enhancement Level 3: Probably Efficacious
Preeclampsia Level 4: Efficacious
Posttraumatic Stress Disorder Level 3: Probably Efficacious
Raynaud’s Disease Level 4: Efficacious
Repetitive Strain Injury Level 2: Possibly Efficacious
Stroke Level 2: Possibly Efficacious
Temporomandibular Muscle and Joint Disorder Level 4: Efficacious
Tinnitus (using biofeedback) Level 3: Probably Efficacious
Tinnitus (using neurofeedback) Level 2: Possibly Efficacious
Traumatic Brain Injury and Post-Traumatic Stress Disorder Level 3: Probably Efficacious
Urinary Incontinence in Children Level 3: Probably Efficacious
Urinary Incontinence in Men Level 3: Probably Efficacious
Urinary Incontinence in Women Level 3: Probably Efficacious
Vasovagal Syncope Level 2: Possibly Efficacious

The field continues to explore new modalities of biofeedback, including neurofeedback using fMRI, respiration using end
tidal carbon monoxide measurement and oxygen saturation levels, and hemoencephalograpy. The field is also striving to
develop new dimensions of clinical treatment and enhancement of health, well-being and performance. Some examples
include procedures to enhance treatment of individuals with intellectual disability, schizophrenia, essential tremor, visual
disorders, psoriasis, skin ulcers, scoliosis, sickle-cell crises (M. S. Schwartz & F. Andrasik, 2016b)

References for Criterion V:

Alhasan, H., Hood, V., & Mainwaring, F. (2017). The effect of visual biofeedback on balance in elderly population: A
systematic review. Clin Interv Aging, 12, 487-497. doi:10.2147/CIA.S127023
cia-12-487 [pii]
Arena, J. G., & Schwartz, M. (2016). Introduction to Psychophysiological Assessment and Biofeedback Baselines. In
M. S. Schwartz & F. Andrasik (Eds.), Biofeedback: A Practitioner's Guide (4th Ed.) (pp. 128-153). New
York: Guilford Press.
Bartlett, L., Sloots, K., Nowak, M., & Ho, Y. H. (2011). Biofeedback for fecal incontinence: A randomized study
comparing exercise regimens. Dis Colon Rectum, 54(7), 846-856. doi:10.1007/DCR.0b013e3182148fef
00003453-201107000-00013 [pii]
Cherniack, E. P. (2006). Biofeedback and other therapies for the treatment of urinary incontinence in the elderly. Altern
Med Rev, 11(3), 224-231.
Culbert, T., & Banez, G. A. (2016). Pediatric Applications. In M. S. Schwartz & F. Andrasik (Eds.), Biofeedback: A
practitioner's guide (4th ed.) (pp. 629-650). New York: Guilford Press.
1743-0003-11-53 [pii]
Jorgensen, M. G. (2014). Assessment of postural balance in community-dwelling older adults - methodological aspects
and effects of biofeedback-based Nintendo Wii training. Dan Med J, 61(1), B4775. doi:B4775 [pii]
Khazan, I. (2009). Psychophysiological stress assessment using biofeedback. J Vis Exp(29). doi:10.3791/1443
1443 [pii]
Khazan, I. (2013). The clinical handbook of biofeedback: A step-by-step guide for training and practice with
mindfulness. West Sussex, UK: Wiley-Blackwell.
Khazan, I. (2016). Overview of Biofeedback. In G. Tan, F. Shaffer, R. Lyle, & I. Teo (Eds.), Evidence-based practice
in biofeedback and neurofeedback (pp. 1-6). Wheat Ridge, Co: Association for Applied Psychophysiology and
Biofeedback.
La Vaque, T. J., Hammond, D. C., Trudeau, D., Monsastra, V., Perry, J., & Lehrer, P. (2002). Template for developing
guidelines for the evaluation of the clinical efficacy of psychophysiological interventions. Applied
Psychophysiology and Biofeedback, 27(4), 273-281.
Lehrer, P. M., Vaschillo, E., Vaschillo, B., Lu, S. E., Scardella, A., Siddique, M., & Habib, R. H. (2004). Biofeedback
treatment for asthma. Chest, 126(2), 352-361. doi:10.1378/chest.126.2.352
S0012-3692(15)31143-0 [pii]
Moss, D., & Shaffer, F. (2016). Foreword: Evidence-Based Practice in Biofeedback and Neurofeedback. In G. Tan, F.
Shaffer, R. Lyle, & I. Teo (Eds.), Evidence-based practice in biofeedback and neurofeedback (3rd ed.). Wheat
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Ridge, CO: Association for Applied Psychophysiology and Biofeedback.
Nada, P. J. (2009). Heart rate variability in the assessment and biofeedback training of common mental health problems
in children. Med Arh, 63(5), 244-248.
Peek, C. J. (2016). A Primer of Traditional Biofeedback Instrumentation. In M. S. Schwartz & F. Andrasik (Eds.),
Biofeedback: A practitioner's guide (4th ed.) (pp. 35-67). New York: Guilford Press.
Peper, E., Wilson, V. S., Gibney, K. H., Huber, K., Harvey, R., & Shumay, D. M. (2003). The integration of
electromyography (SEMG) at the workstation: Assessment, treatment, and prevention of repetitive strain
injury (RSI). Appl Psychophysiol Biofeedback, 28(2), 167-182.
PED2978 [pii]
Schwartz, M. (2016). Intake and Preparation for Intervention. In M. S. Schwartz & F. Andrasik (Eds.), Biofeedback: A
practitioner's guide (4th ed.) (pp. 217-232). New York: Guilford Press.
Schwartz, M. S., & Andrasik, F. (2016a). Biofeedback: A practitioner's guide (4th ed.). New York: Guilford Press.
Schwartz, M. S., & Andrasik, F. (2016b). More Frontiers and Further Forward. In M. S. Schwartz & F. Andrasik
(Eds.), Biofeedback: A practitioner's guide (4th ed.) (pp. 717-738). New York: Guilford Press.
Shaffer, F. (2018). Biofeedback Tutor. Kirksville, MO: Biosource Software.
Sherman, R. A. (2012). Pain: Assessment & intervention from a psychophysiological perspective (2nd ed.). Wheat
Ridge, CO: Association for Applied Psychophysiology and Biofeedback.
Simon, M. A., & Bueno, A. M. (2017). Efficacy of biofeedback therapy in the treatment of dyssynergic defecation in
community-dwelling elderly women. J Clin Gastroenterol, 51(10), e90-e94.
doi:10.1097/MCG.0000000000000794
Tan, G., Shaffer, F., Lyle, R., & Teo, I. (2016). Evidence-based practice in biofeedback and neurofeedback 3rd ed.).
Wheat Ridge, CO: Association for Applied Psychophysiology and Biofeedback.
Yucha, C., & Montgomery, D. (2008). Evidence-based practice in biofeedback and neurofeedback (2nd ed.). Wheat
Ridge, CO: Association for Applied Psychophysiology and Biofeedback.

Education and Training

Criterion VI. Initial acquisition of knowledge and skills. A proficiency is acquired through a defined
program of study and training that enables psychologists to develop the necessary competence to use
this proficiency.

Commentary: Education and training in a proficiency may occur at the doctoral or postdoctoral
level or through an organized continuing education program. Irrespective of when it is offered,
education and training in a proficiency is of a sequential, integrated nature with organized
oversight of didactic and appropriate supervised experience related to the knowledge base and skill
sets distinctive to the proficiency. Background of relevant competencies of faculty/instructors are
described as well as learner evaluation procedures. In addition, there are organizational
mechanisms in place that provide oversight and coordination of the education and training in the
proficiency. When education and training in a proficiency is achieved through interdisciplinary
study, organization/s(s) responsible for the proficiency will describe how the proficiency meets the
criteria within the context of interdisciplinary education and training. If the proficiency is
interdisciplinary be sure to highlight the training component that is specifically relevant to
psychologists.

1. Identify the type of organization or consortium of organizations that provide oversight of education and training
programs in the proficiency.

AAPB is an APA-approved continuing education provider. The Annual Scientific Meeting receives CME credit
approval with oversight from AMEDCO.

AAPB encourages and supports the process of certification of this proficiency through Biofeedback Certification
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International Alliance (BCIA). BCIA offers certification in four distinct areas: Biofeedback (all peripheral
modalities), Heart Rate Variability Biofeedback, Neurofeedback (specific to brain wave training), and pelvic
muscle dysfunction biofeedback (using SEMG biofeedback specifically for elimination disorders and chronic
pelvic pain). Given the burgeoning use of HRV biofeedback, they are also promoting a heart-rate variability
certificate of completion program (https://www.bcia.org/i4a/pages/index.cfm?pageid=3719).

Appendices L & M lists BCIA’s blueprints of knowledge for biofeedback and neurofeedback, which outlines the
science, history, and theory of the specific biofeedback modality being used. Additionally, we have attached the
Essential Skills Checklists (Appendices N & O) and Mentoring Guidelines (Appendices P & Q), which define the
process of learning the application of clinical skills. Also attached is the BCIA Requirements for certification in
Biofeedback and Neurofeedback (Appendices R & S), outlining the steps that describe the rigorous process
involved in becoming BCIA-certified. This process includes completion of didactic training, a course in human
anatomy/physiology or neuroanatomy, an intensive mentorship program working with a BCIA-approved mentor,
and passing a standardized exam.

Describe how the oversight organization/s:

• Defines the learning objectives in terms of competencies within the proficiency, and ensures that these
learning objectives are assessed as program outcomes;

AAPB is an APA-accredited CE provider in compliance with standards and requirements. All training offered,
requires the submission of at least five measurable objectives for approval. A post event electronic evaluation
assesses the attendees’ feedback on whether the course offering met the published objectives. We issue an
annual report to the APA and are on a 5-year renewal process.

AMEDCO audits all AAPB annual meeting content for CME credit issuance compliance with AMA
requirements.

BCIA certification defines learning objectives for the core competencies needed to be proficient in Biofeedback,
Heart Rate Variability Biofeedback, Neurofeedback, and Pelvic Muscle Dysfunction Biofeedback, each with its
own curriculum, mentoring process, and final exam (https://www.bcia.org/i4a/pages/index.cfm?pageid=3352).

• Develops curriculum guidelines regarding the didactic and supervised practice experiences required to
acquire competence in the proficiency. These shall include the content areas to be addressed, the
populations worked with, and the procedures undertaken; and,

AAPB endorses BCIA’s didactic plan regarding knowledge, practical skills, mentoring guidelines, and
requirements for certification (https://www.bcia.org/i4a/pages/index.cfm?pageid=3373). At this time, neither
AAPB nor BCIA require specific populations to be targeted as part of training. This is in part due to the nature
of biofeedback which serves a number of disciplines. Many individuals seeking certification already have
established practices targeting specific disciplines and populations. Thus, the role of mentoring is included to
ensure that learners have an opportunity both from broad-based training as well as specific discussion to
properly apply biofeedback knowledge and skills to their specific clinical population.

• Provides to CRSPPP, the Board of Educational Affairs, and APA members on a regular, periodic basis an
update of the knowledge base, documentation of evidenced-based practice developments, and education
and training program outcomes in the proficiency.

As an APA provider of continuing education, AAPB provides regular updates on educational offerings as a
means of maintaining its accreditation.

In addition, AAPB, in concert with BCIA, regularly reviews knowledge base and training relevant to the field of
applied psychophysiology and biofeedback. We identify any gaps in education and then adjust our offerings to
ensure those deficiencies are addressed in future publications, webinars, conferences, and other educational
opportunities.
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AAPB regularly reviews and updates it publication Evidence-based Practice in Biofeedback and
Neurofeedback.” The current cycle is six years, with the next edition expected in 2021.

BCIA regularly reviews its certification processes and updates curriculum and examinations as needed.

3. Provide examples of the kinds of settings where education and training for the proficiency is acquired (e.g.,
residency, postdoctoral training experience, continuing education, didactic and experiential sequence in a
doctoral program).

Often, training in foundational concepts are provided at the undergraduate and graduate level. Formal exposure to
clinical applications using biofeedback is provided at the graduate level, in some residency and postdoctoral
programs, and in supervised work (examples included courses by Alliant International University/California
School of Professional Psychology, Saybrook University, Truman University and Brigham Young University, see
https://www.bcia.org/i4a/pages/index.cfm?pageid=3428. These are often provided by institutions which provide
APA accredited education. However, BCIA accredits the formal didactic education courses required for
certification to ensure they cover the science as outlined in the blueprint of knowledge statements.

Two examples, CSPP/Alliant University and Widener University provide a way for student to gain their BCIA-required
didactic and mentoring experiences as part of a degree program. Both institutions adhere to BCIA guidelines for
training and evaluation. In addition, internship programs such as Mississippi State Hospital provide a rotation in
biofeedback.

Dr. Fredric Shaffer (current Treasurer of AAPB and Treasurer of BCIA) has developed digital platforms to assist with
knowledge acquisition of biofeedback:
Shaffer, F. (2018). Biofeedback tutor. Kirksville, MO: Biosource Software. (see
https://www.biosourcesoftware.com/biofeedback-tutor-2/)
Shaffer, F. (2018). HRV biofeedback tutor. Kirksville, MO: Biosource Software. (see
https://www.biosourcesoftware.com/hrv-tutor/)

AAPB and other like-minded associations offer continuing education in live delivery format, in-person at annual
conferences, hands-on and didactic training, and live and recorded webinars (AAPB educational recordings are not
valid for CE credit but are offered as reference materials to members). BCIA accepts all APA approved CE credits
as applicable to their standards.

BCIA also has detailed curriculum guidelines and mentoring processes for training in this proficiency (see
Appendices N, O, P & Q).

4. Describe the types of mechanisms that programs offering education and training in the proficiency use to ensure
oversight and coordination of a program of study in the proficiency.

Many of the programs mentioned above use the BCIA blueprint as a syllabus or course outline and the BCIA mentoring
guidelines as a framework for hands-on training to provide the clinical skills (Appendices L & M). Additionally, the
BCIA core reading list for biofeedback and neurofeedback may serve universities and training programs as required for
suggested reading to develop clinical mastery.

Additionally, AAPB education oversight and coordination mechanisms are summarized as follows:

• Doctoral level practitioners involved in the development of the educational content

• Necessary learning objectives for each offering and all additional APA required information audited before
session approval
• Copyright clearance to protect against the use of content that could infringe upon individual and/or
organizational proprietary or confidential information
• Enforcement of our grievance policy, if necessary, to ensure that the appropriate parties and documentation
are followed
• Blind review of educational proposal submissions to ensure the maintenance of cultural and knowledge-based
diversity is respected and maintained
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• All Americans with Disabilities Act requirements for all programs and events
• Appropriate process of meeting and maintaining all APA standards and requirements for all educational
programs sponsored or co-sponsored by AAPB

Each AAPB conference and/or webinar attendee receives an email with a link to an online evaluation form. Evaluations
are tabulated electronically with the quantitative scores and comments provided for each session. Completion of an
evaluation is required before issuance of a CE certificate of attendance. Upon completion of the participant evaluation
data (responses to competency and satisfaction questions), the information is shared with the AAPB Education
Committee/ Program Planning Committee, depending on the type of program provided. The evaluation data is then
shared with the appropriate committee to assess the level of learning that was achieved by the participants resulting
from the CE program. Both qualitative data and comments are reviewed carefully extracting information useful in
developing future CE program offerings, including potential topics, research data/findings, empirical data related to the
use of biofeedback and/or neurofeedback equipment, speakers and/or knowledgeable contacts pertinent to various
topics, specific content areas either missed in the presentation or needing expansion for future events, and potential
gaps in programming needs. Upon completion of the post tests, the exam items and responses are reviewed by the
AAPB Education Committee to determine whether the testing instrument was a good evaluation of the material
presented and additionally whether the learning objectives were met.

5. Describe how the program sponsor ensures that psychology trainees enrolled in the program have completed, or are in
the process of completing, their education and training in the scientific and applied professional foundations of the
profession.

AAPB is in compliance with APA established procedures of reviewing offerings for prerequisite requirements,
educational objectives, and learning goals as demonstrated by the completion of an exam and an evaluation.
Evaluations are reviewed per learning opportunity and evaluated for deficiencies or opportunities which are then built
into future programs. When a university offers curricula based on BCIA requirements, BCIA offers a review of their
syllabus and course outlines to ensure that their trainings are modeled on their blueprints. Additionally, some
universities use BCIA certification exams as an objective test toward successfully completing their program.

6. Describe the qualifications necessary for faculty who teach in these programs.

Faculty are invited based on their body of work and reputation in their area of competency or are selected on the basis
of a peer review. Each faculty member is required to submit a biographical sketch and their CV which include their
education, training, publication and experience that would make them an appropriate instructor specific to the topic.
Because of the varied professional background of those who may be considered experts in the field, we work to ensure
that our faculty can demonstrate professional competence in their respective area of biofeedback.

7. Describe how the program sponsor ensures that all promotional materials have accurate and complete information,
including how potential participants can obtain detailed information about program requirements, goals, objectives, etc.

As an APA-accredited CE provider, we adhere to the requirements as outlined by APA. All promotional materials are
built to incorporate best clinical, professional, and business practices and all learning objectives are clearly stated. A
sample of this year’s educational opportunities is included in Appendix E and F.

8. What qualifications are sought for student admission?

Student members of AAPB are required to provide appropriate documentation regarding student status. Because
biofeedback is a multi-modality proficiency, we recognize students from a wide variety of backgrounds that would
include but not be limited to psychology, medicine, physical or occupational therapy, or even those with a background
that would be well suited for research.

9. Describe how program sponsors provide data on attainment of competence in the proficiency program by participants
as defined by standards set by those responsible for program oversight of the proficiency. This will include both short
and long-term data on program outcomes.

AAPB, an APA-accredited CE provider, has a process of examination and evaluation after each offering. These
evaluations are reviewed to ensure that all learning objectives were attained and the exams demonstrate successful
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delivery of the promised material.

BCIA requires evaluations to be submitted within a short period of didactic course attendance. Evaluations are
reviewed to see if there are trends for positive or negative statements and then are compared to certification exam
performance. Each training provider, including universities, is notified if there is something that needs addressed,
either in accordance with student comments or exam performance that could be tied to a specific program.

10. Describe how program sponsors ensure that the curriculum addresses: (a) ethical decision making and practice, (b)
issues of cultural and individual diversity, and (c) the most current information on evidence-based practice as that
construct is defined by APA policy.

A) Aspects of ethical decision making and practice are built into curriculum. As an example, please reference the
BCIA knowledge guidelines and mentoring activities (Appendices L, M, P, & Q). A large percentage of our
members and course attendees are licensed health care professionals who are required to take continuing education
related to ethics or professional as part of the maintenance of their state-issued licenses. We recognize that many
of these individuals take their ethics coursework outside of AAPB. We do, however, strive to offer various
programs throughout the year. For example, we recently offered a two-part webinar entitled Professional Conduct
in Biofeedback and Neurofeedback: An Overview. In addition, most annual scientific meetings include an APA
accredited ethics presentation.
B) BCIA includes ethics and professional standards as part of the required didactic training for certification.
Additionally, there is a 3-hours of ethics coursework required for recertification. The standards must be met every
four years in order to maintain certification. The certificant may select course offerings that are sponsored by their
national professional organization or they may choose courses offered by AAPB, ISNR, or other accredited
academic institutions. In addition, a home study program may be deemed acceptable, provided the certificant
complete some form of evaluation. Again, BCIA accepts all APA approved CE credits as applicable to their
standards.
C) AAPB makes significant effort to ensure that the most current information is provided in training activities. This
is in part accomplished by publication and dissemination of evidence-based practice in biofeedback and
neurofeedback, as well as relevant white papers regarding clinical practice. In addition, most of these
professionals are responsible, not only to the ethics requirements of BCIA or AAPB; they must also meet their
national and/or state licensing board standard which clearly outline and identify requirements to maintain the
practice.

References for Criterion VI:

No additional references in this section.

Criterion VII. Maintenance of Competence. The organization (s) seeking recognition for the
proficiency is responsible for identifying or providing its practitioners with regularly scheduled
opportunities for continuing professional development in the proficiency practice and assessing
knowledge and skills.

Commentary: This criterion requires that petitioners articulate what continuing education may be
necessary to maintain competency in the proficiency, particularly given the rapidly increasing and
ever-changing research and information related to the proficiency. The petition should specify
which mechanisms are used to achieve these goals.

1. Describe the opportunities for additional continuing professional development and continuing education in the
proficiency practice. Provide detailed examples.

There is a wide range of opportunities for continuing professional development and continuing education in the
specialty field of biofeedback:
A) Assistance with basic training courses (e.g., https://www.bcia.org/i4a/pages/index.cfm?pageID=3427)
B) Webinars (see Appendix F for examples)
C) Mentoring opportunities
D) Preconference Workshops (see Appendix E for example)
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E) Annual conferences (AAPB, ISNR, BFE) (see Appendix E for example)
F) Regional conferences (e.g., https://nrbs.org/annual-conference/)

There continues to be empirical literature (discussed above) for informal ongoing education:
G) Biofeedback (Magazine)
H) Applied Psychophysiology and Biofeedback (Journal)
I) Biofeedback: A Practitioner’s Guide, 4th Edition (M. S. Schwartz & F. Andrasik, 2016a)
J) Evidence-based Practice in Biofeedback and Neurofeedback, 3rd Edition (Tan, et al., 2016)

All of these educational opportunities were designed to reach across a wide range of disciplines, client bases, and
disorders to deliver continuing education that will enhance clinical practice and effective patient outcomes.

2. Describe the formal requirements for additional continuing professional development and continuing education in the
proficiency and recognition of practitioners. What credits are required?

BCIA monitors requirements needed for continuing education and proficiency, in order to maintain certification.
Certificants are required to document at least 48 hours of accredited, blueprint-relevant continuing education,
including at least 3 hours of ethics training to maintain their certification for an additional four years.
(https://www.bcia.org/i4a/pages/index.cfm?pageid=3716)

Most practitioners and members of AABP are also licensed health care professionals who are required to pursue
continuing education to maintain their license. Other national organizations or licensing boards document their
continuing education. These requirements vary by organization, state, and board.

3. Describe how the assessment of an individual's professional development and continuing education as it relates to
initial competency or the maintenance of competency is accomplished in the proficiency.

BCIA has provided a roadmap for any individual interested in pursuing certification—both for those entering the field
at an entry level and those who may have prior experience. This includes validation of license to practice,
documentation of advanced, accredited, blueprint-relevant continuing education including an approved didactic course,
documentation of patient contact hours using the modality, anatomy or neuroanatomy course work, mentoring
experience, and completion of the certification exam (https://www.bcia.org/i4a/pages/index.cfm?pageid=3636).

BCIA monitors certificants. Individuals must document continuing education (stated above) every four years to
maintain certification. Certification may also be removed, such as following state removal of license for a complaint or
violation.

AAPB provides two additional resources to support the level of competency in the field.

First, AAPB has approved the development of a new fellowship recognition level to identify those individuals who
have documented continued expert competency in this proficiency.

New Fellow designation in development: AAPB members with advanced degrees in education, health,
optimal performance, and science-related fields from nationally, internationally, and/or regionally-
accredited universities and/or with state-issued educational or healthcare licenses may qualify as an
AAPB Fellow if they:

(1) Document 12 hours of relevant professional CE per year for the last 4 years (minimum of 48 hours),
which could include:

- completion of nationally, internationally, and/or regionally-accredited university courses

- enrollment in professional state, regional, and/or national meeting presentations, and
professional webinars
- professional instruction of a regionally-accredited university course
- professional meeting presentations
- authorship or editorship of a book, book chapter, or journal article
- completion of a master’s or doctoral dissertation
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- BCIA-approved mentorship

(2) Commit to follow AAPB’s Ethical Principles and Bylaws

The AAPB Board of directors approved this plan on October, 11, 2018. The official launch will be late
December 2018/early January 2019.

Enforcement of Ethical standards: AAPB also provides additional ethics resources for individuals who do not
adhere to the proficiency. As stated in the Code of Ethics (Appendix J):

“When a complaint is made, the AAPB Ethics Committee shall use these ethical principles in evaluating
the AAPB member's conduct. The Ethics Committee shall recommend appropriate additions, deletions or
revisions to these Ethical Principles, as necessary, to the AAPB Board for approval. Thereafter the
membership of the AAPB shall be required to adhere to the revised Ethical Principles.”

“The major concerns of the Ethics Committee of AAPB are to protect the public against unethical practices
by AAPB members and to educate the membership concerning acceptable ethical practice. The committee
attempts to have complaints resolved by the ethics committee of a member's profession whenever possible.

AAPB's Ethical Principles are intended to educate and guide members to prevent ethical misconduct and
should be applied with professional maturity. AAPB encourages complainants to discuss and attempt to
resolve alleged ethical concerns with accused members or applicants. Ethical complaints against an AAPB
member or applicant must be written, signed, and dated by the complainant. When AAPB receives an
ethics complaint, its Executive Director will record the complaint and will write a letter to the complainant
that will describe AAPB's role in ethics cases, encourage the complainant to directly discuss the complaint
with the member or applicant, and if requested by the complainant, identify institutional, state, and/or
national regulatory authorities with jurisdiction.

When that avenue fails, is inappropriate, or when the AAPB member is not professionally licensed or
certified, the committee attempts to resolve complaints privately and informally and to recommend
disciplinary action when unethical conduct is found to exist.

Since AAPB’s approach to ethical issues is educational, it will not recommend that complainants contact
these authorities nor will it represent complainants before these agencies.

The goal of the ethics committee is to be constructive and educative, rather than punitive. The committee
will attempt to have the complaint resolved by the local or state biofeedback society if one exists. When a
complaint is received, the formal procedures of the AAPB will be followed.

Where a regulatory authority officially determines that an AAPB member or applicant has acted
unethically when providing academic, research, clinical, and/or optimal performance services, or when an
individual has misrepresented information during application or membership renewal, the AAPB Board
may revoke or refuse the individual's membership. An AAPB member or applicant may reapply if the
regulatory authority reverses its determination or declares that the individual has satisfied the terms of
probation.”

Together, AAPB and BCIA provide comprehensive programming for initial education, continuing professional
education, recognition of expertise, and safeguards against unethical or uninformed actions that does not represent this
proficiency.

References for Criterion VII:

Schwartz, M. S., & Andrasik, F. (2016). Biofeedback: A practitioner's guide (4th ed.). New York: Guilford Press.

Tan, G., Shaffer, F., Lyle, R., & Teo, I. (2016). Evidence-based Ppractice in biofeedback and neurofeedback (3rd
ed.). Wheat Ridge, CO: Association for Applied Psychophysiology and Biofeedback.
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Evaluation and Assessment

Criterion VIII. Effectiveness. A proficiency demonstrates the effectiveness of the distinct
procedure(s), technique(s), or applied skill set(s) that comprise the proficiency with evidence
consistent with the APA 2005 Policy on Evidence-based Practice.

Commentary: A body of evidence is to be presented that demonstrates the effectiveness of the

proficiency with appropriate problems and populations and documents the best available research.

1. Summarize evidence of the effectiveness of the proficiency, utilizing the published literature, manuscripts published in
refereed journals (or equivalent), outcome studies, practice guidelines, consumer satisfaction surveys, etc., that
demonstrate the efficacy of the proficiency. The manuscripts cited should be relevant to the proficiency, drawn
from a variety of sources and inform the practice of the proficiency.

AAPB and BCIA are responsibly forwarding the evidence base for both psychosocial and physical problems
addressed by biofeedback. This began with an AAPB Task Force formed to identify a standard for evaluating
evidence to treat conditions (La Vaque, et al., 2002), which identified the following levels of efficacy:
Level 1: Not empirically supported. Supported only by anecdotal reports and/or case studies in non peer-
reviewed venues.
Level 2: Possibly Efficacious. At least one study of sufficient statistical power with well identified outcome
measures, but lacking randomized assignment to a control condition internal to the study.
Level 3: Probably Efficacious. Multiple observational studies, clinical studies, wait-list controlled studies, and
within-subject and intrasubject replication studies that demonstrate efficacy.
Level 4: Efficacious.
a) In a comparison with a no-treatment control group, alternative treatment group, or sham
(placebo) control utilizing randomized assignment, the investigational treatment is shown to be
statistically significantly superior to the control condition or the investigational treatment is
equivalent to a treatment of established efficacy in a study with sufficient power to detect
moderate differences,
b) The studies have been conducted with a population treated for a specific problem, for whom
inclusion criteria are delineated in a reliable, operationally defined manner,
c) The study used valid and clearly specified outcome measures related to the problem being
treated,
d) The data are subjected to appropriate data analysis,
e) The diagnostic and treatment variables and procedures are clearly defined in a manner that
permits replication of the study by independent researchers, and
f) The superiority or equivalence of the investigational treatment have been shown in at least two
independent research settings.
Level 5: Efficacious and Specific. The investigational treatment has been shown to be statistically superior to
credible sham therapy, pill, or alternative bona fide treatment in at least two independent research settings.

AAPB has dedicated much of its resources to supporting the aggregation and representation of efficacy of biofeedback
and applied psychophysiology. Appendix I details the most recent findings in the 2016 publication “Evidence-based
Practice in Biofeedback and Neurofeedback, 3rd Edition”. This is a shared effort of many leaders in the field,
thoroughly reviewed by editors and peer reviewers. Below are those conditions currently with supporting evidence and
summarized in the Evidence-based practice in Biofeedback and Neurofeedback, 3rd Edition (Tan, et al., 2016):

Condition Level of Efficacy

Adult Headache Level 4: Efficacious
Attention Deficit Hyperactivity Disorder (ADHD) Level 5: Efficacious and Specific
Alcohol/substance Use Disorders Level 3: Probably Efficacious
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Anxiety and Anxiety Disorders Level 4: Efficacious
Arthritis Level 3: Probably Efficacious
Asthma Level 3: Probably Efficacious
Autism Level 3: Probably Efficacious
Cerebral Palsy Level 2: Possibly Efficacious
Cognitive decline after chemotherapy Level 3: Probably Efficacious
Chronic Pain (orofacial pain, noncardiac chest pain, posture- Level 4: Efficacious
related pain)
Chronic Pain (muscle-related low-back pain, phantom limb pain, Level 3: Probably Efficacious
pelvic floor pain, subluxation of the patella and patellofemoral
pain, cancer pain)
Chronic Pain (carpal tunnel pain, myofascial pain, whiplash, Level 2: Possibly Efficacious
dysmenorrhea, muscle spasms)
Chronic Pain (overuse of muscles, reflex sympathetic dystrophy Level 1: Not Empirically Supported
or complex regional pain syndrome, trigeminal neuralgia)
Constipation Level 4: Efficacious
Coronary Artery Disease Level 2: Possibly Efficacious
Depressive Disorders Level 4: Efficacious
Diabetes (Glycemic Control) Level 4: Efficacious
Diabetes (Intermittent Claudication) Level 2: Possibly Efficacious
Diabetes (Diabetic ulcers) Level 3: Probably Efficacious
Epilepsy Level 4: Efficacious
Erectile Dysfunction Level 4: Efficacious
Facial Palsy Level 3: Probably Efficacious
Fecal Incontinence Level 4: Efficacious
Fibromyalgia Level 3: Probably Efficacious
Functional/Recurrent Abdominal Pain Level 2: Possibly Efficacious
Hyperhidrosis Level 2: Possibly Efficacious
Hypertension Level 4: Efficacious
Immune Function Level 2: Possibly Efficacious
Insomnia Level 3: Probably Efficacious
Irritable Bowel Syndrome Level 4: Efficacious
Motion Sickness Level 3: Probably Efficacious
Performance Enhancement Level 3: Probably Efficacious
Preeclampsia Level 4: Efficacious
Posttraumatic Stress Disorder Level 3: Probably Efficacious
Raynaud’s Disease Level 4: Efficacious
Repetitive Strain Injury Level 2: Possibly Efficacious
Stroke Level 2: Possibly Efficacious
Temporomandibular Muscle and Joint Disorder Level 4: Efficacious
Tinnitus (using biofeedback) Level 3: Probably Efficacious
Tinnitus (using neurofeedback) Level 2: Possibly Efficacious
Traumatic Brain Injury and Post-traumatic Stress Disorder Level 3: Probably Efficacious
Urinary Incontinence in Children Level 3: Probably Efficacious
Urinary Incontinence in Men Level 3: Probably Efficacious
Urinary Incontinence in Women Level 3: Probably Efficacious
Vasovagal Syncope Level 2: Possibly Efficacious

It should be noted that AAPB is already working on an update to be published in 2021, as new research
continues to emerge and evolve in the practice of biofeedback and neurofeedback. Some examples of research to
be reviewed by experts in the field and summarized (if valid) in a future publication:

Ahadi, T., Taghvadoost, N., Aminimoghaddam, S., Forogh, B., Bazazbehbahani, R., & Raissi, G. R. (2017).
Efficacy of biofeedback on quality of life in stages I and II pelvic organ prolapse: A Pilot study. Eur J Obstet
Gynecol Reprod Biol, 215, 241-246. doi:S0301-2115(17)30300-7 [pii]
10.1016/j.ejogrb.2017.06.023
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Blase, K. L., van Dijke, A., Cluitmans, P. J., & Vermetten, E. (2016). [Efficacy of HRV-biofeedback as additional
treatment of depression and PTSD]. Tijdschr Psychiatr, 58(4), 292-300. doi:TVPart_10828 [pii]
Cheon, E. J., Koo, B. H., & Choi, J. H. (2016). The Efficacy of neurofeedback in patients with Major Depressive
Disorder: An open labeled prospective study. Appl Psychophysiol Biofeedback, 41(1), 103-110.
doi:10.1007/s10484-015-9315-8
10.1007/s10484-015-9315-8 [pii]
Collins, J., Mazor, Y., Jones, M., Kellow, J., & Malcolm, A. (2016). Efficacy of anorectal biofeedback in
scleroderma patients with fecal incontinence: A case-control study. Scand J Gastroenterol, 51(12), 1433-1438.
doi:10.1080/00365521.2016.1218537
Forootan, M., Shekarchizadeh, M., Farmanara, H., Esfahani, A. R. S., & Esfahani, M. S. (2018). Biofeedback
efficacy to improve clinical symptoms and endoscopic signs of solitary rectal ulcer syndrome. Eur J Transl
Myol, 28(1), 7327. doi:10.4081/ejtm.2018.7327
Ghahramani, L., Mohammadipour, M., Roshanravan, R., Hajihosseini, F., Bananzadeh, A., Izadpanah, A., &
Hosseini, S. V. (2016). Efficacy of biofeedback therapy before and after sphincteroplasty for fecal
incontinence because of obstetric injury: A randomized controlled trial. Iran J Med Sci, 41(2), 126-131.
Gong, B. Y., Ma, H. M., Zang, X. Y., Wang, S. Y., Zhang, Y., Jiang, N., . . . Zhao, Y. (2016). Efficacy of cranial
electrotherapy stimulation combined with biofeedback therapy in patients with functional constipation. J
Neurogastroenterol Motil, 22(3), 497-508. doi:10.5056/jnm15089
jnm15089 [pii]
Gonzalez-Castro, P., Cueli, M., Rodriguez, C., Garcia, T., & Alvarez, L. (2016). Efficacy of neurofeedback versus
pharmacological support in subjects with ADHD. Appl Psychophysiol Biofeedback, 41(1), 17-25. doi:
0.1007/s10484-015-9299-4
10.1007/s10484-015-9299-4 [pii]
Jokubauskas, L., & Baltrusaityte, A. (2018). Efficacy of biofeedback therapy on sleep bruxism: A systematic
review and meta-analysis. J Oral Rehabil, 45(6), 485-495. doi:10.1111/joor.12628
Leung, K. C., Quinn, R. R., Ravani, P., & MacRae, J. M. (2014). Ultrafiltration biofeedback guided by blood
volume monitoring to reduce intradialytic hypotensive episodes in hemodialysis: Study protocol for a
randomized controlled trial. Trials, 15, 483. doi:10.1186/1745-6215-15-483
1745-6215-15-483 [pii]
Lewis, G. F., Hourani, L., Tueller, S., Kizakevich, P., Bryant, S., Weimer, B., & Strange, L. (2015). Relaxation
training assisted by heart rate variability biofeedback: Implication for a military predeployment stress
inoculation protocol. Psychophysiology, 52(9), 1167-1174. doi:10.1111/psyp.12455
Lin, I. M., Ko, J. M., Fan, S. Y., & Yen, C. F. (2016). Heart rate variability and the efficacy of biofeedback in
heroin users with depressive symptoms. Clin Psychopharmacol Neurosci, 14(2), 168-176.
doi:10.9758/cpn.2016.14.2.168
cpn.2016.14.2.168 [pii]
MacIntosh, A., Vignais, N., & Biddiss, E. (2017). Biofeedback interventions for people with cerebral palsy: A
systematic review protocol. Syst Rev, 6(1), 3. doi: 10.1186/s13643-017-0405-y
10.1186/s13643-017-0405-y [pii]
Markland, A. D., Jelovsek, J. E., Whitehead, W. E., Newman, D. K., Andy, U. U., Dyer, K., . . . Meikle, S. (2017).
Improving biofeedback for the treatment of fecal incontinence in women: Implementation of a standardized
multi-site manometric biofeedback protocol. Neurogastroenterol Motil, 29(1). doi: 10.1111/nmo.12906
Mazor, Y., Ejova, A., Andrews, A., Jones, M., Kellow, J., & Malcolm, A. (2018). Long-term outcome of anorectal
biofeedback for treatment of fecal incontinence. Neurogastroenterol Motil, e13389. doi:10.1111/nmo.13389
McAllister Byun, T. (2017). Efficacy of visual-acoustic biofeedback intervention for residual rhotic errors: A
single-subject randomization study. J Speech Lang Hear Res, 60(5), 1175-1193. doi:10.1044/2016_JSLHR-S-
16-0038
2618451 [pii]
Micoulaud-Franchi, J. A., Salvo, F., Bioulac, S., & Fovet, T. (2016). Neurofeedback in Attention-
Deficit/Hyperactivity Disorder: Efficacy. J Am Acad Child Adolesc Psychiatry, 55(12), 1091-1092. doi:
S0890-8567(16)31739-7 [pii]
10.1016/j.jaac.2016.09.493
Mohagheghi, A., Amiri, S., Moghaddasi Bonab, N., Chalabianloo, G., Noorazar, S. G., Tabatabaei, S. M., &
Farhang, S. (2017). A Randomized trial of comparing the rfficacy of two neurofeedback protocols for
treatment of clinical and cognitive symptoms of ADHD: Theta suppression/beta enhancement and theta
suppression/alpha enhancement. Biomed Res Int, 2017, 3513281. doi:10.1155/2017/3513281
Moore, A., Mannion, J., & Moran, R. W. (2015). The efficacy of surface electromyographic biofeedback assisted
stretching for the treatment of chronic low back pain: A case-series. J Bodyw Mov Ther, 19(1), 8-16. doi:
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10.1016/j.jbmt.2013.12.008
S1360-8592(13)00210-6 [pii]
Moreno-Garcia, I., Meneres-Sancho, S., Camacho-Vara de Rey, C., & Servera, M. (2017). A randomized
controlled trial to examine the posttreatment efficacy of neurofeedback, behavior therapy, and pharmacology
on ADHD measures. J Atten Disord, 1087054717693371. doi: 10.1177/1087054717693371
Nooner, K. B., Leaberry, K. D., Keith, J. R., & Ogle, R. L. (2017). Clinic outcome assessment of a brief course
neurofeedback for childhood ADHD symptoms. J Behav Health Serv Res, 44(3), 506-514.
doi:10.1007/s11414-016-9511-1
10.1007/s11414-016-9511-1 [pii]
Norton, C., Emmanuel, A., Stevens, N., Scott, S. M., Grossi, U., Bannister, S., . . . Knowles, C. H. (2017). Habit
training versus habit training with direct visual biofeedback in adults with chronic constipation: Study protocol
for a randomised controlled trial. Trials, 18(1), 139. doi:10.1186/s13063-017-1880-0
10.1186/s13063-017-1880-0 [pii]
Oktar, T., Donmez, M. I., Ozkuvanci, U., Ander, H., & Ziylan, O. (2018). Animated versus non-animated
biofeedback therapy for dysfunctional voiding treatment: Does it change the outcome? J Pediatr Surg, 53(4),
825-827. doi:S0022-3468(17)30354-8 [pii]
10.1016/j.jpedsurg.2017.06.002
Ozlu, A., Yildiz, N., & Oztekin, O. (2017). Comparison of the efficacy of perineal and intravaginal biofeedback
assisted pelvic floor muscle exercises in women with urodynamic stress urinary incontinence. Neurourol
Urodyn, 36(8), 2132-2141. doi:10.1002/nau.23257
Piaserico, S., Marinello, E., Dessi, A., Linder, M. D., Coccarielli, D., & Peserico, A. (2016). Efficacy of
biofeedback and cognitive-behavioural therapy in psoriatic patients: A single-blind, randomized and
controlled study with added narrow-band ultraviolet B therapy. Acta Derm Venereol, 96(217), 91-95.
doi:10.2340/00015555-2428
Raaben, M., Redzwan, S., Augustine, R., & Blokhuis, T. J. (2018). COMplex Fracture Orthopedic Rehabilitation
(COMFORT) - Real-time visual biofeedback on weight bearing versus standard training methods in the
treatment of proximal femur fractures in the elderly: Study protocol for a multicenter randomized controlled
trial. Trials, 19(1), 220. doi:10.1186/s13063-018-2612-9
10.1186/s13063-018-2612-9 [pii]
Schafer, S. K., Ihmig, F. R., Lara, H. K. A., Neurohr, F., Kiefer, S., Staginnus, M., . . . Michael, T. (2018). Effects
of heart rate variability biofeedback during exposure to fear-provoking stimuli within spider-fearful
individuals: Study protocol for a randomized controlled trial. Trials, 19(1), 184. doi:10.1186/s13063-018-
2554-2
10.1186/s13063-018-2554-2 [pii]
Sielski, R., Rief, W., & Glombiewski, J. A. (2017). Efficacy of biofeedback in chronic back pain: A meta-analysis.
Int J Behav Med, 24(1), 25-41. doi:10.1007/s12529-016-9572-9
10.1007/s12529-016-9572-9 [pii]
Simon, M. A., & Bueno, A. M. (2017). Efficacy of biofeedback therapy in the treatment of dyssynergic defecation
in community-dwelling elderly women. J Clin Gastroenterol, 51(10), e90-e94.
doi:10.1097/MCG.0000000000000794
Tang, J., Huang, Z., Tan, Y., Zhang, N., Tan, A., & Chen, J. (2015). Efficacy of adaptive biofeedback training in
treating constipation-related symptoms. Evid Based Complement Alternat Med, 2015, 959734.
doi:10.1155/2015/959734
Tang, Y., Lin, X., Lin, X. J., Zheng, W., Zheng, Z. K., Lin, Z. M., & Chen, J. H. (2017). Therapeutic efficacy of
neuromuscular electrical stimulation and electromyographic biofeedback on Alzheimer's disease patients with
dysphagia. Medicine (Baltimore), 96(36), e8008. doi:10.1097/MD.0000000000008008
00005792-201709080-00045 [pii]
Taylor, J. B., Nguyen, A. D., Paterno, M. V., Huang, B., & Ford, K. R. (2017). Real-time optimized biofeedback
utilizing sport techniques (ROBUST): A study protocol for a randomized controlled trial. BMC Musculoskelet
Disord, 18(1), 71. doi:10.1186/s12891-017-1436-1
10.1186/s12891-017-1436-1 [pii]
Yu, T., Shen, X., Li, M., Wang, M., & Lin, L. (2017). Efficacy and predictors for biofeedback therapeutic outcome
in patients with dyssynergic defecation. Gastroenterol Res Pract, 2017, 1019652. doi:10.1155/2017/1019652
Zheng, L., Ding, S., Ding, Y., Xue, Y., Zhou, H., Li, M., . . . Wang, J. (2016). [Efficacy analysis of acupuncture
with biofeedback in the treatment of patients with functional anorectal pain]. Zhonghua Wei Chang Wai Ke Za
Zhi, 19(12), 1375-1378. doi:100001882012 [pii]
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It should also be stated that Dr. Steffen, current president of AAPB, has issued a proposal to leaders in the field to develop
strategies to support the findings of these efficacy studies and hopefully the rate at which they are produced. His current
proposal states:

“There is currently a replication crisis in science with only one third of published studies capable of being
replicated. This is true in the health sciences as well as the social sciences. A huge number of studies have
been published that showed promise but nobody else could replicate what was done; therefore, the initial
study was probably inadequately conducted and definitely not generalizable or applicable to real world
settings. Because of the pressure to ‘publish or perish’ many researchers use incomplete research designs,
small sample sizes, and questionable statistical techniques resulting in studies that should not have been
published in the first place.

“The goal of this proposal is to take advantage of the replication crisis in science by leveraging the
membership of AAPB to create studies that have sound research designs, larger samples sizes, and use
appropriate statistical techniques. We can build on existing biofeedback research by developing a network
of researchers and clinicians who have similar biofeedback interests. By having collaborative groups of
biofeedback researchers and clinicians it will be easier to collect larger datasets that will have the
statistical power to demonstrate biofeedback effectiveness. Whereas any single researcher or clinician
may not have the ability to collect a large dataset, combining efforts and working together can result in
statistically powerful studies.

“To facilitate researcher/clinician collaborations, the focus will be on using established biofeedback
protocols that researchers and clinicians located in different geographical areas can employ and collect
similar data. For example, Lehrer’s (2013) HRV biofeedback protocol clearly lays out the process for
conducting HRV biofeedback session by session. When researchers and clinicians follow this protocol,
they can aggregate their data into a larger dataset resulting in more statistical power and more convincing
research studies. The National Institutes of Health frequently uses this approach by creating Program
Projects where researchers around the country receive grants to basically conduct the same study in
different regions of the country, with one large dataset being compiled.

“Three steps to help make this proposal a reality are: 1) identify and connect researchers/clinicians with
similar interests (create interest groups); 2) create a forum where interest groups can interact and work
together (i.e., a listserv); and 3) identify biofeedback protocols that have established validity that interest
groups adopt and follow.”

References for Criterion VIII (other than listed above):

La Vaque, T. J., Hammond, D. C., Trudeau, D., Monsastra, V., Perry, J., & Lehrer, P. (2002). Template for
developing guidelines for the evaluation of the clinical efficacy of psychophysiological interventions. Applied
Psychophysiology and Biofeedback, 27(4), 273-281.

Tan, G., Shaffer, F., Lyle, R., & Teo, I. (2016). Evidence-based practice in biofeedback and neurofeedback (3rd
ed.). Wheat Ridge, CO: Association for Applied Psychophysiology and Biofeedback.

Criterion IX. Quality Improvement. A proficiency promotes ongoing investigations and procedures
to develop further the quality and utility of its applications.

Commentary: The public interest requires the best services possible for consumers. A proficiency,
therefore, continues to seek ways to improve the quality and usefulness of its practitioners' services
beyond its original determination of effectiveness. Such investigations may take many forms.
Petitions describe how the research and practice literatures are regularly reviewed for
developments that are relevant to the proficiency's skills and services, and how this information is
publicly disseminated.
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1. Provide a description of the types of investigations that are designed to evaluate and increase the usefulness of the
applications used in the practice of the proficiency. Estimate the number of researchers conducting these types of
studies, the scope of their efforts, and how your organization and/or other organizations associated with the proficiency
will act to foster these developments. It also is appropriate to provide evidence of current efforts in these areas.

There are currently a number of research groups attempting to evaluate future biofeedback applications
According to ClinicalTrials.gov, there are:

 55 US studies research related to neurofeedback (29 active studies, 20 completed)

 177 US studies completing research related to biofeedback (79 active, 82 completed)

For example:
• There are currently 5 studies at various institutes evaluating the benefit of respiratory or heart rate variability
biofeedback for pediatric asthma.
• There are currently 7 studies at various institutes evaluating the benefit of various modalities of biofeedback
for anxiety and panic.
• There are currently 7 studies at various institutes evaluating the benefit of various modalities of biofeedback
for PTSD.
• There are currently 5 studies at various institutes evaluating the benefit of various modalities of biofeedback
for depression or mood disorders.
• There are currently 9 studies at various institutes evaluating the benefit of neurofeedback for ADHD.

AAPB and BCIA provides a resource for these individuals to share theories as they develop, discuss initial stages
of their research with colleagues, and submit their theories, research findings, and clinical protocols to peer review.

2. Describe how the proficiency seeks ways to improve the quality and usefulness of its practitioners' services beyond its
original determinations of effectiveness.

AAPB and BCIA offer several pathways to improve the quality of practitioners, beyond any determination of
effectiveness of procedures.

1) Publishing outcomes and commentaries on clinical protocols

2) Hosting a listserv to share comments on current science and application, as well as address specific
questions or concerns a practitioner may have.
3) Providing workshops and webinars to teach practitioners and allow them access to directly question the
expert
4) Publishing books and literature on specifics to application of biofeedback principles and treatment
protocols

The AAPB journal, Applied Psychophysiology and Biofeedback Journal (Springer), has an editorial
Board that consists of an editor in chief, Frank Andrasik, PhD and Board chaired by Richard Gevirtz,
PhD, Paul Lehrer, PhD and Christine Hovanitz. It is an indexed journal with a 2013 impact factor of
1,593. All submissions are peer-reviewed by members of the editorial Board as well as outside reviewers
and hold the same scientific rigor as most other indexed journals. Further information about the journal
can be found here: http://www.springer.com/psychology/psychology+general/journal/10484

Recently, the AAPB Board of Directors submitted to the public and practicing professions a cautionary note
towards using physiological monitoring devices that are not standard biofeedback devices or regulated as a Class II
medical device by the FDA as follows:

AAPB Board recommendations for personal use of “biofeedback” hardware, software, and mobile
sensors

AAPB differentiates devices used for biofeedback as:

Bound Systems: Systems that are designed to be used by individuals with limited expertise in
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biofeedback and applied psychophysiology (e.g., reading and interpreting physiological data, designing
evidence-based treatment plans, modifying device for optimal application). Most systems have limited
feedback modalities and limited forms of feedback to the patient/client. Often, comparative data bases are
pre-selected, normative values are assumed, and algorithms generating data for the patient/client are
proprietary. Responsibility for efficiency relies largely on the producer of the equipment. End-users
should take caution interpreting the data. Technicians and healthcare providers using such devices should
follow BCIA code of ethics, as well as all national and state laws related to their professional license.

Unbound Systems: Advanced systems that are designed to be used by individuals with expertise in
biofeedback and applied psychophysiology (e.g., reading and interpreting physiological data, designing
evidence-based treatment plans, modifying device for optimal application). Knowledge of states of body
and brain functioning is required. Not recommended for use by individuals without advanced training in
biofeedback and psychophysiology—certification by BCIA is and national/regional/state licensing board
strongly recommended. Technicians should provide care only under supervision. Systems require elevated
level of administrative and interpretive skill and broad clinical knowledge. Programs, protocols, and
treatment parameters are discrete and determined by individual patient/client need. Progression measures
are often stochastic (compared and contrasted to individualized pretests as well as clinical and normative
data bases).
Mobile applications or unregulated systems: Bound and often unregulated devices sold and used
indiscriminately, often without supporting empirical data. Usually proprietary. Mechanisms of action
frequently undetermined.
Advisory Note:

Biofeedback equipment is classified by the Food and Drug Administration (FDA) as a Class II Medical
Device (www.fda.gov/cdrh/dsma/dsmaclas.html). Medical devices have varying levels of risks and
benefits and the degree of regulation is based on the level of control that the FDA considers being
necessary to assure the safety and effectiveness of the device. There are three levels of classification.
Class I devices have the lowest level of regulation because they present a minimal level of risk for harm.
General controls such as registration, following the Good Manufacturing Practices, and labeling are
considered sufficient for ensuring safety and effectiveness. Class II devices are those for which special
controls are considered necessary by the FDA for assuring safety and effectiveness and where there are
existing methods for providing such assurances. Special controls can include guidance documents, special
labeling requirements, mandatory performance standards, and post market surveillance
(www.fda.gov/cdrh/dsma/dsmaclas.html). Class III devices require the most stringent regulation because
insufficient information exists for assuring safety and effectiveness and these devices are generally those
that support or sustain human life.

Consumers should be advised that certain mobile applications or low to moderately technical devices may
hold themselves out to the public as “biofeedback”, when in fact they are not regulated as such. They may
have poor ability to accurately detect a bodily signal. They may not have research to support the
algorithms of data analysis. They may not have an evidence base that their use can modify individual
functioning in any positive way (or that is does not produce harm). Please be careful when using such
devices and ask a licensed health care provider regarding application of such devices for personal use.

3. Describe how the research and practice literature are regularly reviewed for developments which are relevant to the
proficiency's skills and services, and how this information is publicly disseminated.

As stated above and in the appendices, AAPB and BCIA educate the public and practitioners of updated information
regarding the proficiency regularly through the following:
• Supporting ad advertising updates of the publication “Biofeedback, A Practitioner’s Guide”
• Regularly updating “Evidence-based Practice in Biofeedback and Neurofeedback” (Appendix I)
• AAPB leaders presenting to other organizations about biofeedback (Appendix G)
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• Regularly scheduled Webinars open to the public on AAPB and BCIA websites
• Monthly publications of Applied Psychophysiology and biofeedback (more academic in nature) and
Biofeedback (more practice oriented in nature)
• The AAPB Annual Scientific Meeting is one of the most important platforms to share current research
and best clinical practice. Speakers may be invited because of their recent publication or research. Some
of these same topics, identified by our evaluations, are then reformatted into webinars and publication
articles to be disseminated to a wider audience. AAPB’s state and regional societies also offer
educational opportunities that reflect the best and most current research as described in the literature
today. ISNR has a similar annual meeting to offer the same type of educational opportunities that would
largely impact the neurofeedback community.
• AAPB also educates members when biofeedback-specific organizations worldwide also hold educational
forums. The Biofeedback Foundation of Europe (BFE), the the Applied Neuroscience Society of
Australasia (ANSA) and many country-specific organizations all hold annual scientific meetings to share
the latest research and best practices.

References for Criterion IX:

No additional references in this section.

Criterion X. Guidelines for Proficiency Service Delivery. The proficiency has developed and
disseminated guidelines for practice in the proficiency that expand on the profession's general
practice guidelines and ethical principles 1.

Commentary: Such guidelines are readily available to proficiency practitioners and to members of
the public and describe the characteristic ways in which proficiency practitioners make decisions
about proficiency services and about how such services are delivered to the public.

1. Describe how the proficiency's practitioners assume effective and ongoing communication to members of the discipline
and the public as to the proficiency's practices, practice enhancements, and/or new applications.

Psychologists who are also biofeedback and psychophysiology experts engage in effective and ongoing
communication to the discipline about practices, practice enhancements and new applications through:
- The AAPB website at www.aapb.org, which offers access to:
 Online publications, including our two journals, and publication sales
 Chapter information, where professionals can connect with local resources for referrals and for
peer-to-peer learning.
 Information about certification
 Continuing education online and information about live and teleseminar learning opportunities
 Consumer Alerts and News

- Continuing education
 Annual conference with numerous seminars and workshops
 AAPB Webinars
 Online Reference materials

- Publications including:
 Applied Psychophysiology and Biofeedback, a quarterly, peer-reviewed journal (also accessible
online)

1
In this context, professional proficiency guidelines refer to modes of conceptualization, identification and assessment of
issues, and intervention planning and execution common to those trained and experienced in the practice of the proficiency.
Such professional guidelines may be found in documents or websites including, but not limited to, those bearing such a title
or as described in a variety of published textbooks, chapters, and/or articles focused on such contents.
 Petition Form
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 Biofeedback, a clinical journal published four times a year containing regular and invited
columnists, announcements, and practical articles on treatment, clinical applications and
instrumentation (also accessible online)
 Over 300 titles available in our online bookstore, including E-publications, online courses,
webinar recordings, online magazine subscriptions, and books such as:
• Evidence-Based Practice in Biofeedback and Neurofeedback 3rd Edition, by Gabriel
Tan, Fredric Shaffer, Randall Lyle, and Irene Teo
• Pain: Assessment & Intervention From a Psychophysiological Perspective, 2nd
Edition., by Richard Sherman, PhD
• Biofeedback & Neurofeedback Applications in Sport Psychology, by Benjamin W.
Strack, PhD; Michael K. Linden, PhD; Vietta "Sue" Wilson, PhD
• The Neurofeedback Book, by Michael Thompson and Lynda Thompson
• Biofeedback Mastery: An Experiential Teaching and Self-Training Manual, by Erik
Peper, Hana Tylova, Katherine H. Gibney, Richard Harvey, Didier Combatalade

• Additional learning occurs through other organizations, including the BCIA and the APA.

2. How does your proficiency encourage the development of guidelines of practice?

• Both AAPB and BCIA have established general guidelines of practice (See Appendix K: BCIA
Professional Standards and Ethical Principles of Biofeedback)

• AAPB regularly reviews and publishes leaders in the field who establish guidelines for practice, or
educates the public when AAPB is not the publisher (e.g., (Khazan, 2013; Sherman, 2012)

• Educating the public about and facilitating distribution of updates to the publication “Biofeedback: A
Practitioner’s Guide”

• AAPB regularly updates the book “Evidence-based Practice in Biofeedback Neurofeedback”

• The current president, Dr. Steffen, has developed a proposal to strengthen efficacy studies by developing a
network of researchers and clinicians who have similar biofeedback interests and identify biofeedback
protocols that have established validity that interest groups adopt and follow.

• AAPB published approved guidelines for practice such as:

LaVaque, T.J., Hammond, D.C., Trudeau, D., Monastra, V., Perry, J., Lehrer, P., Matheson, D.,
&Sherman, R. (2002). Template for developing guidelines for the evaluation of the clinical efficacy of
psychophysiological evaluations. Applied Psychophysiology and Biofeedback, 27(4), 273-281.

• Please also see our responses to Criterion V, as many current guidelines have led to the clarification of
practice parameters.

References for Criterion X (other than listed above):

Khazan, I. (2013). The clinical handbook of biofeedbcak: A step-by-step guide for training and practice with
mindfulness. West Sussex, UK: Wiley-Blackwell.

Sherman, R. A. (2012). Pain: Assessment & Intervention From a Psychophysiological Perspective (2nd ed.). Wheat
Ridge, CO: Association for Applied Psychophysiology and Biofeedback.

Criterion XI. Provider Identification and Evaluation. The administrative organization(s)

responsible for the proficiency has sound methods for evaluating competence in the proficiency and
recognizing practitioners who have achieved competency.

Commentary: Identifying psychologists who are competent to practice the proficiency provides a
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significant service to the public. Assessing the knowledge and skill levels of these professionals
helps increase the ability to improve the quality of services provided. Initially practitioners
competent to practice in the proficiency may simply be identified by their successful completion of
an organized sequence of education and training. As the proficiency matures it is expected that the
proficiency will develop more formal structures for the recognition of competency in practitioners.

1. Describe how and by whom the proficiency identifies those who are qualified to practice in the proficiency.

BCIA clearly outlines pre-requisite educational and licensing requirements for their various categories of
certification in biofeedback and neurofeedback (https://www.bcia.org/i4a/pages/index.cfm?pageid=3636).
Certification is differentiated:

• Certification is designed for professionals who work in a health care area, have at least a bachelor's
degree from a regionally-accredited institution in a BCIA-approved area, and plan to treat medical or
psychological disorders under their own license or appropriate legal supervision. This supervisor should
have training and experience with biofeedback and/or neurofeedback, and clinical experience with the
populations and disorders being treated. BCIA offers clinical certification in biofeedback, neurofeedback,
and pelvic muscle dysfunction biofeedback.

• Technician certification is designed for individuals who already have a job and an appropriately BCIA-
certified, licensed supervisor who will guide and take responsibility for their work in accordance with
state law. These individuals will not provide services outside of their supervisors' scope of practice. BCIA
offers technician certification for biofeedback, neurofeedback, and pelvic muscle dysfunction biofeedback
within the United States and Canada.

AAPB and BCIA are firm in these principles:

• Professionals who treat a medical or psychological disorder must carry an appropriate, state-issued license
or if unlicensed, they must agree to work under appropriate supervision.
• All patients/clients must be treated only by those with a scope of practice which includes the ability to
work with this population.
• All practitioners should work only within their area of expertise or should seek supervision.
• All practitioners should only use biofeedback or neurofeedback applications after the demonstration of
entry level competency as is defined by BCIA or demonstrated equivalency.

2. Describe how and by whom the proficiency assesses the competencies of individuals who wish to be identified as
practitioners in this proficiency.

BCIA is the certifying body for the clinical practice of biofeedback. While certification is still voluntary; more
entities are using this credential as the gold standard in the field. BCIA requires 48 hours of accredited continuing
education for recertification which include a minimum of three hours of ethics or professional standards. If a
person does not elect to earn BCIA certification, they may review education and training standards in order to plan
how they may gain this specialized field of study. BCIA-accredited didactic training programs ensure applicants
for certification will learn the fundamental science, history, and theory that is not linked to a specific piece of
equipment or theory.

3. Describe how and by whom the proficiency educates the public and the profession concerning those who are identified
as practitioners of this proficiency. How does the public identify practitioners of the proficiency?

AAPB and BCIA all are involved in public education and protection of consumers. All organizations’ websites
provide access to consumer-relevant articles and resources as well as provider directories. BCIA posts a
practitioner registry of all who are BCIA certified (http://certify.bcia.org/4dcgi/resctr/search.html). AAPB also
posts a practitioner registry of all biofeedback practitioners to help individuals locate a specialist
(https://www.aapb.org/i4a/pages/index.cfm?pageid=3281).

4. Estimate how many practitioners are qualified to practice in this proficiency (e.g., spend 25% or more of their time in
services characteristic of this proficiency). Provide whatever demographic information is available.
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Because biofeedback is largely practiced through one’s profession, not all professionals belong to one organization
or group. Many practitioners also belong to professional organizations who promote biofeedback practice that is
specific to a disease or disorder while others employ the modality only for basic relaxation, optimal functioning or
sports applications. Therefore, it would be an impossible task to estimate the numbers of well-trained people who
offer their services. Currently BCIA has certified more than 2,000 health care professionals to use the modality
clinically. Approximately 70% of AAPB members and BCIA certificants are psychologists.

5. Estimate how many practitioners are qualified to practice in this proficiency (e.g., spend 25% or more of their
time in services characteristic of this proficiency), and whose primary practice is not within the discipline of
psychology (i.e. Pharmacists). Provide whatever demographic information is available.

Of the remaining 30%, many professions represent a wide variety of disciplines such as physical and occupational
therapy, medicine, nursing, and counseling as well as those who work in sports applications or optimal
functioning. According to one recent BCIA demographic study that only included certificants, approximately 5%
are social workers, 8% are either occupational or physical therapists, 15% are counselors, with the rest spread
across other professions such as medicine or nursing.

References for Criterion XI:

No additional references in this section.

END OF PETITION FORM

 PETITION FOR THE RECOGNITION OF A
PROFICIENCY IN PROFESSIONAL PSYCHOLOGY:
Biofeedback and Applied Psychophysiology

LIST OF APPENDICIES

Appendix A .............................................................. Bylaws of the Association for Applied Psychophysiology and Biofeedback

Appendix B ........................................................................................ Biofeedback Magazine: Volume 45, Number 3 (Fall 2017)

. SPECIAL Diversity issue and presentation handout resources

Appendix C .............................. Volume 43, Number 3 (September 2018) issue of Applied Psychophysiology and Biofeedback

Appendix D..................................................................................................... Last 10 years of publications sponsored by AAPB

Appendix E ........................................................................................................... Details of the 2018 Annual Scientific Meeting

Appendix F ................................................................................................................. Last 3 years of AAPB sponsored webinars

Appendix G ............................................................................................................. Selected references from key AAPB leaders

Appendix H .......................................................................................................................................................Letter of Support

Appendix I .................................................................................... Evidence-based Practice in Biofeedback and Neurofeedback

Appendix J .................................................................................................................................................... AAPB Code of Ethics

Appendix K .......................................................................... BCIA Professional Standards and Ethical Principles of Biofeedback

Appendix L .................................................... BCIA Blueprint of Knowledge Statements for Board Certification in Biofeedback

Appendix M.............................................. BCIA Blueprint of Knowledge Statements for Board Certification in Neurofeedback

Appendix N ....................................................................................................... BCIA description of Biofeedback Essential Skills

Appendix O .................................................................................................. BCIA description of Neurofeedback Essential Skills

Appendix P ............................................................................................................. BCIA Mentoring Guidelines for Biofeedback

Appendix Q ....................................................................................................... BCIA Mentoring Guidelines for Neurofeedback

Appendix R ................................................................................................. BCIA Requirements for Certification in Biofeedback

Appendix S ............................................................................................ BCIA Requirements for Certification in Neurofeedback

 APPENDIX A:
Bylaws of the Association for Applied Psychophysiology and Biofeedback

Association for Applied Psychophysiology and Biofeedback BYLAWS

I. Name XII. Finances

II. Purpose XIII. Nominations
III. Membership XIV. Elections
IV. Dues, Fees and Assessments XV. Referendum
V. Chapters XVI. Committees
VI. Sections XVII. Publications
VII. Board XVIII. Non-Inurement
VIII. Powers and Duties of Officers XIX. Dissolution
IX. Executive Director XX. Indemnification
X. Association’s Headquarters XXI. Parliamentary Authority
XI. Annual Meeting XXII. Operating Procedures
XXIII. Amendments

Article I: Name

The name of this organization shall be the Association for Applied Psychophysiology and Biofeedback. Hereinafter it shall be
called the Association.

Article II: Purpose

The objective of the Association shall be to represent and promote the science and practice of self-regulation to enhance
health and performance through the:

A. Encouragement, support and improvement of clinical and educational applications biofeedback and applied
psychophysiology tools and principles using scientific and research evidence.

B. Integration of applied psychophysiology and biofeedback with other self-regulatory methods.

C. Improvement of clinical uses of applied psychophysiology, biofeedback and other self-regulatory methods through
promotion of high standards of professional practice and education.

D. Increased knowledge about applied psychophysiology and biofeedback to the membership via meetings,
educational programs, publications and special interest sections.
E. Promotion of state, regional and international chapters.

F. Dissemination of information to the public about uses of applied psychophysiology and biofeedback.

G. Encouragement of the use of psychophysiological theories and methods to develop products and protocols that
promote prevention, improve health, and enhance quality of life.

H. Provide education and support the Association’s scientific objectives in accordance with its status as a not-for-
profit organization.

Article III: Membership

1. Membership in the Association shall be comprised at a minimum of the following categories: Regular, Early Career,
Retired, Hardship, Associate Member, Student Member, and Honorary Member.

1. Regular Member: Persons interested in the scientific and professional advancement of applied
psychophysiology and biofeedback who practice, teach, or conduct research in the discipline of applied
psychophysiology and biofeedback. Regular members have all rights and privileges of membership,
including the right to serve on committees, to vote, and hold office.
Regular members may, upon written request and approval of a majority of the Membership Committee,
modify their membership status (affecting membership dues).

2. Early Career: Members qualify for Early Career status with documentation of terminal degree and date
received. The Membership Committee will be responsible to review all graduates for automatic
membership changes. Membership status will remain until 3 years from date of degree.

3. Retired (Partial or Full): Member must provide evidence of retirement or partial employment/work only
once. Membership status will not expire.

4. Hardship: Member must provide evidence of financial hardship. Membership status will last 2 consecutive
years, after which time the member must pay Regular membership dues or revert to Associate Member
status.

5. Associate Member: Persons interested in the scientific and professional advancement of applied
psychophysiology and biofeedback. Associate members have all rights and privileges of membership
except:

a. Associate members may not vote or hold office.

b. Associate members will not receive access to printed or on-line AAPB publications as part of
membership benefits.

c. Associate members may have reduced discounts to other benefits offered to Regular members.

6. Student Member: Full-time students or graduate students of regionally-accredited academic institutions

with interests in applied psychophysiology and biofeedback who do not yet have a degree, license or
similar certification that qualifies them for independent practice may become Student members. Student
members have all rights and privileges of membership except:

a. Student members may not vote or hold office (see ‘C’).

b. Student members may participate in Student Council, representing relevant issues/concerns to

the Board. Student members can vote on resolutions of the Student Council.

c. One Student Representative to the Board will have voting privileges on Board decisions.

7. Honorary Members: Any individual who has made an outstanding contribution to the betterment of the
Association or profession may be nominated as an Honorary Member. The Membership Committee will
review and recommend candidates to the Board. No more than one Honorary Member may be named
 each year. Honorary members are exempt from dues, and have all rights of Regular membership.

2. Membership categories are reserved for individual persons, not businesses or corporations. However, the Board
may establish separate corporate sponsorships or relationships that benefit the Association of the field of applied
psychophysiology and biofeedback.

Article IV: Dues, Fees and Assessments

A. Dues and benefits for all categories of membership shall be determined by the Board annually.

B. Nonpayment of dues shall be considered as equivalent to a resignation from the Association.

C. All fees and assessments shall be determined by the Board as needed.

Article V: Chapters

A. Chapter status may be granted to an organization representing the membership interests within a specified region
and meets the qualifications as specified by the Board, provided that a simple majority of its members are
Members of AAPB.

B. A chapter shall be representative of the Association's membership and objectives as well as the scientific and
professional interests of applied psychophysiology and biofeedback within their respective region. Its objectives
shall fall within the scope of those specified in Article II of these Bylaws, and its membership shall not be restricted
on any basis other than interests and qualifications. The Bylaws of a Chapter may not be in conflict with those of
the Association. In the event of such a conflict, the Bylaws of the Association shall prevail.

C. A Chapter may be affiliated with the Association upon demonstrating it meets the requirements to be a Chapter
and approval by the Board. Chapters shall conform to the purposes and stated policies of the Association.

D. Membership in an affiliated Chapter shall not imply individual membership in AAPB. A Chapter that is affiliated
with the Association must accurately communicate the nature and limits of this association to its members and the
public at large. Membership in a chapter and its associated benefits is separate from and not equivalent to
membership in the Association.

E. In the event the Board finds that the conditions of affiliation are not being fulfilled by a Chapter as specified in the
Chapter guidelines or that its affiliation is no longer in the best interest of the Association, the affiliation may be
terminated by a two-thirds vote of the AAPB Board. Following a successful vote for termination, the Chapter must
immediately discontinue all public representation of affiliation with the Association.

A Council of Chapters shall be constituted by one representative from each Chapter and no less than one member of the
Board. The Council may elect one of its members to be a liaison to the Board.

Article VI: Sections

A. A Section consists of a group of AAPB members with a common interest. A Section can be formed according
to the AAPB Policies and Procedures subject to approval by the Board.

B. Each Section must have as its focus a distinct subject area approved by the Board.

C. Sections shall be reviewed annually and renewed by approval of the Board

D. Section bylaws and/or charters shall not be in conflict with those of AAPB.
 E. Sections shall operate in accordance with the Policies and Procedures of AAPB.

Article VII: Board

A. The Board shall consist of the officers of the Association and five additional Board members at large, all of
whom shall be “Regular” members of the Association. Board members at large and the Treasurer shall serve
no more than two consecutive three-year terms. The Executive Director shall serve on the Board ex-officio,
without vote.

B. Regular meetings of the Board shall be held at least annually, at times and places specified by the Board or
Executive Committee. A quorum at any Board meeting shall consist of a majority of the Board’s membership.
Conference calls and use of other technology to convene the Board as a group may constitute a meeting of the
Board.

C. Written notice, either by regular mail, email, or other accepted means of communication, of Board meetings
shall be distributed to each Board member at least two weeks in advance of a scheduled Board meeting.

D. In the case of a vacancy, the Board may: (a) fill the board seat through a special election; (b) appoint an
interim board member; or (c) allow the seat to remain vacant until the next open election. The individual
appointed to fulfill the vacated term shall be eligible to run for a first full term in accordance with these
Bylaws.

E. The Board shall have the authority to take such actions as are necessary for the conduct of the Association’s
affairs in accordance with these Bylaws.

F. Action taken by a mail, telephone, fax, or e-mail ballot of the Board members shall be valid action of the Board
so long as the balloting is conducted in accordance with Colorado corporate laws, shall be reported to the
Board within one month of the close of the ballot, and shall be included in the minutes of the next most recent
meeting to the time of the vote.

Article VIII: Powers and Duties of Officers

A. The officers of the Association shall be: the President, the President-Elect, the Immediate Past President, and
the Treasurer, all with vote and the Executive Director who shall serve ex-officio, without vote. With the
exception of the Executive Director, they shall hold office until their elected successors take office.

B. The Executive Committee shall be comprised of the officers of the Association.

C. The President shall be a member of the Association who has just completed his/her term as President-Elect.
The President shall represent the entire membership and the best interests of the Association. The President
shall be the official spokesperson for the Association, but may assign this authority. The President shall serve
as the presiding officer of the Association and as Chairman of the Board of Directors. The President shall
support and defend policies and programs adopted by the Board of Directors and membership. The President
shall be an ex-officio member of all committees of the Association except as otherwise provided. The President
shall have additional duties, which are not inconsistent with the Bylaws as may be assigned by the Board of
Directors.

D. The President-Elect shall be a member of the Association who is elected by the membership. He/she shall take
office as President-Elect at the close of the annual meeting at which his/her election results are announced.
He/she shall serve as presiding officer of the Association in the absence of the President. The President-Elect
 shall become familiar with the presidential duties and shall perform such duties as are delegated by the
President and/or Board of Directors. The President-Elect shall act in the President's absence or disability. The
President-Elect shall help formulate Association policy, and shall assist the President, upon request. The
President-Elect automatically succeeds to the office of President. If the office of President becomes vacant,
the President-Elect shall serve as President for the unexpired term and shall serve as President for the term to
which he/she was elected. In the event that the President-Elect shall not be able to serve, a President-Elect
shall be nominated by the nominating committee and a special election held. The new President-Elect will take
office immediately.

E. In the event that both the President and the President-Elect shall be unable to serve, the Board shall elect one
of its members to serve as President of the Association until the next regular election, when a new President
and President-Elect shall be elected. The new President shall take office immediately.

F. The Immediate Past-President shall serve on the Board, the Executive Committee, and as chair of the
Nominating Committee for the year immediately following his/her presidency, and shall have such duties as
the Board or the President may designate.

G. The Treasurer shall be a member of the Association and shall be elected by the membership. The Treasurer
shall deliver an annual financial report that has been reviewed by an independent CPA for each fiscal year to
the Board. The Treasurer shall be Chairman of the Association's Finance Committee and serve on the Executive
Committee.

H. Any Officer or Board member may be removed from office before the expiration of the remaining term by a
three-fourths vote of the Board if evidence is present that the best interests of the Association are not being
served. Reasons for removal may include more than two unexcused absences from Board meetings, failure
to meet Board responsibilities, disruptive behavior, unprofessional treatment of colleagues, conflicts of
interest with Board service, and violation of AAPB's Ethical Principles.

Article IX: Executive Director

A. The Association shall retain an Executive Director.

B. The Executive Director shall be appointed by the Board and shall serve as the Secretary of the Association. The
Executive Director shall direct the day-to-day activities of the Association according to the policies and
procedures as approved by the Board.

C. The Executive Director shall serve ex-officio, without vote, as a member of the Board, Executive Committee
and all committees of the Association.

D. The Executive Director shall have authority to sign checks and drafts as an agent of the Association for the
disbursement of funds for duly authorized purposes of the Association.

E. The Executive Director will prepare and present a budget to the Board on an annual basis and will be
responsible for monitoring the budget process and updating the BOD on a quarterly.

F. The Executive Director shall have authority to sign contracts as an agent of and on behalf of the Association in
accordance with its duly approved policies and procedures.

G. The Executive Director shall report to the Board at least annually on the operations of the Association's
Headquarters.

Article X: Association's Headquarters

The Association shall maintain a headquarters for the promotion of the objectives of the Association. The Headquarters shall
be established at such a place and with such facilities and functions as the Board may direct.

Article XI: Annual Meeting

There shall be an annual meeting of the Association at a time and place to be determined by the Board.

Article XII: Finances

A. The fiscal year of the Association shall be set by the Board.

B. All officers and agents of the Association responsible for the receipt, custody and disbursement of funds may
be required to give bond for the faithful discharge of their duties in such sums and with such sureties as the
Board may determine.

C. All checks, drafts, and other orders for the payment of money shall be signed by such agent or agents of the
Association and in such manner as shall be determined by the Board.

D. At the discretion of and under the direction of the Board, a CPA firm will be appointed to perform an annual
independent review or audit as appropriate. Copies shall be distributed to the Board and the acceptance of
same recorded in Board minutes.

Article XIII: Nominations

A. The Nominations Committee shall recommend twice as many candidates as there are vacancies on the Board
of Directors. The Nominations Committee shall select individuals who have capably served AAPB, treated
colleagues with respect, worked cooperatively with others, and whose expertise can best help AAPB achieve
its needs. Nominations Committee members shall strive to represent all of AAPB's membership, promote
diversity among the nominees, and prevent the concentration of power by one group. All candidates must
be confirmed by a majority vote of the Board. No member of the Nominations Committee is eligible to be
nominated for any elected position.

B. Candidates for the Board may be proposed for consideration by the Nominations Committee by a petition
submitted by 2% of the voting membership. Candidates for President-Elect and Treasurer may be nominated
by 4% of the voting membership.

C. Under the direction of the Nominating Committee, the Executive Director shall verify the eligibility of
nominees, confirm their credentials (e.g., regionally-accredited degrees, licensure, and certification), and
ascertain that all nominees are willing to stand for office and meet all requirements to serve. Nominees will
not be eligible if their state license has been suspended or revoked, or is under review by a state regulatory
agency.

D. The Nominations Committee shall verify the eligibility of nominees and ascertain all nominees are willing to
stand for office and meet all requirements to serve.

E. No candidate for any position within AAPB may advertise or campaign in any way beyond the candidacy
statement provided to AAPB.

F. Candidates for president-elect of AAPB’s board must have been either a member of the AAPB board, chair of
an AAPB Section or an AAPB standing committee. In the event no candidate from a member of the board, AAPB
section or standing committee accepts, nominations for president-elect may then be opened to the general
membership.
 G. Nominees to the board must be able to attend 50% of the meetings of the board including conference calls,
virtual meetings, and in-person meetings.

Article XIV: Elections

A. Ballots are valid if returned within fifteen days of the distribution date. Ballots will be tabulated electronically
and a report made to the Board and the membership. Tie votes shall be resolved by a vote of the Board. This
section shall apply to all elections unless otherwise specified in these Bylaws.

B. Board Elections are to be completed no later than 45 days prior to the start of the annual meeting of members.

C. A complete file of all ballots, tallies, and documents of Nominating Committee actions shall be maintained in
the Headquarters office for a period of one-year unless directed otherwise by the Board.

D. Announcement of election results shall be made by the President at or before the Association's Annual Meeting
and/or in an official communication to the membership.

Article XV: Referendum

Upon petition of ten percent of the voting members in good standing, a request for a vote of the members of the Association
upon any matter, not involving an amendment to the Bylaws, may be addressed to the Board. If the matter is not inconsistent
with these Bylaws, the Board shall present it to the membership for a vote. The ballot shall contain a statement of the
arguments for and against the new provisions. The issue will be decided by majority of those voting.

Article XVI: Committees

A. Standing Committee Structure

1. Standing committees perform continuing tasks of the Association.

2. Standing committees shall report at least annually to the Board.

3. Standing committees may not be disbanded without a change in the Bylaws unless otherwise provided in
the Bylaws.

4. Committee chairpersons and members may be appointed to serve one, two or three year terms and may
serve a maximum of six years, unless otherwise provided in the Bylaws.

B. Standing Committees

1. The Membership Committee reviews and recommends membership criteria and policy. Develops
recruitment and retention programs and develops/recommends, evaluates membership benefits. It shall
also serve as a review committee for individual membership issues.

2. The Program Planning Committee plans and coordinates the scientific program and blind peer review
process for the annual convention. All appointments to this committee are for one year.

3. The Education Committee insures that the continuing education needs of the membership are met, a) by
providing educational programs other than the annual conference including but not limited to teleseminars
and workshops, b) insuring compliance with APA and AMA continuing education standards and
requirements, c) ensuring educational programming meets ethical and the highest scientific standards by
peer review and blind review
 4. The Nominations Committee’s responsibility is to prepare a list of qualified candidates for the Association's
elections. The members of this committee shall be: the Immediate Past-President as Chair, the current
President, the President-Elect and the most recent Past-President of the Association who is eligible to serve.

5. The Standards and Professional Practices Committee’s responsibilities are to a) monitor and/or oversee
the monitoring of all Federal rules, regulations and legislation, which affect applied psychophysiology and
biofeedback, b) Oversee and manage ethical and compliance issues within AAPB and its membership,
as defined by the AAPB Code of Ethics, c) establish program for honorary recognition designation in
regard to compliance with the highest professional standards, active engagement with the modality,
and relevant experience, professional achievement, and/or has made a signification impact on the
advancement of Biofeedback, d) act as biofeedback's representative in the area of coding,
terminology development and reimbursement, d) Reestablish biofeedback's proficiency status as
defined by and within the American Psychological Association - encompassing a core of psychological
knowledge and skills, and Includes specific methods for how psychologists typically acquire its
knowledge and skills.

6. The Public Awareness Committee’s responsibilities are to a) inform and educate the public, service
providers and service-users about the benefits and risks of biofeedback, b) recommends and oversees
programs designed to enhance the public's awareness of the biofeedback modality, c) plans and
implements strategies on how to disseminate information in a culturally sensitive manner.

7. The Innovation Committee serves as a resource, facilitator, thought leader to address a broad range
of technology-related, opportunities and issues of interest to AAPB and its members inclusive of
evaluation of associated implications, risks and benefits. The Innovation Committee represents a
guiding coalition to set Innovation priorities, change culture, allocate resources and make
recommendations to the AAPB Board.

C. Ad hoc Committee/Task Force Structure

1. Creation and dissolution of ad hoc committees/task forces must be approved by the Board except those
created within committees or task forces designed to carry out specific duties within the purview of that
committee or task force.

2. Ad hoc committees/task forces perform specific tasks.

3. Ad hoc committees/task forces shall report on a timely basis to the Board except as provided in Article XVI,
Section C, Item 1 of these Bylaws.

4. Ad hoc committees/task forces shall cease when the report is completed or a specified period has ended,
whichever is sooner.

Article XVII: Publications

A. The Association publishes a scientific journal, a clinical journal, and an electronic newsletter as official
communications to the membership.

B. Any notice in the clinical journal, the electronic newsletter, or by mass email shall constitute full notice to all
members of the Association for any purpose.

Article XVIII: Non-Inurement

No part of any income, revenue or grant of, or to the Association, shall inure to the material or pecuniary benefit of members,
officers or other private persons, except that the Association shall be authorized and empowered to pay reasonable
compensation for services rendered in furtherance of one or more of its purposes.

Article XIX: Dissolution

On dissolution of the Association, any funds remaining shall be distributed to one or more not-for-profit, charitable,
educational, scientific or philanthropic organizations to be selected by the Board.

Article XX: Indemnification

A. The liability of a Director of the Association for monetary damages for breach of fiduciary duty as a Director
(including each and every such liability to the members of the Association, to the Association, or to any one or
more of them) shall be eliminated to the fullest extent permitted by law in each and every case where such
liability may be eliminated in any respect. An employee or agent of the Association is entitled to mandatory
indemnification and is entitled to apply for court ordered indemnification to the same extent as provided by
law for a Director or Officer of the Association.

B. The foregoing sentence does not limit the right of the Association to indemnify and advance expenses to an
officer, employee or agent of the Association, who is not a Director, to a greater extent than it may indemnify
or advance expenses on behalf of a Director.

C. Any claims or other disputes arising between or among a member or members, the Association or any of its
officers, directors, employees, or agents concerning any act or omission to act on behalf of the Association or
otherwise relating to the Association or its affairs shall be resolved within the Association in accordance with
its policies and procedures. The resolution within the Association will be the final determination of the dispute.

D. If any member fails to abide by such resolution of the dispute within the Association or ground exist that would
permit a court to overturn or modify the Association action or grant any other relief or redress subject to the
policies and procedures of the Association and Colorado law, the parties shall seek relief or redress only
through arbitration in Denver, Colorado. The party commencing such a proceeding shall pay any costs of any
court or arbitration proceeding including reasonable attorney’s fees that are expended in the defense of such
proceedings where such party does not prevail.

Article XXI: Parliamentary Authority

Roberts Rules of Order shall serve as the Parliamentary reference to govern the proceedings for any or all matters of the
Association or its divisions or sub-groups unless provided otherwise in the Associations documents or the law.

Article XXII: Operating Procedures

The Board may adopt operating procedures, which may not be in conflict with these Bylaws, to govern its procedures. Such
rules may be adopted or repealed by a majority vote of the Board. Proposed operating procedures must be presented in
writing to the Board not less than two weeks prior to its meeting.

Article XXIII: Amendments

A. The Bylaws of the Association may be amended by a two-thirds vote, of the eligible members voting.
Amendments to the Bylaws will be conducted in the same manner as that of Board elections as defined in
these Bylaws. Ballots are valid if postmarked within thirty days of the date distributed.
 B. Amendments may be proposed by the Board or by petition signed by ten percent or more of the full members
of the Association. Votes postmarked or received within thirty days of distribution will be tabulated
electronically, at which time the amendment, if passed by two-thirds vote, shall go into effect.

Adopted by the AAPB, December, 1994

Revisions approved and adopted by the AAPB Board and members: December 1999, March 2010, February 2011, July 2013
and December 2016
 PETITION FOR THE RECOGNITION OF A
PROFICIENCY IN PROFESSIONAL PSYCHOLOGY:
Biofeedback and Applied Psychophysiology

APPENDIX B:
Volume 45, Number 3 (Fall 2017) SPECIAL Diversity issue of Biofeedback Magazine and Presentation
Handout resources
 PETITION FOR THE RECOGNITION OF A
PROFICIENCY IN PROFESSIONAL PSYCHOLOGY:
Biofeedback and Applied Psychophysiology

APPENDIX C:
Volume 43, Number 3 (September 2018) issue of Applied Psychophysiology and Biofeedback
 PETITION FOR THE RECOGNITION OF A
PROFICIENCY IN PROFESSIONAL PSYCHOLOGY:
Biofeedback and Applied Psychophysiology

APPENDIX D:
Last 10 years of publications sponsored by AAPB

Peper, E. (2009). Biofeedback mastery - An experiential teaching and self-training manual. Wheat Ridge, CO: Association for
Applied Psychophysiology and Biofeedback.

Strack, B., Linden, M. & Wilson, V. (2011). Biofeedback & neurofeedback applications in sport psychology. Wheat Ridge, CO:
Association for Applied Psychophysiology and Biofeedback.

Sherman, R. (2012). Pain: Assessment & intervention from a psychophysiological perspective, 2nd ed. Wheat Ridge, CO:
Association for Applied Psychophysiology and Biofeedback.

Thompson, M. & Thompson, L. (2015). Functional neuroanatomy. Wheat Ridge, CO: Association for Applied
Psychophysiology and Biofeedback.

Thompson, M. & Thompson, L. (2015). The neurofeedback book, 2nd ed. Wheat Ridge, CO: Association for Applied
Psychophysiology and Biofeedback.

Tan, G., Shaffer, F., Lyle, R. & Teo, I. (2016). Evidence-based practice in biofeedback and neurofeedback, 3rd ed. Wheat
Ridge, CO: Association for Applied Psychophysiology and Biofeedback.

Moss. D. & Shaffer, F. (2016). Foundations of heart rate variability biofeedback: A book of readings. Wheat Ridge, CO:
Association for Applied Psychophysiology and Biofeedback.
 PETITION FOR THE RECOGNITION OF A
PROFICIENCY IN PROFESSIONAL PSYCHOLOGY:
Biofeedback and Applied Psychophysiology

APPENDIX E:
Program of Events: 2018 Annual Scientific Meeting
 PETITION FOR THE RECOGNITION OF A
PROFICIENCY IN PROFESSIONAL PSYCHOLOGY:
Biofeedback and Applied Psychophysiology

APPENDIX F:
Last 3 years of AAPB sponsored webinars

1. May 7, 2015– Mari Swingle, PhD: Alterations in Electroencephalographic Patterns Associated with Excessive Usage
of i-technologies
2. June 24, 2015 – Robert Reiner, PhD: Biofeedback and Virtual Reality
3. August 13, 2015– Patrick Steffen, PhD: Stress: A Modern Epidemic
4. September 25, 2015 – Fredric Shaffer, PhD: How to Increase the Impact of HRV Biofeedback Training
5. October 5, 2015 – Thomas Collura, PhD: A case of voluntary pain control revealed using EEG and sLORETA Imaging
6. October 19, 2015 – Richard Gevirtz, PhD: Adding Heart Rate Variability Biofeedback (HRVB) to Exposure Therapy
with Trauma Patients
7. November 6, 2015 – Donald Moss, PhD: Professional Ethics and Standards for Biofeedback and Neurofeedback: An
Overview Part I
8. November 13, 2015 – Donald Moss, PhD: Professional Ethics and Standards for Biofeedback and Neurofeedback:
An Overview Part II
9. December 1, 2015 – Pierre Beauchamp, PhD: Mindroom Sport Performance: HRV Self-regulation Program for Peak
Performance
10. December 10, 2015 – Paul Swingle, PhD: Adding Neurotherapy to Your Practice
11. January 29, 2016 – Donald Moss, PhD: Breath Training
12. February 10, 2016 – Fredric Shaffer, PhD: Lessons from the Neuroscience of Addiction
13. February 25, 2016 – Steve Baskin, PhD: Diagnosis and Treatment of Migraine Headache
14. March 30, 2016: Nicholas Dogris, PhD: NeuroField pEMF Fundamentals
15. April 7, 2016 – Christine Moravec, PhD: Psychophysiologic Remodeling in Cardiovascular Disease
16. May 11, 2016 – Richard Sherman, PhD: BCIA Biofeedback Exam Review webinar series on Instrumentation and
A&P - PART 1
17. May 18, 2016 – Richard Sherman, PhD: BCIA Biofeedback Exam Review webinar series on Instrumentation and
A&P - PART 2
18. May 25, 2016 – Richard Sherman, PhD: BCIA Biofeedback Exam Review webinar series on Instrumentation and
A&P - PART 3
19. June 14, 2016 – Christine Moravec, PhD: Psychophysiologic Remodeling in Cardiovascular Disease
20. July 15, 2016 – Leslie Sherlin, PhD: Making Sense: The Path to Training Optimal Performance
21. August 26, 2016 – JP Ginsberg, PhD: HRV Coherence and PTSD
22. September 29, 2016 – Dave Siever, CET: Identifying Diffuse Axonal Interruptions or Injuries through QEEG and
Rapid Recovery Using Audio-visual Entrainment
23. October 27, 2016 – Randy Neblett, MA: Advanced Active SEMG Biofeedback Protocols for Treating Chronic Pain
Part 1
24. November 3, 2016 – Randy Neblett, MA: Advanced Active SEMG Biofeedback Protocols for Treating Chronic Pain
Part 2
25. December 7, 2016 – Pierre Beauchamp, PhD: HRV Self‐regulation Program for Peak
26. January 27, 2017 – Sebern Fisher, MA: Calming the Fear-driven Brain: Neurofeedback in the Treatment of
Developmental Trauma
27. April 12, 2017 – Jeffrey LaMarca, EdD: Neurofeedback with ADHD Elementary Students to Improve Reading
Comprehension
28. May 19, 2017 – Dennis Romig, PhD: Successful Neurofeedback Treatment of Severe Depression
29. June 16, 2017 – Robert Thatcher, PhD: QEEG NFB, Report Writing and Linking Symptoms to Dysregulation in Brain
Networks
30. July 13, 2017 – Tara Austin, MA: Autonomic Balance and Executive Function
31. July 28, 2017 – Rex Cannon, PhD: Addiction: Past, Present and Future of Neurofeedback as a Primary Candidate for
Efficacious Treatment for Substance Use Disorders
32. August 18, 2017 – Richard Harvey, PhD: Cultural Diversity
33. September 28, 2017 – Jon Bale, BSc, BCN-T: General Introduction to Biofeedback - Part 1
34. October 12, 2017 – Jon Bale, BSc, BCN-T: General Introduction to Biofeedback - Part 2
35. October 26, 2017 – Jon Bale, BSc, BCN-T: General Introduction to Biofeedback - Part 3
36. December 8, 2017 – Christine Moravec, PhD: Evidence for the Effectiveness of Biofeedback in Cardiovascular
Disease
37. January 5, 2018 – Donald Moss, PhD: Professional Ethics and Standards Part I – Biofeedback
38. January 12, 2018 – Donald Moss, PhD: Professional Ethics and Standards Part II – Neurofeedback
39. July 10, 2018 – Tami Bulmash, MA: Debunking Myths about Posture and Understanding How it harms or Improves
Health
40. August 1, 2018 – Santiago Brand Ortiz, BA, BCN: An Integrative Approach to Brain Health Optimization
41. December 7, 2018 – Donald Moss, PhD and Angele McGrady, PhD: Biopsychosocial Approaches to Chronic Illness:
the Pathways Model
 PETITION FOR THE RECOGNITION OF A
PROFICIENCY IN PROFESSIONAL PSYCHOLOGY:
Biofeedback and Applied Psychophysiology

APPENDIX G:
Selected references from key AAPB leaders at outside meetings related to biofeedback

Curriculum/Course Development
Benore, E. Resident/Fellow Lecture, “Pediatric Application of Biofeedback”. Provided to residents/fellows at Cleveland
Clinic Lerner College of Medicine, Metro Health, and Case Western Reserve University.
Khazan, I. Clinical supervisor (biofeedback). Pre-doctoral internship at Cambridge Health Alliance, Harvard Medical School.
Khazan, I. Biofeedback mentor for BCIA certification, Boston Center for Health Psychology and Biofeedback.
Khazan, I. Introduction to Biofeedback Workshop (BCIA approved), 42 hours of instruction, Boston Center for Health
Psychology and Biofeedback, sponsored by Massachusetts Psychological Association
Khazan, I. Introduction to Biofeedback Workshop, BCIA approved, 48 hours of instruction, US Army Rangers
Khazan, I. Introduction to Biofeedback Workshop, BCIA approved, 48 hours of instruction, US Navy Special Warfare
Shaffer, F. Course Instructor, “Applied Psychophysiology and Biofeedback”. Truman State University.
Shaffer, F. Course Instructor, “Independent Study in Heart Rate Variability”. Truman State University.
Shaffer, F. Course Instructor, “Physiological Psychology”. Truman State University.
Shaffer, F. (2018). Biofeedback tutor. Kirksville, MO: Biosource Software.
Shaffer, F. (2018). HRV biofeedback tutor. Kirksville, MO: Biosource Software.

Professional Workshops
Benore, E. & Scott, E. (April 2016). Biofeedback in pediatric psychology: An advanced primer. 3 hours. Workshop presented
at the Society for Pediatric Psychology Annual Conference. Atlanta, GA.
Benore, E. & Scott, E. (October 2017). Pediatric Biofeedback: An advanced primer. 3 hours. Workshop presented at the
Society for Developmental and Behavioral Pediatrics Annual Conference. Cleveland, OH.
Khazan, I. (February 2018). Enhancing health and performance with mindfulness and biofeedback. Workshop presented for
the Israeli Biofeedback and Neurofeedback Association (IBNA). Tel Aviv, Israel.
Khazan, I. (June 2017). Biofeedback and mindfulness for resilience and self-regulation. Two-day workshop benefit for the
Center for Mindfulness and Compassion. Harvard Medical School. Cambridge, MA.
Khazan, I. (August 2015). Mindfulness and acceptance-based biofeedback. Invited pre-conference workshop presented at
Applied Neuroscience Society of Australia (ANSA) Annual Scientific Meeting. Adelaide, Australia.
Khazan, I. (February 2014). Mindfulness and acceptance approach to biofeedback. Invited 2-day workshop presented at the
Biofeedback Federation of Europe (BFE) 17th Annual Meeting. Venice, Italy.
Khazan, I. (2012). Overcoming overbreathing. Continuing education workshop presented for Massachusetts Psychological
Association 2012 Spring Continuing Education Series, Wellesley, MA.
Shaffer, F. (2012). Intermediate HRV biofeedback. Workshop presented at the 20th annual meeting of the International
Society for Neurofeedback and Research, Orlando, FL.
Shaffer, F. (2017). BCIA 2-day HRV biofeedback didactic workshop presented at the Applied Neuroscience Society of
Australasia, Canberra, Australia.
Shaffer, F., & Moss, D. (2014). BCIA Biofeedback didactic workshop: Parts I-III. Workshop presented at the 17th annual
meeting of the Biofeedback Federation of Europe, Venice, Italy.
Shaffer, F., & Moss, D. (2017). BCIA 2-day HRV biofeedback didactic workshop presented at the MSBMB Annual Meeting,
Ann Arbor, Michigan.
Shaffer, F., & Moss, D. (2017). BCIA 2-day HRV biofeedback didactic workshop presented at the Biofeedback Federation of
Europe meeting, Aveiro, Portugal.
Shaffer, F., Moss, D., & Peper, E. (2017). BCIA 5-day Biofeedback didactic workshop presented at the Biofeedback
 Federation of Europe meeting, Aveiro, Portugal.
Swingle, M.K., (2017). Screen Based Technology and the Developing Child - Education Workshop Series for Mental health
Professionals. Child & Youth Mental health North Shore MCFC & Clinical Counsellors Association of BC. Vancouver, BC,
Canada.

Presentations and Symposia

Benore, E. (April 2012). Heart Rate Variability Biofeedback: Potential for Complimentary Therapy in Teens with Concussion.
Rebecca D. Considine Research Institute Translational Science Seminar Series.
Benore, E. (January 2013). Pediatric Applications for Biofeedback. Pediatric Grand Rounds, Cleveland Clinic Children's
Hospital for Rehabilitation.
Benore, E. (October 2016). Biofeedback in Pediatric Psychology: A Primer. The Cleveland Clinic Children’s Hospital Pediatric
Rehabilitation Symposium, Cleveland, OH.
Benore, E. (November 2018). Biofeedback in the treatment of postural orthostatic tachycardia syndrome. In
Symposia, Innovative psychological approaches to assessing and treating pediatric patients with autonomic
dysfunction. ABCT 52nd Annual Convention, Washington, D.C.
Khazan, I. (2010). Biofeedback as alternative treatment of Raynaud’s disease. Panel discussion at First Raynaud’s Education
& Support Conference: Boston, MA.
Khazan, I. (2013). Mindfulness and Biofeedback in the Treatment of Anxiety. Presented at the Harvard Medical School
annual conference on Treating Anxiety: Boston, MA.
Khazan, I. (2014). Meditation and Biofeedback: Combining Eastern Traditions with Western Gadgets. Presented at the BFE
17th annual meeting: Venice, Italy.
Khazan, I. (2015). Train your dragon brain: Implications for Biofeedback and Meditation. Presented at Applied Neuroscience
Society of Australia (ANSA) annual scientific meeting: Adelaide, Australia.
Khazan, I. (2017). Resilience and Self-Regulation with Mindfulness and Biofeedback. Presented at the Harvard Medical
School annual conference on Meditation and Psychotherapy: Boston, MA.
Khazan, I. (2018). Mindfulness and Compassion Based Biofeedback. Invited talk to be presented at the annual meeting of
the Mexican Society for Bio and Neurofeedback (SMBN): Queretaro City, Mexico.
Lagos, L.M. (2011). Heart Rate Variability Biofeedback for Post-Concussion Syndrome, Northeastern High School Coaches
Annual Meeting, Atlantic City, NJ.
Lagos, L.M. (2012). Optimal Performance for Collegiate Students and Student-Athletes, Fordham University, New York, NY.
Lagos, L.M. (2013). Psychophysiological Strategies for Peak Performance in Sports, Biofeedback Foundation of Europe
Conference, Venice, Italy.
Lagos, L.M. (2013). Increasing the Academic and Health Performance of Collegiate Students and Athletes, Collegiate
Counseling Centers of NJ & NY Conference, Fordham University, New York, NY.
Lagos, L.M. (2015). Heart Rate Variability Biofeedback for Post Concussion Syndrome, New Jersey State Athletic Control
Board, Trenton, NJ.
Lagos, L.M. (2015). Heart Rate Variability Biofeedback for Post Concussion Syndrome, Center for Rehabilitation, New York
University, New York, NY.
Lagos, L.M. (2017). Keynote Presentation: Heart Rate Variability Biofeedback for Post Concussion Syndrome, Biofeedback
Foundation of Europe, Portugal.
Shaffer, F. (2015). HRV Biofeedback: How, why, and how well does it work? Address at the Northeast Regional
Biofeedback Society annual meeting, Chester, PA.
Shaffer, F. (2016). How to increase the effectiveness of your HRV biofeedback practice. BCIA Clinical Update series.
Shaffer, F. (2016). How to increase the impact of HRV biofeedback. Thought Technology, Ltd. workshop, Montreal, Canada.
Shaffer, F. (2017). Lessons from the neuroscience of addiction for clinicians and Olympic coaches. Keynote address
presented at the Applied Neuroscience Society of Australasia conference, Canberra, Australia.
Shaffer, F. (2017). Lessons from the neuroscience of addiction. Keynote address presented at the Biofeedback Association of
South Africa, Johannesburg, South Africa.
Shaffer, F. (2017). The neuroscience of addiction. BCIA Clinical Update series.
Shaffer, F. (2018). Strategies to increase the effectiveness of HRV biofeedback. BCIA Clinical Update series.
Steffen, P.R. (2015, August). Heart rate variability biofeedback as an adjunct treatment for major depression. Invited
symposium presentation at the annual meeting of the American Psychological Association, Toronto, Canada.
Swingle, M.K. (2013). Vagabonds & Billionaires / Direction or Correction: An Examination of Psychoneurophysiology and
Epigenetics. Canadian Association of Family Enterprise, Family Business Day on Brain Health. Vancouver, Canada.
Swingle, M.K. (2015). Effects of i-Technology/Digital Media on the Brain (EEG) and Behavior. International Society for
Neurofeedback & Research (ISNR), Denver, Colorado, USA.
Swingle, M.K. (2015). Pattern di Disregoazione delle Alpha in Bambini e Giovani Associato con l’utilizzo delle technologie
informatiche (giochi, sms, social media, ecc.). Biofeedback Foundation of Europe 18th International Congress. Rome,
Italy.
Swingle, M.K. (2015). EEG Deregulation Patterns in Adults Diagnosed with an Internet Addiction. Biofeedback Foundation of
Europe 18th International Congress. Rome, Italy.
Swingle, M.K. (2015). Alpha Deregulation Patterns in Children and Youth Associated with Excessive Usage of i-technologies
(gaming texting, social media, etc.). Biofeedback Foundation of Europe 18th International Congress. Rome, Italy.
Swingle, M.K. (May 7, 2018). The Broadband: What/how interactive screen based technology is affecting generalized
social, emotional and cognitive health, wellness, and educational success of college aged students. The good, the bad,
the neutral and the cross over points. Post Secondary Counsellors Association Conference PSCA). Vancouver, BC.

Webinars
Benore, E. (October 2016). Biofeedback in Pediatric Psychology: A Primer. Invited webinar hosted by the Biofeedback
Certification International Alliance.
Benore, E. (October 2017). Biofeedback Mentoring in Pediatrics. Invited webinar hosted by the Biofeedback Certification
International Alliance.
Swingle, M.K. (2016). I-tech on the Brain. New Mind L & L Special Speaker Series.
Swingle, M.K. (2015). Alterations in Electroencephalographic Patterns Associated with Excessive Usage of i-technologies
(e.g., gaming, social media, texting etc.). Association for Applied Psychophysiology and Biofeedback.
Swingle, M.K. (2014). Addiction in the 21st Century: Profiling of Internet Addiction. Swingle Clinic.
Swingle, M.K. (2014). Media, Technology & Mental Health. Swingle Clinic.
Swingle, M.K. (2013). Neurology and the Family, Genotypes, Phenotypes and Environment. Swingle Clinic.
Swingle, M.K. (2012). Learning Disorders, Disabilities & Difficulties. Swingle Clinic
Steffen, P.R. (2016, June). Current approaches in CBT: The Third Wave of Mindfulness and Acceptance and Commitment
Therapy. Invited webinar presentation sponsored by the Behavioral Medicine Research and Training Foundation.

Peer Reviewed Articles

Caldwell, Y. T., & Steffen, P. R. (in press). Adding HRV biofeedback to psychotherapy increases heart rate variability and
improves the treatment of major depressive disorder. International Journal of Psychophysiology.
Dewey, D. P., Belnap, R. K., & Steffen, P. R. (2018). Detangling anxiety: Using hair cortisol levels to understand stress during
study abroad in learning of Arabic in Jordan. The Annual Review of Applied Linguistics, 38, 1-21. Impact factor 2.083.
doi:10.1017/S0267190518000107
Fahrenkamp, A. & Benore, E. (in press). The Role of Heart Rate Variability Biofeedback in Pediatric Chronic Pain
Rehabilitation: A Case Series Design. Clinical Practice in Pediatric Psychology.
Frank, D. L., Khorshid, L., Kiffer, J. F., Moravec, C. S., & McKee, M. G. (2010) Biofeedback in medicine: who, when, why and
how? Mental Health in Family Medicine 7:85-91.
Hughes, B., Steffen, P. R., & Thayer, J. (in press). Special issue on the psychophysiology of stress and Adaptation: Models,
pathways, and implications. International Journal of Psychophysiology.
Lagos, L. M. (2007) Neurofeedback may benefit singers and performers, Psychophysiology Today, 3, 41.
Lagos, L. M. (2007) Stress: Its impact is quicker than you think, Psychophysiology Today, 3, 42.
Lagos, L. M. & Fuhs, M. (2007) Am I safe: A neurobiological perspective of social engagement behaviors, Psychophysiology
Today, 3, 6-9.
McCraty, R., & Shaffer, F. (2015). Heart rate variability: New perspectives on physiological mechanisms, assessment of
self-regulatory capacity, and health risk. Global Advances in Health and Medicine, 4(1), 46-61.
doi:10.7453/gahmj.2014.073
Nielson, C. M., Lockhart, B. D., Hager, R. L., George, J. D., Eggett, D. L., Steffen, P. R., Mitchell, U. H., & Bailey, B. W. (2016).
The effect of CardioWaves interval training on resting blood pressure, resting heart rate, and mind-body wellness.
 International Journal of Exercise Science, 9, 89-100.
Ruiz, J., Sbarra, D., & Steffen, P. R. (in press). Hispanic ethnicity, stress psychophysiology, and paradoxical health outcomes:
A review with conceptual considerations and a call for research. International Journal of Psychophysiology.
Shaffer, F. & Ginsberg, J. P. (2017). An overview of heart rate variability (HRV) metrics and norms. Frontiers in Public Health:
Family Medicine and Primary Care.
https://doi.org/10.3389/fpubh.2017.00258
Shaffer, F., McCraty, R., & Zerr, C. L. (2014). A healthy heart is not a metronome: An integrative review of the heart’s
anatomy and heart rate variability. Frontiers in Psychology, 5, 1040.
Swingle, M. K. (2016). The ‘science’ and ‘research’ of screen based technologies: Helping concerned parents navigate
psychological health and wellness in the digital age. BC Psychologist, 5(4) 7-11.
Steffen, P. R., Austin, T., & DeBarros, A. (2017). Treating chronic stress to address the growing problem of depression and
anxiety: Biofeedback and mindfulness as simple, effective preventative measures. Policy Insights from the Behavioral
and Brain Sciences, 4, 64-70. doi:10.1177/2372732216685333
Steffen, P. R., Austin, T., DeBarros, D., & Brown, T. (2017). The impact of resonance frequency breathing on measures of
heart rate variability, blood pressure, and mood. Frontiers in Public Health. doi: 10.3389/fpubh.2017.00222
Steffen, P. R., Fidalgo, L., Brown, T., Tsui, Y., & Schmuck, D. (2014). Psychotherapy participants show increased
cardiovascular and cortisol reactivity to a laboratory stressor relative to matched controls. Frontiers in Psychology:
Psychology for Clinical Settings, 5, 1-7. doi:10.3389/fpsyg.2014.00795, Impact factor 2.5, cited 1 time.
Steffen, P. R., & Larson, M. J. (2015). A brief mindfulness exercise reduces cardiovascular reactivity during a laboratory
stressor paradigm. Mindfulness, 6, 803-811. doi:10.1007/s12671-014-0320-4, Impact factor 3.692, cited 2 times.

Book Chapters
Belnap, R. K., Bown, J., Dewey, D. P ., Belnap, L., & Steffen, P. R. (2015). Project Perseverance: Helping students become
self-regulating learners. In T. Gregersen, P. MacIntyre, & S. Mercer (Eds.), Positive psychology in SLA. Bristol, UK:
Multilingual Matters.
Hughes, P. A., & Shaffer, F. (2012). Certification and ethics in applied psychophysiology. In W. A. Edmonds, & G. Tenenbaum
(Eds.). Case studies in applied psychophysiology: Neurofeedback and biofeedback treatments for advances in human
performance. West Sussex, UK: Wiley-Blackwell.
Khazan, I. Z. (2013). The clinical handbook of biofeedback: A step-by-step guide for training and practice with mindfulness.
Chichester, West Sussex, UK: Wiley& Sons, Inc.
Moss, D., & Shaffer, F. (2016). Foundations of heart rate variability biofeedback: A book of readings. Wheat Ridge, CO:
Association for Applied Psychophysiology and Biofeedback.
Shaffer, F., & Moss, D. (2006). Biofeedback. In Y. Chun-Su, E. J. Bieber, & B. Bauer (Eds.). Textbook of complementary
and alternative medicine (2nd ed.) (pp. 291-311). Abingdon, Oxfordshire, UK: Informa Healthcare.
Ruiz, J. M., & Steffen, P. R. (2011). Latino Health. In H.S. Friedman (Ed.), The Oxford handbook of health psychology (pp.
805-823). New York: Oxford University Press.
Swingle, M. K. (2016). i-Minds: How cell phones, computers, gaming, and social media are changing our brains, our
behavior, and the evolution of our species (2nd ed.). Gabriola Island, BC, Canada: New Society Press.
Swingle, M. K. (2015). i-Minds: How cell phones, computers, gaming, and social media are changing our brains, our
behavior, and the evolution of our species. Portland, OR: Inkwater Press.
Steffen, P. R. (2015). Stress and Health. In J. DuPree (Ed.), Wellness for life (pp. 195-204). Springville, UT: Plain Sight
Publishing.
Tan, G., Shaffer, F., Lyle, R., & Teo, I. (2016). Evidence-based practice in biofeedback and neurofeedback (3rd ed.). Wheat
Ridge, CO: Association for Applied Psychophysiology and Biofeedback.
 PETITION FOR THE RECOGNITION OF A
PROFICIENCY IN PROFESSIONAL PSYCHOLOGY:
Biofeedback and Applied Psychophysiology

APPENDIX H:
Letters of Support
 PETITION FOR THE RECOGNITION OF A
PROFICIENCY IN PROFESSIONAL PSYCHOLOGY:
Biofeedback and Applied Psychophysiology

APPENDIX I:
Evidence-Based Practice in Biofeedback and Neurofeedback, 3rd Edition
 PETITION FOR THE RECOGNITION OF A
PROFICIENCY IN PROFESSIONAL PSYCHOLOGY:
Biofeedback and Applied Psychophysiology

APPENDIX J:
AAPB Code of Ethics

Approved December 2, 2016

AAPB is an educational, scientific and professional organization whose members work in a variety of
settings and serve in multiple capacities. It is AAPB’s mission to promote and represent the science
and practice of self-regulation to enhance health and performance.
Professional values are an important way of living out an ethical commitment. The following are core
professional values of professionals involved of the research and application of Biofeedback:

A. Enhancing human development and improvement throughout the life span;

B. Honoring diversity and embracing a multicultural approach in support of the worth, dignity,
potential, and uniqueness of people within their social and cultural contexts;
C. Promoting social justice;
D. Safeguarding the integrity of the provider/client relationship;
E. Practicing in a competent and ethical manner.

The fundamental principles of professional ethical behavior are:

• Autonomy, or fostering the right to control the direction of one’s life;
• Non-maleficence, or avoiding actions that cause harm;
• Beneficence, or working for the good of the individual and society by promoting mental health
and well-being;
• Justice, or treating individuals equitably and fostering fairness and equality;
• Fidelity, or honoring commitments and keeping promises, including fulfilling one’s
responsibilities of trust in professional relationships; and
• Veracity, or dealing truthfully with individuals with whom providers/researchers come into
professional contact.

The Code sets forth the ethical obligations of AAPB members and provides guidance intended to
inform the ethical practice of those involved the research and delivery of the Biofeedback modality. It
enables the association to clarify for current and prospective members, and for those served by
members, the nature of the ethical responsibilities held in common by its members. It serves as an
ethical guide designed to assist members in constructing a course of action that best serves those
receiving biofeedback treatments and establishes expectations of conduct.
The intention of this document is aspirational and it will evolve. It is intended as guidance, education
and a preliminary attempt at standardization – not law. If accepted by our members, it would be a
living document.
Note to reader: Current ethics language is in normal type and proposed ethics revisions are in RED
italics/yellow highlight. Rationale is provided for each change.

Competence
A. AAPB members recognize the boundaries of their competence and operate within their level of
competence using only those biofeedback, other psychophysiological self-regulation
techniques, and other client assessment and intervention techniques in which they are
competent based on education, training and experience (supervised and unsupervised), study,
consultation or other professional experience. They also recognize the proper limitations of
psychophysiological self-regulation and inform all concerned parties about the clinical utility of
particular procedures, possible negative effects, and whether the procedures are non-validated
or clinically verified. AAPB members remain current on knowledge concerned with scientific
and professional applications in those areas in which they practice.
B. AAPB members who are service providers should have at least “entry level” competence; i.e.,
licensing or certification from the appropriate state or national association relevant to their
professional activities.
C. Applied psychophysiology and biofeedback assistants and technicians who are not
professionally licensed or certified shall engage in clinical applied psychophysiology and
biofeedback practice activities only under the supervision of a qualified professional.
D. Misrepresentation of one's qualifications, training, experience, degrees, and/or specialty is a
violation of ethics and may be a violation of the law in some states. AAPB members must
accurately describe their qualifications, training, experience, and/or specialty. They must only
list academic degrees (e.g. B.S., M.S., Ph.D., M.D…) such as in healthcare or optimal
performance fields earned from a regionally-accredited academic institution.
E. Practitioners take it upon themselves to seek and obtain appropriate training and supervision
when providing services in areas in which they are not yet competent. In addition, they seek
continuing education, training, and supervision or consultation, as needed to maintain and
expand their areas of competence.

Standards
A. AAPB members are sensitive to prevailing community moral and ethical standards and to the
possible negative impact that deviating from those standards may have upon the quality of
their performance in providing clinical applied psychophysiology and biofeedback services, in
fulfilling their professional responsibilities and in maintaining public trust in the field of applied
psychophysiology and biofeedback sciences. As a categorical statement, sexual contact with
patients/clients, trainees, and research subjects is never ethical.
B. AAPB Members will charge only for clinical services actually provided by them or those
provided by others under their direct supervision. In billing third-party payers, practitioners
abide by the rules and regulations of the third- which generally means the practitioner will
 clearly specify which service they provided directly, which they supervised, as well as providing
information on about their degree, licensure, and/or certification to the payer.
C. AAPB Members clarify any potential or actual conflict of interest that exists when serving
clients, conducting training or research, or when engaged in any other professional activity.
D. Informed consent shall be obtained from clients for all assessment, treatment procedures,
billing, fee collection, and procedures to protect confidentiality (within the legal, mandated
reporting limits of confidentiality such as when there is an evident or credible threat to self or
others), and any such other procedures and activities where informed consent is deemed
appropriate.
E. Written informed consent shall be obtained from clients and patients when providing clinical
services for all non-validated treatment procedures. Determining which procedures are non-
validated can be difficult, yet it is a necessary activity. To determine which procedures are non-
validated requires being familiar with documents such as AAPB’s current version of the Clinical
Efficacy and Cost Effectiveness of Biofeedback Therapy: Guidelines for Third-Party
Reimbursement; the Clinical Applications of Biofeedback and Applied Psychophysiology: A
Series of White Papers Prepared in the Public Interest by AAPB; and, the published scientific
literature related to biofeedback and psychophysiological self-regulation.

Multiculturalism and Diversity

A. AAPB members are encouraged to recognize that, as cultural beings, they may hold attitudes
and beliefs that can detrimentally influence their perceptions of and interactions with
individuals who are different from themselves in terms of race, color, religion, creed, sex,
sexual orientation, gender identity, national origin, ancestry, age, veteran status, disability
unrelated to job requirements, genetic information, military service, socioeconomic class, and
other cultural categories.
B. AAPB members are encouraged to recognize the importance of multicultural
sensitivity/responsiveness to, knowledge of, and understanding about individuals who are
different in terms of race, color, religion, creed, sex, sexual orientation, gender identity,
national origin, ancestry, age, veteran status, disability unrelated to job requirements, genetic
information, military service, socioeconomic class, and other cultural categories.
C. As educators and clinical service providers, AAPB members are encouraged to employ the
constructs of multiculturalism and diversity in education.
D. Culturally-sensitive researchers are encouraged to recognize the importance of conducting
culture-centered and ethical research among persons from diverse race, color, religion, creed,
sex, sexual orientation, gender identity, national origin, ancestry, age, veteran status, disability
unrelated to job requirements, genetic information, military service, socioeconomic class, and
other cultural categories.
E. AAPB members are encouraged to apply culturally appropriate skills in clinical and other
biofeedback practices.
F. AAPB members are encouraged to use positive motivational change processes to support
culturally informed organizational (policy) development and practices.
G. AAPB members regularly engage in professional reading and education (both online and face to
face) on multiculturalism and diversity, keeping up to date on current standards and research.
Protection of Client Rights and Welfare
Professionals adhere to the highest standards of hygiene to protect clients and
staff. Practitioners are responsible to learn and follow hygiene standards applicable to
biofeedback instruments, sensors, and office environments.
Complaints and Concerns
When the above standards are unclear and whenever appropriate, the pertinent ethical
standards of the American Psychological Association, American Psychiatric Association,
the American Nurses Association, the American Physical Therapy Association, the
American Medical Association, the American Dental Association, the American College of
Sports Medicine, the American Academy of Physical Medicine and Rehabilitation, the
National Association of Social Workers (NASW), or other professional associations, and
colleague feedback should be used by AAPB members to determine an ethical course of
action.
When a complaint is made, the AAPB Ethics Committee shall use these ethical principles
in evaluating the AAPB member's conduct. The Ethics Committee shall recommend
appropriate additions, deletions or revisions to these Ethical Principles, as necessary, to
the AAPB Board for approval. Thereafter the membership of the AAPB shall be required
to adhere to the revised Ethical Principles.

AAPB will not intervene in interpersonal conflicts, complaints about individuals who are
not AAPB members or applicants, or disagreements regarding manufacturer or vendor
products, services, business practices, or customer satisfaction. The AAPB Board of
Directors will periodically review and update its Ethical Principles. Thereafter, AAPB
members shall be required to adhere to the revised standards and the laws that govern
their profession.
The AAPB will advocate for psychophysiological self-regulation, biofeedback, applied
psychophysiology and biofeedback research, training and service. For example, AAPB will
advocate by being responsive to individuals or agencies when questions arise concerning
what is “common practice” in applied psychophysiology and biofeedback.

Ethics Committee Procedures

The major concerns of the Ethics Committee of AAPB are to protect the public against
unethical practices by AAPB members and to educate the membership concerning
acceptable ethical practice. The committee attempts to have complaints resolved by the
ethics committee of a member's profession whenever possible.

AAPB's Ethical Principles are intended to educate and guide members to prevent ethical
misconduct and should be applied with professional maturity. AAPB encourages
complainants to discuss and attempt to resolve alleged ethical concerns with accused
members or applicants. Ethical complaints against an AAPB member or applicant must
be written, signed, and dated by the complainant. When AAPB receives an ethics
complaint, its Executive Director will record the complaint and will write a letter to the
complainant that will describe AAPB's role in ethics cases, encourage the complainant to
directly discuss the complaint with the member or applicant, and if requested by the
complainant, identify institutional, state, and/or national regulatory authorities with
jurisdiction.
When that avenue fails, is inappropriate, or when the AAPB member is not professionally
licensed or certified, the committee attempts to resolve complaints privately and
informally and to recommend disciplinary action when unethical conduct is found to
exist.

Since AAPB’s approach to ethical issues is educational, it will not recommend that
complainants contact these authorities nor will it represent complainants before these
agencies.

The goal of the ethics committee is to be constructive and educative, rather than
punitive. The committee will attempt to have the complaint resolved by the local or state
biofeedback society if one exists. When a complaint is received, the formal procedures of
the AAPB will be followed.

Where a regulatory authority officially determines that an AAPB member or applicant has
acted unethically when providing academic, research, clinical, and/or optimal
performance services, or when an individual has misrepresented information during
application or membership renewal, the AAPB Board may revoke or refuse the
individual's membership. An AAPB member or applicant may reapply if the regulatory
authority reverses its determination or declares that the individual has satisfied the
terms of probation.
Individuals desiring more information about the ethical principles or wishing to register a
complaint may contact the Executive Director of AAPB or any member of the Ethics
Committee.

The AAPB Board of Directors will periodically review and update its Ethical
Principles. Thereafter, AAPB members shall be required to adhere to the revised
standards. Individuals desiring more information about these standards may contact
AAPB's Executive Director.
 PETITION FOR THE RECOGNITION OF A
PROFICIENCY IN PROFESSIONAL PSYCHOLOGY:
Biofeedback and Applied Psychophysiology

APPENDIX K:
BCIA Professional Standards and Ethical Principles of Biofeedback
https://www.bcia.org/files/public/ProfessionalStandardsAndEthicalPrinciplesofBiofeedback.pdf
(Reproduced with permission)

The Biofeedback Certification International Alliance

Professional Standards and Ethical Principles of Biofeedback

Preamble

For the purposes of this document, the term BCIA professionals refers to BCIA certificants and those
who have filed a formal application for BCIA certification. Because the Biofeedback Certification
International Alliance (BCIA) and its professionals are committed to the protection of human rights,
they strive to maintain the dignity and worth of the individual while rendering service, conducting
research, and teaching others. They operate within the BCIA Professional Standards and Ethical
Principles (PSEP). They strive to provide the highest quality of service and carefully differentiate
between empirically validated and experimental procedures. They hold themselves responsible for
their actions and make every effort to protect their clients’ welfare. Finally, they limit their services to
those areas in which they have expertise and exemplify the values of competence, objectivity, freedom
of inquiry, and honest communication.

The PSEP is intended to guide all BCIA professionals who commit themselves to adhere to these
Principles as well as to the Principles stated in their licensing act. A copy of the PSEP will be provided to
all BCIA certification applicants and will be available on the BCIA website. The PSEP are intended to
educate and guide professionals to prevent ethical misconduct and should be applied with professional
maturity.

The term biofeedback refers to all modalities for which we provide certification including, but not
limited to, BVP, EEG or neurofeedback, electrodermal, EMG, HRV, respiration, and thermal
biofeedback.

“Biofeedback is a process that enables an individual to learn how to change physiological activity for
the purposes of improving health and performance. Precise instruments measure physiological activity
such as brainwaves, heart function, breathing, muscle activity, and skin temperature. These
instruments rapidly and accurately ‘feed back’ information to the user. The presentation of this
information — often in conjunction with changes in thinking, emotions, and behavior — supports
desired physiological changes. Over time, these changes can endure without continued use of an
instrument.”1

Purpose and Scope

The PSEP consist of guidelines for professional biofeedback practice that are not exhaustive and do not
limit BCIA professionals’ ethical responsibilities. They highlight areas in which ethical concerns often
arise. For BCIA professionals who practice under a state and/or national licensing act, the PSEP are not
meant to
replace, but to confirm and reinforce, professional ethical guidelines.

1. The PSEP should be followed by BCIA certificants, applicants, and their staff who help provide
biofeedback and related services.

2. BCIA professionals’ ethical conduct is measured by the PSEP, state and/or national licensing acts,
and the ethical guidelines of their professional membership organizations where applicable.

3. A violation of the PSEP may lead to disciplinary action or decertification. In some instances, such as
sexual contact with a client, a criminal charge may result from breach of the PSEP and other
professional guidelines for ethical practice.

A. Responsibility
In utilizing biofeedback, BCIA professionals adhere to the highest standards of their profession. They
behave responsibly; accept responsibility for their behavior and its consequences; ensure that
biofeedback is used appropriately; and strive to educate the public concerning the responsible use of
biofeedback in treatment, training, and research. BCIA professionals are responsible for adhering to
the ethical principles of their profession; the local, state and national laws relevant to their
professional activities; and the PSEP.

1. As practitioners, BCIA professionals recognize their obligation to help clients acquire knowledge and
skill through training that represents the best professional practice and that is delivered in the most
cost-effective manner.

2. As teachers, BCIA professionals are committed to the advancement of knowledge. They encourage
the free pursuit of learning by their students and present information objectively, accurately, and
completely.

3. BCIA professionals guard against misuse of their influence since they realize that their professional
services impact the lives of their clients and others.
4. BCIA professionals should only continue biofeedback services as long as their clients benefit from
training. If their clients require an intervention that they are not qualified to provide, they should help
them obtain these services and should never abandon them.

B. Competence
BCIA professionals recognize the boundaries of their competence and only use those biofeedback and
adjunctive techniques in which they have expertise. They also recognize the proper limitations of
biofeedback and inform all concerned parties about the clinical utility of particular procedures,
possible negative effects, and whether the procedures are experimental or clinically verified. BCIA
professionals maintain current knowledge of relevant basic and applied biofeedback research.

1. BCIA professionals should operate within applicable local, state, and national laws as well as in
accordance with the ethical principles of their profession. BCIA certification is not a license to practice
independently.

2. BCIA professionals who treat medical or psychological conditions must demonstrate professional
competence as defined by applicable local, state, and national licensing/credentialing laws. BCIA
certification becomes invalid when a certificant’s license is suspended, revoked, or not renewed due to
an investigation of a complaint.

Once suspended the individual will not be considered by BCIA for a re-certification based on providing
services under supervision. A licensed professional who is suspended may only apply for recertification
by BCIA after the license has been reinstated.

3. BCIA professionals who are not appropriately licensed or credentialed, and who wish to treat
medical or psychological conditions, must acquire appropriate supervision according to applicable
state and national laws and professional codes/regulations.

4. BCIA professionals must accurately describe their qualifications, training, experience, and/or
specialty. They must only list degrees in an approved healthcare field earned from a regionally
accredited academic institution when applying for BCIA certification. BCIA only certifies individuals who
hold these degrees and only lists these credentials in its directory. When BCIA practitioners list BCIA
certification in advertisements, business cards, directories, websites, and similar professional
publications, that listing cannot include an unaccredited degree nor can it list a degree not related to
health care.

C. Ethical Standards

BCIA professionals are sensitive to prevailing community norms and recognize that the violation of
these standards may jeopardize the quality of their services, completion of professional
responsibilities, and public trust in biofeedback.
1. BCIA professionals will only charge for services actually provided by them or by those under their
legal supervision. In billing third party payers, practitioners will comply with the rules and regulations
of the third-party payer, including clearly specifying which services the practitioner provided directly
and which were supervised, and providing information regarding their qualifications (e.g., degree,
license, and certification).

2. BCIA professionals will clarify any potential or actual conflict of interest that exists when serving
clients, conducting training or research, or when engaged in any other professional activity (such as a
workshop in which presenters recommend their own product).

3. BCIA professionals will obtain written informed consent from clients for all assessment and
treatment procedures, billings and fee collections, and procedures to protect confidentiality, as well as
conditions that limit confidentiality.

4. BCIA professionals will obtain written informed consent from clients for all experimental treatment
applications. 2 To distinguish experimental and clinically-validated procedures is difficult and requires
familiarity with related documents.3

D. Multiculturalism and Diversity

1. BCIA professionals are encouraged to recognize that, as cultural beings, they may hold attitudes and
beliefs that can detrimentally influence their perceptions of and interactions with individuals who are
different from themselves ethnically, racially, in sexual orientation, or gender identity.

2. BCIA professionals are encouraged to recognize the importance of multicultural

sensitivity/responsiveness to, knowledge of, and understanding about individuals who are different
ethnically, racially, in sexual orientation, or gender identity.

3. As educators, BCIA professionals are encouraged to employ the constructs of multiculturalism and
diversity in education.

4. Culturally sensitive researchers are encouraged to recognize the importance of conducting culture-
centered and ethical research among persons from diverse ethnic, linguistic, racial, sexual orientation,
or gender identity backgrounds.

5. BCIA professionals are encouraged to apply culturally appropriate skills in clinical and other
biofeedback practices.

6. BCIA professionals are encouraged to use positive motivational change processes to support
culturally informed organizational (policy) development and practices.

7. BCIA professionals regularly engage in professional reading and education (both online and face to
face) on multiculturalism and diversity, keeping up to date on current standards and research.
E. Public Statements
BCIA professionals recognize that all public statements, announcements of services and products,
advertising, and promotional activities concerned with biofeedback should help the public make
informed choices. Statements about biofeedback must be based on scientifically verifiable information,
including recognition of the limits and uncertainties of such data. BCIA professionals must accurately
represent their qualifications, affiliations, and positions, and must not mislead the public.
1. BCIA professionals shall accurately represent the efficacy of biofeedback procedures for all disorders
or conditions being treated.

2. BCIA professionals must use accurate information in statements about biofeedback when providing
services, marketing a product, and in all other professional activities. They consider the context and
source requesting information when making a public statement and guard against misrepresentation.

3. BCIA professionals recognize that they may have personal interests when they promote biofeedback
activities and agree that these interests must be superseded by professional objectivity, concern for
clients’ welfare, and the PSEP and the standards of other professional societies to which they belong.
When a question arises as to their objectivity, they seek professional guidance from appropriate
professional sources like BCIA and their professional associations.

4. Announcements and listing of services and training offered by BCIA professionals, such as service
directory listings, letterheads, business cards, and marketing brochures and websites, should be
accurate and designed in a professional manner, and should adhere to the guidelines of their
professional associations.

F. Confidentiality

BCIA professionals protect the confidentiality of their clients’ data. They may only release information
with the written consent of the client or the client's legal representative, or when nondisclosure would
endanger the client or others.

1. BCIA professionals specify in advance the legal limits of confidentiality to clients, particularly when
collecting fees and complying with mandated reporting laws that concern abuse or neglect.
Confidentiality applies to clients in treatment, students in training, and research participants.

2. Client records are stored and destroyed in ways that maintain confidentiality. BCIA professionals will
keep records for the time required by applicable national and state laws.

G. Protection of Client Rights and Welfare

BCIA professionals protect the welfare of clients, students, research participants, and other groups
with whom they work. They inform all consumers of their rights, provide them with a written
statement of these rights, fully inform them as to the purpose and nature of procedures to be
implemented, and assure that clients’ rights are not abridged.

1. Sexual intimacy with current clients, trainees, supervisees, and research subjects is prohibited. BCIA
professionals should follow the applicable guidelines of state/national law and their professional
associations regarding when sexual intimacy is permissible after termination of a professional
relationship.

2. Professionals adhere to the highest standards of infection mitigation to protect clients and staff.
Practitioners are responsible to learn and follow reasonable disinfection standards applicable to
biofeedback instruments, sensors, and office environments.4

3. In attaching biofeedback sensors, professionals assure that the privacy and rights of the client are
protected and respect the feelings and sensitivities of their clients. Caution and common sense are
required whenever an applicant or certificant has physical contact with clients. Any physical contact
requires the permission of the client. Touching of sensitive body parts, such as breasts or genitals, is
not acceptable in biofeedback practice, with the exception of a medical exam or medical treatment
provided by a licensed medical practitioner.

4. Special care is taken to protect the rights of children when providing biofeedback training or
conducting research. Wherever possible, BCIA professionals should seek children’s agreement to
participate in these activities.

5. BCIA professionals do not discriminate against or refuse services to anyone on the basis of sex,
sexual orientation, gender identity, race, religion, disability, or national origin.

H. Professional Relationships

BCIA professionals recognize the interdisciplinary nature of biofeedback and respect the competencies
of colleagues in all professions. They strive to act in accordance with the obligations of the
organizations with which they and their colleagues are associated. They:

1. should only treat medical disorders if clients have first received a medical evaluation and/or are
under the care of a physician.

2. should strive to be objective in their professional judgment of colleagues and to maintain good
professional relationships even when opinions differ.

3. should avoid multiple relationships with their clients that could impair their professional judgment
or increase the risk of exploitation, and must never exploit clients, students, supervisees, employees,
research participants, or third party payers.
I. Research with Humans and Animals

BCIA professionals conduct research to advance understanding of human behavior, to improve human
health and welfare, and to advance science. They carefully consider alternative research methods and
assure that in the conduct of research the welfare of research participants (human and animal) is
protected. All researchers will adhere to state and national regulations and the professional standards
of their profession with regard to the conduct of research. Research involving humans may be subject
to regulation by local institutional review boards and to state and/or national regulations.2

Animal research may be subject to local institutional animal care and use committees and must comply
with state and national policies on the use of animals.5
1. The results of research will be released in a manner which accurately reflects research results and
only when the findings have satisfied widely-accepted scientific criteria. Any limitations regarding
factors such as sampling bias, small samples, and limited follow-up, will be explicitly stated. All
descriptive materials distributed regarding clinical practice will be factual and straightforward.2

2. The individual researcher is responsible for the establishment and maintenance of acceptable ethical
practice in research. The investigator is also responsible for the ethical treatment of research
participants by collaborators, assistants, students, and employees, all of whom also incur similar
obligations. Information obtained about research participants during the course of an investigation
should be confidential. When the possibility exists that others may obtain access to such information,
ethical research practice requires that this possibility, together with the plans to protect
confidentiality, be explained to the participants as part of the procedure for obtaining informed
consent.

3. Ethical practice requires that the investigator inform participants of all features of the research that
might be reasonably expected to influence their willingness to participate and to explain all other
aspects of the research about which the participant inquires. BCIA professionals protect participants
from physical and psychological discomfort, harm, and danger. If the risk of such consequences exists,
investigators are required to inform the participant of that fact, secure informed consent before
proceeding, and take all possible measures to minimize distress. A research procedure may not be
used if it is likely to cause serious and lasting harm to participants. As participants’ risk increases, so
does the responsibility of the researcher to protect the research participants. Written informed
consent or a verbal and written summary of the research is customary for most kinds of non-survey
research (including a signature by the research participant in both cases).

4. The investigator must respect an individual’s freedom to decline to participate in research or to

discontinue participation at any time. The obligation to protect this freedom requires special vigilance
when the investigator has power over the participant. When a prospective participant is a minor,
investigators should seek the child’s assent.
5. After research data are collected, the investigator must fully debrief participants about the nature of
the study. When scientific or human values justify delaying or withholding information, the investigator
acquires a special responsibility to assure that the participant is not harmed.

Adherence to Professional Standards

BCIA professionals should be knowledgeable about efficacious interventions and adhere to the
professional standards associated with these techniques.3

Additional Standards

BCIA professionals who hold a state or national license/credential should adhere to the guidelines of
the relevant professional licensing act. Additional guidance can be found in the ethical standards of
organizations like the American Psychological Association, American Psychiatric Association, the
American Nurses Association, the American Physical Therapy Association, the American Medical
Association, the American Dental Association, the American College of Sports and Rehabilitation, the
American Academy of Physical Medicine and Rehabilitation, and their international counterparts.

Ethics Complaint Procedures

When BCIA receives a written complaint about the ethical conduct of a BCIA certificant or applicant,
BCIA’s Executive Director will record the complaint and will write a letter to the complainant that will
describe BCIA's role in ethics cases, direct the complainant to directly discuss the complaint with the
provider (certificant or applicant), and if requested by the complainant, identify state and/or national
regulatory agencies with jurisdiction. Since BCIA’s approach to ethical issues is educational, BCIA will
not recommend that complainants contact these agencies nor will it represent complainants before
these agencies.

BCIA will not intervene in complaints about manufacturer or vendor products, services, or sales
practices as these issues do not concern certification and corporations are not BCIA professionals.

While BCIA encourages certificants to first discuss ethical concerns with their colleagues, certificants
may directly contact appropriate regulatory agencies. If an agency declares that a complaint lacks
merit, is frivolous, or is malicious, BCIA will defer to the agency to discipline the complainant.

The BCIA Board of Directors will periodically review and update the PSEP. Thereafter, BCIA
professionals shall be required to adhere to the revised PSEP. Comment is invited. Individuals desiring
more information about these Principles may contact BCIA.
Related Documents and Acknowledgments

1
Biofeedback Alliance and Nomenclature Task Force (2008).
2
Regulations for the protection of human research subjects (45 CFR46 and 56 FR 28003) (Federal
Regulations).
3
Humane care and use of animals (A 343401) (Federal Regulations).
4
Hagedorn, D. (2014). Infection risk mitigation for biofeedback providers. Biofeedback, 42(3), 93-95.
5
G. Tan, F. Shaffer, R. Lyle, & I. Teo (Eds.). Evidence-based practice in biofeedback and neurofeedback
(3rd ed.). Wheat Ridge, CO: Association for Applied Psychophysiology and Biofeedback.

We thank the Association for Applied Psychophysiology and Biofeedback, whose Ethical Principles
were modified and adapted for these Principles.

Original version adopted by BCIA Board of Directors, August 26, 1990.

1st revision prepared by John G. Carlson, Adopted by the BCIA Board of Directors, October 14, 1999.
2nd revision prepared and adopted by the BCIA Board of Directors, March 24, 2002.
3rd revision prepared and adopted by the BCIA Board of Directors, April 5, 2004.
4th revision prepared and adopted by the BCIA Board of Directors, April 1, 2005.
5th revision prepared and adopted by the BCIA Board of Directors, August 26, 2009.
6th revision prepared and adopted by the BCIA Board of Directors, May 18, 2015.
7th revision prepared and adopted by the BCIA Board of Directors, October 6, 2015.
8th revision prepared and adopted by the BCIA Board of Directors, January 29, 2016.
9th revision prepared and adopted by the BCIA Board of Directors, May 2, 2016.
 PETITION FOR THE RECOGNITION OF A
PROFICIENCY IN PROFESSIONAL PSYCHOLOGY:
Biofeedback and Applied Psychophysiology

APPENDIX L:
BCIA Blueprint of Knowledge Statements for Board Certification in Biofeedback
https://www.bcia.org/files/public/Biofeedback/2015BiofeedbackBlueprint.pdf
(Reproduced with permission)

The Biofeedback Certification International Alliance

Blueprint of Knowledge Statements for

Board Certification in Biofeedback

The provider certified in Biofeedback will demonstrate entry-level mastery of:

I. ORIENTATION TO BIOFEEDBACK – 2 hours surface electromyographic (SEMG), and

A. Definition of biofeedback
1. Summarize the AAPB definition of biofeedback
Biofeedback is a process that enables an
individual to learn how to change physiological
activity for the purposes of improving health and
performance. Precise instruments measure
physiological activity such as brainwaves, heart
function, breathing, muscle activity, and skin
temperature. These instruments rapidly and
accurately "feed back" information to the user.
The presentation of this information — often in
conjunction with changes in thinking, emotions,
and behavior — supports desired physiological
changes. Over time, these changes can endure
without continued use of an instrument.
2. Provide an overview of the modalities
commonly used in biofeedback, including blood
volume pulse (BVP), electrodermal (EDR),
electroencephalographic (EEG), heart rate (HR),
heart rate variability (HRV), respiratory (RESP),
temperature (TEMP) biofeedback.
B. History and development of biofeedback
1. Identify the pioneers in biofeedback and their
main contributions (e.g., Basmajian, Budzynski,
Gevirtz, Green, Kamiya, Lehrer, Lubar, Miller and
DiCara, Peper, and Sterman).
2. Summarize the findings of seminal studies in the
development of biofeedback (e.g., Miller &
DiCara, 1967; Taub & School, 1978; Green, Green,
& Norris, 1979).
C. Overview of principles of human learning as they
apply to biofeedback.
1. Summarize the major concepts of classical
and operant conditioning.
2. Explain the relevance of learning principles
to biofeedback training (e.g., shaping and
fading, and generalization).
D. Assumptions underlying biofeedback
 1. Explain how biofeedback training utilizes
feedback and feed-forward.
2. Discuss the concept of self-regulation and III. PSYCHOPHYSIOLOGICAL RECORDING – 8 hours
describe specific self-regulation skills.
3. Explain the roles of passive and active volition in A. Describe the most commonly employed biofeedback
self-regulation training. modalities: blood volume pulse (HR and HRV),
capnometer, electrocardiograph (HR and HRV),
electrodermograph (skin conductance and
potential), electromyography (EMG), oximeter,
respirometer, and thermograph.
II. STRESS, COPING, AND ILLNESS – 3 hours 1. Discuss sensors and typical placements
a. Explain when professionals should use
A. Summarize these models of stress and illness: wide and narrow SEMG placements, the
1. Biopsychosocial phenomenon of volume conduction, and
2. Transactional how these placements affect
3. Allostatic load measurements and vulnerability to
4. Dysponesis artifacts.
B. Explain psychophysiological reactions to stressful b. Discuss when professionals should use
events. larger or smaller diameter electrodes and
1. Acute stress the rationale for each choice.
a. Fight-or-flight or freeze response 2. Explain the physiological mechanisms that
i. Sympathetic-adrenomedullary generate these signals.
activation 3. Explain how to prepare the skin.
ii. Relationship to panic disorder and 4. Describe characteristic signals:
somatization a. Units of measurement
b. Parasympathetic responses: b. Typical amplitude and frequency ranges
i. Polyvagal theory (e.g., fainting, 5. Summarize common artifacts, their appearance
freezing, tend-and-befriend) in a raw signal, and strategies for their control.
c. Respiratory responses
i. Overbreathing B. Explain the purpose of a tracking test and how to
ii. Apnea perform it for each biofeedback modality.
iii. Gasps and sighs
C. Explain how to measure and achieve acceptable skin-
2. Chronic Stress electrode impedance in SEMG recording.
a. Hypothalamic-pituitary-adrenocortical
activation D. Summarize how you can check electrode cables for
b. Health consequences of chronic stress breaks.
i. Psychoneuroimmunology (PNI) and its
implications for immune-related illness E. Explain how to prevent shock hazards (e.g., optical
ii. Effects on HRV and its implications for isolation, and telemetry).
illness and death
F. Explain how the following electronic concepts apply
C. Discuss psychosocial mediators of stress to biofeedback. Where they measure instrument
1. Cognitive appraisal of stressors, conditions in performance, recognize acceptable values:
which the stress response can be beneficial or 1. Conduction and insulation
harmful, and coping resources. 2. Voltage (E)
2. Affect (e.g., anger, anxiety, hostility, compassion, 3. Current (I)
depression, gratitude, and hopelessness). 4. Resistance (R)
3. Personality dispositions 5. Ohm’s Law (E=IR)
a. Self-efficacy 6. Power
b. Resilience 7. Impedance (Z)
c. Optimism 8. Signal-to-noise ratio and sensitivity
d. Big 5 personality traits 9. Differential amplifiers
e. Type D personality 10. Common mode rejection
4. Social support 11. Frequency
 12. Low-pass, high-pass, and notch filters
13. Bandpass and bandwidth: explain the effect
of narrow and wide bandpasses on EMG
amplitude and vulnerability to artifacts
14. Power spectrum and Fast-Fourier analysis
15. Time constant
16. Resolution
G. Describe aseptic techniques to prevent transmission
of infection.
1. Explain how to disinfect clinic surfaces, including
furniture.
2. Describe how to disinfect sensors and cables.
3. Discuss how disposable sensors reduce infection
risk.
4. Understand how personal reusable sensors
(e.g., rectal or vaginal) reduce infection risk.
IV. RESEARCH METHODOLOGY - 2 hours
A. Understand the difference between experimental and
non-experimental designs, as well as the use of
randomly controlled and non-randomized designs, and
the conclusions that can be drawn from each.
B. Explain the importance of internal and external
validity, reliability, and power in evaluating research
findings.
C. Understand basic descriptive and inferential statistics.
D. Explain how meta-analyses help professionals evaluate
treatment efficacy.
E. Summarize evidence-based practice efficacy criteria as
outlined in the Template for Developing Guidelines for
the Evaluation of Clinical Efficacy of
Psychophysiological Interventions and Evidence-Based
Practice in Biofeedback and Neurofeedback.
F. Review and summarize key research studies that have
established current efficacy levels of major
applications of biofeedback (e.g., asthma, headache,
and hypertension).
V. SURFACE EMG (SEMG) APPLICATIONS – 6 hours
A. Understand skeletal muscle anatomy and physiology
1. Explain the concept of a motor unit and
functions of small and large motor units.
2. Describe the EMG frequency distributions seen
in relaxed, strongly contracted, and fatigued
muscles.
B. Identify the location and functions of major muscle
groups trained in biofeedback.
C. Describe common muscle actions (e.g., flexion and
extension).
D. Understand the anatomy and physiology involved in
the following disorders:
1. Low back pain
2. Tension-type headache
3. TMJD
E. For chronic musculoskeletal pain, explain:
1. Ascending and descending pain pathways
2. Gate control theory
3. Trigger point mechanisms
4. Allodynia
F. Explain the following treatment strategies
1. SEMG assessment
a. Static versus dynamic assessment
b. The clinical significance of SEMG asymmetry
and sustained muscle contraction
2. SEMG tension recognition and discrimination
training
3. SEMG down-training and up-training
G. Identify target muscles, typical electrode
placements, SEMG treatment protocols, and their
efficacy for the following conditions:
1. Tension-type headache
2. TMJD
3. Posterior neck and upper back pain
4. Low back pain
5. Pain due to poor workplace ergonomics
VI. AUTONOMIC NERVOUS SYSTEM (ANS) APPLICATIONS –
8 hours
A. Understand the anatomy and physiology of the
autonomic nervous system.
1. Describe the sympathetic, parasympathetic, and
enteric branches in terms of their location,
innervation of major organs, and actions.
2. Anatomy and autonomic innervation of the
cardiovascular, electrodermal, GI, and
respiratory systems.
3. The mechanisms that contribute to heart rate
variability (HRV).
B. Explain the following psychophysiological concepts:
1. Tonic, phasic, and spontaneous activity
2. Orienting and defensive responses
 3. Arousal/activation D. Describe breathing assessment and training
4. Adaptation and habituation techniques
5. Homeostasis and the boundary model 1. How to assess overbreathing
6. Individual response stereotype 2. How to teach healthy breathing
7. Situational specificity of physiological response a. Explain the importance of effortlessness in
8. Placebo and nocebo effects breathing
b. Describe how to teach abdominal breathing
C. Explain ANS assessment strategies c. Summarize strategies to correct
1. Psychophysiological stress and dysfunctional breathing patterns (e.g.,
relaxation profiles overbreathing)
2. Resonance frequency breathing rate
determination E. Explain the pathophysiology, treatment protocols,
and their efficacy for the following disorders:
D. Describe ANS training strategies 1. Asthma
1. Biofeedback-assisted relaxation 2. COPD
2. HRV biofeedback 3. Panic disorder
3. Peripheral blood flow (BVP and temperature)
biofeedback
4. Skin conductance/potential biofeedback VIII. INTERVENTION STRATEGIES – 8 hours

E. Explain the pathophysiology, treatment protocols, A. Intake procedures

and their efficacy for the following disorders: 1. Explain how to assess the presenting problem
1. Anxiety a. Measure the frequency, intensity, and
2. Depression duration of symptoms
3. Hypertension b. Identify what exacerbates and alleviates the
4. Irritable bowel syndrome symptoms
5. Migraine headache c. Document prior treatment for the presenting
6. PTSD problem, including medication, medical and
7. Raynaud’s disease mental health histories
8. Recurrent abdominal pain
B. Treatment Planning
Explain how to use empirical evidence and individual
VII. RESPIRATORY APPLICATIONS – 3 hours assessment results to choose appropriate
biofeedback training methods.
A. Describe respiratory anatomy and physiology,
including the muscles used in inhalation and C. Education
exhalation. 1. Explain biofeedback and the individual’s role in
this learning process
B. Explain the physiological mechanisms that 2. Identify the psychophysiology underlying the
generate end-tidal CO2 and regulate oxygen individual’s concern(s)
distribution to tissues. 3. Explain how biofeedback can address the
1. Explain the importance of pH in respiratory individual’s concern(s)
physiology 4. Discuss how to adjust your client’s expectations
2. Explain the importance of the Bohr effect 5. Explain the importance of practice to
3. Recognize healthy end-tidal CO2 and oxygen biofeedback training success
saturation values D. Training
1. Explain how to:
C. Describe the following breathing patterns: a. establish a baseline and compare client
1. Effortless breathing progress within and across sessions
2. Overbreathing and hyperventilation b. structure a biofeedback training session
3. Clavicular breathing c. select and evaluate appropriate biofeedback
4. Thoracic breathing displays
5. Reverse breathing d. adjust display speed and resolution
6. Apnea e. utilize shaping and reinforcement in
biofeedback training
 f. provide verbal feedback during biofeedback
training
g. set short-term and long-term training goals
h. assign home practice and promote client
accountability
i. use symptom and practice logs in biofeedback
training
j. schedule training to promote transfer of
training and reduce the risk of relapse
2. Summarize strategies to prepare a client for
graduation
3. Describe how to evaluate training success
E. Training resources
1. Summarize strategies to increase mindfulness
2. Explain how to integrate autogenic training,
progressive muscle relaxation, visualization and
imagery, and effortless breathing into
biofeedback
IX. PROFESSIONAL CONDUCT – 2 hours
A. Certification
1. Understand the difference between certification
and licensure
2. Explain how the voluntary surrender or
revocation of a license affects BCIA certification
3. Recognize the importance of continuing
education and advanced training
4. Describe how BCIA responds to complains
regarding the ethical conduct of its certificants
B. Responsibility and competence
1. Understand one’s responsibility and liability in
provision of services
2. Demonstrate competence in all aspects of
service provided
©2006 by the Biofeedback Certification International Alliance, (formerly the Biofeedback Certification Institute of America (BCIA). No
portion of this document may be reproduced in any form without the permission in writing of BCIA.
©2015 by the Biofeedback Certification International Alliance. No portion of this document may be reproduced in any form without the
permission in writing of BCIA.
3. Explain why professionals must limit the scope
of practice to areas of expertise and to services
permitted by the relevant practice act.
4. Understand the difference between
experimental versus experimentally-validated
treatments, and how to explain this to
prospective patients
5. Identify contraindications to treatment
6. Understand the ethical principles of one’s
primary profession and the challenges of
complying with competing ethical guidelines
7. Discuss how to ethically advertise, market
services, and make public statements
C. Client rights
1. Explain how to ensure privacy, confidentiality,
and secure privileged communication
2. Describe how to obtain informed consent for
assessment and treatment
3. Summarize procedures for accepting clients,
avoiding abandonment, and making appropriate
referral
4. Explain how to protect client privacy, rights,
feelings, and sensitivities when attaching
biofeedback sensors
5. Discuss universal precautions in biofeedback
6. Explain how to ensure equal access to health
care
D. Supervision and consultation
1. Discuss appropriate consultation and supervision
in biofeedback
2. Understand the requirement that BCIA-certified
technicians operate under BCIA-certified
supervisors.
3. Explain the purposes of consultation and
supervision
4. Describe the process of supervision
5. Outline the guidelines for seeking supervision
E. Professional relationships
1. Explain the issue of multiple relationships (dual
relationships)
2. Discuss how to avoid conflicts of interest and
exploitation of clients
3. Describe how to communicate client progress
with a referring physician.
4. Discuss consultation, referral, and relationships
with other professionals
5. Explain how to monitor health and medication
6. Describe procedures for dealing with unethical
behavior of colleagues
F. Record keeping
1. Discuss how to maintain technical and legal
records
2. Identify legally-required records and applicable
requirements for their retention
3. Explain how to document a client’s medical
history
4. Describe how to maintain records security to
ensure confidentiality
 PETITION FOR THE RECOGNITION OF A
PROFICIENCY IN PROFESSIONAL PSYCHOLOGY:
Biofeedback and Applied Psychophysiology

APPENDIX M:
BCIA Blueprint of Knowledge Statements for Board Certification in Neurofeedback
http://www.bcia.org/files/public/EEG/2015NeurofeedbackBlueprint.pdf
(Reproduced with permission)

The Biofeedback Certification International Alliance

Blueprint of Knowledge Statements for

Board Certification in Neurofeedback

The provider certified in Neurofeedback will have knowledge of:

I. Orientation to Neurofeedback – 4 hours operant conditioning, discrimination, shaping,

A. Definition of Neurofeedback (EEG Biofeedback)
Neurofeedback is employed to modify the
electrical activity of the CNS including EEG, event
related potentials, slow cortical potentials and
other electrical activity either of subcortical or
cortical origin. Neurofeedback is a specialized
application of biofeedback of brainwave data in
an operant conditioning paradigm. The method is
used to treat clinical conditions as well as to
enhance performance.
generalization and extinction.)
2. Application of learning principles to
Neurofeedback (e.g., generalization to the life
situation, discrimination training, length and
number of sessions, etc.)
D. Assumptions underlying Neurofeedback:
1. Concepts of feedback and control in biological
systems.
2. Basic psychophysiology of stress and attention

B. History and Development of Neurofeedback
1. Pioneers in EEG and Neurofeedback
(e.g., Caton, Berger, Adrian, Kamiya, others)
2. Discuss highlights of the seminal studies in
Neurofeedback (e.g., Sterman 1968, 2000,
Lubar 1976, Birbaumer 1982, others)
C. Overview of principles of human learning as they
apply to neurofeedback
1. Learning theory (e.g. habituation, classical and
II. Basic Neurophysiology & Neuroanatomy - 4 hours
A. Neurophysiology
1. Bioelectric origin and functional correlates
of EEG (pyramidal cell and dipole activity,
resonance and synchrony, etc.)
2. Definition of ERPs and SCPs.
3. Relationship of post-synaptic potentials
and action potentials to EEG
4. Neuroplasticity (e.g. LTD, LTP)

B. Functional Neuroanatomy
1. Basic neuroanatomy of ascending
sensory pathways to cortex
2. Thalamic, cortical, and subcortical generators of
EEG.
3. General cortical and subcortical anatomy.
4. Major functions of cortical lobes and major
subcortical structures and Brodmann areas.
5. Overview of connectivity, phase, and coherence
concepts related to EEG networks and tracts
(e.g. default network, nodes & modules.)
III. Instrumentation & Electronics – 4 hours
A. Essential Terms & Concepts
Basic metrics and terminology in electronics and
instrumentation such as, impedance, differential
amplifier principles, analog and digital filters, basic
electrical terms (e.g. AC, DC, sine waves, volume
conduction, Nyquist principle, gain, Fourier
transform, low/high bandpass and notch filters,
etc.), and common mode rejection
B. Signal Acquisition
1. 10-20 International Standard measurement
and nomenclature for 19 recording sites, both
classical and modified
2. Comparison of QEEG to other neuroimaging
techniques (e.g. PET, fMRI, CT, MEG, SPECT,
etc.)
3. Use of limited number of electrodes (fewer
than 19).
4. Montage options and their characteristics
5. Recognizing and correcting signals of
noncerebral origin, such as but not limited to:
a. Electromyographic
b. Electro-ocular
c. Cardiac (pulse)
d. Sweat (skin impedance)
e. Cable sway
f. 60 Hz (grounding)
g. Electrode “pop”
6. Recognizing normal EEG patterns
a. posterior dominant rhythm
b. difference between eyes open and eyes
closed resting conditions (e.g. posterior
alpha attenuation)
c. developmental aspects of EEG
d. diurnal influences on EEG
7. Evaluation of subject variables during
acquisition
a. alertness-drowsiness
b. medication/drug/alcohol effects
c. physical relaxation
d. eyes closed/eyes open/anxiety
C. Signal Processing
1. Analog, raw EEG
2. Basic signal measurement terms (e.g.
amplitude, magnitude, power, Hz)
3. Filtering methods and subjective
characteristics of frequency bands (delta,
theta, alpha, beta, gamma)
4. Waveform morphology
5. Source localization (LORETA inverse
solution, Laplacian analysis)
6. Clinically significant raw EEG waveforms
(e.g. Mu, spike & wave, SMR, sleep
spindles, etc.)
D. Aseptic Techniques
1. Client and trainer hygiene
2. Equipment sterilization
3. Cross contamination
E. Instrumentation Demonstration
Client preparation, basic set-up and operation of
EEG equipment, proper electrode attachment
and location of 10-20 sites, elimination of
artifact from EEG recording, recognition of
spike/wave activity in the raw EEG, etc.
IV. Research Evidence Base for Neurofeedback – 2 hours
A. Interpretation of the methodological and statistical
criteria and procedures for determining levels of
efficacy and effectiveness of neurofeedback, as
outlined in the Template for Developing Guidelines
for the Evaluation of Clinical Efficacy of
Psychophysiological Interventions and Evidence-
Based Practice in Biofeedback & Neurofeedback.
B. Key research studies establishing current efficacy
levels of major applications of Neurofeedback (e.g.,
ADHD, Substance Abuse, Optimal Performance, etc.)
V. Psychopharmacological Considerations – 2 hours
A. Potential effects of prescribed and non-
prescribed drugs on clinical presentation.
B. Potential effects of prescribed and non-
prescribed drugs on EEG measures.
C. Potential effects of different drugs on
neurofeedback assessment and training
VI. Patient/Client Assessment - 4 hours

A. Intake Assessment
1. The client’s presenting symptoms and goals,
medical and psychological conditions,
medications, psychosocial and family history,
and relevant biographical information, etc.
2. Pre and post-treatment assessments such as
neuropsychological tests, continuous
performance tests, EEG/QEEG, appropriate to
your practice and licensure.
B. EEG Assessment
1. Standardized EEG Assessments
(1 or 2-channel baselines)
2. Overview of QEEG – 19-channel QEEG or an
abbreviated Q
a. Reading topographical displays (brain maps)
and connectivity/coherence displays
b. Normative Databases
- definition
- common properties
- how they are used
3. Recognizing common normal and abnormal
patterns in the EEG (e.g., posterior alpha
blocking with eyes open; excessive high
frequency beta in alcoholism and anxiety; high
frontocentral theta to beta ratio in ADHD, etc.)
C. Ongoing Assessment
1. Methods of periodic objective evaluation
of patient/client progress
2. Adjusting and evaluating treatment
procedures to improve outcome
D. Assessment Demonstration
Perform a basic EEG assessment, an
abbreviated Q recording and/or attaching
electrode cap and completing an abbreviated
Q or 19-channel QEEG recording
VII. Developing Treatment Protocols – 6 hours
A. Evolution of neurofeedback protocols
Early protocols based on published studies
(e.g.,Peniston Protocol and revised Peniston
Protocols for alcoholism/PTSD, Theta/Beta protocol
for ADHD, SMR protocol for epilepsy, etc.)
1. Protocols based on results of EEG analysis and
psychometric assessments
2. Selecting a treatment model: standard
(researched) protocols, QEEG-based amplitude
and coherence/connectivity training, z-score
training, LORETA z-score training, source
localization training, SCP methods, etc.
B. Steps in protocol development and treatment
planning using one or more of the treatment models
C. Demonstration and case example exercises for
practice using steps/decision tree for applying client
assessment data to neurofeedback protocol
selection and treatment/training planning
VIII. Treatment Implementation – 6 hours
A. Client preparation for neurofeedback (e.g.,
orientation to neurofeedback and procedures; pre-
training methods – respiration training, relaxation
methods such as progressive relaxation, autogenic
suggestions, HRV biofeedback, etc.)
B. Therapeutic relationship, coaching, and
reinforcement strategies
C. Procedures and mechanics of conducting a
neurofeedback session
1. Monitoring client reaction to treatment (e.g., use
of pre-session questionnaires, etc.)
2. Obtaining clean EEG data (e.g., proper electrode
attachment, impedance, artifact elimination, etc.)
3. Selecting appropriate electrode montages
4. Setting thresholds for amplitude training
5. Monitoring client progress (e.g., identifying
drowsiness, revising protocols and moving to
new sites, medication issues, identifying
contraindications to treatment and adverse
reactions, reading/interpreting session
reports/graphs, etc.)
D. Introduction to Alpha-Theta Training
1. Applications (e.g., to over arousal conditions:
anxiety, alcoholism, PTSD, etc.)
2. Indicators for using revised or original Peniston
Protocol
3. Issues related to alpha-theta crossovers,
emotional abreactions, etc.
4. Psychotherapeutic skills and additional training
beyond Introductory level course required for
Alpha-Theta practitioners
E. Guidelines and Cautions for Remote Training – refer
to the ISNR Guidelines
F. Full Neurofeedback Session Demonstrations.
IX. Current Trends in Neurofeedback – 2 hours
A. Identify current trends such as z-score training,
LORETA z-Score training, etc.
 B. Combining neurofeedback with other modalities
(e.g., HRV, respiration, HEG, neuromodulation
systems, etc.)
1. Describe respiratory anatomy and physiology,
including the muscles used in inhalation and
exhalation
2. Explain the physiological mechanisms that
generate end-tidal CO2 and regulate oxygen
distribution to tissues
a. Explain the importance of pH in respiratory
physiology
b. Explain the importance of the Bohr effect
c. Recognize healthy end-tidal CO2 and
oxygen saturation values.
3. Describe the following breathing patterns:
a. Effortless breathing
b. Over-breathing and hyperventilation
c. Clavicular breathing
d. Thoracic breathing
e. Reverse breathing
4. Describe the effects of over-breathing on the EEG
Neurofeedback services should be limited to the
practice standards and guidelines of one’s license or
the license of their supervisor and also to those
areas where one has:
1. Sufficient training (e.g., alpha/theta)
2. Familiarity with the client population and
disorders (e.g., age, diagnosis, etc.)
D. Client rights
1. Privacy, confidentiality, and privileged
communication
2. Informed consent to assessment and treatment,
treatment contract apprising of possible adverse
effects
3. Accepting clients, abandonment, and appropriate
referral
4. Equal access to health care
5. HIPAA compliance

X. Ethical & Professional Conduct – 2 hours

A.
1997 by the Biofeedback Certification Institute of America. No portion of this document may be reproduced in any form without the
permission in writing of the Biofeedback Certification Institute of America.

2004 Revision prepared by the EEG Specialty Certification committee and adopted by the BCIA Board of Directors.

©2006 by the Biofeedback Certification International Alliance,(formerly the Biofeedback Certification Institute of America (BCIA). No portion
of this document may be reproduced in any form without the permission in writing of BCIA.

©2014 Revision prepared by Neurofeedback Certification Review Task Force and approved by the BCIA Board.

©2018 Revision approved by the BCIA Board.

Ethical and Legal Practice

Familiarity with the BCIA Certification Guidelines,
Professional Standards and Ethical Principles of
Biofeedback, ISNR Practice Guidelines for
Neurofeedback and ISNR Code of Ethics, and the
practice guidelines of one’s primary profession

1. Experimental vs. commonly accepted

neurofeedback treatment
2. Advertising, marketing of services, and public
statements
3. Continuing education and training

B. Clinical Practice
When treating a medical or psychological disorder,
one is required to carry a valid state-issued health
care license from a BCIA-approved health care field
or agree to work under supervision.

C. Scope of Practice
E. Supervision
1. Appropriate consultation and supervision in
neurofeedback;
2. Purposes and process of supervision and
consultation
3. Purposes and process of mentoring.

F. Professional relationships
1. Dual relationships
2. Conflicts of interest and exploitation of clients
3. Consultation, referral, and relationships with
other professionals
4. Medical and medication monitoring
5. Procedures for dealing with unethical behavior
and consumer complaints

Total: 36 hours
 PETITION FOR THE RECOGNITION OF A
PROFICIENCY IN PROFESSIONAL PSYCHOLOGY:
Biofeedback and Applied Psychophysiology

APPENDIX N:
BCIA description of Biofeedback Essential Skills
http://www.bcia.org/files/public/Biofeedback/BFEssentialSkillsCheckList.pdf
(Reproduced with permission)

Biofeedback Essential Skills Check List

http://www.bcia.org/files/public/Biofeedback/BFEssentialSkillsCheckList.pdf

A beginning biofeedback practitioner should be able to demonstrate mastery of the following basic skills, as
attested by their BCIA-approved Mentor who will initial each item as complete.

Blood Volume Pulse

 Explain the blood volume pulse signal and biofeedback to a client.
 Explain PPG sensor attachment to a client, and obtain permission to monitor him or her.
 Explain how to select a placement site and demonstrate how to attach a PPG sensor to minimize light and
movement artifacts.
 Perform a tracking test by asking your client to raise the monitored hand above the heart and then lower
the hand.
 Identify common artifacts in the raw PPG signal, especially movement, and explain how to control for
them and remove them from the raw data.
 Explain the major measures of heart rate variability, including HR Max - HR Min, pNN50, SDNN, and SDRR.
 Explain why we train clients to increase power in the low frequency band of the ECG and how breathing at
5-7 breaths per minute helps them accomplish this.
 Demonstrate how to instruct a client to utilize a feedback display.
 Describe strategies to help clients increase their heart rate variability.
 Demonstrate an HRV biofeedback training session, including record keeping, goal setting, site selection,
baseline measurement, display and threshold setting, coaching, and debriefing at the end of the session.
 Demonstrate how to select and assign a practice assignment based on training session results.
 Evaluate and summarize client/patient progress during a training session.

EMG
 Explain the EMG and biofeedback to a client.
 Explain skin preparation and electrode placement to a client, and obtain permission to monitor him or
her.
 Explain how to protect the client from infection transmitted by the sensor.
  Identify active- and reference-electrode placements using a marking pencil for bilateral cervical
paraspinal, frontalis, masseter, sternocleidomastoid, and trapezius sites.
 Demonstrate skin preparation and electrode placement.
 Measure electrode impedance for each active-reference electrode pair and ensure that impedance is
sufficiently low and balanced.
 Perform a tracking test for your placement, instructing the client to contract and then relax the monitored
muscle.
 Identify common artifacts in the raw EMG signal, including 50/60Hz, bridging, ECG, loose electrode,
movement, and radio frequency, and explain how to control for them and remove them from the raw
data.
 Demonstrate how to instruct a client to utilize a feedback display.
 Demonstrate a surface EMG biofeedback training session, including record keeping, goal setting, site
selection, bilateral and unilateral recording, and bandpass selection, baseline measurement, display and
threshold setting, coaching, and debriefing at the end of the session.
 Demonstrate how to select and assign a practice assignment based on training session results.
 Evaluate and summarize client progress during a training session.

Heart Rate
 Explain the ECG signal and biofeedback to a client.
 Explain ECG sensor attachment to a client, and obtain permission to monitor him or her.
 Explain how to select a placement site and demonstrate how to attach ECG sensors to minimize
movement artifact.
 Demonstrate skin preparation.
 Perform a tracking test by asking your client to slowly inhale and then exhale as you watch the change in
heart rate.
 Identify movement artifact in the raw ECG signal, and explain how to control movement and remove this
artifact from the raw data.
 Explain the major measures of heart rate variability, including HR Max - HR Min, pNN50, SDNN, and SDRR.
 Explain why we train clients to increase power in the low frequency band of the ECG and how breathing at
5-7 breaths per minute helps them accomplish this.
 Demonstrate how to instruct a client to utilize a feedback display.
 Describe strategies to help clients increase their heart rate variability.
 Demonstrate an HRV biofeedback training session, including record keeping, goal setting, site selection,
baseline measurement, display and threshold setting, coaching, and debriefing at the end of the session.
 Demonstrate how to select and assign a practice assignment based on training session results.
 Evaluate and summarize client progress during a training session

Respiration
 Explain the respiration signal, healthy breathing, and biofeedback to a client.
 Explain sensor attachment to a client, and obtain permission to monitor him or her.
 Explain how to select a placement site and demonstrate how to attach a respiration sensor to the chest
and abdomen. Show how to monitor the accessory muscles to measure breathing effort.
 Perform a tracking test asking your client to take a slow, deep breath.
 Identify breath holding, gasping, and movement artifact in the respiration signal, and how to remove
them from the raw data.
 Explain how to identify clavicular breathing, excessive breathing effort, reverse breathing, and thoracic
breathing.
 Explain how posture and clothing can affect breathing.
 Demonstrate how to find your client's resonance frequency and explain why this is important.
 Demonstrate how to instruct a client to utilize a breathing pacer and the feedback display.
 Discuss strategies for slowing down your client's breathing toward 5-7 breaths per minute.
  Demonstrate a respiratory biofeedback training session, including record keeping, goal setting, site
selection, baseline measurement, display and threshold setting, coaching, and debriefing at the end of the
session.
 Demonstrate how to select and assign a practice assignment based on training session results.
 Evaluate and summarize client progress during a training session.

Skin Conductance/Skin Potential

 Explain the SC/SP signal and biofeedback to a client.
 Explain sensor attachment to a client, and obtain permission to monitor him or her.
 Explain how to select a placement site and demonstrate how to attach a sensor to minimize movement
artifact.
 Explain how to protect the client from infection transmitted by the sensor.
 Perform a tracking test by asking your client to take 3 quick breaths.
 Identify common artifacts in the raw SC/SP signal, including movement and respiration, and explain how
to control for them and remove them from the raw data.
 Demonstrate how to instruct a client to utilize a feedback display.
 Demonstrate an electrodermal biofeedback training session, including record keeping, goal setting, site
selection, baseline measurement, display and threshold setting, coaching, and debriefing at the end of the
session.
 Demonstrate how to select and assign a practice assignment based on training session results.
 Evaluate and summarize client progress during a training session.

Temperature
 Explain the temperature signal and biofeedback to a client.
 Explain thermistor attachment to a client, and obtain permission to monitor him or her.
 Explain how to select a placement site and demonstrate how to attach a thermistor to minimize
blanketing, movement, and stem artifacts.
 Perform a tracking test by asking your client to blow on the thermistor bead.
 Identify common artifacts in the raw temperature signal, including draft and movement, and explain how
to control for them and remove them from the raw data.
 Demonstrate how to instruct a client to utilize a feedback display.
 Describe strategies to help clients with cold hands, who warm very slowly, or who cool when they
attempt to warm their hands.
 Demonstrate a temperature biofeedback training session, including record keeping, goal setting, site
selection, whether to record bilaterally or unilaterally, baseline measurement, display and threshold
setting, coaching, and debriefing at the end of the session.
 Demonstrate how to select and assign a practice assignment based on training session results Evaluate
and summarize client progress during a training session.

I attest that this work has been completed for: ____________________________________.

Name of Candidate for BCIA Certification

Signature of the Mentor: _____________________________________ Date: ______________

Printed Name of Mentor: _____________________________________ BCIA #:_____________

If using more than 1 mentor, please make copies of this document for each mentor to complete.
 PETITION FOR THE RECOGNITION OF A
PROFICIENCY IN PROFESSIONAL PSYCHOLOGY:
Biofeedback and Applied Psychophysiology

APPENDIX O:
BCIA description of Neurofeedback Essential Skills
https://www.bcia.org/files/public/EEG/NeurofeedbackEssentialSkillsList.pdf
(Reproduced with permission)

NEUROFEEDBACK ESSENTIAL SKILLS LIST

A beginning neurofeedback practitioner should be able to demonstrate mastery of the following basic skills, as
attested by their BCIA-approved Mentor who will initial each item as completed.

Client/Patient Orientation
___ 1. In layman’s language, explain to a new client EEG biofeedback, self-regulation concepts, and operant
conditioning of brainwave activity.
___ 2. Explain the major stages in the neurofeedback treatment/training process, from initial intake and
assessment to progress monitoring and reporting. ___ 3. Explain client’s role and responsibilities in the
neurofeedback process.
___ 4. At initial session, explain how the neurofeedback session process and equipment works, including:
 purpose and steps involved in skin preparation
 steps in electrode attachment and selection of site placements; assure client about safety of
“sensors”/electrodes
 meaning of primary features of the feedback screens and concepts of amplitude and frequency
and/or z-scores
 relationship between client activity and on-screen feedback changes
 session recording and progress monitoring screens.

___ 5. Obtain written client permission for treatment/training using a thorough Informed Consent form.

Intake, Assessment and Protocol Selection

___ 1. Document a thorough client symptom and medication history and gather background information relevant
to treatment/training goals
___ 2. Provide a thorough EEG baseline assessment, using the following skills:
 perform correct measurements to name and locate on the scalp each of the International 10-20
System electrode placement sites
 properly prepare scalp and ears and attach electrodes to selected assessment sites or attach an
electrode cap if doing a full-cap quantitative EEG
  correctly perform all steps to collect a qEEG recording or multi-channel EEG assessment: checking
impedances, removing artifact, and collecting eyes-open and eyes-closed data
 demonstrate basic understanding of a qEEG assessment report, as well as the most commonly
reported components of qEEG databases (absolute power, relative power, phase, coherence, z-score
comparisons, etc.)
 identify recordings indicating spike and wave activity requiring consultation with a neurologist or
qEEG expert
 use all intake, psychometric, and baseline EEG assessment data to select target electrode placement
sites and montages for neurofeedback treatment/training
 Select an initial neurofeedback protocol and explain rationale to client.

Use and Maintenance of Neurofeedback Equipment

___ 1. Demonstrate thorough knowledge of operation of neurofeedback equipment of choice:
 Make correct hardware connections and start hardware.
 Make correct electrode connections to the hardware.
 Identify and remove (or control for) sources of common artifacts in the raw EEG signal.
 Troubleshoot common equipment failures according to manufacturer’s recommendations.

___ 2. Demonstrate thorough knowledge of appropriate software for selected equipment:

 Accurately select, install, and run neurofeedback treatment/training software.
 Identify components, applications, and limitations of selected software package.

Neurofeedback Session Management and Reporting

___ 1. Conduct neurofeedback treatment/training sessions involving the following procedures:
 Provide initial orientation and instructions to client at first treatment/training session.
 Prior to subsequent sessions, query client (and/or parent) verbally and/or via pre-session
questionnaire on client’s positive and negative reactions to previous session.
 Maintain basic hygiene procedures in attaching (and cleaning) electrodes.
 Remind client of the training objectives for session and their role in attending to and responding to
feedback.
 Start treatment/training software program, set up selected protocol parameters, and run basic
feedback functions.
 As appropriate, set initial training thresholds and adjust as needed.
 Identify and remove sources of artifact appearing in session recordings.
 Monitor session recordings and provide coaching and supplemental verbal feedback to client during
sessions, as appropriate.
 Save session data per equipment guidelines and review session results with client.
 Assign homework to client that supports and supplements session training goals.
 Consult with client’s prescribing physician and/or providers of other concurrent treatments as
necessary to avoid treatment complications and maximize treatment outcomes.
 Identify as soon as possible in the treatment/training process when neurofeedback is not working for
a client; identify cause(s) for lack of progress; make necessary protocol or other training program
adjustments; or, when necessary, recommend termination of neurofeedback.
 In collaboration with client, determine when neurofeedback treatment/training goals have been met
and mutually plan for treatment termination and follow-up.
 Conduct all aspects of neurofeedback treatment and training in accordance with BCIA, AAPB and ISNR
codes of ethical practice.
___ 2. Maintain orderly and up-to-date client files, including
 session-by-session training records, significant session events and client comments
 changes in client medication, significant life changes, allergies, etc. that may impact
treatment/training results
 reports of consultations with other treatment providers, family members, teachers, etc.

Use of Supplemental Therapeutic and Training Modalities

___ 1. Demonstrate ability to establish positive, constructive relationships with clients and their family members,
using basic counseling and communication skills
___ 2. Document adequate training and demonstrate skills required to use appropriate counseling/therapy
methods to supplement neurofeedback with clients having mental health diagnoses
___ 3. Document adequate training in use of alpha-theta neurofeedback protocols. Demonstrate ability to select
appropriate clients for alpha-theta training as well as apply appropriate therapy methods when using these
protocols
___ 4. Document adequate training in other neuromodulation modalities (such as HRV biofeedback, AVS, CES, etc.)
for use in conjunction with neurofeedback, and demonstrate ability to select and use appropriate adjunctive
modalities with individual clients.

I attest that this work has been completed for: ____________________________________.

Name of Candidate for BCIA Certification

Signature of the Mentor: _____________________________________ Date: ______________

Printed Name of Mentor: _____________________________________ BCIA #:_____________

If using more than 1 mentor, please make copies of this document for each mentor to complete.
 PETITION FOR THE RECOGNITION OF A
PROFICIENCY IN PROFESSIONAL PSYCHOLOGY:
Biofeedback and Applied Psychophysiology

APPENDIX P:
BCIA Mentoring Guidelines for Biofeedback
https://www.bcia.org/files/public/Biofeedback/GenMentoringGuidelines.pdf
(Reproduced with permission)

The Biofeedback Certification International Alliance

Guidelines & Policies for Mentoring
Candidates for Board Certification in Biofeedback

BCIA believes that mentoring is essential to ensuring quality in the delivery of biofeedback services and that it is
critical to the training of beginning biofeedback providers. This document is intended to provide a framework for
mentoring of candidates for Board Certification. Both the mentor and candidate should operate within applicable
local, state, and federal laws that govern their practice; the BCIA Professional Conduct and Ethical Principles of
Biofeedback (PSEP); and the ethical principles of their profession/occupation. Mentoring does not substitute for
supervision required for professional licensure or insurance reimbursement.
Mentoring involves a relationship between a mentor and candidate that promotes the development of skill,
knowledge, responsibility, and ethical standards in the practice of biofeedback. Through mentoring, the candidate
learns to apply these skills to specific practice situations.

I. Definitions
A. Mentoring is the process of transmitting knowledge and skills from the trained to the untrained or the
experienced to the less experienced practitioner.
B. Candidate is one who has submitted an application with documentation of the educational prerequisite and
a filing fee, and has been approved.
C. Supervision is the legal oversight and responsibility for the work of an unlicensed person. This is regulated
by the state board of the licensed professional. In some cases a mentor and supervisor may be one in the
same. Because supervision is regulated by state licensing boards, it is imperative that a licensed provider
understand their own practice standard guidelines and abide by the laws that govern their license and
their scope of practice.

II. Qualifications and Limitations of Mentors

The following criteria are required for an individual to serve as a mentor:
A. BCIA Certification
The mentor must be Board Certified in Biofeedback (BCB). Occasionally, because of geographic location or
other special circumstances, a candidate cannot be mentored by a professional who is Board certified. If
there is a professional available who by exceptional merit and experience would be able to provide
appropriate mentoring, a special review of his/her credentials is requested prior to starting training.
B. Experience
The mentor must have at least two years experience in the practice of biofeedback and with a similar client
base as the candidate. Biofeedback must be a significant portion of the person’s professional work.
C. Limitations
 A mentor should operate within applicable local, state, and federal laws as well as in accordance with the
regulations of their profession or occupation. Mentors should operate within the limits of their expertise,
training, and professional license/credential.
Mentorship does not substitute for supervision required for professional licensure and it does not assume
responsibility for the work of an unlicensed person. These are unique and separate contractual
agreements between two professionals.

III. Biofeedback Mentoring Requirements

Mentoring involves two essential components: contact hours with the mentor and hands-on practical
experience, and should be provided by a Board certified clinician (BCB), who has been approved to serve
in this capacity.
A. Mentoring Contact Hours
The mentor and candidate must have a minimum of 20 contact hours together. This time is to be used to
review a minimum of: 10 sessions of personal biofeedback; 50 patient/client sessions; and 10 case
studies. At least two of the contact hours must involve direct observation. All mentoring contact hours
may be completed face-to-face or through the use of live phone and/or web meetings, including the 2
hours of direct observation, so long as the mentor can view the candidate’s screen during a live session.
All sessions are a minimum of 20 minutes.
B. Hands-On Practical Experience
1. 10 Sessions of Personal Biofeedback Training - The candidate is hooked up and using biofeedback for self-
regulation training. The mentor should review the candidate’s self-regulatory skills demonstrated with
no less than 10 sessions of personal training involving EMG, Thermal, and HRV modalities. The
candidate may elect to be trained by the mentor as a real client or can review their completed
biofeedback sessions with the mentor.
2. 50 Patient/Client Sessions - The candidate is attaching the electrodes and running the full sessions, not
merely observing. The mentor should review the candidate’s work with a variety of conditions. This
should involve no less than five clients over a minimum of 10 weeks. A minimum of 50 separate
biofeedback sessions is to include 10 each of EMG, Thermal, and HRV biofeedback. The remaining 20
sessions should include any combination of EMG, Thermal, GSR, HRV, and respiration. The mentor
should make sure the candidate has good skills in all demonstrated biofeedback modalities as well as
proper and proficient use of equipment and hook-up techniques.
3. 10 Case Studies: The case study presentations should reflect a client from intake through protocol
selection/adjustment, and discharge. These should be actual cases presented either by the mentor to
broaden the candidate’s exposure to a wide variety of biofeedback scenarios or can be presented by
the candidate, but only if the cases are ones not previously discussed in the 50 patient/client sessions.
This is the only type of mentoring that is well done in online group settings. BCIA also offers mentoring
webinars, each providing one contact hour to review two case studies.
C. Essential Skills List
A candidate should be able to demonstrate mastery of these basic skills as attested by their BCIA-approved
Mentor, who will work with the candidate to assess each item and initial as completed.

IV. Obligations and Responsibilities of the Mentor

A. Experienced professionals have an obligation to provide mentoring to those entering the field, thus
ensuring that new providers are adequately trained. Mentors are not responsible for the patient, unless
they are also licensed as supervisors who have taken legal responsibility for the client. The process of
mentoring is simply teaching the hands-on application of biofeedback skills.
B. Mentors should maintain objectivity and should have no conflict of interest, including dual relationships.
BCIA does not endorse providing mentoring to a family member. Although the mentor is in a position of
power, the candidate must be treated with respect. This position must not be used to exploit the
candidate in any way, including sexual harassment.
C. The mentor also has an obligation to the patients/clients of the candidate, and must take appropriate action
against unethical conduct of the candidate and one’s self. If the mentor believes that the candidate is
 unqualified to deliver biofeedback services, this must be clearly stated through an evaluation or some
other appropriate method.

V. Professional Commitment
BCIA expects mentors to be:
- active in the field of biofeedback and their profession as evidenced by affiliations with professional
organizations and as required for BCIA recertification.
- free of active sanction by a disciplinary proceeding.
- involved in formalized training and professional development in the practice of biofeedback. This may
include workshops, continuing education programs, and study of current literature.
- experienced with the candidate’s client population and methods of practice.
- knowledgeable about issues related to diversity such as race, language, culture, gender, sexual orientation,
age, and disability.
- technically and professionally experienced with a major time and career commitment to the field of applied
psychophysiology and biofeedback.

VI. Client Confidentiality

BCIA encourages clinicians to maintain HIPAA compliant methods for all electronic communications. This
would include communications with mentors, colleagues, other professionals, and insurance companies.
Such compliance would include, but not be limited to, use of coded numbers in place of names, using
initials, altered birth dates, blacking out identifying information, or other means of making patient
identification impossible. BCIA encourages individuals to check with their employer, risk manager, or
HIPAA regulations to make certain they are in compliance.

VII. Procedures
A. BCIA recommends that mentoring of biofeedback training with patients/clients should take place after the
candidate is a pre-qualified BCIA applicant and completes didactic training through an accredited training
program, unless the training is part of a degree granting program from an accredited college or university
that offers course work concurrently with a practicum.
B. Mentoring can begin when the candidate can demonstrate some basic competence with equipment and is
only the time spent reviewing the actual work as outlined by BCIA. Primarily working on equipment issues
or technical support is not mentoring and should not be included.
C. Filing a Mentor Application
The certificant should file a Mentor Application and await approval from BCIA prior to beginning hands-on
training. Approved applications are valid for one year and during that time, the mentor may simply email
BCIA with new candidate names or any significant changes to the information.
D. Mentoring Agreement
BCIA recommends, but does not require, a written mentoring agreement that should be signed by both the
mentor and candidate prior to starting to work together. It should be amended and renegotiated as
needed to reflect any necessary changes. The agreement should include, but not be limited to the
following:
1. obligations of the mentor and the candidate.
2. a set period of time (no more than one year) or renegotiated at the end of the time.
3. a statement to abide by the ethical principles of the mentor’s profession and the BCIA Professional
Standards and Ethical Principles of Biofeedback. (PSEP).
4. a plan to address conflicts between mentor and candidate.
5. a fee charged for mentoring.
6. a process for termination of the mentoring relationship.
7. an evaluation or performance appraisal to be done at specified intervals.
E. Documentation
1. Recording Contact Hours and Sessions
 Mentoring progress should be recorded by both the mentor and candidate. BCIA provides an optional log
sheet that can serve as a recording document during the mentoring process.
2. Mentor’s Signature Upon Completion
The application contains a section that can be signed upon completion of the work with the candidate.
There is a separate statement one can submit to document exactly what was done with the candidate.
Some candidates work with more than one mentor, so it is imperative that the mentor edit the
statement and sign off on only what was accomplished.
3. Essential Skills List
This checklist must be reviewed with the candidate and the mentor must initial as each skill is tested and
approved. Should the entire list not be completed, the mentor is to sign off only on what was approved
and submit the list directly to BCIA, not to the candidate.

VIII. Liability Issues

Although it is rare for a mentor to be held liable for the mistakes made by the candidate, we advise prudence
when the treatment of patients is involved. We strongly advise that the mentor verify the professional
liability insurance of the candidate when the treatment of patients is involved. It is ill advised to treat
patients without obtaining professional liability insurance. In order to avoid liability problems, we strongly
advise that the following risk management procedures be instituted by the mentor. A. Monitor the
candidate’s professional functioning as well as the mentoring process on a regular basis. Document all
interactions.
B. Ensure that biofeedback services are performed according to accepted standards.
C. To protect patient confidentiality, a mentor should insist on an informed consent form regarding disclosure
of information if the identity of the client/patient is evident.
D. Identify any practice that might pose a danger to patients/clients and quickly take remedial action.
E. Identify any inability to practice due to impairment by alcohol, drugs, illness, stress, or personal problems.

IX. Continuing Education Credit

In order to receive accredited hours for BCIA recertification, an approved Mentor Application should be on file
with BCIA. A mentor may earn 5 Accredited CE hours for each pre-approved candidate who is mentored
for a minimum of 15 hours.
 PETITION FOR THE RECOGNITION OF A
PROFICIENCY IN PROFESSIONAL PSYCHOLOGY:
Biofeedback and Applied Psychophysiology

APPENDIX Q:
BCIA Mentoring Guidelines for Neurofeedback
https://www.bcia.org/files/public/EEG/EEGMentoringGuidelines.pdf
(Reproduced with permission)

The Biofeedback Certification International Alliance

Guidelines & Policies for Mentoring
Candidates for Board Certification in Neurofeedback

BCIA believes that mentoring is essential to ensuring quality in the delivery of neurofeedback services and that it is
critical to the training of beginning neurofeedback providers. This document is intended to provide a framework
for mentoring of candidates for Board Certification. Both the mentor and candidate should operate within
applicable local, state, and federal laws that govern their practice; the BCIA Professional Conduct and Ethical
Principles of Biofeedback (PSEP); and the ethical principles of their profession/occupation. Mentoring does not
substitute for supervision required for professional licensure or insurance reimbursement.

Mentoring involves a relationship between a mentor and candidate that promotes the development of skill,
knowledge, responsibility, and ethical standards in the practice of biofeedback. Through mentoring, the candidate
learns to apply these skills to specific practice situations.

I. Definitions

A. Mentoring is the process of transmitting knowledge and skills from the trained to the untrained
or the experienced to the less experienced practitioner.

B. Candidate is one who has submitted an application with documentation of the educational
prerequisite and a filing fee, and has been approved.

C. Supervision is the legal oversight and responsibility for the work of an unlicensed person. This is
regulated by the state board of the licensed professional. In some cases a mentor and supervisor
may be one in the same. Because supervision is regulated by state licensing boards, it is
imperative that a licensed provider understand their own practice standard guidelines and abide
by the laws that govern their license and their scope of practice.

II. Qualifications and Limitations of Mentors

The following criteria are required for an individual to serve as a mentor:

 A. BCIA Certification

The mentor must be Board Certified in Neurofeedback (BCN). Occasionally, because of

geographic location or other special circumstances, a candidate cannot be mentored by a
professional who is Board certified. If there is a professional available who by exceptional merit
and experience would be able to provide appropriate mentoring, a special review of his/her
credentials is required prior to starting training.

B. Experience

The mentor must have at least two years’ experience in the practice of biofeedback and with a
similar client base as the candidate. Neurofeedback must be a significant portion of the person’s
professional work.

C. Limitations

A mentor should operate within applicable local, state, and federal laws as well as in accordance
with the regulations of their profession or occupation. Mentors should operate within the limits
of their expertise, training, and professional license/credential.

Mentorship does not substitute for supervision required for professional licensure and it does
not assume responsibility for the work of an unlicensed person. These are unique and separate
contractual agreements between two professionals.

III. Biofeedback Mentoring Requirements

Mentoring involves two essential components: contact hours with the mentor and hands-on practical
experience, and should be provided by a Board certified clinician (BCN), who has been approved to serve
in this capacity.

A. Mentoring Contact Hours

The mentor and candidate must have a minimum of 25 contact hours together. This time is to be
used to review a minimum of: 10 sessions of personal neurofeedback; 100 patient/client
sessions; and 10 case studies. At least two of the contact hours must involve direct observation.
All mentoring contact hours may be completed face-to-face or through the use of live phone
and/or web meetings, including the 2 hours of direct observation, so long as the mentor can view
the candidate’s screen during a live session. All sessions are a minimum of 20 minutes.

B. Hands-On Practical Experience

1. 10 Sessions of Personal Neurofeedback Training - The candidate is hooked up and using

neurofeedback for self-regulation training. The mentor should review the candidate’s
self-regulatory skills demonstrated with no less than 10 sessions of personal training
using neurofeedback. The candidate may elect to be trained by the mentor as a real
client or can review their completed neurofeedback sessions with the mentor.
 2. 100 Patient/Client Sessions - The candidate is attaching the electrodes and running the
full sessions, not merely observing. The mentor should review the candidate’s work with
a variety of conditions. This should involve no less than six clients over a minimum of 10
weeks. The mentor should make sure the candidate has good skills in demonstrated
neurofeedback protocols, as well as proper and proficient use of equipment and hook-
up techniques.

3. 10 Case Studies: The case study presentations should reflect a client from intake
through protocol selection/adjustment, and discharge. These should be actual cases
presented either by the mentor to broaden the candidate’s exposure to a wide variety
of neurofeedback scenarios or can be presented by the candidate, but only if the cases
are ones not previously discussed in the 100 patient/client sessions. This is the only type
of mentoring that is well done in online group settings. BCIA also offers mentoring
webinars, each providing one contact hour to review two case studies.

C. Essential Skills List

A candidate should be able to demonstrate mastery of these basic skills as attested by their BCIA-
approved Mentor, who will work with the candidate to assess each item and initial as completed.

IV. Obligations and Responsibilities of the Mentor

A. Experienced professionals have an obligation to provide mentoring to those entering the field,
thus ensuring that new providers are adequately trained. Mentors are not responsible for the
patient, unless they are also licensed as supervisors who have taken legal responsibility for the
client. The process of mentoring is simply teaching the hands-on application of neurofeedback
skills.

B. Mentors should maintain objectivity and should have no conflict of interest, including dual
relationships. BCIA does not endorse providing mentoring to a family member. Although the
mentor is in a position of power, the candidate must be treated with respect. This position must
not be used to exploit the candidate in any way, including sexual harassment.

C. The mentor also has an obligation to the patients/clients of the candidate, and must take
appropriate action against unethical conduct of the candidate and one’s self. If the mentor
believes that the candidate is unqualified to deliver neurofeedback services, this must be clearly
stated through an evaluation or some other appropriate method.

V. Professional Commitment

BCIA expects mentors to be:

- active in the field of neurofeedback and their profession as evidenced by affiliations with professional
organizations and as required for BCIA recertification.

- free of active sanction by a disciplinary proceeding.

- involved in formalized training and professional development in the practice of neurofeedback. This may
include workshops, continuing education programs, and study of current literature.

- experienced with the candidate’s client population and methods of practice.

 - knowledgeable about issues related to diversity such as race, language, culture, gender, sexual
orientation, age, and disability.

- technically and professionally experienced with a major time and career commitment to the field of
neurofeedback.

VI. Client Confidentiality

BCIA encourages clinicians to maintain HIPAA compliant methods for all electronic communications. This
would include communications with mentors, colleagues, other professionals, and insurance companies.
Such compliance would include, but not be limited to, use of coded numbers in place of names, using
initials, altered birth dates, blacking out identifying information, or other means of making patient
identification impossible. BCIA encourages individuals to check with their employer, risk manager, or
HIPAA regulations to make certain they are in compliance.

VII. Procedures

A. BCIA recommends that mentoring of neurofeedback training with patients/clients should take
place after the candidate is a pre-qualified BCIA applicant and completes didactic training
through an accredited training program, unless the training is part of a degree granting program
from an accredited college or university that offers course work concurrently with a practicum.

B. Mentoring can begin when the candidate can demonstrate some basic competence with
equipment and is only the time spent reviewing the actual work as outlined by BCIA. Primarily
working on equipment issues or technical support is not mentoring and should not be included.

C. Filing a Mentor Application

The certificant should file a Mentor Application and await approval from BCIA prior to beginning
hands-on training. Approved applications are valid for one year and during that time, the mentor
may simply email BCIA with new candidate names or any significant changes to the information.

D. Mentoring Agreement
BCIA recommends, but does not require, a written mentoring agreement that should be signed
by both the mentor and candidate prior to starting to work together. It should be amended and
renegotiated as needed to reflect any necessary changes. The agreement should include, but not
be limited to the following:

1. obligations of the mentor and the candidate.

2. a set period of time (no more than on year) or renegotiated at the end of the time.
3. a statement to abide by the ethical principles of the mentor’s profession and the BCIA
Professional Standards and Ethical Principles of Biofeedback. (PSEP).
4. a plan to address conflicts between mentor and candidate.
5. a fee charged for mentoring.
6. a process for termination of the mentoring relationship.
7. an evaluation or performance appraisal to be done at specified intervals.

E. Documentation
 1. Recording Contact Hours and Sessions
Mentoring progress should be recorded by both the mentor and candidate. BCIA
provides an optional log sheet that can serve as a recording document during the
mentoring process.

2. Mentor’s Signature Upon Completion

The application contains a section that can be signed upon completion of the work with
the candidate. There is a separate statement one can submit to document exactly what
was done with the candidate. Some candidates work with more than one mentor, so it
is imperative that the mentor edit the statement and sign off on only what was
accomplished.

3. Essential Skills List

This checklist must be reviewed with the candidate and the mentor must initial as each
skill is tested and approved. Should the entire list not be completed, the mentor is to
sign off only on what was approved and submit the list directly to BCIA, not to the
candidate.

VIII. Liability Issues

Although it is rare for a mentor to be held liable for the mistakes made by the candidate, we advise
prudence when the treatment of patients is involved. We strongly advise that the mentor verify the
professional liability insurance of the candidate when the treatment of patients is involved. It is ill advised
to treat patients without obtaining professional liability insurance. In order to avoid liability problems, we
strongly advise that the following risk management procedures be instituted by the mentor.

A. Monitor the candidate’s professional functioning as well as the mentoring process on a regular
basis. Document all interactions.

B. Ensure that biofeedback services are performed according to accepted standards.

C. To protect patient confidentiality, a mentor should insist on an informed consent form regarding
disclosure of information if the identity of the client/patient is evident.

D. Identify any practice that might pose a danger to patients/clients and quickly take remedial
action.

E. Identify any inability to practice due to impairment by alcohol, drugs, illness, stress, or personal
problems.

IX. Continuing Education Credit

In order to receive accredited hours for BCIA recertification, an approved Mentor Application should be
on file with BCIA. A mentor may earn 5 Accredited CE hours for each pre-approved candidate who is
mentored for a minimum of 15 hours.
 PETITION FOR THE RECOGNITION OF A
PROFICIENCY IN PROFESSIONAL PSYCHOLOGY:
Biofeedback and Applied Psychophysiology

APPENDIX R:
BCIA Requirements for Certification in Biofeedback

Biofeedback Certification Requirements:

Prerequisite Education
Candidates are required to hold a bachelor degree or higher from a regionally accredited academic institution, in a
BCIA approved health care field including: psychology, medicine, nursing (including two-year registered nurses
with license, not LVNs or LPNs), physical therapy, respiratory therapy, occupational therapy, social work,
counseling, rehabilitation, chiropractic, recreational therapy, dental hygiene, dentistry, physician's assistant (with
certification or license), exercise physiology, speech pathology, and sports medicine. The following fields require a
master’s degree: music therapy and counseling education (M.Ed. in counseling).

Didactic Biofeedback Education - 42 Hours

Candidates can meet this requirement by completing a three semester-hour university course or its equivalent or
completing a BCIA accredited training program that covers the blueprint.
Required Hours
I Orientation to Biofeedback 2
II Stress, Coping & Illness 3
III Psychophysiological Recording 8
IV Research Methodology 2
V Surface EMG (SEMG) Applications 6
VI Autonomic nervous System (ANS) Applications 8
VII Respiratory Applications 3
VIII Intervention Strategies 8
IX Professional Conduct 2

Practical Biofeedback Training - 20 contact hours with a BCIA approved mentor to review:
·10 sessions of personal biofeedback, demonstrating self-regulation.
·50 sessions of patient/client treatment as follows: 10 sessions each of Thermal, EMG, and HRV. The remaining 20
sessions are to include any combination of EMG, Thermal, GSR, HRV, and respiration training.
·10 case studies.
*Sessions are a minimum of 20 minutes.

Essential Skills List – must be submitted for each candidate.

Human Anatomy/Physiology Course

A comprehensive course in human anatomy, physiology, or human biology from a BCIA accredited program or a
regionally accredited academic institution fulfills this requirement.

License/Credential for Independent Practice

When treating a medical or psychological disorder, a current health care license in a BCIA approved health care
field, issued by the state in which you practice is required. Unlicensed practitioners must agree to work under the
supervision of an appropriately credentialed health care professional who has training and experience with
biofeedback and the populations and disorders being treated. All international candidates must be licensed.

Written Examination
A three-hour objective examination covering the Blueprint areas is required of all candidates. Examinations are
offered in various locations or by special exam using a proctor for an additional fee.
 PETITION FOR THE RECOGNITION OF A
PROFICIENCY IN PROFESSIONAL PSYCHOLOGY:
Biofeedback and Applied Psychophysiology

APPENDIX S:
BCIA Requirements for Certification in Neurofeedback

Neurofeedback Certification Requirements:

Prerequisite Education
Candidates are required to hold a bachelor degree or higher from a regionally accredited academic institution, in a
BCIA approved health care field. Licensed RNs are accepted with an AA degree. BCIA approved health care fields
include: psychology, medicine, nursing (including two-year registered nurses with license, not LVNs or LPNs),
physical therapy, occupational therapy, social work, counseling, rehabilitation, chiropractic, recreational therapy,
physician's assistant (with certification or license), exercise physiology, speech pathology, and sports medicine.
The following fields require a master’s degree: music therapy and counseling education (MEd in counseling).
Degrees in health care fields other than those listed above must be submitted for review.

Didactic Neurofeedback Education - 36 Hours

Candidates can meet this requirement by completing a three semester-hour university course or its equivalent or
completing a BCIA accredited training program that covers the blueprint:

Required Hours
I Orientation to Neurofeedback 4
II Basic Neurophysiology & Neuroanatomy 4
III Instrumentation & Electronics 4
IV Research Evidence Base for Neurofeedback 2
V Psychopharmacological Considerations 2
VI Patient Client Assessment 4
VII Developing Treatment Protocols 6
VIII Treatment Implementation 6
IX Current Trends in Neurofeedback 2
X Ethical & Professional Conduct 2

Practical Neurofeedback Training - 25 contact hours with a BCIA approved mentor to review:
• 10 sessions of personal neurofeedback, demonstrating self-regulation
• 100 sessions of patient/client treatment
• 10 case study presentations.
*sessions are a minimum of 20 minutes.
Two contact hours must be face to face.

Essential Skills List – must be submitted for each candidate.

Neuroanatomy/Neurophysiology Course
A comprehensive course in neuroanatomy, neurophysiology, or physiological psychology from a regionally
accredited academic institution or BCIA accredited program fulfills this requirement.

License/Credential for Independent Practice

When treating a medical or psychological disorder, a current health care license in a BCIA approved health care
field, issued by the state in which you practice is required. Unlicensed practitioners must agree to work under the
legal supervision of an appropriately credentialed health care professional who has training and experience with
neurofeedback and the populations and disorders being treated. All international candidates must be licensed.

Written Examination
A three-hour objective examination covering the Blueprint areas is required of all candidates. Examinations are
offered in various locations or by special exam using a proctor for an additional fee.
Biofeedback
Volume 45, Issue 3, pp. 49
DOI: 10.5298/1081-5937-45.3.01
SPECIAL ISSUE
AAPB Endorses the APA’s Authoritative Diversity/
Inclusivity Guidance Framework
The 2017/18 AAPB Board of Directors
Beginning in 2015, the Association for Applied Psycho-
physiology and Biofeedback (AAPB) leadership considered
the continuing evolution of the study and practice of the
biofeedback modality in consideration of psychology and
other disciplines, changes in society at large, and emerging
data about the different needs for particular individuals and
groups historically marginalized or disenfranchised within
and by psychology based on their ethnic/racial heritage and
social group identity or membership.
To that end, AAPB has formally endorsed the compo-
nents of the American Psychological Association (APA)
‘‘Guidelines on Multicultural Education, Training, Re-
search, Practice and Organizational Change for Psycholo-
gists.’’ As an organization that crosses professional
disciplines, AAPB applies and encourages these principles
and guidelines to all respective disciplines that utilize the
application of applied psychophysiology and biofeedback.
All AAPB volunteers and members are expected to follow
these guidelines.
 Guideline #1: Biofeedback practitioners, educators, and
researchers are encouraged to recognize that, as cultural
beings, they may hold attitudes and beliefs that can
detrimentally influence their perceptions of and interac-
tions with individuals who are ethnically and racially
different from themselves.
 Guideline #2: Biofeedback practitioners, educators, and
researchers are encouraged to recognize the importance
ÓAssociation for Applied Psychophysiology & Biofeedback
www.aapb.org
of multicultural sensitivity/responsiveness, knowledge,
and understanding about ethnically and racially different
individuals.
 Guideline #3: As educators, biofeedback practitioners,
educators, and researchers are encouraged to employ the
constructs of multiculturalism and diversity in psycho-
logical education.
 Guideline #4: Culturally sensitive psychological re-
searchers are encouraged to recognize the importance of
conducting culture-centered and ethical psychological
research among persons from ethnic, linguistic, and racial
minority backgrounds.
 Guideline #5: Biofeedback practitioners, educators, and
researchers strive to apply culturally appropriate skills in
clinical and other applied psychological practices.
 Guideline #6: Biofeedback practitioners, educators, and
researchers are encouraged to use organizational change
processes to support culturally informed organizational
(policy) development and practices.
The AAPB Board of Directors’ enthusiastic endorsement
of the APA’s Guidance on behalf of our members reflects
our commitment to the highest standards of practice, care,
knowledge, competency, excellence, and professionalism.
This special issue of Biofeedback magazine is a
compilation of diversity/cultural resource material to serve
as a reference to our members.
Biofeedback | Fall 2017
49
 Biofeedback
Volume 45, Issue 3, pp. 50–51
DOI: 10.5298/1081-5937-45.3.02
SPECIAL ISSUE
Diversity and Cultural Competence in Health Care
Settings: The Merits of Unbiased Multicultural
Observation in Clinical and Research Context
Judith-Jolie Mairs-Levy, DHEd, MPH, CHES, CCTC
Cross-Cultural & Integrative Wellness Researcher and Practitioner; Epidemiologist; and Medical Writer; Office of Research, American Urological Association,
Linthicum, MD
Keywords: cultural competency, diversity, clinical outcomes, inclusion, demographics, healthcare
Originally published March 1, 2016, at https://www.
linkedin.com/pulse/diversity-cultural-competence-health-
care-settings-dr-judith-jolie/. Reprinted with permission.
Diversity and cultural competence are now part of a major
phenomenon in our changing demographics, and the way
we deliver care. This should be the norm rather than the
exception, not just in health care settings, but in every
workplace. As the issue of cultural sensitivity and inclusion
relates to clinical and research settings, it is an inevitable
fact that patients will look, think, act, and speak different
from their clinicians and providers. They also will have a
wider range of ethnic identifications, religions, beliefs,
customs, behaviors, and so on that lead to rich diversity and
cultural complexity.
As such, it is critical that the merits of multicultural
observation and recognition in clinical and research context
be celebrated—not negated. Especially since the provider–
patient relationship is quite unique. For starters, therapeutic
recommendations can never substitute for a clinician’s
conscientious attempts to understand and become acquainted
with the population being served. More specifically, health
care professionals who genuinely hope to deliver culturally
relevant services to diverse ethnic and racial patient
populations must have substantial training and experience
in working with the diverse groups they wish to serve.
Unbiased, open-minded multicultural observation and
therapeutic recommendations can serve as learning mo-
ments that can facilitate a better patient–provider relation-
ship, and provide guidelines that stimulate and inform
clinicians and practitioners towards best practices in treating
Fall 2017 | Biofeedback
conditions and issues specific to certain groups or
populations. Such knowledge should be based on the major
components and concepts of multiculturalism and must
facilitate sound understanding of, and sensitivity towards,
50
ÓAssociation for Applied Psychophysiology & Biofeedback
www.aapb.org
the worldviews of the various racial/ethnic minority
groups.
While the recommendations are stated explicitly, clini-
cians and practitioners must also understand their rationale
and conceptual framework before applying them. This is
where in-depth multicultural observation from a clinical
and research point of view becomes critical. Uninformed
application and lackluster observation and experience in the
field may result in barriers to care, including but not limited
to: little to no access to services and under-utilization of the
services that are in fact available, and can often result in
overall inappropriate and nonbeneficial services to patients
and the research field in general.
Furthermore, such applications should never be prac-
ticed, recommended, or applied rigidly without regard for
multicultural context, individual differences, subgroup
variations, and the specific life circumstance of diverse
patient or client populations and their unique settings,
circumstances, and conditions. As health care providers,
this fundamental shift in demographics and the way we
deliver care, remind us there is no ‘‘one size fits all’’ in
medicine.
To this end, it is critical that unbiased multicultural
observation in clinical and research contexts be placed at the
forefront of all interaction with patients and clients. It is
even more critical for multicultural contextual knowledge
to be disseminated and reflected in clinical and research
vehicles geared towards educating not just those working in
the field, but also the public. This inclusion must also reflect
the necessary components to facilitate the ongoing dialogue
about the importance of the acknowledgement of culture in
informing clinical and research work, and improving health
and patient outcomes.
Without this acknowledgement, racial and ethnic-related
health disparities will only increase. Furthermore, there will
be even more room for biases, prejudices, and stereotyping,
 Mairs-Levy

which are harmful, and have proved fatal in some cases. It is Ideally, the improved system will be less of a financial
critical to understand that multicultural aspects of research burden on the health care system, the government, the
and observation, and the inclusion and cognizance of economy and the nations’ gross domestic product expen-
cultural competence in working with diverse and specific diture overall. This modified way of thinking and
populations, are never ending states. In other words, there observing the importance of culture in clinical settings
is, and always will be, a need for clinicians to stay abreast of will get us closer to a healthier America, a better health
changes and updates, as well as improvements and growth care system, and a more comparable health expenditure to
in multicultural inclusion in clinical and research contexts that of other industrialized nations, including but not
through continuing education on the part of clinicians, limited to Canada, Norway, Switzerland, France, Ger-
practitioners, educators, and researchers.
many, and Japan.
Essentially, the path to becoming culturally proficient in
working with a plethora of racial/ethnic minority popula-
tions, and discovering and maintaining the standards and
the merits of unbiased multicultural observation in clinical
and research contexts are, and should always remain as part
of, an ongoing process that encompasses a continuous and
lifelong journey for clinicians, educators, researchers, and
all health care professionals—allied and otherwise.
Finally, the merits of unbiased multicultural observa-
tion in clinical and research contexts are numerous. They
include but are not limited to: better, more equitable
Judith-Jolie Mairs-Levy
health care for all; improved patient–provider relationship;
and a greater understanding of the role of culture in
sickness, illness, and cultural beliefs of the causes of ill Correspondence: Dr. Judith-Jolie Mairs-Levy, DHEd, MPH, CHES,
health and diseases. Such initiatives must include a sincere CCTC. National Graduate School of Quality Management, Disser-
tation Chair of Health Care Systems, Arlington, VA, email: jmairs@
and genuine cognizance of multicultural observation to ngs.edu.
facilitate better access to health services, and to reduce
health disparities towards a better health care system.

Biofeedback | Fall 2017

51
 Biofeedback
Volume 45, Issue 3, pp. 52–63
DOI: 10.5298/1081-5937-45.3.03
SPECIAL ISSUE
Cultural Competence: Annotated Bibliography
2009–2014
Acknowledgment: This bibliography was researched and
compiled by Xiaofan Wei, a Brown University graduate
student, as part of the Northeast Ethics Education
Partnership, funded by the National Science Foundation’s
Ethics Education in Science and Engineering. With
additions from Dianne Quigley, PhD, adjunct assistant
professor (research) at Brown University. Reprinted with
permission from Brown University.
Adamson, J., Warfa, N., & Bhui, K. (2011). A case study
of organisational Cultural Competence in mental health-
care. BMC Health Services Research, 11(1), 218.
Abstract: Ensuring Cultural Competence (CC) in health-
care is a mechanism to deliver culturally appropriate care
and optimise recovery. In policies that promote cultural
competence, the training of mental health practitioners is a
key component of a culturally competent organisation. This
study examines staff perceptions of CC and the integration
of CC principles in a mental health care organisation. The
purpose is to show interactions between organisational and
individual processes that help or hinder recovery orientated
services. We carried out a case study of a large mental
health provider using a cultural competence needs analysis.
We used structured and semi-structured questionnaires to
explore the perceptions of healthcare professionals located
in one of the most ethnically and culturally diverse areas of
England, its capital city London. There was some evidence
that clinical staff were engaged in culturally competent
activities. We found a growing awareness of cultural
competence amongst staff in general, and many had
attended training. However, strategic plans and procedures
that promote cultural competence tended to not be well
communicated to all frontline staff, whilst there was little
understanding at corporate level of culturally competent
clinical practices. The provider organisation had commenced
a targeted recruitment campaign to recruit staff from
under-represented ethnic groups and it developed collabo-
rative working patterns with service users. There is
Fall 2017 | Biofeedback
evidence to show tentative steps towards building cultural
competence in the organisation. However, further work is
needed to embed cultural competence principles and
practices at all levels of the organisation, for example, by
introducing monitoring systems that enable organisations
52
ÓAssociation for Applied Psychophysiology & Biofeedback
www.aapb.org
to benchmark their performance as a culturally capable
organisation.
Beach, M. C., Price, E. G., Gary, T. L., Robinson, K. A.,
Gozu, A., Palacio, A., . . . Cooper, L. A. (2005). Cultural
competence: A systematic review of health care provider
educational interventions. Medical Care, 43(4), 356–373.
Abstract: Objective: We sought to synthesize the
findings of studies evaluating interventions to improve
the cultural competence of health professionals. Design:
This was a systematic literature review and analysis.
Methods: We performed electronic and hand searches from
1980 through June 2003 to identify studies that evaluated
interventions designed to improve the cultural competence
of health professionals. We abstracted and synthesized data
from studies that had both a before- and an after-
intervention evaluation or had a control group for
comparison and graded the strength of the evidence as
excellent, good, fair, or poor using predetermined criteria.
Main Outcome Measures: We sought evidence of the
effectiveness and costs of cultural competence training of
health professionals. Results: Thirty-four studies were
included in our review. There is excellent evidence that
cultural competence training improves the knowledge of
health professionals (17 of 19 studies demonstrated a
beneficial effect), and good evidence that cultural compe-
tence training improves the attitudes and skills of health
professionals (21 of 25 studies evaluating attitudes demon-
strated a beneficial effect and 14 of 14 studies evaluating
skills demonstrated a beneficial effect). There is good
evidence that cultural competence training impacts patient
satisfaction (3 of 3 studies demonstrated a beneficial effect),
poor evidence that cultural competence training impacts
patient adherence (although the one study designed to do
this demonstrated a beneficial effect), and no studies that
have evaluated patient health status outcomes. There is
poor evidence to determine the costs of cultural competence
training (5 studies included incomplete estimates of costs).
Conclusions: Cultural competence training shows promise
as a strategy for improving the knowledge, attitudes, and
skills of health professionals. However, evidence that it
improves patient adherence to therapy, health outcomes,
and equity of services across racial and ethnic groups is

lacking. Future research should focus on these outcomes
and should determine which teaching methods and content
are most effective.
Berger, G., Conroy, S., Peerson, A., & Brazil, V. (2014).
Clinical supervisors and cultural competence. The Clinical
Teacher, 11(5), 370–374.
Abstract: To investigate how clinical supervisors of junior
doctors provide feedback and assessment on cultural
competence, one of several professionalism skills outlined
in the Australian Curriculum Framework for Junior Doctors.
Twenty clinical supervisors were recruited to a qualitative
study in a regional hospital in Queensland, Australia. Data
from semi-structured interviews (June–August 2011) were
thematically analysed. Interviews revealed that cultural
competence was interpreted by the supervising clinicians as
a vague concept, and that junior doctors were not assessed in
this area. Additional themes related to the cultural compe-
tence of junior doctors, as reported by their supervisors,
included: limited direct supervision of, and feedback to, junior
doctors; variations in approaches to assessment; clinicians’
communication focuses on clinical aspects of disease process;
perceived lack of cultural diversity among staff and patients;
acceptance of laypersons as English interpreters; language
barriers with international medical graduates; and patients’
low levels of health literacy. Supervisors were unable to
define cultural competence in ways that enable them to apply
the concept to clinical training for junior doctors. Specific
training in cultural competence, and guidelines for its
assessment, is therefore recommended for clinical supervisors
and junior doctors to improve their approaches to patient care
and health outcomes.
Chen, H-C., McAdams-Jones, D., Tay, D. L., & Packer, J.
M. (2012). The impact of service–learning on students’
cultural competence. Teaching and Learning in Nursing, 7
67–73.
Abstract: The purpose of this study was to enhance
students’ cultural competence through a service–learning
project in a community clinic. This quasi-experimental
study used a pretest–posttest control group design. Twenty-
six nursing students volunteered either in the comparison
or in the experimental group. The students in the
experimental group significantly increased their cultural
knowledge (Z ¼ 2.51, p ¼ .01) and the total score of
cultural competence (Z ¼ 2.07, p ¼ .04).
Cherner, R., Olavarria, M., Young, M., Aubry, T., &
Marchant, C. (2014). Evaluation of the organizational
cultural competence of a community health center: A
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multimethod approach. Health Promotion Practice, 15(5),
675–684.
Abstract: Cultural competence is an important compo-
nent of client-centered care in health promotion and
community health services, especially considering the
changing demographics of North America. Although a
number of tools for evaluating cultural competence have
been developed, few studies have reported on the results of
organizational cultural competence evaluations in health
care or social services settings. This article aims to fill this
gap by providing a description of a cultural competence
evaluation of a community health center serving a diverse
population. Data collection included reviewing documents,
and surveying staff, management, and the Board of
Directors. The organization fully met 28 of 53 standards
of cultural competence, partially met 21 standards, and did
not meet 2 standards, and 2 standards could not be assessed
due to missing information. The advantages and lessons
learned from this organizational cultural competence
evaluation are discussed.
Convoy, S., & Westphal, R. J. (2013). The importance of
developing military cultural competence. Journal of Emer-
gency Nursing: JEN: Official Publication of the Emergency
Department Nurses Association, 39(6), 591–594.
Abstract: The initiative of First Lady Michelle Obama and
Dr Jill Biden, Joining Forces, has helped to create awareness
and momentum to recognize a specific military culture and to
standardize competence across the US national health care
system. An understanding of military culture can prove to be
invaluable when caring for military veterans, reservists, and
their family members in your emergency department. With
this lens, seemingly innocuous pieces of information may be
transformed into important insights. Insights foster dia-
logues. Dialogues solicit therapeutic rapports. Therapeutic
rapports result in therapeutic alliances. Therapeutic alliances
have the potential to play an important role in health care
outcomes and lives.
Cooper, L.-A., Vellurattil, R. P., & Quiñones-Boex, A.
(2014). Pharmacy students’ perceptions of cultural compe-
tence encounters during practice experiences. American
Journal of Pharmaceutical Education, 78(2), Article 31.
Abstract: To determine pharmacy students’ perceptions
regarding cultural competence training, cross-cultural
Biofeedback | Fall 2017
experiences during advanced pharmacy practice experiences
(APPEs), and perceived comfort levels with various cultural
encounters. Fourth-year pharmacy (P4) students were
asked to complete a questionnaire at the end of their fourth
APPE. Fifty-two of 124 respondents (31.9%) reported
53
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having 1 or more cultural competence events during their
APPEs, the most common of which was caring for a patient
with limited English proficiency. Students reported high
levels of comfort with specific types of cultural encounters
(disabilities, sexuality, financial barriers, mental health),
but reported to be less comfortable in other situations.
Delgado, D. A., Ness, S., Ferguson, K., Engstrom, P. L.,
Gannon, T. M., & Gillett, C. (2013). Cultural competence
training for clinical staff: Measuring the effect of a one-
hour class on cultural competence. Journal of Transcultural
Nursing: Official Journal of the Transcultural Nursing
Society, 24(2), 204–213.
Abstract: In an environment of changing demographics
and health care disparities, it is essential that nurses
continue to develop competence in providing care across
cultures. This article presents the findings of a pilot project
to measure and compare self-reported cultural competence
scores before and after participation in one of the core
classes of a cultural competence curriculum. Cultural
competence of the staff of a patient care unit (N ¼ 98)
was assessed prior to the class, at 3 months, and at 6 months
posteducation using the Inventory for Assessing the
Process of Cultural Competence Among Healthcare Pro-
fessionals–Revised. The results demonstrated that following
an educational intervention the participants self-reported a
statistically significant increase (p ¼ .03) in cultural
competence within the category range of cultural aware-
ness. Providing cultural competence education may better
equip nurses to care for patients from diverse cultures.
Delphin-Rittmon, M. E., Andres-Hyman, R., Flanagan,
E. H., & Davidson, L. (2013). Seven essential strategies for
promoting and sustaining systemic cultural competence.
Psychiatric Quarterly, 84(1), 53–64.
Abstract: Racial and ethnic disparities are disturbing
facets of the American healthcare system that document the
reality of unequal treatment. Research consistently shows
that patients of color experience poorer quality of care and
health outcomes contributing to increased risks and
accelerated mortality rates relative to their white counter-
parts. While initially conceptualized as an approach for
increasing the responsiveness of children’s behavioral
health care, cultural competence has been adopted as a
key strategy for eliminating racial and ethnic health
Fall 2017 | Biofeedback
disparities across the healthcare system. However, cultural
competence research and practices largely focus on
improving provider competencies, while agency and system
level approaches for meeting the service needs of diverse
populations are given less attention. In this article we offer
54
seven essential strategies for promoting and sustaining
organizational and systemic cultural competence. These
strategies are to: (1) Provide executive level support and
accountability, (2) Foster patient, community, and stake-
holder participation and partnerships, (3) Conduct organi-
zational cultural competence assessments, (4) Develop
incremental and realistic cultural competence action plans,
(5) Ensure linguistic competence, (6) Diversify, develop,
and retain a culturally competent workforce, and (7)
Develop an agency or system strategy for managing staff
and patient grievances. For each strategy we offer several
recommendations for implementation.
Friedman, H., Glover, G., Sims, E., Culhane, E., & Guest,
M. (2013). Cross-cultural competence: Performance-based
assessment and training. Organization Development Jour-
nal, 31(2), 18–30.
Abstract: A trans-disciplinary conceptualization of cross-
cultural competency was used to develop performance-based
assessment and training methods. Starting with socio-
cultural encounters (interactions among people holding
different cultural perspectives), we elicited cultural dilemmas
based on culturally universal dimensions through surveying
U.S. military personnel having cross-cultural operational
experience. We used these dilemmas to build assessment and
training tools, and pilot-tested simulations. Although our
efforts focused within a military setting, our approach is
applicable to any organizational and professional setting.
Fung, K., Lo, H.-T., Srivastava, R., & Andermann, L.
(2012). Organizational cultural competence consultation to
a mental health institution. Transcultural Psychiatry, 49(2),
165–184.
Abstract: Cultural competence is increasingly recognized
as an essential component of effective mental health care
delivery to address diversity and equity issues. Drawing
from the literature and our experience in providing cultural
competence consultation and training, the paper will discuss
our perspective on the foundational concepts of cultural
competence and how it applies to a health care organization,
including its programs and services. Based on a recent
consultation project, we present a methodology for
assessing cultural competence in health care organizations,
involving mixed quantitative and qualitative methods. Key
findings and recommendations from the resulting cultural
competence plan are discussed, including core principles,
change strategies, and an Organizational Cultural Compe-
tence Framework, which may be applicable to other health
care institutions seeking such changes. This framework,
consisting of eight domains, can be used for organizational

assessment and cultural competence planning, ultimately
aiming at enhancing mental health care service to the
diverse patients, families, and communities.
Harris, G. L. A. (2010). Cultural competence: Its promise
for reducing healthcare disparities. Journal of Health and
Human Services Administration, 33(1), 2–52.
Abstract: Healthcare disparities have reached such
disproportionate levels of disease burden for certain groups
that the issue has become a national priority. This article
examines the most recent iteration of the healthcare
disparities movement, the aggressive legislative steps by
the federal government to disrupt its destructive path and
the promise that cultural competence holds for healthcare
providers and the healthcare industry as a whole in placing
the patient back at the center of healthcare treatment. Such
efforts, it is argued, will be instrumental in helping to
reduce healthcare disparities and make the healthcare
delivery experience a more positive outcome for all patients.
Hayes, S. C., Muto, T., & Masuda, A. (2011). Seeking
cultural competence from the ground up. Clinical Psychol-
ogy: Science and Practice, 18(3), 232–237.
Abstract: The present article briefly reviews early
evidence of the applicability of acceptance and commitment
therapy and its underlying psychological flexibility model
to Asians and Asian Americans. Cultural adaptation is an
important goal, and we describe how it might be due within
a functional contextual approach, namely, by linking
cultural knowledge to processes and principles of psycho-
pathology and behavior change. This approach in essence
links cultural adaptation to functional analysis. Ideas in the
target article, for example about a transcendent sense of
self, are used as examples of how this can be performed.
Hester, R. J. (2012). The promise and paradox of cultural
competence. HEC Forum, 24(4), 279–291.
Abstract: Cultural competence has become a ubiquitous
and unquestioned aspect of professional formation in
medicine. It has been linked to efforts to eliminate race-
based health disparities and to train more compassionate and
sensitive providers. In this article, I question whether the
field of cultural competence lives up to its promise. I argue
that it does not because it fails to grapple with the ways that
race and racism work in U.S. society today. Unless we change
our theoretical apparatus for dealing with diversity to one
that more critically engages with the complexities of race, I
suggest that unequal treatment and entrenched health
disparities will remain. If the field of cultural competence
incorporates the lessons of critical race scholarship, however,
Annotated Bibiolography
it would not only need to transform its theoretical
foundation, it would also need to change its name.
Hickling, F. W., & Paisley, V. (2014). Issues of clinical
and cultural competence in Caribbean migrants. Transcul-
tural Psychiatry, 49(2), 223–244.
Abstract: The level of out-migration from the Caribbean
is very high, with migration of tertiary-level educated
populations from Caribbean countries being the highest in
the world. Many clinicians in receiving countries have had
limited diagnostic and therapeutic experience with Carib-
bean migrants, resulting in diagnostic and therapeutic
controversies. There is an urgent need for better under-
standing of these cultural differences. The paper explores
issues of clinical and cultural competence relevant to
assessing, diagnosing, and treating Caribbean migrants
with a focus on three areas: cultural influences on illness
phenomenology; the role of language differences in clinical
misunderstandings; and the complexities of culture and
migration. Clinical issues are illustrated with case studies
culled from four decades of clinical experience of the first
author, an African Jamaican psychiatrist who has worked in
the Caribbean, North America, Europe, and New Zealand.
Hill, B., & Mills, J. (2013). Situating the ‘beyond’:
Adventure-learning and indigenous cultural competence.
Discourse Studies in the Cultural Politics of Education,
34(1), 63–76.
Abstract: In 2010 an Indigenous Elder from the
Wiradjuri nation and a group of academics from Charles
Stuart University travelled to Menindee, a small locality on
the edge of the Australian Outback. They were embarked
upon an ‘‘adventure learning’’ research journey to study
ways of learning by creating a community of practice with
an Elder from the Ngyampa/Barkandji Nation. The article
first explores the implications of this innovative approach to
transformative learning for professional development and
for teaching and learning practice. It then reflects on the
significance of location for pedagogic approaches aimed at
closing the education gap between Aboriginal and non-
Aboriginal Australians in universities.
Jeffreys, M. (2010). Teaching cultural competence in
nursing and health care (2nd ed.). New York: Springer
Publishing Company.
Biofeedback | Fall 2017
Abstract: ‘‘This book will help educators understand the
multidimensional process of cultural competence, and the
vignettes it provides will be useful to anyone who teaches
cultural competence."—Nursing Education Perspectives. In
our multicultural society, nurses and health care providers,
55
 Annotated Bibiolography
educators and administrators, professional association lead-
ers, and researchers must work toward achieving cultural
competency. This new edition, along with the digital Cultural
Competence Education Resource Toolkit, offers a unique and
effective guide to do just that. Newly updated and revised,
this book presents ready-to-use materials for planning,
implementing, and evaluating cultural competence strategies
and programs. Users will learn to identify the needs of
diverse constituents, evaluate outcomes, prevent multicul-
tural-related workplace conflict, and much more. Complete
with vignettes, case exemplars, illustrations, and assessment
tools, this book is required reading for those working in
academic settings, health care institutions, employee educa-
tion, and nursing and health care organizations and
associations. Key Features: Offers a wide selection of
educational activities and techniques for diverse learners.
Presents guidelines for helping educators, students, and
professionals to maximize strengths, minimize weaknesses,
and facilitate success. Describes toolkit questionnaires for
measuring and evaluating cultural learning and performance.
Provides guidelines for employee orientation programs to
achieve cultural competence in the workplace. The Digital
Cultural Competence Education Resource Toolkit: The
Toolkit consists of three sets of tools and a total of 21
distinct tools. The three sets of tools are: Resources for
Academic Settings; Resources for Health Care Institutions;
and Resources for Professional Associations. Taken together,
the tools provide a comprehensive set of materials for
planning, implementing, and evaluating cultural competence
education strategies and programs. These tools may be used
alone or in conjunction with other tools and will be of use to
a broad range of readers at all levels: nurses, educators,
administrators, association leaders, managers, researchers,
students, and other health care providers. The Tools and this
book will enable you to achieve optimal cultural competence.
Jeffreys, M. R., & Dogan, E. (2013). Evaluating cultural
competence in the clinical practicum. Nursing Education
Perspectives, 34(2), 88–94.
Abstract: The main purpose is to introduce a tool for
evaluating the extent of culturally specific care provided for
a diverse clientele, the frequency of cultural assessments,
and the development of culturally sensitive and profes-
sionally appropriate attitudes, values, and beliefs. Legal,
ethical, and accreditation mandates demand theoretically
Fall 2017 | Biofeedback
based, valid, comprehensive tools to assess aspects of
culturally specific care; yet no relevant ones existed. The
Cultural Competence Clinical Evaluation Tool (CCCET)
was administered at the end of a second semester medical-
surgical nursing course (n ¼ 161). The Content Validity
56
Index (CVI) was 0.91. The reliability coefficients provided
evidence for internal consistency. Student and teacher
ratings were relatively close, suggesting that respondents
took the task of CCCET completion seriously and honestly,
that cultural competence was a visible theme throughout
the course, and that students and instructors worked closely
together in the clinical practicum setting to achieve learning
objectives (including cultural competence).
Jellinek, M. S., Henderson, S. W., Pumariega, A. J.,
Rothe, E., & Rogers, K. (2009). Cultural competence in
child psychiatric practice. Journal of the American Acad-
emy of Child & Adolescent Psychiatry, 48(4), 362–366.
Abstract: The US health care system, including the mental
health system, has not been effective in addressing the needs
of culturally diverse populations. This has resulted in racial/
ethnic disparities in health and mental health, including
lower access to treatment services and evidence-based
treatments, and higher morbidity and, possibly, mortality,
than Euro-Americans. This is reflected in the overrepresen-
tation of minority children in the child welfare and juvenile
justice systems, who also experience high rates of mental
disorders and lack of access to appropriate services to divert
them from such placements. In response to these mounting
clinical and service delivery challenges, cultural competence
has become one of the core principles of the children’s
community-based systems of care movement. Here, Pumar-
iega et al. examine the cultural challenges to diagnosis and
treatment of minority children and the application of the
cultural competence model to assessment and treatment.
Johnson, Y. M., & Munch, S. (2009). Fundamental
contradictions in cultural competence. Social Work, 54(3),
220–231.
Abstract: Cultural competence (CC) is considered highly
relevant to social work practice with clients belonging to
ethnic and racial minority groups, as the burgeoning
literature and creation of practice standards on CC attest.
However, examination of the conceptual underpinnings of
CC reveals several major anomalies. The authors argue that
several aspects of CC contradict central social work concepts
or are at odds with current, standard social work practice.
These contradictions extend to the epistemological founda-
tions of CC and the rights and dignity of the individual. To
further stress the conceptual tensions at the heart of CC, the
authors incorporate recent philosophical work addressing
collective identities and group rights. The question of
whether culturally competent practice is achievable is also
addressed. The authors urge academicians and practitioners
to thoroughly examine the theoretical and ethical bases of CC

because of their highly important ramifications for social
work practice.
Kaufmann, H. R., Englezou, M., & Garcı́a-Gallego, A.
(2014). Tailoring cross-cultural competence training. Thun-
derbird International Business Review, 56(1), 27–42.
Abstract: This study tests a new framework for capturing
the different training needs required to become intercultur-
ally competent. Indications for the need for specialized
training methods differentiated by target segments are
provided. Many researchers have suggested that an over-
generalization of cultural differences within a proposed
framework can lead to a gap between the skills being learned
and the application of these skills in organizational practices.
It has been also suggested that a ‘‘one-size-fits-all’’ approach
might not be effective, as various aspects of the training need
to be tailored in order to fit the culture and the specific
organization. Comparing the short-term and long-term
benefits of various training options, a problem arises when
an individual has learned to be competent within a particular
cultural setting but, in fact, she or he is not able to transfer
that knowledge and use it appropriately in another cultural
setting. We used a questionnaire to test not only the
dimension of intercultural competence but also the level of
emotional intelligence, communication styles, and character
traits and the degree of correlation of these concepts. We also
compare low-context and high-context cultures as an attempt
to distinguish different subcategories of different cultural
trends and needs. Ó 2013 Wiley Periodicals, Inc.
Kirmayer, L. J. (2012). Rethinking cultural competence.
Transcultural Psychiatry, 49(2), 149–164.
Abstract: In recent years, cultural competence has
become a popular term for a variety of strategies to address
the challenge of cultural diversity in mental health services.
This issue of Transcultural Psychiatry presents papers from
the McGill Advanced Study Institute in Cultural Psychiatry
on ‘‘Rethinking Cultural Competence from International
Perspectives,’’ which was held in Montreal, April 27 and 28,
2010. Selected papers from the meeting have been
supplemented with other contributions to the journal that
fit the theme. Taken together, these papers show how
conceptual analysis and critique of cultural competence can
point toward ways to improve the cultural responsiveness,
appropriateness and effectiveness of clinical services, and in
doing so contribute to reducing health disparities
Kratzke, C., & Bertolo, M. (2013). Enhancing students’
cultural competence using cross-cultural experiential learn-
ing. Journal of Cultural Diversity, 20(3), 107–111.
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Abstract: The purpose of this study was to explore
undergraduate community health students’ perceptions of
their cultural competence. Little is known about students’
cultural awareness, knowledge, and skills after their experi-
ence working with diverse cultural groups and language
barriers. A cross-cultural experiential learning exercise was
used as an educational approach. Reflective writing was used
to elicit students’ attitudes of the other culture and their
coping skills. Three themes emerged as cultural awareness
and knowledge, observation and learning, and cross-cultural
communication. Results underscore the need for student
academic preparation using cross-cultural educational ap-
proaches to enhance cultural competence.
Larson, K. L., Ott, M., & Miles, J. M. (2010).
International cultural immersion: En vivo reflections in
cultural competence. Journal of Cultural Diversity, 17(2),
44–50.
Abstract: A baccalaureate nursing program developed
and implemented an international cultural immersion
course in Guatemala to explore the impact of cultural
immersion on student nurses’ cultural competence. This
qualitative descriptive study generated data through in-
depth interviews and en vivo reflective journals. The three
themes: Navigating daily life, Broadening the lens, and
Making a difference, revealed an expanded context and
worldview of culture. International service learning seemed
to pervade all aspects of the students’ experience. Exercises
in participant-observation and reflective writing could
enhance student self-awareness and their ability to benefit
from a cultural immersion course.
Laws, T., & Chilton, J. A. (2013). Ethics, cultural
competence, and the changing face of America. Pastoral
Psychology, 62(2), 175–188.
Abstract: The population in the United States is
increasingly multicultural. So, too, is the U.S. physician
workforce. The combination of these diversity dynamics
sets up the potential for various types of cultural conflict in
the nation’s examining rooms, including the relationship
between religion and medicine. To address the changing
patient-physician landscape, we argue for a broad scale
intervention: interdisciplinary bioethics training for physi-
cians and other health professionals. This approach seeks to
promote a common procedural expectation and language
Biofeedback | Fall 2017
which can lead to an improved, patient-centered approach
resulting in better patient-physician relationships that
contribute to better health outcomes across the U.S.
population. The authors illustrate their thesis and solution
using a well-known case of cross-cultural dynamics taken
57
 Annotated Bibiolography
from religion and medicine—Anne Fadiman’s The Spirit
Catches You and You Fall Down.
Leung, A. K.-Y., Lee, S.-L., & Chiu, C.-Y. (2013). Meta-
knowledge of culture promotes cultural competence.
Journal of Cross-Cultural Psychology, 44(6), 992–1006.
Abstract: A behavioral signature of cross-cultural
competence is discriminative use of culturally appropriate
behavioral strategies in different cultural contexts. Given
the central role communication plays in cross-cultural
adjustment and adaptation, the present investigation
examines how meta-knowledge of culture—defined as
knowledge of what members of a certain culture know—
affects culturally competent cross-cultural communication.
We reported two studies that examined display of
discriminative, culturally sensitive use of cross-cultural
communication strategies by bicultural Hong Kong Chinese
(Study 1), Chinese students in the United States and
European Americans (Study 2). Results showed that
individuals formulating a communicative message for a
member of a certain culture would discriminatively apply
meta-knowledge of the culture. These results suggest that
unsuccessful cross-cultural communications may arise not
only from the lack of motivation to take the perspective of
individuals in a foreign culture, but also from inaccurate
meta-knowledge of the foreign culture.
Long, T. B. (2012). Overview of teaching strategies for
cultural competence in nursing students. Journal of
Cultural Diversity, 19(3), 102–108.
Abstract: Multiple curricular approaches are being used to
teach cultural competency to nursing students in the United
States in accordance with accrediting board standards. As
nurse educators are searching for evidence based teaching
practices, this article reviews the most commonly current
teaching methods being used. Although a variety of methods
are being implemented, little empirical evidence exists to
suggest any one methodology for teaching cultural compe-
tency for nursing students produces significantly better
outcomes. The use of clinical experiences, standardized
patients and immersion experiences have produced the most
favorable results which increase student awareness, knowl-
edge and confidence in working with ethnically diverse
patients.
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Lu, P.-Y., Tsai, J.-C., & Tseng, S. Y. H. (2014). Clinical
teachers’ perspectives on cultural competence in medical
education. Medical Education, 48(2), 204–214.
Abstract: Globalisation and migration have inevitably
shaped the objectives and content of medical education
58
worldwide. Medical educators have responded to the
consequent cultural diversity by advocating that future
doctors should be culturally competent in caring for patients.
As frontline clinical teachers play a key role in interpreting
curriculum innovations and implementing both explicit and
hidden curricula, this study investigated clinical teachers’
attitudes towards cultural competence training in terms of
curriculum design, educational effectiveness and barriers to
implementation. This study was based on interviews with
clinical teachers from university-affiliated hospitals in
Taiwan on the subject of cultural competence. The data were
transcribed verbatim and translated into English. The
interviews were analysed using grounded theory to identify
and categorise key themes. Five main themes emerged: (i)
there was a clear consensus that students currently lack
sufficient cultural competence; (ii) the teachers agreed that
increased exposure to cultural diversity improved students’
cultural understanding; (iii) present curriculum design was
generally agreed to be inadequate, and it was argued that
devoting space to developing cultural competence across the
curriculum would be a worthwhile endeavour; (iv) different
methods of performance assessment were proposed; and (v)
the main obstacles to teaching and assessing cultural
competence were perceived to be a lack of commonly agreed
goals, the low priority accorded to it in an overloaded
curriculum and the inadequacy of teachers’ cultural compe-
tence. Eliciting the viewpoints of the key providers is a first
step in curriculum innovation and reform. This study
demonstrates that clinical teachers acknowledge the need
for explicit and implicit training in cultural competence, but
there needs to be further debate about the overall goals of
such training, the time allotted to it and how it should be
assessed, as well as a faculty-wide development programme
addressing pedagogical needs.
McGinnis, S. L., Brush, B. L., & Moore, J. (2010).
Cultural similarity, cultural competence, and nurse work-
force diversity. Western Journal of Nursing Research,
32(7), 894–909.
Abstract: Proponents of health workforce diversity argue
that increasing the number of minority health care
providers will enhance cultural similarity between patients
and providers as well as the health system’s capacity to
provide culturally competent care. Measuring cultural
similarity has been difficult, however, given that current
benchmarks of workforce diversity categorize health
workers by major racial/ethnic classifications rather than
by cultural measures. This study examined the use of
national racial/ethnic categories in both patient and
registered nurse (RN) populations and found them to be a

poor indicator of cultural similarity. Rather, we found that
cultural similarity between RN and patient populations
needs to be established at the level of local labor markets
and broadened to include other cultural parameters such as
country of origin, primary language, and self-identified
ancestry. Only then can the relationship between cultural
similarity and cultural competence be accurately deter-
mined and its outcomes measured.
Ortega, R. M., & Coulborn, K. (2011). Training child
welfare workers from an intersectional cultural humility
perspective: A paradigm shift. Child Welfare, 90(5), 27–49.
Abstract: The increasing diversity of the populations
encountered and served by child welfare workers challenges
cultural competence models. Current concerns focus on the
unintentional over-emphasis on shared group characteristics,
undervaluing unique differences of individuals served, and
privileging worker expertise about the client’s culture,
thereby exacerbating the power imbalance between them.
This article promotes cultural humility in child welfare
service delivery as a complement to cultural competence, to
liberate workers from expectations of cultural expertise about
others, and to actively engage the clients, inclusive of their
cultural differences, in the service delivery process. Skills and
practice principles are discussed.
Quigley, D. (2016). Building cultural competence in
environmental studies and natural resource sciences.
Society and Natural Resources, 29(6), 725–737.
Abstract: Environmental studies and natural resource
sciences frequently engage diverse cultural groups in field
practices and research. This article reviews evidence of the
usefulness of cultural competence theory and its skill
components in nursing, social work, and psychology to
demonstrate the importance of analogous training in the
environmental sciences. The Northeast Ethics Education
Partnership (NEEP) has promoted short courses and work-
shops for training graduate students and faculty in environ-
mental studies, natural resource sciences, and engineering in
cultural competence. In conjunction with this training, NEEP
has gathered and reviewed published accounts of environ-
mental field experience with respect to cultural competence
that participants found useful. This article describes materials
and methods of this training; promotes the need to develop an
‘‘environmental cultural competence theory and practice’’;
identifies barriers to such theoretical development training in
graduate schools; and suggests potential solutions.
Qureshi, A., Collazos, F., Ramos, M., & Casas, M.
(2008). Cultural competency training in psychiatry. Euro-
Annotated Bibiolography
pean Psychiatry: The Journal of the Association of
European Psychiatrists, 23(1), 49–58.
Abstract: Recent reports indicate that the quality of care
provided to immigrant and ethnic minority patients is not at
the same level as that provided to majority group patients.
Although the European Board of Medical Specialists recog-
nizes awareness of cultural issues as a core component of the
psychiatry specialization, few medical schools provide training
in cultural issues. Cultural competence represents a compre-
hensive response to the mental health care needs of immigrant
and ethnic minority patients. Cultural competence training
involves the development of knowledge, skills, and attitudes
that can improve the effectiveness of psychiatric treatment.
Cognitive cultural competence involves awareness of the
various ways in which culture, immigration status, and race
impact psychosocial development, psychopathology, and
therapeutic transactions. Technical cultural competence in-
volves the application of cognitive cultural competence, and
requires proficiency in intercultural communication, the
capacity to develop a therapeutic relationship with a culturally
different patient, and the ability to adapt diagnosis and
treatment in response to cultural difference. Perhaps the
greatest challenge in cultural competence training involves the
development of attitudinal competence inasmuch as it requires
exploration of cultural and racial preconceptions. Although
research is in its infancy, there are increasing indications that
cultural competence can improve key aspects of the psychiatric
treatment of immigrant and minority group patients.
Schim, S. M., Doorenbos, A. Z., & Borse, N. N. (2006).
Enhancing cultural competence among hospice staff. The
American Journal of Hospice & Palliative Care, 23(5), 404–
411.
Abstract: A critical component in making hospice and
palliative care services accessible and acceptable to diverse
communities is preparation of all providers to enhance
cultural competence. This article reports a study designed to
test an educational intervention aimed at expanding cultural
awareness, sensitivity, and competence with a multidisci-
plinary and multilevel team of hospice workers. The purpose
of this quasi-experimental, longitudinal, crossover design
was to test the effects of an educational intervention for
multidisciplinary hospice providers. Findings demonstrated
that even with a modest face-to-face intervention, cultural
Biofeedback | Fall 2017
competence scores were significantly greater after the
educational intervention for participants in both groups.
Although the intervention proved successful at enhancing
cultural competence scores among diverse types of hospice
workers, limitations and logistic insights gained from this
59
 Annotated Bibiolography
pilot suggest the need for examination of alternative methods
of program delivery.
Schutte, C. (2014). Mandating cultural competence
training for dependency attorneys. Family Court Review,
52(3), 564–577.
Abstract: Dependency attorneys who represent children in
child abuse and neglect proceedings engage in cross-cultural
lawyering. Beyond the inevitable cultural differences be-
tween lawyer and child client in terms of education,
development, and age, there are often differences in race,
sexual orientation, language, neighborhood of residence, and
countless other cultural dimensions. Cultural differences can
lead to miscommunications and misunderstandings between
attorney and client, which in turn hurt the quality of
representation. Increasing the cultural competence of an
attorney can improve the attorney’s ability to work
effectively with children from different cultures. Unfortu-
nately, very few states currently require cultural competence
training for attorneys who represent children. This article
calls for making cultural competence training mandatory for
all dependency attorneys to improve the quality of
representation for children involved in the dependency
system.
Siegel, C., Haugland, G., Reid-Rose, L., & Hopper, K.
(2011). Components of cultural competence in three mental
health programs. Psychiatric Services (Washington, D.C.),
62(6), 626–631.
Abstract: The aim of this study was to identify
components of cultural competence in mental health
programs developed for cultural groups by community and
mental health professionals from these groups. Three
programs were studied: a prevention program primarily
serving African-American and Afro-Caribbean youth, a
Latino adult acute inpatient unit, and a Chinese day
treatment program in a community-based agency. Nine
study-trained field researchers used a semistructured instru-
ment that captures program genealogy, structure, processes,
and cultural infusion. Program cultural elements were
identified from field notes and from individual and group
interviews of consumers and staff (N ¼ 104). A research-
group consensus process with feedback from program staff
was used to group elements by shared characteristics into the
program components of cultural competence. Components
Fall 2017 | Biofeedback
included communication competencies (with use of colloqui-
alisms and accepted forms of address); staff in culturally
acceptable roles; culturally framed trust building (such as
pairing youths with mentors), stigma reduction, friendly
milieus (such as serving culturally familiar foods and playing
60
music popular with the culture), and services; and peer,
family, and community involvement (including use of peer
counselors and mentors, hosting parent weekends, and
linking clients with senior center and community services).
Incorporating these components into any program in which
underserved cultural populations are seen is recommended
for improving cultural competence.
Smith, E. A., & Mireles, M. (2011). Community of
Competencee: Part II—Application of a new organizational
concept to health care. Clinical Governance: An Interna-
tional Journal, 16(4), 50–61.
Abstract: Purpose: The paper aims to propose that
Community of Competence TM (C of C), as a catalyst for
change, can foster and accelerate a paradigm shift in how
longstanding, complex problems in health care are perceived,
interpreted, and resolved. When multiple stakeholders within
a C of C share a common or superordinate goal, group
productivity increases as more effective and efficient use is
made of human and material resources. Design/methodology/
approach: The authors used the logical step-by-step process of
systems thinking to see the whole picture, from beginning to
end. Continuously cycling trial solutions back through the
entire system improved the depth and breadth of results.
Participants in each of the three ongoing projects used the
safety and welfare of patients, the only true customers of
health care, as a superordinate goal. This sole focus expedited
and clarified decision making and provided valuable informa-
tion on best practices for use in improving the safety and
overall quality of patient-centered care. Findings: Results of
anecdotal, observational, and documented findings validated
the decision to continue using patient safety and patient
welfare as the common, unifying superordinate goal in health
care. The flexible structure and competency-based, interactive
work environment of C of C support networking and sharing
of unique competencies and knowledge to guide a focused,
streamlined problem-solving processes. Originality/value: C
of C has been used for more than seven years to analyze high-
priority healthcare problems and to create comprehensive,
realistic solutions. When members of a proven competence
identify a superordinate goal, collaborate and openly share
tacit and explicit knowledge, the efficiency, effectiveness, and
quality of solutions increase.
Smith, L. S. (2013). Reaching for cultural competence.
Nursing, 43(6), 30–37.
Abstract: Nurses are culturally unique individuals who
subscribe to nursing and healthcare cultures as well as their
own culturally learned assumptions and viewpoints. Like-
wise, their patients have cultural attitudes and preferences,

which may conflict with those of the nurse or the healthcare
culture. Nurses need to be aware of cultural differences in
order to provide competent and compassionate patient care.
Smith discusses what culturally competent nursing care
means, why it is important, and how nurses can deliver it.
Starr, S. S., & Wallace, D. C. (2011). Client perceptions
of cultural competence of community-based nurses. Journal
of Community Health Nursing, 28(2), 57–69.
Abstract: Cultural competence is best understood by
assessing provider and client perspectives. In this descriptive
quantitative study, clients assessed dimensions of nurses’
cultural competence including communication, decision-
making, and interpersonal style. Nurses in 7 county health
departments in North Carolina assessed their own cultural
competence. Sixty-nine clients completed the Interpersonal
Processes of Care and 71 nurses completed the Cultural
Competence Assessment. Clients perceived their nursing care
to contain key components of cultural competence. Nurses
rated themselves as moderate to high cultural competence.
Consistencies were noted between the clients’ and nurse
perceptions of cultural competence. These findings contribute
to the enhancement of cultural competence among commu-
nity nurses.
Sue, D. W. (2011). Multidimensional facets of cultural
competence. The Counseling Psychologist, 29(6), 790–821.
Abstract: Calls for incorporating cultural competence in
psychology have been hindered for a number of reasons: belief
in the universality of psychological laws and theories, the
invisibility of monocultural policies and practices, differences
over defining cultural competence, and the lack of a conceptual
framework for organizing its multifaceted dimensions. A
proposed multidimensional model of cultural competence
(MDCC) incorporates three primary dimensions: (a) racial and
culture-specific attributes of competence, (b) components of
cultural competence, and (c) foci of cultural competence. Based
on a 3 (Awareness, Knowledge, and Skills) 3 4 (Individual,
Professional, Organizational, and Societal) 3 5 (African
American, Asian American, Latino/Hispanic American,
Native American, and European American) factorial combi-
nation, the MDCC allows for the systematic identification of
cultural competence in a number of different areas. Its uses in
education and training, practice, and research are discussed.
Tervalon, M., & Murray-Garcı́a, J. (1998). Cultural
humility versus cultural competence: A critical distinction
in defining physician training outcomes in multicultural
education. Journal of Health Care for the Poor and
Underserved, 9(2), 117–125.
Annotated Bibiolography
Abstract: Researchers and program developers in medical
education presently face the challenge of implementing and
evaluating curricula that teach medical students and house
staff how to effectively and respectfully deliver health care to
the increasingly diverse populations of the United States.
Inherent in this challenge is clearly defining educational and
training outcomes consistent with this imperative. The
traditional notion of competence in clinical training as a
detached mastery of a theoretically finite body of knowledge
may not be appropriate for this area of physician education.
Cultural humility is proposed as a more suitable goal in
multicultural medical education. Cultural humility incorpo-
rates a lifelong commitment to self-evaluation and self-
critique, to redressing the power imbalances in the patient-
physician dynamic, and to developing mutually beneficial and
nonpaternalistic clinical and advocacy partnerships with
communities on behalf of individuals and defined populations.
van Driel, M., & Gabrenya, W. K. (2013). Organizational
cross-cultural competence: Approaches to measurement.
Journal of Cross-Cultural Psychology, 44(6), 874–899.
Abstract: The present study was designed to assess the
viability of developing quantitative measures of cross-
cultural competence as an emergent organizational-level
construct using samples of military organizations. Cross-
cultural competence has predominantly been discussed as
an individual-level construct but has not been extensively
assessed as an organizational-level phenomenon. A syn-
thesis of the cross-cultural competence, organizational
intelligence, and multilevel analysis literatures was used
to construct a theoretical basis for organizational cross-
cultural competence and the development of quantitative
measures of the construct. Based on this synthesis, three
strategies were identified for assessing cross-cultural
competence at the organizational level of analysis. Three
studies were conducted to test these three strategies, each of
which was supported empirically through the successful
generation of interpretable organization-level scales and
subscales. In a fourth study, each of the organization-level
measures developed in Studies 1, 2, and 3 was found to be
related to organization-level indices of organizational
climate, perceived organization effectiveness, and cohesion.
Vasiliou, M., Raftopoulos, V., & Kouta, C. (2013). The use
of the Cultural Competence Assessment Tool (CCATool) in
Biofeedback | Fall 2017
community nurses: The pilot study and test-retest reliability.
International Journal of Caring Sciences, 6(1), 44–52.
Abstract: Background: Nurses are responsible and
accountable for their nursing practice and there is a need
to be culturally and linguistically competent in all of their
61
 Annotated Bibiolography
encounters. To be culturally competent community nurses
should have the appropriate transcultural education. It is
therefore important to assess the level of cultural compe-
tence of the community nurses, within their everyday
practice. Aim: The aim of the article was the cultural
adaptation of the Cultural Competence Assessment Tool
based on Papadopoulos, Tilki and Taylor Model in a sample
of Cypriot community nurses. Methodology: To explore
the psychometric properties of the Cultural Competence
Assessment Tool that has been distributed in a sample of 28
community nurses. Also, a pre- and post-measurement has
been applied to assess the test-retest reliability of the tool.
Results: The analysis has shown that the Cultural
Competence Assessment Tool has good psychometric
properties and it is easy to understand by the community
healthcare professionals. Results showed that 60.7%
disagreed that there is the same level of cultural
competency with other European countries and 89.3%
reported that assessment of their cultural competence is
needed. Using the special analysis software for this tool, the
pilot study showed that Cypriot community nurses have
some degree of cultural awareness. Conclusion: Culturally
competent care is both a legal and a moral requirement for
health and social care professionals. Valuing diversity in
health and social care enhances the delivery and effective-
ness of care for all people, whether they are members of a
minority or a majority cultural group. Using an appropriate
tool for assessing cultural competence is very important and
useful for health professionals to be culturally competent.
Wendt, D. C., & Gone, J. P. (2014). Rethinking cultural
competence: Insights from indigenous community treat-
ment settings. Transcultural Psychiatry, 49(2), 206–222.
Abstract: Multicultural professional psychologists rou-
tinely assert that psychotherapeutic interventions require
culturally competent delivery for ethnoracial minority clients
to protect the distinctive cultural orientations of these clients.
Dominant disciplinary conceptualizations of cultural compe-
tence are ‘‘kind of person’’ models that emphasize specialized
awareness, knowledge, and skills on the part of the
practitioner. Even within psychology, this approach to
cultural competence is controversial owing to professional
misgivings concerning its culturally essentialist assumptions.
Unfortunately, alternative ‘‘process-oriented’’ models of
cultural competence emphasize such generic aspects of
Fall 2017 | Biofeedback
therapeutic interaction that they remain in danger of losing
sight of culture altogether. Thus, for cultural competence to
persist as a meaningful construct, an alternative approach
that avoids both essentialism and generalism must be
recovered. One means to capture this alternative is to shift
62
focus away from culturally competent therapists toward
culturally commensurate therapies. Indigenous communities
in North America represent interesting sites for exploring
this shift, owing to widespread political commitments to
Aboriginal cultural reclamation in the context of postcolo-
niality. Two examples from indigenous communities illus-
trate a continuum of cultural commensurability that ranges
from global psychotherapeutic approaches at one end to local
healing traditions at the other. Location of culturally
integrative efforts by indigenous communities along this
continuum illustrates the possibility for local, agentic, and
intentional deconstructions and reconstructions of mental
health interventions in a culturally hybrid fashion.
West-Olatunji, C., Goodman, R. D., Mehta, S., &
Templeton, L. (2011). Creating cultural competence: An
outreach immersion experience in southern Africa. Interna-
tional Journal for the Advancement of Counselling, 33(4),
335–346.
Abstract: With disasters on the rise, counselors need to
increase their cultural awareness, knowledge, and skills to
work with affected communities. This study reports
outcomes of a four-week immersion experience in southern
Africa with six counselor-trainees. Data sources for this
qualitative study were: daily journals and demographic
forms. Outcomes suggest that sustained contact with
community residents and daily supervision experiences
served to improve cultural awareness. Recommendations
include pushing through students’ resistance using a non-
linear dynamic model of transformation.
Whitley, R. Religious competence as cultural compe-
tence. Transcultural Psychiatry, 49(2), 245–260.
Abstract: Definitions of cultural competence often refer to
the need to be aware and attentive to the religious and
spiritual needs and orientations of patients. However, the
institution of psychiatry maintains an ambivalent attitude to
the incorporation of religion and spirituality into psychiatric
practice. This is despite the fact that many patients, especially
those from underserved and underprivileged minority
backgrounds, are devotedly religious and find much solace
and support in their religiosity. I use the case of mental
health of African Americans as an extended example to
support the argument that psychiatric services must become
more closely attuned to religious matters. I suggest ways in
which this can be achieved. Attention to religion can aid in
the development of culturally competent and accessible
services, which in turn may increase engagement and service
satisfaction among religious populations.

Wilson, A. H., Sanner, S., & McAllister, L. E. (2010). A
longitudinal study of cultural competence among health
science faculty. Journal of Cultural Diversity, 17(2), 68–72.
Abstract: The purpose of this study was to measure the
process of cultural competence over time in a group of Health
Science Faculty teaching nursing and other allied health
students. Faculty (n ¼ 28) were administered the Inventory
for Assessing the Process of Cultural Competence Among
Healthcare Professionals (IAPCC) prior to a cultural
competence workshop, immediately after the workshop,
and again at three months, six months and 12 months. The
mean scores increased significantly with each administration
of the IAPCC from the pretest administration (52.17) to the
12 month administration (59.71) demonstrating new knowl-
edge related to cultural competence as a process.
Xu, Y. (2009). Cultural competence ‘‘Tool Kit’’ and
‘‘Snapshot.’’ Home Health Care Management & Practice,
21(4), 300–302.
Abstract: In the past few years, a number of important
events related to cultural competence have happened. For
instance, The Sullivan Commission (2004) released its
report on the status of minorities in the health professions,
the American Academy of Nursing Expert Panel published
its report on cultural competence (Giger et al., 2007), and
the 2008 National League of Nursing Summit took place
with a theme on ‘‘Diversity in Nursing Education.’’
Recently, I came across two documents on cultural
competence. The first one is the Tool Kit for Teaching
Cultural Competence in Nursing Education (Tool Kit
hereafter) by the American Association of Colleges of
Nursing (AACN, 2008). The second one is a report on a
national survey study titled Hospitals, Language, and
Culture: A Snapshot of the Nation (Snapshot hereafter) by
the Joint Commission (Wilson-Stronks & Galvez, 2007). In
this column, I will review the two seminal documents and
address their utility and implications for nursing education
and practice. For the purpose of this column, cultural
competence is broadly conceptualized so that it can be
applied not only to individuals but also to institutions.
Zander, P. E. (2007). Cultural competence: Analyzing
the construct. Journal of Theory Construction & Testing,
11(2), 50–54.
Abstract: Rapidly changing demographics in the U.S.
present increased opportunities for relationships with
individuals of other cultures and ethnicities. Consequently
practitioners in the helping and caring disciplines need to be
prepared to provide culturally competent care. The goal of
this evolutionary concept analysis is to explore the
Annotated Bibiolography
construct of cultural competence as it is used in nursing
and several related disciplines. The historical evolution of
the construct, cultural competence, and major issues
associated with the construct will be investigated.
Additional Cultural Competence Articles
Boyle, J. (1998). Cultural influences on implementing
environmental impact assessment: insights from Thailand,
Indonesia, and Malaysia. Environmental Impact Assess-
ment Review, 18, 95–116.
Brown, P. (2010). Institutional review board challenges
related to community-based participatory research on
human exposure to environmental toxins: A case study.
Environmental Health, 9, 1–12.
Caldwell, J., Davis, J., Du Bois, B., Echo-Hawk, H.,
Erickson, J., Goins, R., . . . Stone, J. (2005). Culturally
competent research with American Indians and Alaska
Natives: Findings and recommendations of the first
symposium of the work group on American Indian research
and program evaluation methodology. The Journal of the
National Center, 12(1), 1–21.
Evans, M., Meija-Maya, L., Zayas, L., Boothroyd, R., &
Rodriguez, O. (2001). Conducting research in culturally
diverse inner-city neighborhoods: some lessons learned.
Journal of Transcultural Nursing, 12, 6–14.
Foster, J. (2009). Cultural humility and the importance
of long-term relationships in international partnerships.
Journal of Obstetric Gynecological & Neonatal Nursing,
38, 100–107.
Kumagai, A., & Lypson, M. (2009). Beyond cultural
competence: Critical consciousness, social justice, and
multicultural education. Academic Medicine, 84, 782–787.
Oscos-Sanchez, M., Lesser, J., & Kelly, P. (2008).
Cultural competence: A critical facilitator of success in
community-based participatory action research. Issues in
Mental Health Nursing, 29, 197–200.
Petrovich, A., & Lowe, M. (2005). Developing cultural
competence: Student and alumni perspectives. Journal of
Teaching in Social Work, 25(3/4), 157–176.
Sahota, P. (2007). Research regulation in American
Indian/Alaska Native communities: Policy and practice
considerations. NCAI Policy Research Center. Retrieved
November 11, 2017 from https://depts.washington.edu/
ccph/pdf_files/.pdf
Seeleman, C., Suurmond, J. & Stronks, K. (2009).
Cultural competence: A conceptual framework for teaching
Biofeedback | Fall 2017
and learning. Medical Education, 43, 229–237.
Williams, C. (2005). Training for cultural competence:
Individual and group processes. Journal of Ethical &
Cultural Diversity in Social Work, 14(1/2), 111–143.
63
 Biofeedback
Volume 45, Issue 3, pp. 64–68
DOI: 10.5298/1081-5937-45.3.06
Special Issue
The Biofeedback Certification International Alliance,
Professional Standards and Ethical Principles of
Biofeedback
Preamble
For the purposes of this document, the term BCIA
professionals refers to BCIA certificants and those who
have filed a formal application for BCIA certification.
Because the Biofeedback Certification International Alliance
(BCIA) and its professionals are committed to the
protection of human rights, they strive to maintain the
dignity and worth of the individual while rendering service,
conducting research, and teaching others. They operate
within the BCIA Professional Standards and Ethical
Principles (PSEP). They strive to provide the highest
quality of service and carefully differentiate between
empirically validated and experimental procedures. They
hold themselves responsible for their actions and make
every effort to protect their clients’ welfare. Finally, they
limit their services to those areas in which they have
expertise and exemplify the values of competence, objec-
tivity, freedom of inquiry, and honest communication.
The PSEP is intended to guide all BCIA professionals
who commit themselves to adhere to these Principles as
well as to the Principles stated in their licensing act. A copy
of the PSEP will be provided to all BCIA certification
applicants and will be available on the BCIA website. The
PSEP are intended to educate and guide professionals to
prevent ethical misconduct and should be applied with
professional maturity.
The term biofeedback refers to all modalities for which
we provide certification including, but not limited to, BVP,
EEG or neurofeedback, electrodermal, EMG, HRV, respi-
ration, and thermal biofeedback.
Fall 2017 | Biofeedback
‘‘Biofeedback is a process that enables an individual to
learn how to change physiological activity for the purposes
of improving health and performance. Precise instruments
measure physiological activity such as brainwaves, heart
function, breathing, muscle activity, and skin temperature.
64
ÓAssociation for Applied Psychophysiology & Biofeedback
www.aapb.org
These instruments rapidly and accurately ‘feed back’
information to the user. The presentation of this informa-
tion—often in conjunction with changes in thinking,
emotions, and behavior—supports desired physiological
changes. Over time, these changes can endure without
continued use of an instrument.’’1
Purpose and Scope
The PSEP consist of guidelines for professional biofeedback
practice that are not exhaustive and do not limit BCIA
professionals’ ethical responsibilities. They highlight areas
in which ethical concerns often arise. For BCIA profession-
als who practice under a state and/or national licensing act,
the PSEP are not meant to replace, but to confirm and
reinforce, professional ethical guidelines.
1. The PSEP should be followed by BCIA certificants,
applicants, and their staff who help provide biofeedback
and related services.
2. BCIA professionals’ ethical conduct is measured by the
PSEP, state and/or national licensing acts, and the
ethical guidelines of their professional membership
organizations where applicable.
3. A violation of the PSEP may lead to disciplinary action
or decertification. In some instances, such as sexual
contact with a client, a criminal charge may result from
breach of the PSEP and other professional guidelines for
ethical practice.
A. Responsibility
In utilizing biofeedback, BCIA professionals adhere to the
highest standards of their profession. They behave respon-
sibly; accept responsibility for their behavior and its
consequences; ensure that biofeedback is used appropriate-
ly; and strive to educate the public concerning the

responsible use of biofeedback in treatment, training, and
research. BCIA professionals are responsible for adhering to
the ethical principles of their profession; the local, state and
national laws relevant to their professional activities; and
the PSEP.
1. As practitioners, BCIA professionals recognize their
obligation to help clients acquire knowledge and skill
through training that represents the best professional
practice and that is delivered in the most cost-effective
manner.
2. As teachers, BCIA professionals are committed to the
advancement of knowledge. They encourage the free
pursuit of learning by their students and present
information objectively, accurately, and completely.
3. BCIA professionals guard against misuse of their
influence since they realize that their professional
services impact the lives of their clients and others.
4. BCIA professionals should only continue biofeedback
services as long as their clients benefit from training. If
their clients require an intervention that they are not
qualified to provide, they should help them obtain these
services and should never abandon them.
B. Competence
BCIA professionals recognize the boundaries of their
competence and only use those biofeedback and adjunctive
techniques in which they have expertise. They also
recognize the proper limitations of biofeedback and inform
all concerned parties about the clinical utility of particular
procedures, possible negative effects, and whether the
procedures are experimental or clinically verified. BCIA
professionals maintain current knowledge of relevant basic
and applied biofeedback research.
1. BCIA professionals should operate within applicable
local, state, and national laws as well as in accordance
with the ethical principles of their profession. BCIA
certification is not a license to practice independently.
2. BCIA professionals who treat medical or psychological
conditions must demonstrate professional competence as
defined by applicable local, state, and national licensing/
credentialing laws. BCIA certification becomes invalid
when a certificant’s license is suspended, revoked, or not
renewed due to an investigation of a complaint.
Once suspended the individual will not be considered
by BCIA for a re-certification based on providing
services under supervision. A licensed professional
who is suspended may only apply for recertification by
BCIA after the license has been reinstated.
BCIA Professional Standards
3. BCIA professionals who are not appropriately licensed
or credentialed, and who wish to treat medical or
psychological conditions, must acquire appropriate
supervision according to applicable state and national
laws and professional codes/regulations.
4. BCIA professionals must accurately describe their
qualifications, training, experience, and/or specialty.
They must only list degrees in an approved healthcare
field earned from a regionally accredited academic
institution when applying for BCIA certification. BCIA
only certifies individuals who hold these degrees and
only lists these credentials in its directory. When BCIA
practitioners list BCIA certification in advertisements,
business cards, directories, websites, and similar profes-
sional publications, that listing cannot include an
unaccredited degree nor can it list a degree not related
to health care.
C. Ethical Standards
BCIA professionals are sensitive to prevailing community
norms and recognize that the violation of these standards
may jeopardize the quality of their services, completion of
professional responsibilities, and public trust in biofeed-
back.
1. BCIA professionals will only charge for services
actually provided by them or by those under their
legal supervision. In billing third-party payers, practi-
tioners will comply with the rules and regulations of
the third-party payer, including clearly specifying
which services the practitioner provided directly and
which were supervised, and providing information
regarding their qualifications (e.g., degree, license, and
certification).
2. BCIA professionals will clarify any potential or actual
conflict of interest that exists when serving clients,
conducting training or research, or when engaged in any
other professional activity (such as a workshop in which
presenters recommend their own product).
3. BCIA professionals will obtain written informed consent
from clients for all assessment and treatment proce-
dures, billings and fee collections, and procedures to
protect confidentiality, as well as conditions that limit
confidentiality.
Biofeedback | Fall 2017
4. BCIA professionals will obtain written informed consent
from clients for all experimental treatment applications.2
To distinguish experimental and clinically validated
procedures is difficult and requires familiarity with
related documents.3
65
 BCIA Professional Standards
D. Multiculturalism and Diversity
1. BCIA professionals are encouraged to recognize that, as
cultural beings, they may hold attitudes and beliefs that
can detrimentally influence their perceptions of and
interactions with individuals who are different from
themselves ethnically, racially, in sexual orientation, or
gender identity.
2. BCIA professionals are encouraged to recognize the
importance of multicultural sensitivity/responsiveness
to, knowledge of, and understanding about individuals
who are different ethnically, racially, in sexual orienta-
tion, or gender identity.
3. As educators, BCIA professionals are encouraged to
employ the constructs of multiculturalism and diversity
in education.
4. Culturally sensitive researchers are encouraged to
recognize the importance of conducting culture-centered
and ethical research among persons from diverse ethnic,
linguistic, racial, sexual orientation, or gender identity
backgrounds.
5. BCIA professionals are encouraged to apply culturally
appropriate skills in clinical and other biofeedback
practices.
6. BCIA professionals are encouraged to use positive
motivational change processes to support culturally
informed organizational (policy) development and
practices.
7. BCIA professionals regularly engage in professional
reading and education (both online and face to face) on
multiculturalism and diversity, keeping up to date on
current standards and research.
E. Public Statements
BCIA professionals recognize that all public statements,
announcements of services and products, advertising, and
promotional activities concerned with biofeedback should
help the public make informed choices. Statements about
biofeedback must be based on scientifically verifiable
information, including recognition of the limits and
uncertainties of such data. BCIA professionals must
accurately represent their qualifications, affiliations, and
positions, and must not mislead the public.
1. BCIA professionals shall accurately represent the
efficacy of biofeedback procedures for all disorders or
Fall 2017 | Biofeedback
conditions being treated.
2. BCIA professionals must use accurate information in
statements about biofeedback when providing services,
marketing a product, and in all other professional
activities. They consider the context and source
66
requesting information when making a public statement
and guard against misrepresentation.
3. BCIA professionals recognize that they may have
personal interests when they promote biofeedback
activities and agree that these interests must be
superseded by professional objectivity, concern for
clients’ welfare, and the PSEP and the standards of
other professional societies to which they belong. When
a question arises as to their objectivity, they seek
professional guidance from appropriate professional
sources like BCIA and their professional associations.
4. Announcements and listing of services and training
offered by BCIA professionals, such as service directory
listings, letterheads, business cards, and marketing
brochures and websites, should be accurate and designed
in a professional manner, and should adhere to the
guidelines of their professional associations.
F. Confidentiality
BCIA professionals protect the confidentiality of their
clients’ data. They may only release information with the
written consent of the client or the client’s legal represen-
tative, or when nondisclosure would endanger the client or
others.
1. BCIA professionals specify in advance the legal limits of
confidentiality to clients, particularly when collecting
fees and complying with mandated reporting laws that
concern abuse or neglect. Confidentiality applies to
clients in treatment, students in training, and research
participants.
2. Client records are stored and destroyed in ways that
maintain confidentiality. BCIA professionals will keep
records for the time required by applicable national and
state laws.
G. Protection of Client Rights and Welfare
BCIA professionals protect the welfare of clients, students,
research participants, and other groups with whom they
work. They inform all consumers of their rights, provide
them with a written statement of these rights, fully inform
them as to the purpose and nature of procedures to be
implemented, and assure that clients’ rights are not
abridged.
1. Sexual intimacy with current clients, trainees, super-
visees, and research subjects is prohibited. BCIA
professionals should follow the applicable guidelines of
state/national law and their professional associations

regarding when sexual intimacy is permissible after
termination of a professional relationship.
2. Professionals adhere to the highest standards of
infection mitigation to protect clients and staff. Practi-
tioners are responsible to learn and follow reasonable
disinfection standards applicable to biofeedback instru-
ments, sensors, and office environments.4
3. In attaching biofeedback sensors, professionals assure
that the privacy and rights of the client are protected and
respect the feelings and sensitivities of their clients.
Caution and common sense are required whenever an
applicant or certificant has physical contact with clients.
Any physical contact requires the permission of the
client. Touching of sensitive body parts, such as breasts
or genitals, is not acceptable in biofeedback practice, with
the exception of a medical exam or medical treatment
provided by a licensed medical practitioner.
4. Special care is taken to protect the rights of children
when providing biofeedback training or conducting
research. Wherever possible, BCIA professionals should
seek children’s agreement to participate in these
activities.
5. BCIA professionals do not discriminate against or refuse
services to anyone on the basis of sex, sexual
orientation, gender identity, race, religion, disability,
or national origin.
H. Professional Relationships
BCIA professionals recognize the interdisciplinary nature of
biofeedback and respect the competencies of colleagues in all
professions. They strive to act in accordance with the
obligations of the organizations with which they and their
colleagues are associated. They:
1. should only treat medical disorders if clients have first
received a medical evaluation and/or are under the care
of a physician.
2. should strive to be objective in their professional
judgment of colleagues and to maintain good profes-
sional relationships even when opinions differ.
3. should avoid multiple relationships with their clients
that could impair their professional judgment or
increase the risk of exploitation, and must never exploit
clients, students, supervisees, employees, research par-
ticipants, or third party payers.
I. Research with Humans and Animals
BCIA professionals conduct research to advance under-
standing of human behavior, to improve human health and
BCIA Professional Standards
welfare, and to advance science. They carefully consider
alternative research methods and assure that in the conduct
of research the welfare of research participants (human and
animal) is protected.
All researchers will adhere to state and national
regulations and the professional standards of their profes-
sion with regard to the conduct of research. Research
involving humans may be subject to regulation by local
institutional review boards and to state and/or national
regulations.2
Animal research may be subject to local institutional
animal care and use committees and must comply with state
and national policies on the use of animals.5
1. The results of research will be released in a manner
which accurately reflects research results and only when
the findings have satisfied widely-accepted scientific
criteria. Any limitations regarding factors such as
sampling bias, small samples, and limited follow-up,
will be explicitly stated. All descriptive materials
distributed regarding clinical practice will be factual
and straightforward.2
2. The individual researcher is responsible for the estab-
lishment and maintenance of acceptable ethical practice
in research. The investigator is also responsible for the
ethical treatment of research participants by collabora-
tors, assistants, students, and employees, all of whom
also incur similar obligations. Information obtained
about research participants during the course of an
investigation should be confidential. When the possibil-
ity exists that others may obtain access to such
information, ethical research practice requires that this
possibility, together with the plans to protect confiden-
tiality, be explained to the participants as part of the
procedure for obtaining informed consent.
3. Ethical practice requires that the investigator inform
participants of all features of the research that might be
reasonably expected to influence their willingness to
participate and to explain all other aspects of the
research about which the participant inquires. BCIA
professionals protect participants from physical and
psychological discomfort, harm, and danger. If the risk
of such consequences exists, investigators are required
to inform the participant of that fact, secure informed
consent before proceeding, and take all possible mea-
Biofeedback | Fall 2017
sures to minimize distress. A research procedure may
not be used if it is likely to cause serious and lasting
harm to participants. As participants’ risk increases, so
does the responsibility of the researcher to protect the
research participants. Written informed consent or a
67
 BCIA Professional Standards
verbal and written summary of the research is
customary for most kinds of non-survey research
(including a signature by the research participant in
both cases).
4. The investigator must respect an individual’s freedom to
decline to participate in research or to discontinue
participation at any time. The obligation to protect this
freedom requires special vigilance when the investigator
has power over the participant. When a prospective
participant is a minor, investigators should seek the
child’s assent.
5. After research data are collected, the investigator must
fully debrief participants about the nature of the study.
When scientific or human values justify delaying or
withholding information, the investigator acquires a
special responsibility to assure that the participant is not
harmed.
Adherence to Professional Standards
BCIA professionals should be knowledgeable about effica-
cious interventions and adhere to the professional standards
associated with these techniques.3
Additional Standards
BCIA professionals who hold a state or national license/
credential should adhere to the guidelines of the relevant
professional licensing act. Additional guidance can be found
in the ethical standards of organizations like the American
Psychological Association, American Psychiatric Associa-
tion, the American Nurses Association, the American
Physical Therapy Association, the American Medical
Association, the American Dental Association, the Amer-
ican College of Sports and Rehabilitation, the American
Academy of Physical Medicine and Rehabilitation, and their
international counterparts.
Ethics Complaint Procedures
When BCIA receives a written complaint about the ethical
conduct of a BCIA certificant or applicant, BCIA’s Executive
Director will record the complaint and will write a letter to
the complainant that will describe BCIA’s role in ethics
cases, direct the complainant to directly discuss the
complaint with the provider (certificant or applicant), and
if requested by the complainant, identify state and/or
national regulatory agencies with jurisdiction. Since BCIA’s
approach to ethical issues is educational, BCIA will not
Fall 2017 | Biofeedback
recommend that complainants contact these agencies nor
will it represent complainants before these agencies.
68
BCIA will not intervene in complaints about manufac-
turer or vendor products, services, or sales practices as these
issues do not concern certification and corporations are not
BCIA professionals.
While BCIA encourages certificants to first discuss
ethical concerns with their colleagues, certificants may
directly contact appropriate regulatory agencies. If an
agency declares that a complaint lacks merit, is frivolous,
or is malicious, BCIA will defer to the agency to discipline
the complainant.
The BCIA Board of Directors will periodically review
and update the PSEP. Thereafter, BCIA professionals shall
be required to adhere to the revised PSEP. Comment is
invited. Individuals desiring more information about these
Principles may contact BCIA.
Related Documents and Acknowledgments
1
Biofeedback Alliance and Nomenclature Task Force (2008).
2
Regulations for the protection of human research subjects (45
CFR46 and 56 FR 28003) (Federal Regulations).
3
Humane care and use of animals (A 343401) (Federal
Regulations).
4
Hagedorn, D. (2014). Infection risk mitigation for biofeedback
providers. Biofeedback, 42(3), 93-95.
5
Tan, G., Shaffer, F., Lyle, R., & Teo, I. (Eds.). Evidence-based
practice in biofeedback and neurofeedback (3rd ed.) Wheat
Ridge, CO: Association for Applied Psychophysiology and
Biofeedback.
We thank the Association for Applied Psychophysiology and
Biofeedback, whose Ethical Principles were modified and adapted
for these Principles.
Original version adopted by BCIA Board of Directors, August 26,
1990.
1st revision prepared by John G. Carlson, Adopted by the BCIA
Board of Directors, October 14, 1999.
2nd revision prepared and adopted by the BCIA Board of
Directors, March 24, 2002.
3rd revision prepared and adopted by the BCIA Board of Directors,
April 5, 2004.
4th revision prepared and adopted by the BCIA Board of Directors,
April 1, 2005.
5th revision prepared and adopted by the BCIA Board of Directors,
August 26, 2009.
6th revision prepared and adopted by the BCIA Board of Directors,
May 18, 2015.
7th revision prepared and adopted by the BCIA Board of Directors,
October 6, 2015.
8th revision prepared and adopted by the BCIA Board of Directors,
January 29, 2016.
9th revision prepared and adopted by the BCIA Board of Directors,
May 2, 2016.
 Multi-Cultural Diversity Considerations for
Organizations and Individuals
AAPB 18 August 2017 Webinar

Richard Harvey Harvey, (presenter)

with contributions from Annette Booiman and Imei Lin

Slides based on training material from the National Center for Cultural Competence (NCCC) as well as from the Proceed, Inc. National Center for Training and Technical Assistance.
 LEARNING OBJECTIVES:
Participants will learn how to:

• Specify multi-cultural models

• Identify stages of competence

• Develop plans for implementing culturally competent skills

• Implement best practices for multicultural training

 Three Models:
• Cultural competence: The level of a provider’s knowledge, attitude, and
skills about cultural values and health-related beliefs, disease incidence
and prevalence, and treatment efficacy for diverse cultural groups.

• Cross-cultural efficacy: Providers proficiently learn how their own culture

and behaviors can impact others of different cultures, and understand
how patients’ culturally-based behaviors may impact the provider.

• Cultural humility: Providers engage in regular self-evaluation and self-

critique. Goal is to developed power-balanced relationships with
patients of different cultures.
• Source: www.integration.samhsa.gov, based on the work of Chavez, 2012; Kirmayer, 2012; Tervalon & Murray-Garcia, 1998
 Many Terms to Describe
Cultural Diversity Awareness

Culturally relevant Culturally aware

Linguistically Competent Culturally Effective

Culturally Appropriate Cultural sensitivity

Culturally Competent Culturally Proficiency

Multicultural Competence Cultural Humility

 Stages of Competence
1. cultural destructiveness

2. cultural incapacity

3. cultural blindness

4. cultural pre-competence

5. cultural competency

6. cross-cultural efficacy

7. cultural humility
Cross et al (1989); Towards a Culturally Competent System of Care . National Center for Cultural Competence (NCCC)
Cultural Destructiveness
Cultural Incapacity
 Cultural Blindness
All That We Share Danish video ( https://www.youtube.com/watch?v=jD8tjhVO1Tc )
Cultural Pre-Competence
 RACE
GENDER
AGE

ABILITY INCOME
DISABILITY JOB
(Hidden) (SES/CLASS)

URBANICITY EDUCATION

CULTURAL
IDENTITIES
&
EFFICACY

RELIGION
IMMIGRATION BELIEFS
STATUS VALUES

ACCULTURATION FAMILY AND

LANGUAGE OPPRESSION COMMUNITY
SOCIAL IDENTITY EXPERIENCE SUPPORT
Quick Self-Check Using the Cultural Competence Continuum
Cross, Bazron, Dennis & Isaacs, 1989

What Stage Are You In? Characteristics

RED attitudes, behaviors, values, and practices that are

destructive to a cultural group
ORANGE lack of skill and knowledge to respond effectively
to the needs, interests and preferences of
culturally and linguistically diverse groups
YELLOW beliefs and practices that support viewing and
treating all people as the same

GREEN level of awareness about your strengths and areas

for growth to respond effectively to culturally and
linguistically diverse populations
BLUE has acceptance and respect for differences

PURPLE holds culture in high esteem

Cultural Humility and Social Justice
Cultural Humility and Social Justice
Cultural Humility and Social Justice
Appropriate
Pictures? The winner

©Annette Booiman,
MensendieckMoves
 Bare Shoulders
Privacy, Modesty, Confidentiality
Dutch Biofeedback
Society,
• The physical therapist
would like to use a
picture of a bare
shouldered woman,
seen from the back.
• The psychologists
could not agree with
the picture ©Annette Booiman,
MensendieckMoves
 Hand placements
Can facilitate a
functional
movement/breathing.
The Sykegrep or
other manual hand
techniques gives a
professional frame
Guide the therapist
through effective,
appropriate hand
placements

De Telegraaf nov. 1981 ©Annette Booiman,

Sykegrep, Lingsten & Halvorsen, 2003 MensendieckMoves
 NONVERBAL COMMUNICATION

• “TO DO” people tend to use and trust words so

written communication is most effective

• “TO BE” people use and trust all senses so

face-to-face communication is the most effective
 CULTURAL CONTINUUMS
‘To Do’ Behavior ‘To Be’ Identity
Earned Status Ascribed Status
Individual Achievement Affiliation
Individual Action Stability
Equality Inequality
Immediate family Extended Family
Self Reliance Reliance on Others
Independence Interdependence
Individual Competition Cooperation
Individualism Collectivism
Guilt Shame
Future Past or Heritage
Class Mobility Caste Rigidity
• Youth • Adults
• Male • Female
• Urban • Rural
• Heterogeneous • Homogeneous
• Modern • Traditional
• Low-Context • High-Context
• Humane • Human
• Linear • Cyclical
• External rules • Internal rules
 Views of Time
Slide 5:
Perception of Time and Space

Time

• Monochronic -- linear quantitative time, most

common in the northern and western
hemispheres
• Polychronic -- cyclical time w/ unraveling and
unlimited continuity, most common in southern
and eastern hemispheres

Space -- differences in comfortable

distance between people
 Views of Fate
Slide 6:
Fate and Personal Responsibility

Extent to which we feel ourselves

to be the masters of our lives

Extent to which we see ourselves

as subject to things outside our
control
 Views of Face
Slide 7:
Face and Face-Saving

Face is the standing a person has in

the eyes of others

The importance of “face” and

face-saving varies across cultures

• Some cultures value “face” more than their own

well-being

• Other cultures do not care about face all that

much
 Building Cultural Humility
• Visit a church, temple, mosque… • Read (i.e., local print media when
you travel)
• Consume a variety of news
sources • Go to the movies / museum
• Look for culture
• Eat diverse foods
• Join a multicultural group
• Learn a new language
• Take a culture class
• Attend cultural celebrations
• Create a faith club
• Find a cultural coach
D. Livermore, 2010
 The End
of the main presentation, with the following additional slides for further discussion as time permits
 Iceberg
Concept of
Culture

Weaver (1986)
BEHAVIOR
BELIEFS
VALUES
AND
THOUGHT
PATTERNS
 BASIC AMERICAN BELIEFS

Extreme Individualism
and
Distrust of Strong Centralized
Authority
 MISPERCEPTIONS
OTHERS HAVE OF
AMERICANS

Americans don’t help others

Americans don’t honor elders

Fons Trompenaars and Geert Hofstede
Cultural Dimensions
 HOFSTEDE’S DIMENSIONS
• POWER DISTANCE (PDI)

• INDIVIDUALISM (IDV)

• MASCULINITY (MAS)

• UNCERTAINTY AVOIDANCE INDEX (UAI)

• LONG-TERM ORIENTATION (LTO)

 HOFSTEDE’S DIMENSIONS

POWER DISTANCE (PDI)

INDIVIDUALISM (IDV)

MASCULINITY (MAS)

UNCERTAINTY AVOIDANCE INDEX (UAI)

LONG-TERM ORIENTATION (LTO)

 Some Analysis of
Communications
• Nice weather we’re having!
• High-Context – Relational- Associative

• Sunny, high in the 20s.

• Low Context - Abstractive - Analytical
Communication Styles
A B
A B
A B
 Resources
• Hall, Edward. Beyond Culture.

• Hofstede, Geert. Culture’s Consequences: Comparing values, behaviors, institutions, and organizations across nations. Thousand Oaks, CA: Sage Publications, 2001.

• Weaver, Gary R., ed. Culture, Communication and Conflict, 2nd edition. Boston, MA:Pearson Publishing, 2000.

• Weaver, Gary & Adam Mendelson, America’s

Midlife Crisis: The Future of a Troubled Superpower. Boston, Intercultural Press, 2008.

• www.interculturalpress.com

• www.imi.american.edu

• California Tomorrow, Cultural Competency: What is it and Why it Matters, December, 2006.

• King, Mark A., Sims, Anthony, & Osher, David., How is Cultural Competence Integrated in Education?

• Cross, T., Bazron, B., Dennis, K., & Isaacs, M., Towards a culturally competent system of care: A monograph on effective services from minority children who are severely emotionally

disturbed: Volume I.: Georgetown University

Child Development Center, 1989.

• Goode, T.D., Jones, W., Dunne, C., & Bronheim, S. And the journey continues… Achieving cultural and

linguistic competence in systems serving children and

youth with special health care needs and their families.

National Center for Cultural Competence, Georgetown

University Center for Child and Human Development, 2007.

• California Tomorrow, Cultural Competency: What is it and Why it Matters, December, 2006.

• King, Mark A., Sims, Anthony, & Osher, David., How is Cultural Competence Integrated in Education?

• Cross, T., Bazron, B., Dennis, K., & Isaacs, M., Towards a culturally competent system of care: A monograph on effective services from minority children who are severely emotionally

disturbed: Volume I.: Georgetown University

Child Development Center, 1989.

• Goode, T.D., Jones, W., Dunne, C., & Bronheim, S. And the journey continues… Achieving cultural and

linguistic competence in systems serving children and

youth with special health care needs and their families.

National Center for Cultural Competence, Georgetown

University Center for Child and Human Development, 2007.

 BIOFEEDBACK AND
NEUROFEEDBACK:
THE FUTURE OF
I N T E G R AT I V E H E A LT H
AND PERFORMANCE

AAPB 49TH ANNUAL SCIENTIFIC MEETING

APRIL 11 – 14, 2018

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ORLANDO, FL
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mentoring also available. (APA CE’s*) www.@stresstherapysolutions.com
*on selected workshops only. 532-031 v2.2 3-14-18
 TABLE OF CONTENTS

Exhibit Hall and Registration Hours.................................... 9

Daily Program
Wednesday............................................................ 10
Thursday................................................................ 14
Friday..................................................................... 19
Saturday................................................................. 27
Posters ............................................................................... 35
Exhibitors............................................................................ 40
General Information........................................................... 51
2019 Save the Date! Denver, Colorado............................ 53
50th Anniversary

Welcome
Association for Applied Psychophysiology & Biofeedback
(AAPB), the pioneering professional society devoted to
education and research in this field, welcomes you to its
49th Annual Scientific Meeting.
The goal of this conference is to bring clinicians, physicians,
researchers and professionals involved with biofeedback and
applied psychophysiology together to exchange information,
ideas, scientific data and to share experiences. Biofeedback
is a process that enables an individual to learn how to change
physiological activity for the purposes of improving health and
performance. Precise instruments measure physiological activity
such as brainwaves, heart function, breathing, muscle activity
and skin temperature. These instruments rapidly and accurately
“feed back” information to the user. The presentation of this
information — often in conjunction with changes in thinking,
emotions and behavior — supports desired physiological
changes. Over time, these changes can endure without
continued use of an instrument. Hot topics in biofeedback
encompass HRV, Neurofeedback, Optimal Performance.
Our dynamic schedule of presenters and subject matter
categorization was designed with YOU — applied
psychophysiology and biofeedback professionals — in mind.
At the meeting, you will:
• Learn effective practices, practical ideas, and innovative
solutions in sessions covering hot topics, basic science,
clinical Interventions, interpersonal communications and
optimal performance
• Connect with vendor partners who offer a wealth of
information on new products, services and solutions for
your needs
• Engage with professionals who share common interests

1
 Annual Scientific Meeting
highlights include:

• 5 Keynote Sessions featuring WORLD renowned

scientists and practitioners:

J. David Creswell, PhD, Director of the

Health and Human Performance Laboratory,
Carnegie Mellon University, will present
a keynote lecture on Mindfulness
Interventions and Their Effects on the
Brain, Physiology and Health.

Rusty Shelton, Founder and CEO of

Shelton Interactive, will present a keynote
lecture on writing, publishing, and social
media for healthcare professionals.

Hasan Asif, MD, Founder and Medical

Director, Brain Wellness Center will deliver
a neurofeedback-focused presentation.

2018 Presidential Lecturer: Stuart

Donaldson, PhD, licensed psychologist
with areas of interest including pain, pain
management, psychophysiology, and
computers in psychology. Dr. Donaldson
will speak on the investigation and
biofeedback approach to concussions.

2018 Distinguished Scientist Lecturer:

Evgeny Vaschillo, PhD, Associate Research
Professor, Rutgers, will share his work on
Biofeedback, Baroreflex, and Cardiovascular
System Functioning.

• 29 Pre-conference Workshops on Wednesday, April 11

and Thursday, April 12
• Over 40 Breakout Sessions that include a variety of
panels, symposia and lectures
• Poster Abstract Viewing featuring a wealth of research
will be exhibited onsite
• Exhibit Hall and Networking Receptions to allow you to
meet and collaborate with those who share an interest
in biofeedback
• MAXIMUM 36 total program APA CE credits allows you
to get the lion’s share of required credits for licensures
and certifications
2
 CONFERENCE TRACKS and LEVELS

The meeting sessions are categorized into the following

TRACKS, to allow you to select those sessions that are
most relevant to you.

Basic Science (All Levels): Applied Psychophysiology and

Biofeedback are objective and evidence-based fields.
They are grounded in an understanding of several related
disciplines; neurophysiology, neuroanatomy, cognitive
psychology, neuropsychology, cardiovascular physiology,
respiratory physiology, public health and others. AAPB
supports and encourages research that contributes to the
development and growth of applied psychophysiology
and biofeedback and the program committee is seeking
quality research from any discipline linked to biofeedback
or applied psychophysiology. These sessions focus on
underlying mechanisms and may be experimental or
descriptive or literature reviews.

Clinical Interventions and Optimal Performance: Sessions

in this track target licensed clinicians working with patients
as well as performance trainers and educators working
with clients. These sessions provide evidence for successful
biofeedback training options. The presentations typically
involve patients wanting specific therapeutic treatments
and interventions to address clinically diagnosed problems
or, healthy clients wanting to improve overall functioning
seeking techniques and approaches to enhance optimal
performance.

Hot Topics: Presentations featured in this track are

focused on new ideas, technological advances, challenges
and new applications of psychophysiological science.
These sessions will provide a venue for more speculative
thinking as well as information on developments from
other disciplines that could impact the way we conduct
biofeedback. The emerging area of portable, miniaturized,
wearable or implantable sensors is one example of a
Hot Topic.

All session LEVELS are categorized as Introductory,

Intermediate, Advanced and All. Complete information,
including session descriptions, learning objectives,
presenter bios, associated risks, practice GAP correction
analysis and more are available online at www.aapb.org,
in full compliance with APA and AMA continuing education
requirements.

3
 ABOUT AAPB

The Association for Applied Psychophysiology and

Biofeedback (AAPB) was founded in 1969 as the
Biofeedback Research Society. The goals of the association
are to promote a new understanding of biofeedback and
advance the methods used in this practice. AAPB is a non-
profit organization as defined in Section 501(c)(6) of the
Internal Revenue Service Code.

Mission
AAPB promotes and represents the science and practice of
self-regulation to enhance health and performance

Vision
To integrate self-regulation into everyday life

Strategic Goals
• Public Awareness
• Standardization
• Membership Growth
• Innovation
Contact us at: info@aapb.org or 800.477.8892.

CONTINUING EDUCATION

Psychologists: AAPB is approved by the American

Psychological Association (APA) to offer continuing
education for psychologists. AAPB maintains responsibility
for this program and its content. The AAPB 49th Annual
Scientific Meeting offers a MAXIMUM of 36 hours.
BCIA Recertification: Hour-for-hour attendance in breakout
sessions and workshops may be used to fulfill the continuing
education requirement for recertification with the certificate
of attendance.

Physicians Accreditation Statement: In support of

improving patient care, this activity has been planned and
implemented by Amedco and the Association for Applied
Psychophysiology & Biofeedback. Amedco is jointly
accredited by the American Council for Continuing Medical
Education (ACCME), the Accreditation Council for Pharmacy
Education (ACPE), and the American Nurses Credentialing
Center (ANCC), to provide continuing education for the
healthcare team.

Credit Designation Statement - Amedco designates this

live activity for a maximum of 36.50 AMA PRA Category
1 CreditsTM. Physicians should claim only the credit
commensurate with the extent of their participation in
the activity.

4
 A Sincere Thank You to Our 2018 Sponsors
Platinum Sponsor
Name Badge Lanyards and Cyber Cafe brought to you by
Bio-Medical Instruments Inc. – www.bio-medical.com
Gold Sponsor
Welcome Bags brought to you by NeuroField, Inc. –
www.Neurofield.com
Silver Sponsor
Thought Technology – www.thoughttechnology.com
Bronze Sponsor
Notebooks brought to you by Mynd Lift – www.myndlift.com

AAPB 2018 AWARDS

AND RECOGNITION:
DISTINGUISHED SCIENTIST AWARD

Congratulations to:
Evgeny Vaschillo, PhD
Associate Research Professor, Rutgers

The AAPB Distinguished Scientist Award is presented

annually “in recognition of an outstanding career and scientific
contribution to the field of applied psychophysiology and
biofeedback.” This award recognizes a scientist who has
advanced Biofeedback through a significant body of research
conducted, as judged by publications, awards and peer
reviews, and has made a major impact upon the field of study,
both nationally and/or internationally. Nominees must hold a
doctoral degree in a psychology, biomedical science, medicine,
or other health-related field. Recipients are selected based on
the following evaluation criteria:
• Scientific importance of research discoveries
• Mentorship of students, postdoctoral fellows, and
new faculty
• Continued impact on the field
The Distinguished Scientist Award winner will present at
the 2018 Annual Scientific Meeting on Saturday, April
14 at 5:15 pm - 6:30 pm. Be sure to support Dr. Vaschillo
in this monumental achievement by attending his
special presentation:
Biofeedback, Baroreflex,
and Cardiovascular System Functioning
5
ABOUT OUR RECIPIENT:
In 1998, Dr. Vaschillo graduated from the Saint Petersburg
State University of Aerospace Instrumentation (Russia) with
a master’s degree in electromechanical engineering. Right
after graduating, he worked at the companies supporting
the Russian space program, where he studied heart rate
variability (HRV) and effects of rhythmical stimulation of the
cardiovascular system by breathing, muscle tension, and
emotion. His work particularly emphasized the baroreflex
and the possibilities of applying resonance frequency
HRV biofeedback to train Russian cosmonauts to function
better in space. After getting his PhD in human and
animal physiology at the Scientific Research Institute for
Experimental Medicine (in1983), he worked on developing
physiological methods to evaluate and control functional
states of the ‘human-operator’ in extreme environmental
conditions, with applications to cosmonaut crews,
submarine crews, and athletic teams. Later, these techniques
were expanded to treat patients with asthma and various
neuroses as well as to sport performance. In 1998 he
came to United States and has continued studying the
cardiovascular system and the baroreflex using biofeedback.
Dr. Vaschillo joins the following group of distinguished
individuals. Past awardees include:
1995 - Neal Miller, PhD
1996 - Niels Birbaumer, PhD
1997 - John Basmajian, MD
1998 - Edward Taub, PhD
1999 - Johann Stoyva, PhD and Tom Budzynski, PhD
2000 - Angele McGrady, PhD
2001 - Bernard T. Engel, PhD
2002 - Frank Andrasik, PhD
2003 - Edward Blanchard, PhD
2004 - M. Barry Sterman, PhD
2005 - Paul Lehrer, PhD
2006 - Joel Lubar, PhD
2007 - Susan Middaugh, PhD
2008 - Richard Gevirtz, PhD
2009 - John Arena, PhD
2010 - Alan Glaros, PhD
2011 - Steven Wolf, PhD, PTA, PT
2012 - Julian F. Thayer, PhD
2013 - Erik Peper, PhD
2014 - Steven Baskin, PhD
2015 - Estate Sokhadze, PhD
2016 - Michael Thompson, MD; Lynda Thompson, PhD
2017 - Ute Strehl, PhD
Federation of Associations in Behavioral and Brain
Sciences (FABBS) Early Career Impact Award
Genomary Krigbaum, PsyD, BCB, LP
Lifetime Achievement Award
Gabriel Sella, MD
Student Advocate Award
Jay Gunkelman, QEEG-D
6
 2018 FERB Student Travel Scholarship Recipients
Allison Beachum East Carolina University
Ashlie Bell Saybrook University
Joseph Berlinger Truman State University
Sarah-Nicole Bostan Alliant International University S.D.
Ahalee Cathey Texas Tech University
Alejandro Heredia Cedillo San Francisco State University
Sommer Christie University of Calgary
Aaron Craven East Carolina University
Genesis Crus-Molina East Carolina University
Catherine Darling Kent State University
Jana Downum Saybrook State University
Amy Fahrenkamp Kent State University
Lucia Foster-Engen Alliant International University S.D.
Nicholas Gravett Truman State University
Cody Gustaveson Alliant International University S.D.
Hillary Hedgecock Truman State University
Kelsey James Texas Tech University
Karissa Logan Bastyr University
Rahel Katz Bosten College
Karenjot Kaur Yeshiva University
Tacy Rae LeBaron East Carolina University
John Locke East Carolina University
Lauren Mason San Francisco State University
Alexis Maxwell East Carolina University
Nicholas McCann Truman State University
Daniel Owen Truman State University
Yuri Pavlov University of Tubingen
Jacqueline Pecoraro Truman State University
Brian Rankin Alliant International University S.D.
Joe Riddle East Carolina University
Bo Robertson Alliant International University S.D.
Andrew Smith Truman State University
Lena Stampfli San Francisco State University
Atticus Toriello East Carolina University
Carolyn Trasko Saybrook University
Hannah Urban Truman State University
Mark Versella Rutgers University
Elizabeth Villagomez San Francisco State University
Zachary White Truman State University
Zhenyu Zhang Boston University

2018 BCIA Francine Butler Scholarship Recipients

Jessica Ledwith, nominated by Chris Branciere, BCB,

University of North Florida

Brian Rankin and Roya Iravani, nominated by Richard

Gevirtz, PhD, BCB, of Alliant University

Cosima Hoetger, nominated by Carol Austad, PhD, BCB

of Central Connecticut State University

7
 2018 Annual Scientific Meeting Program
Planning Committee

This meeting would not be possible without the dedication,

passion and ongoing efforts of the following individuals:

Inna Khazan, PhD

Committee Co-Chair
Clinical Psychologist
Harvard Medical School

Urszula Klich, PhD

Committee Co-Chair
Clinical Psychologist
My Mindful Way of Life, LLC

Jay Gunkelman, QEEG-D

Chief Scientific Officer
Brain Science International

Rick Harvey, PhD

Associate Professor
San Francisco State University

Brad S. Lichtenstein, ND
Naturopathic Physician
Bastyr University/The Breath SPACE

Heather Poupore-King, PhD

Clinical Assistant Professor
Stanford University

Christine Sanchez, PhD, CC-AASP

Mental Performance Specialist
Quarterline

Gabriel Sella, MD, MPH, MSC, PHD

AAPB President
G.E. Sella MD, Inc.

Join AAPB Today!

aapb.org
800-477-8892

8
 Exhibit Hall and Registration Hours:

Exhibit Hours

Thursday, April 12, 2018
Exhibitor Set-up 8:00am – 12:00pm
Exhibit Hall Open 2:00pm – 7:45pm
Opening Reception in Exhibit Hall
7:45pm – 9:30pm
(optional)

Friday, April 13, 2018

Exhibit Hall Open 7:00am – 7:00pm

Saturday, April 14, 2018

Exhibit Hall Open 7:00am – 1:00pm
Exhibitor Teardown 1:00pm – 4:00pm

Registration Hours

Tuesday, April 10 5:00pm to 7:00pm

Wednesday, April 11 7:00am to 7:00pm
Thursday, April 12 7:00am to 7:00pm
Friday, April 13 7:00am to 7:00pm
Saturday, April 14 7:00am to 6:30pm

Be sure to visit
the exhibitors in
Grand Sierra Ballroom - E
A wealth of knowledge awaits….

9
 DAILY PROGRAM:
Tuesday, April 10
_________________________________________
Registration Open
Grand Sierra Foyer North
5:00pm - 7:00pm

Wednesday, April 11
_________________________________________
Registration Open
Grand Sierra Foyer North
7:00am - 7:00pm
Pre-Conference Workshop Attendee ONLY
Continental Breakfast
Curacao Foyer
7:00am - 8:00am

Pre–Conference Workshops (Admission to pre-

conference workshops are by ticket only. Tickets may
be purchased at the registration counter)

FULL DAY WORKSHOPS

Beginning at 8:00am — all full-day sessions will be
concluded by 5pm or 5:30pm

Time: 8:00am-5:00pm
Room: Curacao 3
WS01: Advanced Infraslow Neurofeedback Workshop:
ISF-sLORETA - Part 1
Presenters: Mark Smith, LCSW
Level: Advanced
Track: Hot Topics
Focus: Clinical and Research
Target Audience: Those who have attended a beginner ISF
workshop and are interested in advanced applications of
Infraslow Neurofeedback Training.
CE credits: 7

Time: 8:00am-5:00pm
Room: Curacao 4
WS02: Adding Neurotherapy to Your Practice:
The CLINICALQ and BRAINDRIVING
Presenters: Paul G. Swingle, PhD
Level: Introductory
Track: Basic Science (All Levels)
Focus: Clinical
Target Audience: Healthcare providers
CE credits: 7

Tuesday/Wednesday 10
Time: 8:00am-5:30pm
Room: Curacao 5
WS03: BCIA Heart Rate Variability Biofeedback
Certificate of Completion Workshop - Part 1**
Presenters: Fredric Shaffer, PhD, BCB; Donald Moss, PhD,
BCB, BCN
Level: Introductory
Track: Clinical Interventions and Optimal Performance
Focus: Clinical and Research
Target Audience: Biofeedback/neurofeedback practitioners,
psychologists, clinical counselors, clinical social workers,
marriage and family therapists, nurses, physicians, and
other healthcare professionals and academicians interested
in utilizing heart rate variability (HRV) biofeedback in their
practice or research.
CE credits: 7.5
** This full-day workshop fulfills 7.5 hours of BCIA’s
Certificate of Completion in Heart Rate Variability (HRV)
Biofeedback didactic blueprint and provides a practical
introduction to this exciting modality.

Time: 8:00am-5:00pm
Room: Curacao 6
WS04: NeuroField pEMF, tACS, tDCS, tRNS and EEG
Neurotherapy — Part 1
Presenters: Nicholas Dogris, PhD, BCN, QEEG-D; Tiff
Thompson, PhD, MFT,BCN,QEEGD,REEGT
Level: Intermediate, Advanced
Track: Clinical Interventions and Optimal Performance,
Hot Topics
Focus: Clinical
Target Audience: Neurotherapy professionals who are
Interested in learning how to improve operant conditioning
procedures and methodology in their clinical practice.
Also, professionals who wish to learn more about
neuromodulation and neurostimulation technology.
CE credits: 7

Time: 8:00am-5:00pm
Room: Curacao 7
WS05: Practical Applications of Mindfulness, Acceptance,
and Compassion for Biofeedback Practitioners
Presenters: Inna Khazan, PhD, BCB; Urszula Klich, PhD, BCB
Level: Intermediate
Track: Clinical Interventions and Optimal Performance
Focus: Clinical
Target Audience: anyone interested in learning more about
integrating mindfulness and biofeedback together
CE credits: 7

11 Wednesday
 HALF - DAY WORKSHOPS (AM)
Time: 8:00am-12:00pm
Room: Curacao 8
WS07: Understanding Breath - Teaching Breathwork
without Equipment
Presenters: Brad S. Lichtenstein, ND, BCB
Level: Introductory
Track: Basic Science (All Levels)
Focus: Clinical
Target Audience: Anyone interested in the anatomy and
physiology of breathing, how posture, movement and
exercises can improve breathing, or those who teach
respiration or HRV biofeedback
CE credits: 4

12:00pm-1:00pm
Lunch Break – ON YOUR OWN

HALF - DAY WORKSHOPS ( AFTERNOON)

Time: 1:00pm - 5:00pm
Room: Curacao 8
WS08: BCIA Neurofeedback Review
Presenters: Lynda Thompson, PhD; Michael Thompson, MD, BSc,
D.Psych, CRPC
Level: Intermediate-Advanced
Track: Basic Science
Focus: Clinical
CE credits: 4

Time: 1:00pm - 5:00pm

Room: Bonaire 6
WS10: New Advances in Electrical NeuroImaging: Linking
Symptoms to the Patient’s Brain
Presenters: Robert Thatcher, PhD
Level: Intermediate
Track: Basic Science (All Levels)
Focus: Clinical
Target Audience: Students and professionals
CE credits: 4

HALF - DAY WORKSHOPS (EVENING)

Time: 5:30pm to 9:30pm
Room: Curacao 3
WS11: Stand Tall, Don’t Slouch: How Posture Feedback
and the Alexander Technique Can Improve Health
Presenters: Erik Peper, PhD; Tami Bulmash, STAT and AmSAT
Certified Alexander Technique Teacher

Wednesday 12
Level: Intermediate
Track: Hot Topics
Focus: Clinical
Target Audience: Healthcare professionals, educators,
clients
CE credits: 4

Time: 5:30pm to 9:30pm

Room: Curacao 4
WS12: QEEG Guided Assessment and Neurofeedback for
ADD and Autistic Spectrum Disorder
Presenters: Michael K Linden, PhD
Level: Introductory
Track: Basic Science (All Levels)
Focus: Clinical and Research
Target Audience: Psychologists/neuropsychologists,
physicians, therapists, physicians/neurologists, nurses,
educators, biofeedback/neurofeedback clinicians, students,
researchers.
CE credits: 4

Time: 5:30pm to 9:30pm

Room: Bonaire 5
WS14: Pediatric Biofeedback: An Exciting and
Rewarding Challenge!
Presenters: Paula Grayson, RN, MA, BCB; Madonna Ozman,
RN, MA, BCB
Level: Intermediate
Track: Clinical Interventions and Optimal Performance
Focus: Clinical
Target Audience: Biofeedback practitioners who wish to
incorporate children and adolescents into their practice or
those who already work with these groups but want improve
their skills in dealing with the pediatric population.
CE credits: 4

Thursday, April 12
_________________________________________
Registration Open
Grand Sierra Foyer North
7:00am - 7:00pm

Pre-Conference Workshop Attendee ONLY Continental

Breakfast
Curacao Foyer
7:00am - 8:00am

Exhibitor Move-In
Grand Sierra Ballroom – E
6am-12pm

13 Wednesday/Thursday
 Pre–Conference Workshops (Admission to pre-
conference workshops are by ticket only. Tickets may
be purchased at the registration counter.)

FULL DAY WORKSHOPS

Time: 8:00am-5:00pm
Room: Curacao 1
WS15: Advanced Infraslow Neurofeedback Workshop:
ISF-sLORETA - Part 2
Presenters: Mark Smith, MSW
Level: Advanced
Track: Hot Topics
Focus: Clinical and Research
Target Audience: Those who have attended a beginner ISF
workshop and are interested in advanced applications of
Infraslow Neurofeedback Training.
CE credits: 7

Time: 8:00am-5:00pm
Room: Curacao 3
WS16: Stimulation Technologies: Audio-visual
Entrainment, Cranio-electro Stimulation and transcranial
DC Stimulation – Physiology and Clinical Outcomes
Presenters: Dave Siever, CET
Level: Intermediate
Track: Clinical Interventions and Optimal Performance
Focus: Clinical and Research
Target Audience: This course is particularly of benefit to
those who have been practicing with a clinical population
for some time and realize the need for learning about EEG
& qEEG and have some more innovative tools in their
tool chest. This applies to nurses, MDs, hypno-therapists,
biofeedback and neurofeedback practitioners.
CE credits: 7

Time: 8:00am-5:00pm
Room: Curacao 5
WS18: NeuroField pEMF, tACS, tDCS, tRNS and EEG
Neurotherapy - Part 2
Presenters: Nicholas Dogris, PhD, BCN, QEEG-D; PhD, BCN,
QEEG-D; Tiff Thompson, PhD, MFT,BCN,QEEGD,REEGT
Level: Intermediate, Advanced
Track: Clinical Interventions and Optimal Performance,
Hot Topics
Focus: Clinical
Target Audience: Neurotherapy professionals who are
Interested in learning how to improve operant conditioning
procedures and methodology in their clinical practice.

Thursday 14
Also, professionals who wish to learn more about
neuromodulation and neurostimulation technology.
CE credits: 7

Time: 8:00am-5:30pm
Room: Curacao 6
WS19: Heart Rate Variability Biofeedback (HRVB):
How to Do It, Why It Works, and for What - Part 2**
Presenters: Richard Gevirtz, PhD; Paul Lehrer, PhD
Level: Intermediate
Track: Clinical Interventions and Optimal Performance
Focus: Clinical
Target Audience: Any one with biofeedback experience
interested in deepening their understanding of HRV
biofeedback
CE credits: 7.5
** This full-day workshop fulfills 7.5 hours of BCIA’s
Certificate of Completion in Heart Rate Variability (HRV)
Biofeedback didactic blueprint and provides a practical
introduction to this exciting modality.

Time: 8:00am-5:00pm
Room: Curacao 7
WS20: Brain-computer Interfaces for Assessment,
Communication and Rehabilitation
Presenters: Christoph Guger, PhD
Level: Intermediate
Track: Hot Topics
Focus: Research
Target Audience: Neurologists, physio-therapists,
occupational-therapists, researchers, BCI developers
CE credits: 4
FREE TO ATTENDEES

HALF - DAY WORKSHOPS (AM)

Time: 8:00am-12:00pm
Room: Bonaire 5
WS21: Social Media Bootcamp: How to Use Social Media
To Get Meaningful Results
Presenters: Rusty Shelton
Level: All
Track: Hot Topics
Focus: Marketing
Target Audience: All
CE credits: 4

Time: 8:00am-12:00pm
Room: Bonaire 6
WS22: BCIA Biofeedback Certification Exam Review

15 Thursday
Presenters: Fredric Shaffer, PhD, BCB; Donald Moss, PhD, BCB,
BCN; Patrick Steffen, PhD, BCB; Inna Khazan, PhD, BCB; Judy
Crawford, BCIA Executive Director
Level: Introductory
Track: Basic Science (All Levels)
Focus: Clinical and Research
Target Audience: Professionals who want to add
biofeedback to their practice, preparing for the BCIA
Biofeedback certification exam, or who want a
comprehensive review of their knowledge.
CE credits: 4

Time: 8:00am-12:00pm
Room: Antigua 1
WS23: Biofeedback, Virtual Reality and Other Techniques
Used to Facilitate the Suppression of Anxiety
Presenters: Robert Reiner, PhD, BCB, BCN;
Heather Davidson, PsyD
Level: Intermediate
Track: Hot Topics / Clinical Interventions and Optimal
Performance
Focus: Clinical
Target Audience: Mental health professionals and students
interested in learning about cutting age technologies.
CE credits: 4

12:00pm-1:00pm
Lunch Break – ON YOUR OWN

HALF - DAY WORKSHOPS ( AFTERNOON)

Time: 1:00pm to 5:00pm

Room: Bonaire 5
WS24: Stress – Less Effective Assessment & Intervention
Based on Understanding Neurophysiology
Presenters: Lynda Thompson, PhD; Michael Thompson, MD, B.Sc.,
D.Psych, CRPC
Level: Intermediate
Track: Clinical Interventions and Optimal Performance
Focus: Clinical
Target Audience: Health Professionals including but not
limited to: Medical Doctors, Psychologists, and other
professionals and students in the health professions.
CE credits: 4

Time: 1:00pm to 5:00pm

Room: Bonaire 6
WS25: Write Easier, Faster, Better: Techniques to Tame
Your Text!
Presenters: Susan E. Aiello, BS, DVM

Thursday 16
Level: Intermediate
Track: Hot Topics
Target Audience: Clinicians and researchers who wish to
improve their writing skills
CE credits: 4

Time: 1:00pm to 5:00pm

Room: Antigua 1
WS26: Quantitative EEG Guided TMS Pulse Placement
and Combined Use of Neurofeedback
Presenters: Hasan Asif, MD; Aza Mantashashvili, MD
Level: Intermediate
Track: Clinical Interventions and Optimal Performance
Focus: Clinical
Target Audience: Psychiatrist. Neurofeedback therapist,
biofeedback practitioners, Therapist interested in
neurobiology of psychotherapeutic process
CE credits: 4

17 Thursday
 CONFERENCE Kick off
Exhibits Open
Grand Sierra Ballroom – E
2pm-6:30pm
During the Annual Meeting, be sure to visit the Expo Hall
for the latest information on the equipment, products and
services you need to practice biofeedback more effectively
and efficiently. Don’t miss this opportunity to speak one-
on-one with representatives from those organizations that
support the field and AAPB.

Time: 5:30pm-6:30pm
Room: Bonaire 1
Optimal Performance Sections Meeting
Presenter: Vietta Sue Wilson, PhD, on integrated mental training
Current members of the Optimal Performance Section as
well as prospective members, who are interested in joining
the Section, are invited to attend.
CE credits: 0

KEYNOTE PRESENTATION
Time: 6:30pm-7:45pm
Room: Grand Sierra Ballroom – F-I
KEY1: Mindfulness Interventions and Their Effects on
the Brain, Physiology and Health
Presenters: J. David Creswell, PhD, Director of the Health and
Human Performance Laboratory, Carnegie Mellon University
Level: Intermediate
Track: Hot Topics
CE Credits: 1

Over the last two decades there has been

significant interest in mindfulness training
interventions for health. But little is known about
how these interventions, which train a mindset of
being open and receptive to present moment experience,
might affect health over time. In this talk, Dr. Creswell will
describe current mindfulness intervention approaches, and
a series of studies he has conducted that depict potential
brain and physiological stress reduction pathways linking
these interventions with a broad range of health outcomes.
Dr. Creswell’s will share the science and application of
this affordable, evidence-based approach for fostering
stress resilience.

About Dr. Creswell:

J. David Creswell is an Associate Professor in Psychology and the
Neural Basis of Cognition at Carnegie Mellon University. His work
focuses on understanding what makes people resilient under stress, and
includes work on mindfulness and self-affirmation processes. David
received the American Psychological Association and the American

Thursday 18
Psychosomatic Society Early Career Awards, and was named a Rising
Star by the Association for Psychological Science. His work has been
profiled by a broad range of media outlets, including the New York
Times, LA Times, and the Today Show.

Time: 7:45pm to 9:30pm

Welcome Reception in Exhibit Hall
Grand Sierra Ballroom – E
We are glad you are in Orlando with us! Join us for networking,
hors d’ouevers, cash bar and networking in the Exhibit Hall

Friday, April 13
_________________________________________
Time: 6am-7am
Room: Boca Patio
YOGA/Meditation

Time: 7am-8am
Room: Grand Sierra Ballroom – E
Continental Breakfast in Expo Hall

Time: 7am-7pm
Room: Grand Sierra Ballroom – E
Exhibits Open

Time: 7am-7pm
Room: Grand Sierra Foyer North
Registration

Time: 7am-8am
Room: Curacao 1
Springer Breakfast Meeting - Editorial Board
(BY INVITATION ONLY)

CONCURRENT and GENERAL SESSIONS

Time: 8am-9am
Room: Curacao 2
EXHIBITOR DEMO: CNS VITAL SIGNS EXD1
CE credits: 0
Welcome to the CNS Vital Signs exhibitor demonstration.
In this brief showcase learn about CNS Vital Signs rapid
computerized cognitive testing assessment platform. Watch a
brief demonstration, view some real world case studies. View
firsthand our extensive best practices experience and you’ll
recognize why CNS Vital Signs is a widely utilized customizable
and economical tool set used in Biofeedback, Neurofeedback
Training and in other clinical settings all over the world. CNS
Vital Signs www.cnsvs.com provides a scientifically valid way
to initially assess and then longitudinally follow your patient’s
outcomes over time. Immediately after each assessment is

19 Thursday/Friday
administered an easily interpreted patient report is produced
that auto-scores a subjects test results. Tests are normed ages
8-89, results measure 11 Cognitive domains in areas such as
MEMORY, EXECUTIVE FUNCTION, ATTENTION, COGNITIVE
FLEXIBILITY and REACTION TIME. During the show case we
will show you how to download our free testing software,
schedule a free personalized one on one training webinar
and receive 15 free no cost assessment sessions for a risk
free evaluation. To learn more attend our workshop demo or
call toll free (888)750-6941, email support@cnsvs.com or begin
your free trial by registering at www.cnsvs.com. Representing
CNS Vital Signs is Cary Rogers Vice President of Sales and
Practice Development.

Time: 8am-9am
Room: Curacao 3
ORAL1: HRV Oral Presentations
Presenters: Carmen Russsoniello, PhD, LPC, BCB, BCN; George
T. Stegeman, PhD; Christina Brown-Bochicchio, MS, LRT; Matthew
Fish, PhD; Jenny Marks, RN, PHN, MPH, BSN; Linda P. Bolin,
PhD, RN, ANP; Carolyn Horne, PhD, RN; Allison Bradley, BS,
CTRS; Allison Beachum, BS Biology Expected May, 2019; Aaron
Craven, LRT/CTRS; Henry J. Svec, PhD, MEd, BEd, BA
Level: All Levels
Track: Hot Topics
Focus: Clinical and Research
CE credits: 1

Time: 8am-9am
Room: Curacao 4
BOS01: The Current State of Biofeedback in Children
Presenters: Ethan Benore, PhD, BCB, ABPP; Erin Brann, PhD;
Amy Fahre, MS; Katy Darling, MS
Level: Introductory
Track: Clinical Interventions and Optimal Performance
Focus: Clinical
CE credits: 1

Time: 8am-9am
Room: Curacao 5
BOS02: Current and Future Applications of Brain-
Computer Interfaces
Presenters: Christoph Guger, PhD
Level: Advanced
Track: Hot Topics
Focus: Clinical and Research
CE credits: 1

Time: 8am-9am
Room: Curacao 6
BOS03: Presidential Symposium on the Clinical Efficacy
of Biofeedback and Neurofeedback.
Presenters: Paul Lehrer, PhD; Khushbu Shah; Karenjot Kaur,
PhD Clinical Psychology (Health Emphasis) candidate at Yeshiva
Friday 20
University; Tara Austin, BA and Master of Music; Mark V. Versella, Jr.;
Ashlie Bell, PhD(c), LCSW, BCN; Carolyn Trasko, PhD(c), LCSW
Level: Introductory
Track: Clinical Interventions and Optimal Performance
Focus: Clinical
CE credits: 1

Presidential Lecture
Time: 9:15am-10:30am
Room: Grand Sierra Ballroom – F-I
KEY02: Longitudinal Measurement of the Frequency and
Intensity of Concussions in Junior Hockey Players Utilizing
the QEEG
Presenter: Stuart Donaldson, PhD, BCN
Level: Advanced
Track: Hot Topics
Target Audience: All
CE Credits: 1

Utilizing the QEEG, particularly the MTBI

probability index, and the severity index,
72 junior A hockey players were studied over
a period of two years. Data will be examined
on the consistency and reliability of the MTBI and
severity measures. The location of the concussed sites
(International 10/20 system) will be reviewed with a tentative
hypothesis proposed explaining the complex nature of
this phenomenon.

About Dr. Donaldson

Dr. Stu Donaldson is a licensed psychologist in the Province of Alberta
and graduated from the University of Calgary in 1989 with a PhD
in Clinical Psychology with areas of interest including pain, pain
management, psychophysiology, and computers in psychology. Since
then he has completed numerous workshops and seminars receiving
his Senior Fellowship in Biofeedback. He is listed with the Canadian
Register of Health Service Providers in Psychology, and is a Diplomate
with the American Board of Psychological Specialties - Rehabilitation
Psychology; Diplomate - American Board of Forensic Examiners,
and Diplomate & Senior Disability Analyst - American Board
of Disability Analysts. He has lectured around the world and has
published 40 papers in journals on topics ranging from myofascial
pain syndrome, to fibromyalgia, and concussions in sports. He is the
past President of the Association of Applied Psychophysiology and
Biofeedback and Awarded Life Membership Psychologist’s Association
of Alberta in 2012.

Time: 10:30am to 11am

Room: Grand Sierra Ballroom – E
Break (Refreshments)

Time: 11am-12:30pm
Room: Curacao 7

21 Friday
BOS37: Biofeedback, Virtual Reality and Other
Techniques Used to Facilitate the Suppression of Anxiety
Presenters: Robert Reiner, PhD, BCB, BCN; Heather Davidson, PsyD
Level: Intermediate
Track: Hot Topics / Clinical Interventions and Optimal
Performance
Focus: Clinical

Time: 11am-12:30pm
Room: Curacao 8
BOS04: Writing Without Fear
Presenters: Susan E. Aiello, BS, DVM
Level: Intermediate
Track: Hot Topics
Focus: Clinical and Research
CE credits: 1.5

Time: 11am-12:30pm
Room: Curacao 1
BOS05: Using ISF to Maximize Rehabilitation Success in
Soldiers Presenting with PTSD
Presenters: Mark Smith, MSW; Sharie Woelke, BMR
Level: Introductory
Track: Hot Topics
Focus:
CE credits: 1.5

Time: 11am-12:30pm
Room: Curacao 2
BOS06: Psychophysiological and psychometric
assessment before, during and after intensive leadership
development
Presenters: Wesley E. Sime, PhD, MPH; Al Ringleb, PhD
Level: Intermediate
Track: Clinical Interventions and Optimal Performance
Focus:
CE credits: 1.5

Time: 11am-12:30pm
Room: Curacao 3
BOS07: Concussion Panel Discussion
Presenters: J. Lucas Koberda, MD, PhD; Michael K Linden, PhD,
Psychology; Leah Lagos, PsyD; Randy Benson, MD
Level: Introductory
Track: Hot Topics
Focus: BOS07
CE credits: 1.5

Time: 12:30pm-1:30pm
Room: Curacao 4
EXHIBITOR DEMONSTRATION:
THOUGHT THECHNOLOGY
Say farewell to the legacy Physiology and EEG Suites, as
Thought Technology revs up to unlock human potential with
Friday 22
BioGraph’s new multi-application software package. Want
to see what the future has in store? Join us to see how you
could be assessing, self-regulating, and cross-integrating the
respiratory, cardiovascular, autonomic, central, and muscular
nervous systems.
CE Credits: 0

Time: 12:30pm-2:00pm
Room: On Your Own
Lunch Break

SECTION MEETING
TIME: 12:45pm-1:45pm
ROOM: Curacao 7
International Stress Management Association (ISMA)
Section Meeting Lunch and Presentation: CURRENT
RESEARCH AND FUTURE DIRECTIONS
Presenters: Patrick Steffen, PhD, Paul Lehrer, PhD, Jan B
Newman, MD, FACS
**All Welcome
Lunch Provided for $10 fee - payable onsite.
CE credits: 0

SPECIAL SESSION/Lunch & Learn

Time: 12:45pm-1:45pm
Room: Curacao 5
LL1: Lessons Learned from Elmer Green’s Life and Work
Presenters: Adrian Van Deusen
Level: Introductory
Track: Hot Topics
Focus: Research

Time: 2pm-3:30pm
ROOM: Curacao 8
BOS08: Research and Clinical Aspects of Autonomic
Self-Regulation for Sensitized Pain
Presenter: JP ( Jack) Ginsberg, PhD
Level: Intermediate
Track: Clinical Interventions and Optimal Performance
Focus: Clinical and Research
CP credits: 1.5

NOTE: SPECIAL TIME! Time: 1:30pm-3:30pm

Room: Curacao 1
BOS09: Functional Neuroanatomy – Key Brodmann
Areas, Commissures, Fasciculi, and Networks.
Presenters: Lynda Thompson, PhD; Michael Thompson, MD, BSc,
DPsych, CRPC
Level: Intermediate
Track: Basic Science (All Levels)
Focus: Clinical and Research
CE credits: 2

23 Friday
Time: 2pm-2:30pm
Room: Curacao 6
BCIACERT: BCIA Certification 101
Presenters: Judy Crawford, Executive Director, Biofeedback
Certification International Alliance (BCIA)
Target Audience: If you have ever wondered about
becoming a BCIA certified practitioner in Biofeedback,
Neurofeedback, or Pelvic Muscle Dysfunction Biofeedback,
this informal discussion will lead you through the process
and requirements and answer any questions you may have.
CE Credits: 0

Time: 2pm-3:30pm
Room: Curacao 4
BOS10: Applied Psycho-Physiology in Sport Performance:
Bridging the Gap Between Research and the Real World.
Presenters: Harry van der Lei; Richard Gevirtz, PhD; Leah Lagos,
PsyD; Domagoj Laustic, PhD, AASP-CMPC, PTR, USPTA;
Wes Sime, PhD, MPH
Level: Intermediate
Track: Hot Topics
Focus: Research
CE credits: 1.5

Time: 2pm-3:30pm
Room: Curacao 3
BOS11: Expect the Unexpected
Presenters: Jay Gunkelman, QEEG-D
Level: Introductory
Track: Clinical Interventions and Optimal Performance
Focus: Clinical
CE credits: 1.5

Time: 2pm-3:30pm
Room: Curacao 2
BOS12: An Integrative Model and Clinical Approach to
Frontal Brain Activation in Emotion and Behavior
Presenters: Thomas Collura, PhD, MSMHC; Ronald Bonnstetter,
PhD; Nancy Wigton, PhD
Level: Intermediate
Track: Hot Topics
Focus: Clinical and Research
CE credits: 1.5

Time: 2:35pm-3:05 pm
Room: Curacao 6
BCIARECERT: BCIA Recertification 101
Presenters: Judy Crawford, Executive Director, Biofeedback
Certification International Alliance
Target Audience: Those considering recertification will
be led through an informal discussion on the process and
requirements.
CE Credits: 0

Friday 24
Time: 3:30pm-4pm
Room: Grand Sierra Ballroom – E
Break (Refreshments)

Time: 4pm-5pm
Room: Curacao 5
BOS13: Drug Exposure in Utero: Clinical Definition,
Characteristics and Symptoms, Neurophysiology, and
Effects Across Developmental Domains
Presenters: Rex Cannon, Phd
Level: Advanced
Track: Basic Science (All Levels)
Focus: Clinical and Research
CE credits: 1

Time: 4pm-5pm
Room: Curacao 7
BOS15: Cultivating Gratitude, Compassion, Courage,
and Resilience with HRV Biofeedback and Mindfulness
Presenters: Inna Khazan, PhD, BCB; Leah Lagos, PsyD
Level: Introductory
Track: Hot Topics
Focus: Clinical
CE credits: 1

Time: 4pm-5pm
Room: Curacao 8
BOS16: Placebo Concepts in Biofeedback Practice
Presenters: Richard Harvey, PhD
Level: Introductory
Track: Basic Science (All Levels)
Focus: Clinical and Research
CE credits: 1

Time: 4pm-7pm
Room: Curacao 2
BCIAEX: BCIA Certification Exam
This 3-hour time slot is reserved for all pre-approved
candidates wishing to sit for their certification exams in
biofeedback, neurofeedback or pelvic muscle dysfunction.
Please be sure that you have filed your application, had it
approved, and have submitted your exam registration form
at least 2 weeks prior to the exam. Please contact info@
bcia.org for more information or to check on your status.

Time: 5pm to 6pm

Room: Curacao 3
AAPB Board Meeting
By invitation only

Time: 5:05pm-6:05 pm
Room: Curacao 4
BOS17: Fix Your Business, Fix Your Patients

25 Friday
Presenters: Seth Conger, BCN-t
Level: Intermediate
Track: Hot Topics
Focus: Clinical
CE credits: 1

Time: 5:05pm-6:05pm
Room: Curacao 5
BOS18: Personalized EEG-Neurofeedback as a Treatment
for ADHD
Presenters: Caroline Dupont, BSc; Andrea Szabo, PhD, BCN;
Helene Briseboi, PhD, BCN; Brendan Parsons, MA, BCN
Level: Intermediate
Track: Hot Topics
Focus: Clinical and Research
CE credits: 1

Time: 5:05pm-6:05pm
Room: Curacao 7
BOS20: Stress Where Are We Now: Physiology,
Manifestations and Management
Presenters: Jan Newman, MD, MA, FACS, ABIHM
Level: Intermediate
Track: Hot Topics
Focus: Clinical
CE credits: 1

KEYNOTE PRESENTATION:
Time: 6:15-7:30pm
Room: Grand Sierra Ballroom – F-I
KEY03: Mastering the New Media Landscape: 10 Steps
to Building Your Platform
Presenters: Rusty Shelton, Author and CEO of Zilken Media,
University of Texas
Level: Intermediate
Track: Hot Topics
Target Audience: All
CE Credits: 1

The media landscape has changed dramatically

over the past few years with the growth of
social media, which is impacting patients and
healthcare professionals alike. This presentation
focuses on how healthcare leaders can tap into the power
of social media and platform development to positively
impact lives and achieve personal and professional goals.
It will introduce the audience to trends currently dominating
the social media landscape and will look at how healthcare
professionals can harness the growing power of social
media and platform development to reach their audience
with important information. This presentation will peel back
the curtain on the new media landscape and will show how
to build a meaningful online platform. Rusty has worked

Friday 26
with some of the world’s biggest brands and thought
leaders and his 10-step plan combines insights from the
changing worlds of publicity, social media and marketing to
help you cut through the clutter and build a large platform.
You will leave the presentation with a roadmap you can
follow to build a meaningful online brand that you can use
to grow your following and make a bigger impact.

About Mr. Shelton

Rusty Shelton first spoke at Harvard on the changing world of PR
and marketing at the age of 23. He is the co-author (alongside Barbara
Cave Henricks) of Mastering the New Media Landscape:Embrace the
Micromedia Mindset (Berrett-Koehler, 2016), which debuted at #2
on the Austin American-Statesman bestseller list and is endorsed by
Seth Godin, David Meerman Scott, Tom Rath, Sally Hogshead and
many others. Rusty’s commentary on the changing world of PR and
marketing has been featured in Forbes, Inc. Magazine, Wharton, Huff
Post and many other top media outlets. He is the founder and CEO of
Zilker Media, a full-service marketing and PR agency that represents
some of the world’s leading authorities, including Captain “Sully”
Sullenberger. Rusty has helped launch more than 30 New York Times
& Wall Street Journal bestsellers, including The One Thing and
The Confidence Code.

Time: 7:30pm-9:00pm
Room: Grand Sierra Ballroom – E
Presidential & Poster Reception
Join us for a networking reception and take advantage
of the informal interactive process between an author
and a host of viewers allows for meaning dialogue about
the SCIENCE!

Time: 9:00pm-12:00am
Room: See Invitation in Registration Packet/or Check with
AAPB Staff at the registration counter
STUDENT PARTY – Invitation Only – All students welcome!

Saturday, April 14
_________________________________________
YOGA/Meditation
Boca Patio
6am-7am

Continental Breakfast in Expo Hall

Grand Sierra Ballroom – E
7am-8am

Exhibits Open
Grand Sierra Ballroom – E
7am-1:00pm

27 Friday/Saturday
Time: 7am-6:30pm
Room: Grand Sierra Foyer North
Registration

Time: 8am-9am
Room: Curacao 4
BOS21: Enhancing Wellness and Reducing Burnout in
University Students and Medical Trainees
Presenters: Angele McGrady, PhD; Rick Harvey, PhD;
Erik Peper, PhD
Level: Intermediate
Track: Basic Science (All Levels)
Focus: Clinical and Research
CE credits: 1

Time: 8am-9am
Room: Curacao 5
BOS22: Using Augmented Reality & Multi-Modal
Anatomical Imagery in the Treatment of Cortical
Re-mapping, Body Schema, & Chronic Pain
Presenters: Timothy J. Sobie, PT, PhD, BSc
Level: Intermediate
Track: Clinical Interventions and Optimal Performance
Focus: Clinical and Research
CE credits: 1

Time: 8am-9am
Room: Curacao 6
ORAL2: PTSD Oral Presentations
Presenters: Joseph Riddle, BS; Alexis Maxwell, BS; John Locke, B.S.
LRT/CTRS; Atticus Toriello Alexis Maxwell, BS; Tacy LeBaron,
BS; Aaron Craven, LRT/CTRS; Carmen V. Russoniello, PhD, LRT,
LPC, BCB, BCN, Professor and Director
Level: Introductory
Track: Basic Science (All Levels)
Focus: Clinical and Research
CE credits: 1

Time: 8am-9am
Room: Curacao 7
BOS23: Integrating Biofeedback Services Within an
Academic Medical Center Focusing on Chronic Pain
Management
Presenters: Heather King, PhD; Sarah Gray, PsyD;
Level: Introductory
Track: Clinical Interventions and Optimal Performance
Focus: Clinical
CE credits: 1

Time: 8am-9am
Room: Curacao 8
BOS24: Evidence for the Effectiveness of Biofeedback
in Cardiovascular Disease

Saturday 28
Presenters: Christine Moravec, PhD
Level: Introductory
Track: Basic Science (All Levels)
Focus: Clinical and Research
CE credits: 1

KEYNOTE PRESENTATION:
Time: 9:30am-10:30am
Room: Grand Sierra Ballroom – F-I
KEY04: A Multidimensional Approach to Diagnostic
and Therapeutic
Presenters: Hasan Asif, MD, Founder and Medical Director,
Brainwellness Center
Level: Introductory
Track: Basic Science
Target Audience: All
CE Credits: 1

The field of mental health is divided in its

diagnostic and therapeutic approaches:
Biological vs Psychological, Body Vs mind,
Neurochemical intervention Vs Brain
modulation. There is a need for a comprehensive
approach which brings different fields together on solid
theoretical grounds- a methodology which enables us to
bridge the gap in our understanding of different systems
and offers a comprehensive multi modal therapeutic
synthesis. BrainWellness center diagnostic and treatment
methodology is such an attempt. It involves comprehensive
diagnostic evaluation integrating BIO stress TEST, qEEG
analysis and psychodynamic formulations in one whole and
then offers qEEG informed psychotropic use, BIO feedback,
Neurofeedback, Brain modulation (transcranial magnetic
stim) along with Psychotherapy in one integrated session.
This current presentation is to explore the theoretical
basis of such an integration and its implementation in daily
clinical setting.

About Dr. Asif:

Hasan Asif, MD, founder and Medical Director of the Brain Wellness
Center, is a board-certified psychiatrist who has been in private
practice for fifteen years. A 1990 graduate of A.I.M.C in Lahore,
Pakistan, Dr. Asif finished post graduate training in psychiatry at
New York Medical College in Valhalla, New York in 1995. In 1996
he joined the faculty of the University of West Virginia as assistant
professor of psychiatry. He served as a Medical Director of Adult
Partial Hospital in Four Winds Hospital in Katonah, NY. Currently,
he is a consulting psychiatrist at Lawrence Hospital Center in
Bronxville, New York.

Time: 10:30am-11:00am
Room: Grand Sierra Ballroom – E

29 Saturday
Networking Break / EXHIBITOR DRAWING
Must be present to win!!

Time: 11am – 12pm

Room: Curacao 1
EXHIBITOR DEMONSTRATION - NeuroField
CE credits: 0

Time: 11am-12:30pm
Room: Curacao 2
BOS25: Professional Ethics and Practice Standards for
Biofeedback and Neurofeedback: An Overview
Presenters: Donald Moss, PhD
Level: Intermediate
Track: Clinical Interventions and Optimal Performance
Focus: Clinical
CE credits: 1.5

Time: 11am-12:30pm
Room: Curacao 3
BOS26: The EEG/qEEG Signature of Diffuse Axonal TBI,
its Connection to Alzheimer’s and Remediation with
Audio-visual Entrainment
Presenters: Dave Siever, CET
Level: Intermediate
Track: Hot Topics
Focus: Clinical and Research
CE credits: 1.5

Time: 11am-12:30pm
Room: Curacao 4
BOS27: We Can Do Better: Achieving Peak Performance
in Sports
Presenters: Erik Peper, PhD, BCB; Leah Lagos, PsyD; Vietta
Wilson, PhD, BCB, BCN
Level: Introductory
Track: Hot Topics
Focus: Clinical and Research
CE credits: 1.5

Time: 11am-12:30pm
Room: Curacao 5
ORAL3: Biofeedback Oral Presentations
Presenters: Howard Hall, PhD,PsyD., BCB; Lamees Khorshid,
PsyD, BCB, BCN; Thomas H. Fine, MA; Justin Feinstein; Katie
Fleischman, PhD; Inna Khazan, PhD, BCB; Reza Zomorrodi, PhD
Level: All Levels
Track: Clinical Interventions and Optimal Performance
Focus: Clinical
CE credits: 1.5

Time: 11:30am-12:30pm
Room: Curacao 6

Saturday 30
EXHIBITOR DEMO: Bio-Medical, Inc.
CE credits: 0

Time: 12:30pm-2:00pm
Room: On Your Own
Lunch Break

Time: 12:45pm-1:45pm
Room: Bonaire 5/6
Student Roundtable & Lunch – Complimentary
to students and invited guests only

Time: 1pm-4:00pm
Room: Grand Sierra Ballroom – E
Exhibits Teardown

Time: 2pm-3:30pm
Room: Curacao 1
BOS28: Interpersonal Biofeedback: A Hybrid of
Biofeedback and Couples Counseling
Presenters: Steven C. Kassel, MFT, BCB, BCN
Level: Intermediate
Track: Clinical Interventions and Optimal Performance
Focus: Clinical and Research
CE credits: 1.5

Time: 2pm-3:30pm
Room: Curacao 2
BOS29: Practical Strategies for Teaching Your Clients
to Breathe
Presenters: Inna Khazan, PhD, BCB; Fredric Shaffer, PhD, BCB
Level: Introductory
Track: Clinical Interventions and Optimal Performance
Focus: Clinical and Research
CE credits: 1.5

Time: 2pm-3:30pm
Room: Curacao 3
BOS30: Benefits of Posture Training using Biofeedback
Presenters: Kelsey James, BSc; Erik Peper, PhD; Annette Booiman,
PhD; Jacalyn McComb, PhD; Ahalee Cathey, BS, Lauren Mason
Level: Introductory
Track: Clinical Interventions and Optimal Performance
Focus: Clinical and Research
CE credits: 1.5

Time: 2pm-3:30pm
Room: Curacao 4
BOS31: Resolving the Concussion Conundrum
Presenters: Robert Conder, PsyD, ABPP; Alanna A. Conder, PsyD;
Lynda Thompson, PhD; Michael Thompson, MD, BSc, DPsych, CRPC
Level: Intermediate
31 Saturday
Track: Clinical Interventions and Optimal Performance
CE credits: 1.5

Time: 2pm-3:30pm
Room: Curacao 5
BOS36: The Effect of Synchronized Neurostimulation and
Neuromodulation on Depression, Anxiety and ADHD
Presenters: Nicholas Dogris, PhD, BCN, QEEG-D
Level: All
Track: Clinical Interventions and Optimal Performance
Focus: Clinical and Research
CE credits: 1.5

Time: 3:30pm-4pm
Room: Grand Sierra Foyer North
Break (Refreshments)

Time: 4:05pm-5:05pm
Room: Curacao 7
ORAL4: HRV Oral Presentations 2
Presenters: Sommer Christie, BSc, MHK; Nicholas Gravett, Senior,
Pre-Med; Fredric Shaffer, PhD, BCB; Amy S. Welch, PhD
Level: Intermediate
Track: Clinical Interventions and Optimal Performance
CE credits: 1

Time: 4:05pm-5:05pm
Room: Curacao 8
BOS32: Mobile Neurofeedback for Pain Management in
Veterans with TBI and PTSD
Presenters: Eric Elbogen, PhD
Level: Introductory
Track: Clinical Interventions and Optimal Performance
Focus: Clinical and Research
CE credits: 1

Time: 4:05pm-5:05pm
Room: Curacao 1
BOS33: Application of a Piloted Biofeedback
Pediatric Headache Protocol and Adaptability with
Challenging Cases.
Presenters: Katie Fleischman, PhD
Level: Introductory
Track: Clinical Interventions and Optimal Performance
Focus: Clinical
CE credits: 1

Time: 4:05pm-5:05pm
Room: Curacao 2
BOS34: MultiCultural Diversity Topics for
Biofeedback Practitioners

Saturday 32
Presenters: Richard Harvey, PhD
Level: Introductory
Track: Clinical Interventions and Optimal Performance
Focus: Clinical and Research
CE credits: 1

Time: 4:05pm-5:05pm
Room: Curacao 3
BOS35: Advances in Coherence Based Neurofeedback
Training
Presenters: Robert Cober, PhD
Level: Intermediate
Track: Hot Topics
Focus: Clinical and Research
CE credits: 1

KEYNOTE PRESENTATION:
Distinguished Scientist Lecture
Time: 5:15-6:30pm
Room: Grand Sierra Ballroom – F-I
KEY05: Biofeedback, Baroreflex, and Cardiovascular
System Functioning
Presenter: Evgeny Vaschillo, PhD, Associate Research
Professor, Rutgers
Level: Intermediate
Track: Basic Science
Target Audience: All
CE Credits: 1

The AAPB Distinguished Scientist Award

is presented annually “in recognition of an
outstanding career and scientific contribution
to the field of applied psychophysiology and
biofeedback.” This award recognizes a scientist who has
advanced Biofeedback through a significant body of
research conducted, as judged by publications, awards and
peer reviews, and has made a major impact upon the field
of study, both nationally and/or internationally. Nominees
must hold a doctoral degree in a psychology, biomedical
science, medicine, or other health-related field. Recipients
are selected based on the following evaluation criteria:
scientific importance of research discoveries; mentorship of
students, postdoctoral fellows, and new faculty; continued
impact on the field.

Dr. Vaschillo’s career in the biofeedback field in the United

States has been aided by teamwork with his teacher
and friend Paul Lehrer. For the past 20 years they have
worked together to investigate cardiovascular regulation
and specifically the baroreflex; both are related to HRV
biofeedback, which is a method of controlling them and
helping them to restore balance in autonomic nervous

33 Saturday
system. They consider biofeedback to be a biological
procedure by which external feedback improves human
ability to voluntarily control autonomic functions and
some parameters of brain function. Heart rate variability
biofeedback can be used to treat various physiological
and mental disorders and diseases. Heart rate variability
biofeedback can also be applied to investigating natural
mechanisms for regulation of various physiological
processes. Biofeedback allows us to impose sine-wave
oscillations in the cardiovascular system (CVS) processes,
thus allowing us to apply classical engineering approaches
to studying CVS functioning. They have successfully
used HRV biofeedback for treating various neuroses,
asthma, fibromyalgia, and post-concussion syndrome,
and depression but the main part of our studies used
biofeedback as a tool for CVS functioning investigation.
The results of using HRV biofeedback for treatment, as well
as for investigating CVS functioning will be presented.

They have studied:

• Resonance properties of the CVS,
• HRV biofeedback effects on various CVS processes and
the baroreflex system,
• Features of each of the three baroreflex branches,
• More recently, we have investigated the possibility of
using paced rhythmical sighing as a tool to explore CVS
functioning in the frequency range of 0.05-0.08 Hz, which
relates to vascular tone (VT) control. This work could be
the basis for developing a VT biofeedback procedure for
treating various vasomotor disorders.

ABOUT DR. Vaschillo:

In 1968, Dr. Vaschillo graduated from the Saint Petersburg State
University of Aerospace Instrumentation (Russia) with a master’s
degree in electromechanical engineering. Right after graduating, he
worked at the companies supporting the Russian space program, where
he studied heart rate variability (HRV) and effects of rhythmical
stimulation of the cardiovascular system by breathing, muscle tension,
and emotion. His work particularly emphasized the baroreflex and the
possibilities of applying resonance frequency HRV biofeedback to train
Russian cosmonauts to function better in space. After getting his PhD
in human and animal physiology at the Scientific Research Institute
for Experimental Medicine (in1983), he worked on developing
physiological methods to evaluate and control functional states of
the ‘human-operator’ in extreme environmental conditions, with
applications to cosmonaut crews, submarine crews, and athletic teams.
Later, these techniques were expanded to treat patients with asthma
and various neuroses as well as to sport performance. In 1998 he came
to United States and has continued studying the cardiovascular system
and the baroreflex using biofeedback.

Saturday 34
 POSTERS:

101: Updated Heart Rate Variability Norms for

Healthy Undergraduates
Presented by: Nicholas Gravett; Hanna Urban; Andrew Smith;
Hillary Hedgecock; Jackie Pecoraro; Dan Owen; Nick McCann;
Fredric Shaffer, PhD Psychology, Professor, Truman
State University

102: A Survey of Prescription Drug Effects on Heart Rate

Variability Measurements
Presented by: Nicholas Gravett; Hanna Urban; Andrew Smith;
Hillary Hedgecock; Nick McCann; Zachary Meehan, MA, BS;
Fredric Shaffer, PhD Psychology, Professor, Truman
State University

103: An Examination of Artifact-Corrected

Neurofeedback in Mediating Outcomes on
Objective Measures of Attention
Presented by: Jeffry La Marca, PhD; Daniel Cruz, PhD, ABPP;
Austin T. Guerra, MA; Jennifer Fandino, MA; Fabiana R.
Cacciaguerra, MA; Joseph J. Fresco, MA

104: Modulation of Brain Oscillatory Activity to

Drive Brain Function via Near-Infra Red
Stimulation (tNIRS)
Presented by: Reza Zomorrodi

105: The Effectiveness of Battlefield Acupuncture in

Reducing Pain: A Heart Rate Variability Analysis
Presented by: Allison Beachum; Carmen Russoniello;
Aaron Craven
*CITATION POSTER*

106: The Effectiveness of Remote HRV Training in

Reducing Symptoms of PTSD in Combat Exposed
Marines and Corpsmen
Presented by: Carmen Russoniello, PhD; George T. Stegeman;
Christina Brown-Bochicchio; Kevin O’Brien, PhD; Matthew
Fish, PhD; Jenny Marks; Tabitha Alverio, CTR, Senior Research
Associate; Angela Sutherland, CTR, Senior Research Associate

107: Regulation of Emotional State and Personality

by Means of Alpha Neurofeedback
Presented by: Yuri G. Pavlov

Note: Names are printed as indicated in the abstract collector.

We do not correct or verify punctuation consistency
35
108: The Efficacy of Neurofeedback Treatment for
Children with Developmental Trauma: A Case Study
Presented by: Rahel L Katz; Katie Martin; Zhenyu Zhang; Asif
Zaarur; Ainat Rogel; Diana Martinez, PhD, MD, Director of
NFB Clinic, the Trauma Center at JRI Michael Suvak, PhD,
Senior Research Associate, the Trauma Center at JRI Hilary
Hodgdon, PhD, Director of Research Operation, the Trauma
Center at JRI Bessel van der Kolk, MD, Founder and
Medical Director, the Trauma Center at JRI

109: Upper Alpha Neurofeedback Training Has No Effect

on Working Memory
Presented by: Yuri G. Pavlov

110: The Effect of Facial Expression on Heart Rate

Variability and Related Autonomic Activity
Presented by: Dan Owen

111: Secondary Post-Traumatic Stress and Its Treatment

in Children of PTSD Veterans
Presented by: Alexis Maxwell; Tacy LeBaron;
Carmen V. Russoniello

112: A Case Study of Virtual Reality Graded Exposure

Therapy (VRGET) in Military Personnel with Post-
Traumatic Stress Symptoms
Presented by: Joseph Riddle; Alexis Maxwell; Atticus Toriello;
Carmen V. Russoniello

113: The Impact of Mobile HRV Training on Depression

in Military Personnel with Posttraumatic
Stress Disorder
Presented by: John Locke; Carmen Russoniello
*CITATION POSTER*

114: The Effectiveness of a Cloud Based HRV

Biofeedback Program in Reducing Anxiety
Symptoms in Marines and Corpsmen With PTSD
Presented by: Aaron Craven; Carmen Russoniello

115: Obstacles In Measuring Vagal Recovery:

Artifacts, Confounds, and Possible Solutions
Presented by: Cody Gustaveson; Lucia Foster-Engen;
Bo Robertson; Brian Rankin; Richard Gevirtz, PhD

116: Body Schema Acuity Training & Feldenkrais

Movements compared to Core Stabilization
Biofeedback & Motor Control Exercises:
RCT / Effects on Chronic Low Back Pain in
an Outpatient Setting
Presented by: Timothy J. Sobie
Note: Names are printed as indicated in the abstract collector.
We do not correct or verify punctuation consistency
36
117: Effects of a Structured Resiliency Program on
Perceived Stress and Burnout in Residents from
Family Medicine and Internal Medicine
Presented by: Angele McGrady; Alyse Stolting; Amy Riese;
Julie Brennan; Archit Sahai; Jennifer Tripi Emily Sudhakar

118: Validity of Serial 7’s as Cognitive Stress Test in

Measures of Heart Rate Variability
Presented by: Sarah-Nicole Bostan; Natasha Nemanim;
Richard Gevirtz

119: Biofeedback Fighting the Silent Killer:

Continuous BP Monitoring and HRV
Presented by: Linda P. Bolin; Carolyn Horne; Allison Bradley

120: Psychophysiological Markers or Emotional Eating

Presented by: Lucia Foster-Engen; Cody Gustave; Richard
Gevirtz; Veronica Perez; Liana Abascal, PhD

122: Effect of the Upright Posture Training Program

on Spinal Angles and Self-esteem in College-
aged Students
Presented by: Kelsey James

123: Gender Differences in the Outcomes of

Neurofeedback Treatment for Children with
Developmental Trauma
Presented by: Zhenyu Zhang; Rahel Katz; Ainat Rogel; Michael
Suvak; Hilary, Hodgdon, PhD,; Diana Martinez, PhD, MD, the
Trauma Center at JRI; Asif Zaarur, BA, Research Assistant, the
Trauma Center at JRI; Katie Martin, BA, Research Assistant,
the Trauma Center at JRI; Bessel van der Kolk, MD, Founder
and Medical Director, the Trauma Center at JRI

124: Does Self-Guided Heart Rate Variability

Biofeedback Increase Undergraduate Conners
CPT3 Performance?
Presented by: Nicholas Gravett; Zachary White

125: Gender Differences in Couples’ Psychophysiological

Response
Presented by: Matthew Fish; Jakob F. Jensen; Özlem Köse;
Braden J. Brown

126: A Biofeedback Approach to Rehabilitation in

Post-Stroke Aphasia
Presented by: Bijoyaa Mohapatra

Note: Names are printed as indicated in the abstract collector.

We do not correct or verify punctuation consistency
37
127: Effect of Paced Breathing at Low-frequency Peak
of HRV on Baroreflex Sensitivity
Presented by: Masahito Sakakibara; Munehisa Kaneda;
Leo O Oikawa

128: HRV Biofeedback Reduces Chronic Pain Symptom

Cluster Burden
Presented by: JP (Jack) Ginsberg, PhD; M. Berry
*CITATION POSTER*

129: The Effect of the Upright Posture Trainer on

Muscular Endurance and Fatigue
Presented by: Ahalee Cathey; Ty Palmer, PhD, Texas
Tech University

130: Characteristics of EEG Induced by Heart Rate

Variability Biofeedback in Healthy People.
Presented by: Simona Carrubba

131: Group Biofeedback in Patients with Postural

Orthostatic Tachycardia Syndrome (POTS)
Presented by: Carolyn J. Fisher; Wendy E. Sweet; Alison Swift;
Brittany Goldstein; Robert Wilson; Christine S. Moravec, PhD,
Staff Director of Research Education and Training,
Cleveland Clinic

132: Individual Alpha Peak Frequency in Ice Hockey

Shooting Performance
Presented by: Sommer Christie; Selenia di Fronso; Maurizio
Bertollo; Penny Werthner

133: Biofeedback Treatment with Stroke Survivors

in Rehabilitation
Presented by: Jana Downum

134: Presidential Symposium on the Clinical Efficacy

of Biofeedback and Neurofeedback
Presented by: Zachary Meehan; Nicholas Gravett;
Fredric Shaffer, PhD

135: Wearable Posture Feedback Training:

Effects on Health
Presented by: Lauren Mason; Monica Joy; Erik Peper;
Richard Harvey

136: HRV Norms for Children and Adolescents from

a Clinical Site
Presented by: Roya Iravani; Brian Rankin; Richard Gevirtz

Note: Names are printed as indicated in the abstract collector.

We do not correct or verify punctuation consistency
38
137: The Case for a Limits of Agreement (LoA) Criterion
for Ultra-Short-Term (UST) HRV Measurements
Presented by: Nicholas Gravett; Hillary Hedgecock; Jackie
Pecoraro; Dan Owen; Joseph Berlinger; Fred Shaffer, PhD Psychology
*CITATION POSTER*

138: A Paradigm Shift in The Treatment of Post-

Traumatic Stress Disorder: A Case Study
Presented by: George Rozelle, PhD; George Lindenfield, PhD

139: Re-Training the Injured Brain: Neurofeedback as

an Acute Concussion Intervention
Presented by: David Ims

140: Start with Nutrition and Exercise to Improve

Energy and Mood
Presented by: Lena Stampfli; Erik Peper; Richard Harvey

141: Posture Effects on Math Performance

Presented by: Lauren Mason; Erik Peper; Richard Harvey;
I-Mei Lin

142: The Effect of Head and Neck Position on Cervical

Muscle Tension, Symptoms and Head Rotation
Presented by: Elizabeth Villagomez; Alejandro Heredia;
Erik Peper; Richard Harvey; Annette Booiman

143: Does Self-Guided Heart Rate Variability

Biofeedback Increase Undergraduate Conners
CPT3 Performance?
Presented by: Nicholas Gravett; Hannah Urban; Andrew Smith;
Hillary Hedgecock; Zachary White

144: Identifying a Cross-correlation between Heart

Rate Variability and Skin Conductance Using
Pain Intensity on Healthy College Students
Presented by: Genesis Cruz-Molina, Sungham Kim,
Brian Sylcott, Carmen Russoniello, PhD

Note: Names are printed as indicated in the abstract collector.

We do not correct or verify punctuation consistency
39
 EXHIBITORS:
Applied Neuroscience, Inc.
BOOTH 21
8200 Bryan Dairy Road,
Suite 315
Largo, FL 33777-1355
USA
Phone: 727-244-0240
Fax: 727-392-1436
qeeg@appliedneuroscience.com
www.appliedneuroscience.com
Applied Neuroscience, Inc. (ANI) provides the most comprehensive
and integrated qEEG assessment and Neurofeedback (NFB) system
in the world. ANI is the inventor of real-time Z score Neurofeedback
and the 1st to develop Z score LORETA Neurofeedback of brain
networks linked to symptoms. NeuroGuide software provides 1 to
19 channel Z score NFB with symptom check lists and an automatic
clinical report writer. NeuroGuide specializes in 3-dimensional
neuroimaging to link symptoms to nodes and connections in the
brain. Also, ANI has developed the Brain-Computer-Interface (BCI)
BrainSurfer for NFB of 3D network dynamics.

Biofeedback Certification International Alliance (BCIA)

BOOTH 27
5310 Ward Road, Suite 201
Arvada, CO 80002
USA
Phone: (720) 502-5829
Email: info@bcia.org
Web: info@bcia.org
BCIA is recognized as the certification body for the clinical practice
of biofeedback by both the Association of Applied Psychophysiology &
Biofeedback (AAPB) and the International Society for Neurofeedback
and Research (ISNR). The Biofeedback Certification Institute of
America (BCIA) was formed in January 1981 to establish and
maintain professional standards for the provision of biofeedback
services and to certify those who meet these standards.

PLATINUM SPONSOR
Bio-Medical Instruments, Inc.
BOOTHS 23 and 24
38875 Harper Ave
Clinton Township, MI 48036
USA
Phone: 800-521-4640
Fax: 586-756-5020
sales@bio-medical.com
www.bio-medical.com

40
Bio-Medical Instruments is the largest distributor of clinical
biofeedback & neurofeedback equipment and supplies. With over
30 years in the field of biofeedback and neurofeedback sales and service,
BMI can help you find the equipment that fits both your needs and
budget. BMI offers & stocks a wide range of both new and used
products from all major manufacturers. You can count on Bio-Medical
Instruments for fast deliveries, great service and a knowledgeable staff.
If you have older equipment in need of repair, BMI may be able to help.
Call toll free 800-521-4640 or visit www.bio-medical.com.

BrainMaster Technologies, Inc.

BOOTHS 12, 13, 14
195 Willis Street
Bedford, OH 44146
USA
Phone: 440-232-6000
Fax: 440-232-7171
sales@brainm.com
www.brainmaster.com
Your comprehensive source manufacturer offering leading-edge
neurofeedback hardware, software, support and educational training.
Atlantis 4 and 8 channel series w/24 bit, USB with built in continuous
impedance checking; built in photic, vibro & auditory protocol driven
feedback! Full general biofeedback capability. Discovery 24 channel
system offers QEEG and optional neurofeedback training up to
19 channels w/Live Z Score, Live sLoreta Z Score DVD, multi-media
DVD package, general biofeedback, slow cortical and more. Built-in
artifact detection. Comprehensive analysis and more. AC/DC amps.
Ease of use, flexibility, versatility, expansion capability, wide range of
reports. Flexible for all types of power/amplitude type training protocols
including data based guidance! Affordable and expandable.

CNS Vital Signs

BOOTH 7
598 Airport Blvd Suite 1400t
Morrisville, NC 27560
USA
Phone: 888-750-6941
Fax: 888-650-6795
support@cnsvs.com
www.cnsvs.com
CNS Vital Signs is a world leader in computerized-neurocognitive
assessment tools. Baseline cognition to document treatment need.
Track outcome results of NFT/CBT treatment. Used by over 12k
clinicians and researchers in 52 countries, tests are available in over
50 languages. Software, training and a pilots tests are free.
Visit www.cnsvs.com

41
East Carolina University
BOOTH 4
Carol G. Belk Building
Room 2404
Greenville, NC 27858
USA
Phone: (252) 328-0021
Email: fishm@ecu.edu
Web: hhp.ecu.edu/rcls/cap/

EEG Education and Research

BOOTH 5
1234 NW 14th Avenue
Gainsville, FL 32601
USA
Phone: 888-521-9803
info@eegstore.com
www.eegstore.com
EEG Education & Research is dedicated to advancing the science and
application of neurofeedback. Clinicians value our courses for healthcare
professionals, and our annual Neurofeedback Interchange Conference.
Our diverse professional community of researchers and clinicians use
the versatile EEGer4T Neurofeedback Software in a broad range
of settings.

Expo Enterprise, Inc.

BOOTH 29
3560 Polaris Avenue, #27
Las Vegas, NV 89103
USA
Phone: (720) 272-2666
Email: expo89102@yahoo.com
www.nano-ions.com
We promote medical bracelets. They help with fat loss, reduce water
retention, improve blood circulation, help cleanse liver and kidneys,
help heal skin disorders, reduction in emotional maladies such as
anxiety and depression, relieve from acute and chronic illness and
many more. They also protect human’s body from Wi-Fi radiation.
Our product is very good for people who work a lot with electronics,
computers, who have to sit or stand a lot, who work night shifts or have
stressful life. So, basically it works for everybody and all age groups.

Feel Good, Inc.

BOOTH 18
1460 Gemini Blvd, #8
Orlando, FL 32837
USA
Phone: 407-986-3351
rechelle@feelgoodinc.org
www.feelgoodinc.com

42
Feel Good, Inc. provides portable TENS (transcutaneous electrical
nerve stimulation) units offering wide variety of benefits, including
alleviating back, nerve and diabetic pain and migraines. Our units
can also improve circulation, sleep patterns and have been shown
to decrease the use of pain relievers that can cause negative
side effects.

Foundation for Education and Research in Biofeedback

(FERB)
BOOTH 25
Phone: (510) 688-8298
Email: qeegjay@sbcglobal.net
Web: https://www.aapb.org/i4a/pages/index.cfm?pageid=3280
The Foundation for Education and Research in Biofeedback and
Related Sciences (FERB) was formed in 1985 at the urging of then
AAPB president, Neal Miller, PhD. He felt that the organization
had a mission to continue to support research and clinical applications
in our ever broadening field. A key way to do that is to encourage
the interest and application of work by students which will lead to
further demonstration of the efficacy of Biofeedback techniques. Purpose
and Mission: To promote and support education, special papers and
publications, scholarships, recognition awards and research in the area
of applied psychophysiology.

g. tec medical engineering GmbH

BOOTH 28
Sierningstr. 14
Schiedlberg, Austria, 4521
Phone: 5184951551
office@gtecus.com
www.gtec.at

ISNR
BOOTH 16
13876 SW 56th St., PMB 311
Miami, FL 33175
office@isnr.org
www.isnr.org
ISNR is the only international professional membership society
dedicated solely to the advancement and support of Neurofeedback.

Lenyosys
BOOTH 17
2805 Oakland Park Blvd, #441
Fort Lauderdale, FL 33306
USA
Phone: (888) 619-2929
Email: info@lenyosys.com
Web: www.lenyosys.com
Lenyosys, a leader in Bioregulation Therapy (BRT) technology, offers
a comprehensive portfolio of BRT devices that use advanced pulsed

43
electromagnetic field signaling (PEMF) to help improve biological
communications and restore natural healing activities. The LENYO
line of BRT products includes professional, home and mobile devices.

Mind Media BV
BOOTH 8
Louis Eijssenweg 2 B
6049 CD Herten (NL)
The Netherlands
Phone: +31-475-410123
Fax: +31-475-330602
Email: info@mindmedia.nl
www.mindmedia.com
Mind Media offers integrated and easy to use equipment for
biofeedback, neurofeedback, qEEG and psychophysiological research.
We empower health professionals to assess and train the human mind-
body interface for improving health and performance. Ever since its
foundation in 1992, Mind Media has been a pioneer in developing
smart solutions for visualizing the physiological processes of the body
and brain. Our wireless NeXus line can measure a wide range of
different parameters simultaneously like brainwaves (EEG), muscle
tension (EMG), heart rate variability, blood volume pulse, skin
conductance, temperature, respiration, and more.

Myndlift Ltd
BOOTH 15
Lincoln Street 19
Tel Aviv, 6713411
Israel
Phone: (972) 505586392
Email: hello@myndlift.com
Web: www.myndlift.com
Myndlift offers therapist-guided home neurofeedback using wearable
and mobile technology. The solution allows clinicians to send patients
home with an affordable, easy to use equipment. They can also
customize protocols and target specific frequencies for the neurofeedback
training using a beautiful online dashboard that aggregates all of the
session’s data.

GOLD SPONSOR
NeuroField, Inc.
BOOTH 22
PO Box 506
Bishop, CA 93515
USA
Phone: 760-872-4200
Fax: 760-873-8007
contact@neurofield.com
www.neurofield.com
NeuroField is finally here. This new technology is the result of years
of study into the energetic art and science of balancing the human
44
body so as to promote health and wellness. NeuroField represents the
integration of multiple energetic healing arts that are combined in such
a way so as to create a synergistic, energetic, balancing response that is
rapid, and in many cases, amazing.

NeuroFlow
BOOTH 6
1608 Walnut Street
Suite 1200
Philadelphia, PA 19103
USA
Phone: (267) 319-8045
Email: info@neuroflowsolution.com
Web: www.neuroflowsolution.com
NeuroFlow helps mental health patients feel better faster. We offer
secure, real-time technology that optimizes mental wellness and
performance through effective monitoring, positive reinforcement,
and targeted guidance. We enhance and accelerate engagement by
demonstrating tangible progress through patient-generated data
including biometrics, questionnaires, and journaling. By improving
retention and protocol adherence, we promote better health outcomes
for patients and business growth for providers.

Physiocom Design
BOOTH 3
8396 Eghon Rd
Kingston, WA 98346
Phone: 360-779-3853
physiosens@gmail.com
Physiocom Design, an engineering and production company, produces
advanced physiological instruments. With 40 years of bio-engineering
experience, we have developed the newest and most cost effective
measuring equipment. The same engineers of J&J Engineering have
designed new products using the latest technology. The compact designs
provide a general purpose physiological signal monitor in a case the
size of a pack of playing cards. Add a small computer, and you have a
complete system in your pocket.

Plux Wireless Biosignals SA

BOOTH 20
Av 5 De Outubro N.70-8 Andar
plux@plux.info
www.plux.info
Established in 2007, PLUX creates innovative products for
Physiotherapists and Researchers, by developing an advanced biosignal
monitoring platform that integrates wearable body sensors such as
electromyography (EMG), electrocardiography, respiration, and
accelerometers combined with wireless connectivity and software
applications to deliver real value recognized by our target markets.

45
Saybrook University
BOOTH 19
475 14th Steet, 9th Floor
Oakland, CA 94612
USA
Phone: 510-593-2926
Fax: 510-455-7046
admissions@saybrook.edu
www.saybrook.edu
SAYBROOK UNIVERSITY College of Integrative Medicine and
Health Sciences Saybrook University offers master’s and doctoral
degrees and certificates, with emphasis on mind-body medicine,
applied psychophysiology, optimal functioning, integrative nutrition,
wellness coaching, counseling, and psychology. Leading researchers and
practitioners in biofeedback, neurofeedback, and behavioral medicine
provide instruction. Saybrook programs combine residential and online
instruction, providing education for busy professionals.

Springer Science+Business Media

BOOTH 26
233 Spring Street
New York, NY 10013
USA
Phone: 1-800-SPRINGER
Outside U.S. - (212) 620-8085
customerservice@springer.com
www.springer.com
Springer is a leading global scientific publisher, providing researchers
in academia, scientific institutions, and corporations and other
professionals with quality content via innovative information products
and services. Free sample copies of pertinent journals will be available
at our exhibit booth, as well as a 20% discount on books.

Stens Corporation
BOOTH 9
3020 Kerner Blvd, Suite D
San Rafael, CA 94901
USA
Phone: 415-455-0111
Toll Free: 800-257-8367
Fax: 415-455-0333
sales@stens-biofeedback.com
www.stens-biofeedback.com
Find out why the NeXus family of wireless systems is the standard that
other biofeedback products are compared to:
• Beautiful graphics and resolution
• Wireless
• 24- bit
• Easy to use software

46
• Easy to build protocols and screen displays
• Little or no tech support (but always available for FREE!)
The NeXus products and nationally held workshops are available solely
through Stens!

SILVER SPONSOR
Thought Technology, Ltd.
BOOTHS 1 and 2
8205 Montreal/Toronto Blvd.
Suite 223
Montreal West, Quebec H4X 1N1
Canada
Phone: (514) 489-8251
Fax: (514) 489-8255
Email: workshops@thoughttechnology.com
Web: www.thoughttechnology.com
Thought Technology has your clinical solutions for evaluating and
improving client health, whether it be cardiovascular (HRV),
autonomic, muscular, or cerebral functioning. Visit our booth to learn
more about our new harmonized software solution that integrates
multiple systems into a single coordinated assessment and self-
regulation tool.

Vielight Inc.
BOOTHS 10-11
346A Jarvis St
Toronto, Ontario, M4Y 2G6
CAN
Phone: 855-875-6841
info@vielight.com
www.vielight.com
Vielight has helped numerous neurofeedback practices around
the world to achieve quick brainwave entrainment through its
photobiomodulation (PBM) devices. Already embarking on resolving
Alzheimer’s disease, R&D is also directed at ADD, depression, anxiety,
autism and other brain conditions. Evidence is emerging that Vielight
can also enhance high level mindful states.

47
AAPB 49th Annual Scientific Meeting Floor Plan

EXHIBITORS
Thought Technologies, Inc. 1, 2
Physiocom Design 3
East Carolina University 4
EEG Education and Research 5
NeuroFlow 6
CNS Vital Signs 7
Mind Media BV 8
STENS Corporation 9
Vielight Inc. 10, 11
BrainMaster Technology Ltd 12, 13, 14
Myndlift Ltd 15
ISNR 16
Lenyosys 17
Feel Good, Inc. 18
Saybrook University 19
Plux Wireless Biosignals SA 20
Applied Neuroscience, Inc. 21
NeuroField, Inc. 22
Bio-Medical Instruments, Inc. 23, 24
Foundation for Education and Research
in Biofeedback (FERB) 25
Springer Science+Business Media 26
BCIA 27
g. tec medical engineering GmbH 28
Expo Enterprise 29

48
Site Map – Caribe Royale Hotel and Convention Center

49
Site Map – Caribe Royale Hotel and Convention Center

50
 GENERAL INFORMATION
Overall Conference Objectives:
• Discuss new psychophysiology and biofeedback methods
to evoke human potential and achieve results in a clinical
setting.
• Determine psychophysiology and biofeedback techniques
to improve patients’ quality of life.

Americans with Disabilities Act (ADA) Statement:

ADA accommodations will be made in accordance with the
law. If you require ADA accommodations, please indicate
what your needs are at the time of registration. We cannot
ensure the availability of appropriate accommodations
without prior notification.

Product Guidelines: 1) Some of the products exhibited here

many not be effective for the suggested applications. 2)
Some of the equipment being exhibited may not have been
registered by the FDA. 3) An FDA declaration of safe and
effective use may not apply to uses being promoted here.
Please check with each vendor to ascertain FDA status
of any device you are considering. 4) AAPB makes
no endorsement, either stated or implied regarding
the products.

Name Tags
All attendees at the meeting sessions or exhibits must
register and wear their name tags to gain entry to
presentations or the exhibit hall.

Tickets Required
Admission to workshops is by ticket only. Tickets may be
purchased either through pre-registration or on-site. Tickets
purchased on-site will be strictly on a space-available basis.

Medical Attention
Should a medical emergency arise, please dial the Operator
or contact Conference Center/Hotel Security.

The Annual Program Committee requests your

cooperation in observing the following guidelines for
etiquette in session rooms:
• Videotaping, audio taping, or photographing the
presentations is strictly prohibited (unless preauthorized).
• Mobile phones, pagers and other devices generating
sound must be turned off in the session rooms.
• Attendees using laptop computers, personal digital
assistants, or other electronic devices generating light
must sit in the back half of the room to avoid disturbing
fellow attendees.
51
Anti-Harassment policy
The AAPB Annual Scientific Meeting is dedicated to
providing a harassment-free conference experience
for everyone, regardless of gender, gender identity
and expression, sexual orientation, disability, physical
appearance, body size, race, age or religion. We do not
tolerate harassment of conference participants in any
form. Conference participants violating these rules may
be sanctioned or expelled from the conference, without
a refund, at the discretion of the conference organizers.
Our anti-harassment policy can be found at:

LINK TO FULL POLICY:

https://www.aapb.org/i4a/pages/index.cfm?pageid=3744

EXHIBITOR PRIZE DRAWING

WIN A $200 American Express Gift Card

DRAWING HELD AT 10:45 am in the Expo Hall on
Saturday, April 14, 2018 in the Exhibit Hall,
Grand Sierra Ballroom E
MUST BE PRESENT TO WIN!
To be eligible to enter this prize drawing, you must:
1) Visit each exhibitor’s booth and receive a signature
in the corresponding square of the Exhibitor Prize
Drawing Card
2) Complete the contact information section
3) Turn in your completed card at AAPB Registration no
later than 10:00 am on Saturday, April 14, 2018
4) Each attendee may enter this drawing only once
5) Must be present to win—the drawing will be held at
10:45 am on Saturday, April 14, 2018 in the Exhibit Hall,
Grand Sierra Ballroom E

No purchase necessary to enter or win. Void where prohibited.

Sponsor: Association for Applied Psychophysiology and
Biofeedback (“AAPB”), located at 10200 West 44th Avenue,
Suite 304, Wheat Ridge, CO 80033, is the sponsor of this
promotion. AAPB reserves the right, at its sole discretion,
to cancel, modify or terminate the prize drawing at any time.

52
 SAVE THE DATE!

2019 AAPB 50th Annual Scientific Meeting

March 13-16, 2019
Denver Tech Center Marriott
Denver, Colorado

The AAPB annual meeting on March 13-16, 2019 in

Denver will be AAPB’s 50th anniversary year, and
the program will be rich with content and a huge
celebration of the impact that biofeedback and applied
psychophysiology has had on health clinical practice and
scientific research. Our theme resonates with this idea:
“Applied Psychophysiology and Biofeedback: Rooted
in the Past, Empowering the Future”. Make your plans
to attend this special meeting and renew friendships that
have endured since the inception of The Biofeedback
Research Society. We are already hard at work creating
a program that will reflect the AAPB’s prestigious history.

53
Notes:
Notes:
Notes:
Notes:
 AAPB Section Meetings
Optimal Performance 5:50pm-6:30pm
The Optimal Performance Section is proud to announce that
Dr. Vietta Sue Wilson will be presenting on integrated mental
training. Dr. Wilson will discuss neurofeedback interspersed with HRV
training and self-regulation to advance sport skill. Current members
of the Optimal Performance Section as well as prospective members,
who are interested in joining the Section, are invited to attend.
International Stress Management Association-US (ISMA)
Friday, April 13,2018
12:45pm-1:45pm
ISMA Invites all AAPB attendees to join us for our Annual Meeting
and Presentation:
Current Research and Future Directions
Speakers: Patrick Steffen PhD, Paul Lehrer PhD, Jan B Newman MD, FACS
Lunch Available for $10 fee - payable onsite.
We welcome students and researchers to discuss your projects and
input. The International Stress Management Association is the oldest
continuous association dedicated to the study and remediation of
stress. ISMA’s US Branch is a section of the Association of Applied
Psychophysiology and Biofeedback. Today ISMA has branches around
the world including Australasia, Brazil, France, German Speaking Europe,
Hong Kong, India, Japan, The Netherlands, Russia, the United Kingdom.

Call for AAPB

Webinar Presenters
Earn $400 while helping your fellow
professionals grow their knowledge base

Through our webinar program, AAPB provides participants

with high-quality education and training without leaving the
home or office. AAPB offers a broad range of programming
hosted by experts to help keep participants up-to-date
on the latest research, clinical applications, trends, best
practices, hot topics and subjects of special interest in
the arena of applied psychophysiology and biofeedback
(neurofeedback, optimal performance, HRV).
Participants gain insight and knowledge to help them
take their careers to the next level, while gaining valuable
APA continuing education credits. We invite you to be a
part of this education initiative, giving our members the
knowledge and skills they need to elevate the science and
practice of applied psychophysiology and biofeedback.
We invite you to submit a proposal to conduct a webinar
presentation. Interested parties should contact Michelle
Cunningham at mcunningham@kellencompany.com.
We look forward to reviewing your submission, and will
contact you if your topic has been chosen!
 The Biofeedback
Certification
International Alliance

BCIA certifies individuals who meet

education and training standards in
biofeedback, neurofeedback, and
biofeedback for pelvic muscle dysfunction,
and progressively recertifies those who
advance their knowledge through
continuing education.

More than qualified -

BCIA Certified!
We’ve moved—Same great service at a new location!

5301 Ward Rd., #201, Arvada, CO 80002

Phone: (303) 420-2902
www.bcia.org - info@bcia.org
MAR1168-00
 20
16

Evidence-based practice in

Biofeedback &
Neurofeedback
3 Edition
rd

GABRIEL TAN, FREDRIC SHAFFER, RANDALL LYLE, AND IRENE TEO

 Evidence-Based Practice
in Biofeedback and Neurofeedback

Third edition
 Association for Applied Psychophysiology and Biofeedback (AAPB)

Founded in 1969, AAPB is the foremost international association for the study of biofeedback
and applied psychophysiology. AAPB is an interdisciplinary organization representing the fields
of psychology, psychiatry, medicine, dentistry, nursing, physical therapy, occupational therapy,
social work, education, counseling, and others.

AAPB’s mission is to promote and represent the science and practice of self-regulation to
enhance health and performance. Its vision is to integrate self-regulation into everyday life.

AAPB
10200 W. 44th Ave #304
Wheat Ridge, CO 80033
303 422 8436 phone 303 422 8894 fax
Email: info@aapb.org

Copyright/Ownership
Copyright © 2016
Association for Applied Psychophysiology and Biofeedback

ISBN 978-0-9842979-6-2
Evidence-Based Practice in Biofeedback and Neurofeedback, Third Edition

All rights reserved. No part of this publication may be reproduced or utilized in any form
or by any means, electronic or mechanical, including photocopying, recording, or by any
information storage and retrieval system, without permission in writing from the publisher.
 Evidence-Based Practice in Biofeedback and Neurofeedback

Praise for Evidence-Based Practice in Biofeedback and

Neurofeedback
Evidence-Based Practice in Biofeedback and Neurofeedback (3rd ed.) is the most comprehensive
review of research in the field of neurofeedback and biofeedback available to clinicians. The
diversity of topics will extend the clinician’s knowledge. This serves as a vital resource to
validate the use of these modalities. Perhaps the most important aspect of this review is the
ranking of the studies for each disorder based on the methodological quality of the research. I
recommend this book, not only to every clinician, but to all researchers interested in doing
biofeedback and neurofeedback research. This will allow researchers to explore the extent of
research thus far done, and will open the door to new ideas that can be investigated in the future.
Deborah R. Simkin, MD, DFAACAP, Diplomat ABIHM, BCN
Clinical Assistant Professor
Department of Psychiatry
University of Emory
School of Medicine

The completely revised Evidence-Based Practice in Biofeedback and Neurofeedback (3rd ed.)
provides the most comprehensive and up-to-date evidence-based and neuroscientifically
supported information available in print anywhere. Every clinical condition has been thoroughly
reviewed, rigorously revised and updated, and meticulously documented and referenced by
respected experts in the field, ensuring that this will be a continually accessed tool for clinicians,
researchers, and academicians looking for the most accurate, evidence-based information
covering a comprehensive listing of clinical conditions for which ever-accumulating experience
and evidence exist. This reference integrates the rigorous guidelines adopted by the Boards of
Directors of both the Association for Applied Psychophysiology and Biofeedback (AAPB) and
the International Society for Neurofeedback and Research (ISNR). For those in the worldwide
field of neuromodulation and neurotherapy, this is an immeasurably valuable tool and vital
resource to ensure we increasingly attain to the highest standards of scientific investigation and
clinical expertise. Well done!
Robert P. Turner, MD, MSCR, QEEGD, BCN
Associate Professor of Clinical Pediatrics & Neurology
University of South Carolina School of Medicine & Palmetto Health Richland Children's
Hospital
 Dedication

Dedication of the 2016 Edition

Gabriel Tan, Fredric Shaffer, Randy R. Lyle, and Irene Teo

The editors thank Carolyn Yucha, PhD, Christopher Gilbert, PhD, BCB, and Doil Montgomery,
PhD, who edited the previous editions of this reference. Their diligent work set the bar high for
future editions.
We thank Donald Moss, PhD, BCB, BCN, for his co-authorship of the Foreword, and Inna
Khazan, PhD, BCB, for contributing the Overview of Biofeedback.
We thank Judy Crawford, BCIA Executive Director, for her advocacy of this reference,
recommendations for topics and contributors, and co-authorship of the section on BCIA
Certification.
We thank Zachary Meehan of the Truman State University Center for Applied
Psychophysiology for copy editing, checking references, and providing hyperlinks to article
abstracts for the PDF version of this document.
We recognize financial support from AAPB and administrative support from the Kellen
Company.
Finally, we recognize the section authors whose expertise made this third edition possible:

Martijn Arns Hartmut Heinrich Richard A. Sherman

Jeffrey Bolek Carolyn Huntley Estate M. Sokhadze
Tracy Brown Inna Khazan Patrick R. Steffen
Robert Coben Paul M. Lehrer Mark J. Stern
Aisha Cortoos Silvia Mandrini Ute Strehl
Judy Crawford Matthew Mannion Gabriel Tan
Elena Dalla Toffola Olivier Mairesse Irene Teo
Emily Dessy Angele McGrady Robert W. Thatcher
Stuart Donaldson Michael G. McKee Tina Tin
Christopher L. Edwards Zachary M. Meehan Rosella Togni
Noel Casteel Larson Ford Doil D. Montgomery David Trudeau
Dale S. Foster Christine S. Moravec Lai Wei Wei
Richard Gevirtz Donald Moss Shin Yi Wong
Christopher Gilbert Nathalie Pattyn Mary C. Woods
Jay Ginsberg Sarah Prinsloo Sarah Wyckoff
Allan G. Glaros Rachel Ricca Carolyn Yucha
Nicholas Gravett Fredric Shaffer Christopher L. Zerr
Robert A. F. Guiles Steven Shearman
Ingrid Harm-Ernandes Leslie Sherlin
 Evidence-Based Practice in Biofeedback and Neurofeedback

Table of Contents
Foreword: Evidence-Based Practice in Biofeedback and Neurofeedback ................................................. i
Donald Moss and Fredric Shaffer
Chapter 1 – Overview of Biofeedback ...................................................................................................... 1
Inna Khazan
Chapter 2 – Clinical Efficacy of Biofeedback Therapy: Explanation of Efficacy Levels ........................ 5
Carolyn Yucha and Doil D. Montgomery
Chapter 3 – Biofeedback Certification International Alliance (BCIA) ..................................................... 7
Judy Crawford and Fredric Shaffer
Chapter 4 – The Biofeedback Certification International Alliance Professional
Standards and Ethical Principles of Biofeedback ................................................................................ 9
Chapter 5 – Adult Headache ................................................................................................................... 16
Tracy Brown and Patrick R. Steffen
Chapter 6 – Attention Deficit Hyperactivity Disorder (ADHD) ............................................................. 18
Martijn Arns, Hartmut Heinrich, and Ute Strehl
Chapter 7 – Alcohol Substance Abuse Disorders .................................................................................... 22
Estate M. Sokhadze and David Trudeau
Chapter 8 – Anxiety and Anxiety Disorders ........................................................................................... 27
Donald Moss
Chapter 9 – Arthritis ................................................................................................................................ 32
Mary C. Wood and Christopher L. Edwards
Chapter 10 – Asthma ............................................................................................................................... 35
Paul M. Lehrer
Chapter 11 – Autism ............................................................................................................................... 37
Robert Coben and Rachel Ricca
Chapter 12 – Cerebral Palsy ................................................................................................................... 43
Jeffrey Bolek
Chapter 13 – Chemobrain ....................................................................................................................... 45
Sarah Prinsloo
Chapter 14 – Chronic Pain ...................................................................................................................... 46
Richard A. Sherman, Gabriel Tan, Lai Wei Wei, and Tina Tin
Chapter 15 – Constipation ..................................................................................................................... 51
Irene Teo
Chapter 16 – Chronic Obstructive Pulmonary Disease (COPD) ............................................................ 54
Christopher Gilbert
Chapter 17 – Coronary Artery Disease ................................................................................................... 55
Christine S. Moravec and Michael G. McKee
Chapter 18 – Depressive Disorders ......................................................................................................... 57
Fredric Shaffer and Christopher Zerr
Chapter 19 – Diabetes Mellitus ............................................................................................................... 62
Fredric Shaffer and Zachary M. Meehan
Chapter 20 – Epilepsy ............................................................................................................................. 69
Gabriel Tan and Chin Yi Wong
Chapter 21 – Erectile Dysfunction .......................................................................................................... 73
Fredric Shaffer and Steven Shearman
Chapter 22 – Facial Palsy ....................................................................................................................... 75
Elena Dalla Toffola, Silvia Mandrini, and Rosella Togni
Chapter 23 – Fecal Incontinence ............................................................................................................. 79
Irene Teo
Chapter 24 – Fibromyalgia ..................................................................................................................... 81
Stuart Donaldson
 Table of Contents

Chapter 25 – Functional/Recurrent Abdominal Pain .............................................................................. 83

Robert A. F. Guiles, Mark J. Stern, Carolyn Huntley, and Richard Gevirtz
Chapter 26 – Hyperhidrosis .................................................................................................................... 84
Fredric Shaffer and Matthew Mannion
Chapter 27 – Hypertension ..................................................................................................................... 85
Angele McGrady
Chapter 28 – Immune Function .............................................................................................................. 87
Fredric Shaffer and Zachary Bartochowski
Chapter 29 – Insomnia ............................................................................................................................ 91
Emilie Dessy, Aisha Cortoos, Olivier Mairesse, and Nathalie Pattyn
Chapter 30 – Irritable Bowel Syndrome ................................................................................................. 95
Mark J. Stern, Robert A. F. Guiles, Carolyn Huntley, and Richard Gevirtz
Chapter 31 – Motion Sickness ................................................................................................................ 97
Fredric Shaffer and Nicholas Gravett
Chapter 32 – Performance Enhancement .............................................................................................. 101
Leslie Sherlin and Noel Larson Ford
Chapter 33 – Preeclampsia .................................................................................................................... 107
Fredric Shaffer and Zachary M. Meehan
Chapter 34 – Posttraumatic Stress Disorder ......................................................................................... 109
Jay Ginsberg, Dale S. Foster, and Gabriel Tan
Chapter 35 – Raynaud’s Disease ........................................................................................................... 113
Carolyn Yucha
Chapter 36 – Repetitive Strain Injury (RSI) ......................................................................................... 115
Fredric Shaffer
Chapter 37 – Stroke ............................................................................................................................... 118
Jeffrey Bolek
Chapter 38 – Temporomandibular Muscle and Joint Disorder (TMJD) Pain ....................................... 120
Alan G. Glaros
Chapter 39 – Tinnitus ............................................................................................................................ 122
Fredric Shaffer and Matthew Mannion
Chapter 40 – Traumatic Brain Injury (TBI) and Posttraumatic Stress Disorder (PTSD) ...................... 125
Dale S. Foster and Robert W. Thatcher
Chapter 41 – Urinary Incontinence: Children ....................................................................................... 128
Ingrid Harm-Ernandes
Chapter 42 – Urinary Incontinence: Men ............................................................................................. 130
Ingrid Harm-Ernandes
Chapter 43 – Urinary Incontinence: Women ......................................................................................... 131
Ingrid Harm-Ernandes
Chapter 44 – Vasovagal Syncope .......................................................................................................... 133
Fredric Shaffer
References .............................................................................................................................................. 135
 Evidence-Based Practice in Biofeedback and Neurofeedback

Foreword:
Evidence-Based Practice in Biofeedback and Neurofeedback
Donald Moss, PhD, BCB, BCN,1 and Fredric Shaffer, PhD, BCB2
1
Saybrook University, 2Truman State University

Biofeedback and Neurofeedback

Biofeedback is a technique that enables an individual to learn how to change physiological
activity for the purposes of improving health and performance (Gilbert & Moss, 2003; Schwartz
& Andrasik, 2003; Shaffer & Moss, 2006). In 2007, the Association for Applied Psychophysiol-
ogy and Biofeedback (AAPB), the International Society for Neurofeedback and Research
(ISNR), and the Biofeedback Certification Institute of America (BCIA) commissioned a Task
Force on Nomenclature to develop an official definition of biofeedback:
Biofeedback is a process that enables an individual to learn how to change physiological
activity for the purposes of improving health and performance. Precise instruments measure
physiological activity such as brainwaves, heart function, breathing, muscle activity, and skin
temperature. These instruments rapidly and accurately “feed back” information to the user.
The presentation of this information—often in conjunction with changes in thinking,
emotions, and behavior—supports desired physiological changes. Over time, these changes
can endure without continued use of an instrument. (Schwartz, 2010)
This feedback of information about physiological processes assists the individual to increase
awareness of these processes and to gain voluntary control over body and mind.
Biofeedback instruments measure muscle activity, skin temperature, electrodermal activity
(sweat gland activity), respiration, heart rate, heart rate variability, blood pressure, brain
electrical activity, and blood flow. Research shows that biofeedback, alone and in combination
with other behavioral therapies, is effective for treating a variety of medical and psychological
disorders, ranging from headache to hypertension to temporomandibular disorder to attentional
disorders. The present publication surveys these applications and reviews relevant outcome
research.
Biofeedback is a multidisciplinary field. Biofeedback instruments are used by physicians,
nurses, psychologists, counselors, physical therapists, occupational therapists, health coaches,
optimal performance trainers, and others. The primary certification organization for both
biofeedback and neurofeedback, the Biofeedback Certification International Alliance (BCIA),
certifies health professionals in a variety of fields, including psychology, medicine, nursing,
physical therapy, respiratory therapy, occupational therapy, social work, counseling, counseling
education, music therapy, rehabilitation, chiropractic, recreational therapy, dental hygiene,
physician's assistant, exercise physiology, speech pathology, and sports medicine. An updated list
of health care professions eligible for certification, and specific requirements for academic
degrees, certification, and licensure is available on the BCIA website (www.bcia.org).
Biofeedback therapies teach the individual to take a more active role in maintaining personal
health and achieving higher level mind-body health and performance. A primary goal of
biofeedback therapies is the acquisition of self-regulation skills and the generalization of these
skills to everyday life outside the clinic.
Neurofeedback is a specialty field within biofeedback that is devoted to training people to
gain control over electrophysiological processes in the human brain (Demos, 2005; Evans &
Abarbanel, 1999; LaVaque, 2003; Thompson & Thompson, 2015). Neurofeedback uses

i
 Foreword

information from the electroencephalogram (EEG) to show patterns of electrical activation in the
cortex. Many neurological and medical disorders are accompanied by abnormal patterns of
cortical activity (Hammond, 2006). Neurofeedback practitioners use a baseline EEG, and
sometimes a multisite quantitative EEG (QEEG), to identify abnormal patterns (LaVaque, 2003),
and then re-train the brain to modify aberrant patterns.
Newer techniques in neurofeedback include the use of low-resolution electromagnetic
tomography (LORETA) to assess and re-train deeper brain structures, below the surface of the
cortex (Canon et al., 2009). In addition, Z-score neurofeedback training utilizes a real time
software compilation of multiple measurements into a single “Z-score,” an index of abnormality;
the neurofeedback display then provides feedback as the Z-score lessens, showing that multiple
parameters are normalizing (Collura et al., 2010).
Neurofeedback practice is growing rapidly with the widest acceptance for applications for
attention deficit hyperactivity disorder (ADHD), learning disabilities, seizures, depression,
acquired brain injuries, substance abuse, and anxiety (Clinical EEG, 2000; Tan, Shaffer, Lyle, &
Tse, 2016).

Complementary and Integrative Medicine

Biofeedback and neurofeedback are not new; they have been under development since the first
biofeedback research conference in 1969 (Moss, 1998). Biofeedback shares many principles and
explanatory concepts with mainstream biomedicine, including an emphasis on physiological
mechanisms and a research-based approach to investigating new interventions. Biofeedback
techniques make sense to scientifically minded clinicians, and biofeedback therapies combine
well with medical therapies for disorders ranging from headache to hypertension.
Many biofeedback therapies have been developed as an extension of basic laboratory
research. Richard Davidson, for example, reported basic neuroscience findings that persons with
greater activation of right frontal areas of the cortex showed a disposition toward depressive
responses (Davidson, 1995, 2000). Peter Rosenfeldt then took this laboratory observation and
created a neurofeedback protocol to retrain the left-right asymmetry in the frontal cortex. In
follow-up studies, Rosenfeld and colleagues showed clinically significant improvements in mood
in patients with depressive disorders (Baehr & Rosenfeld, 2003; Baehr, Rosenfeld, Baehr, &
Earnest, 2002) and later with premenstrual dysphoric disorder (Baehr, Miller, Rosenfeld, &
Baehr, 2004; Baehr, Rosenfeld, Miller, & Baehr, 2004).
Nevertheless, biofeedback and neurofeedback are also attractive approaches for individuals
who are seeking complementary therapies and integrative medicine (Lake & Moss, 2003).
Complementary therapies are therapies outside the primary medical model that nevertheless
share paradigmatic assumptions with biomedicine and serve to augment mainstream treatments.
Integrative medicine is the combination of complementary and mainstream treatments in one
comprehensive treatment package (NIH, 2015).
The public currently appears to seek out therapies that: 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) are
noninvasive; and 4) elicit the body’s own healing response (Jonas & Levin, 1999; Moss, 2003).
James Gordon, the first chairman of the Federal Advisory Council of the NIH Office of
Alternative Medicine, has emphasized that educating individuals in self-care must be at the
center of this new medicine in order to deal with the changing picture of health problems today,
especially the increasing incidence of chronic conditions (Gordon, 1996). Self-regulation skills
are an important component within self-care, and biofeedback is a useful tool in teaching self-
regulation skills.
Both biofeedback and neurofeedback are holistic therapies, based on the recognition that
changes in the mind and emotions affect the body, and changes in the body also influence the
ii
 Evidence-Based Practice in Biofeedback and Neurofeedback

mind and emotions. 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. The positive effects of feedback training enhance
health, learning, and performance. There are biofeedback protocols to address many of the
disorders, including anxiety, depression, and chronic pain, for which the public is using comple-
mentary therapies in high numbers (Barnes, Bloom, & Nahin, 2008; Bassman & Uellendahl, 2003;
Burke, 2003; Freeman, 2008; Kessler et al., 2001). Biofeedback and neurofeedback complement
the mainstream treatments of biomedicine, and integrate well for use in medical clinics.

Evidence-Based Practice
Biofeedback and neurofeedback also provide the kind of evidence-based practice the health care
establishment is demanding today (Geyman, Devon, & Ramsey, 2000; Sackett, Straus,
Richardson, Rosenberg, & Haynes, 2000). The Cochrane Collaboration (www.cochrane.org),
Evidence-Based Medicine (http://ebm.bmj.com) and the Journal of Evidence-Based Medicine
(http://onlinelibrary.wiley.com/subject/code/000054) are three of many resources for current
principles of evidence-based medicine and evidence based practice.
Evidence-based practice is a process of using the best evidence, preferably research findings,
to guide the delivery of health services. Levels of evidence range from case reports and
observational studies to randomized clinical trials. From the beginning, biofeedback developed
as a research-based approach, emerging directly from laboratory research on psychophysiology
and behavior therapy. The field of feedback therapies has maintained its close relationship with
both pure and applied empirical research. Pure research takes place largely in laboratories and
seeks new understandings of neurophysiological mechanisms underlying disorders such as panic
disorder and hypertension. Better recognition of underlying mechanisms continues to inspire new
biofeedback treatment approaches. One such line of research is using high resolution functional
magnetic resonance imaging (fMRI) to learn more about the pathophysiology of various
conditions, identify brain areas activated during biofeedback, and re-train brain regions and
functional brain networks (Andrasik & Rime, 2007; Hamson et al., 2012; Stoeckel et al., 2014).
In turn, many biofeedback applications have been tested and proven, both in research and
practice.
Biofeedback and neurofeedback are also approaches that rely on well-developed professional
standards and guidelines for competent practice. An international certification organization, the
Biofeedback Certification International Alliance (BCIA, formerly the Biofeedback Certification
Institute of America), has established blueprints of necessary knowledge and skills and conducts
examinations qualifying individuals for certification in general biofeedback, heart rate variability
biofeedback, neurofeedback, and pelvic floor disorders such as urinary incontinence. (Infor-
mation on certification standards is available at www.bcia.org). The BCIA has provides a
document outlining Professional Standards and Ethical Principles of Biofeedback (2015),
providing guidelines for ethical practice, also available at www.bcia.org.

Efficacy and Clinical Effectiveness

The present volume fills a void in the biofeedback and neurofeedback practice world: the need
for a standardized assessment of clinical efficacy and effectiveness for feedback-based therapies.
“Efficacy” refers to the determination of a training or treatment effect derived from a systematic
evaluation obtained in a controlled clinical trial (LaVaque et al., 2002). “Clinical effectiveness”
assesses how well a treatment works in actual clinical settings with typical clinical populations.
Everyday clinical practice includes more individuals who suffer with subsyndromal conditions
and comorbid disorders and who are already participating in multiple treatments beyond the
researcher’s control. It is rare for the average primary care physician or behavioral health
iii
 Foreword

practitioner to see a patient who has only one medical condition, who clearly meets diagnostic
criteria, and who is not involved in other therapies.
Evidence-based practice must take into account both efficacy in controlled research settings
and effectiveness in the real world of clinical practice. Neither the general public nor the novice
biofeedback practitioner can always assess which applications are well documented and which
remain more experimental. Attending biofeedback and neurofeedback conferences, one hears
discussion of many promising new approaches, and websites often claim “well-documented
efficacy” for a variety of new approaches. Nevertheless, today’s research climate has higher
standards for “efficacy” and “effectiveness” than were current during much of the time period in
which biofeedback and neurofeedback evolved. The present publication applies current standards
of research methodology to biofeedback and neurofeedback practice.

Efficacy Standards
In 2001, the two professional associations in this practice area, the Association for Applied
Psychophysiology and Biofeedback (AAPB) and the International Society for Neuronal
Regulation, now known as the International Society for Neurofeedback and Research (ISNR),
together commissioned a Task Force to develop official standards for research methodology,
establishing what kinds of research are required for each of five levels of efficacy, ranging from
the lowest level, “not empirically supported,” to the highest level, “efficacious and specific.”
That Task Force report has been published along with a brief introduction describing the context
and need for its development (LaVaque et al. 2002; Moss & Gunkelman, 2002). The efficacy
guidelines themselves can be found, with criteria for each rating, in the present document.
The Task Force created rigorous standards, which are not easily applied to feedback
therapies. There are inherent difficulties, for example, in creating a double-blind condition for a
therapy that is founded on enhancing self-awareness of body and mind. For example, “sham
feedback” (feedback that does not reflect the subject’s actual physiological state) has been used
as a control condition in biofeedback research. Yet, perceptive individuals often notice that the
auditory or visual feedback does not fit with their perceptions of their bodies; they are not
blinded as the methodology requires. There are also ethical implications today, following the
international Declaration of Helsinki, published by the World Medical Association (2000), in
using placebos or sham therapies when the relative efficacy of one of the treatment conditions is
already known (LaVaque et al. 2002).
In addition, most efficacy studies in the past have compared biofeedback alone to placebo or
to currently accepted therapies. This approach attempts to isolate the specific therapeutic effects
of biofeedback, which is important from a research standpoint. In clinical practice, however,
biofeedback is often combined with a wide variety of adjunctive therapies, including relaxation
training, visualization, behavior therapies, client education, and other strategies. James Gordon,
director of the Center for Mind Body Medicine, has advocated that future outcome research
should compare integrative packages of alternative therapies, including biofeedback, to placebo
alone or to accepted therapy packages (2003).
Nevertheless, it is critical to apply prevailing standards for outcome research to provide a
credible rating of therapeutic interventions for today’s evidence-based health care sector. Failing
to do so exposes biofeedback and neurofeedback to the danger of being left by the wayside as
irrelevant in today’s best practices-focused treatment milieu.

Efficacy in Perspective
The present volume does not attempt exhaustive reviews of all research on each application.
Rather, this volume reviews a sampling of the best available evidence and, in concise form, rates
each application according to the official AAPB/ISNR efficacy guidelines.
iv
 Evidence-Based Practice in Biofeedback and Neurofeedback

A parallel series of white papers conducted a more comprehensive review. Seven white
papers were published in the series, and other white papers have been published independently
on the efficacy of various biofeedback and neurofeedback applications. The white paper series
reviewed the efficacy of biofeedback for attention deficit disorders (Monastra, Lynn, Linden,
Lubar, Gruzelier, & LaVaque, 2005), anorectal disorders (Palsson, Heymen, & Whitehead,
2004), hypertension (Linden & Moseley, 2006), temporomandibular disorders (Crider, Glaros, &
Gevirtz, 2005), tension and migraine headache (Nestoriuc, Martin, Rief, & Andrasik, 2008),
Raynaud’s disease (Karavidas, Tsai, Yucha, McGrady, & Lehrer, 2006), substance abuse
(Sokhadze, Cannon, & Trudeau, 2008), and urinary incontinence (Glazer & Laine, 2006).
Beyond this series, Wheat and Larkin (2010) published a critical review of research assessing
the efficacy of heart rate variability (HRV) for a variety of disorders, and reported significant
clinical improvements following HRV training, across several disease states. However, Wheat
and Larkin also noted methodological inadequacies in many of the published studies on HRV
biofeedback. A recent study by Greenhalgh, Dickson, and Dundar (2009), for example, reviewed
the research on the use of biofeedback with hypertension and similarly emphasized the relatively
small samples in studies to date, the lack of longer term follow-up to show meaningful duration
of any therapeutic effects, and the need to integrate newer forms of biofeedback (including heart
rate variability training) into well-controlled clinical trials.
A lower efficacy rating does not necessarily indicate an application is not helpful. In some
cases, a lower rating has been applied chiefly because the relevant research has not yet been
conducted. In other cases, a lower rating means the application benefits some subjects and not
others because of wide intersubject variability. Human beings are not uniform. On a group
comparison basis, these selective successes may not be statistically significant.
If a prospective client cannot tolerate the available medication therapies in traditional
medicine, or if the individual is averse to staying with a medication, then “possibly efficacious”
feedback therapies may be reasonable alternatives.
Many of today’s well-accepted medical procedures have never been subjected to the rigorous
efficacy standards adopted here. Many medications, in particular, are utilized off-label; that is,
they are prescribed for specific medical conditions not indicated by the Food and Drug
Administration and for which no rigorous clinical trials exist. Other medical therapies have been
tested in randomized clinical trials and show reliable but relatively small effects. In a clinical
drug trial with 10,000 subjects, even a small benefit will produce a statistically significant effect.
Some reports on antidepressants, for example, showed outcomes no better than placebo (Finniss
et al., 2010; Kirsch, 2008), while another recent report using a growth mixture modeling
methodology (Gueorguieva, Mallinckrodt, & Krystal, 2011) showed that three quarters of
patients did better on medication than on placebo, while another 25% failed to benefit or did
more poorly than those on placebo. Yet, these medications are among the most frequently
prescribed in most primary care clinics.
Similarly, many of the widely used educational methods for assisting students with learning
disabilities have yet to be subjected to rigorous scrutiny. A “possibly efficacious” or “probably
efficacious” biofeedback or neurofeedback application may still be relatively powerful compared
to the mainstream alternatives available to an individual with learning challenges.
The feedback therapies also provide a useful alternative for clients who show adverse effects
to medications, those who fail to respond to mainstream therapies, and those who prefer more
natural, self-regulation–oriented treatment.

v
 Overview of Biofeedback
Chapter 1 – Overview of Biofeedback
Inna Khazan, PhD, BCB1,2
1
Harvard Medical School
2
Boston Center for Health Psychology and Biofeedback
Definition
Since its conception as a field of study in the
1960s, biofeedback has been defined in
many ways. In 2007, a standard definition of
biofeedback was crafted by a task force
comprised of scientists and clinicians,
working on behalf of The Association for
Applied Psychophysiology and Biofeedback
(AAPB), the Biofeedback Certification
International Alliance (BCIA), and the
International Society for Neurofeedback and
Research (ISNR). The task force defined
biofeedback as “a process that enables an
individual to learn how to change physiolog-
ical activity for the purposes of improving
health and performance. Precise instruments
measure physiological activity such as
brainwaves, heart function, breathing,
muscle activity, and skin temperature. These
instruments rapidly and accurately ‘feed
back’ information to the user. The presenta-
tion of this information—often in conjunc-
tion with changes in thinking, emotions, and
behavior—supports desired physiological
changes. Over time, these changes can
endure without continued use of an
instrument."
Biofeedback Treatment and Training in
Various Settings
Biofeedback is used in clinical, educational,
and peak performance settings. In clinical
settings, biofeedback may be performed by
mental health practitioners (e.g., psycholo-
gists, social workers, marriage and family
counselors, and mental health counselors),
physical or occupational therapists, physi-
cians, nurses, and dentists. In these settings,
biofeedback is typically used as treatment
for specific disorders, such as anxiety,
attention deficit hyperactivity disorder
(ADHD), migraines, chronic pain, temporo-
1
mandibular joint disorder (TMJD), and
urinary incontinence.
The term biofeedback treatment in these
clinical settings is necessitated by the
expectation of clients or patients to receive
treatment for their problem, by the clinicians
who are used to providing treatment, and by
the insurance companies that reimburse only
for treatment. However, the term treatment
has the connotation of passivity on the part
of the client or patient who is receiving
treatment from an active clinician. This
perception of passivity is contrary to the
active engagement on the part of the client
that is necessary for successful outcomes.
Biofeedback training is the more accurate
term describing active client participation, in
which the client trains to use specific
biofeedback skills. However, using training
as the only term to describe biofeedback is
limiting: insurance companies will not
reimburse for procedures not considered
treatment, and clients may not buy into an
intervention that is not considered treatment.
One way to reconcile the apparent
contradiction between the needs of a clinical
setting and the need for a more active
engagement on the part of the client is to
view biofeedback training during each
individual session as being part of the com-
prehensive biofeedback treatment. Biofeed-
back treatment is developed by the clinician
based on assessment of the presenting
problem and the empirical evidence
supporting specific biofeedback interven-
tions. Treatment incorporates a certain set of
biofeedback skills prescribed for the
presenting problem and delivered through
biofeedback training with the purpose of
improving symptoms. Biofeedback training
in this case refers to the process of learning
specific biofeedback skills in-session and
 Evidence-Based Practice in Biofeedback and Neurofeedback
then practicing these skills outside of
session.
The distinction between treatment and
training becomes unnecessary in educational
and peak performance settings, where
biofeedback is most easily seen as training,
with active engagement on the part of the
client. Educational (e.g., self-improvement
courses) and peak performance (e.g., athletic
training, artistic and executive performance
coaching) settings often call for the same
skills as those used in clinical settings, with
the exception that these skills are not used to
correct a problem, but rather to further
improve existing strengths and abilities.
Biofeedback Modalities
Biofeedback training typically utilizes one
or more of the following modalities:
• Respiratory – measuring rate and pattern
of breathing, and blood levels of carbon
dioxide
• Cardiovascular – measuring heart rate,
heart rate variability (HRV), respiratory
sinus arrhythmia (RSA), and blood
volume pulse
• Neuromuscular – measuring muscle ten-
sion with surface electromyography
(SEMG)
• Skin conductance (SC) – measuring
eccrine sweat gland activity
• Peripheral skin temperature – measuring
finger and/or toe temperature
• Central nervous system (brain) – meas-
uring electrical signals from the brain
(brainwaves) using electroencephalog-
raphy (EEG). This modality is typically
referred to as neurofeedback.
Choice of specific modalities used in
biofeedback training depends on the issue
that the client would like to address. This
book is intended to serve as a guide in
determining which biofeedback modalities
are most appropriate to use with each client.
Literature reviews and summaries presented
for each disorder (or area of training) indic-
ate which biofeedback modalities are empir-
ically supported for use with that disorder.
2
For example, thermal biofeedback is an
empirically supported treatment for migraine
headache (Nestoriuc, 2007); SEMG biofeed-
back is indicated for tension headaches
(Bembalgi & Naik, 2013; Nestoriuc et al.,
2007), TMJD (Crider et al., 2005, Mora et al.,
2013), and urinary incontinence (Newman,
2014); and neurofeedback is an empirically
supported treatment for ADHD (Arns et al.,
2009, 2014).
Rapport and Client Buy-In
Regardless of which modalities of biofeed-
back are chosen for training, rapport and
positive relationship with a client are
extremely important for treatment success.
Studies, such as the one conducted by
Martin, Garske, and Davis (2000), have
shown that there is a significant relationship
between treatment success in psychotherapy
and the quality of the therapeutic alliance
between therapist and client. The “person
factor” has also been shown to be crucial for
success in biofeedback training. For exam-
ple, a study by Taub (Taub, 1977; Taub &
School, 1978) found large differences in
success of hand warming between two
groups of participants, one of which was
trained by a “friendly” therapist, while the
other was trained by an “impersonal” thera-
pist. The differences in success of training
were astounding—9.1% success for the
impersonal therapist group vs. 90.5% for the
friendly therapist group!
With the added complexity of untangling
wires, preparing the skin, and attaching
sensors in biofeedback, it is easy to get lost
in the technical details and neglect the per-
sonal connection with the client. It is there-
fore that much more important to use the
initial evaluation and the first few minutes
of each biofeedback session to establish and
maintain rapport.
Positive reinforcement is a great con-
tributor to building and maintaining a con-
nection with the client, as well as a crucial
element of success in biofeedback skill
acquisition. A reinforcer is defined as any-
thing that increases the frequency of a
 Overview of Biofeedback
certain behavior—biofeedback skills prac-
tice in our case. Verbal praise on the part of
the therapist, the satisfaction the client expe-
riences when achieving a goal, and the
auditory/visual rewards built in to most
biofeedback training programs are powerful
reinforcers.
Further facilitating success of training is
the client’s belief in the credibility of the
proposed treatment as the best choice, also
referred to as client buy-in. The therapist can
increase client buy-in by providing the client
with a clear rationale for the proposed
treatment and a basic understanding of the
physiology underlying both the presenting
problem and the specific biofeedback
intervention(s) proposed by the therapist. A
study by Oliveira, Gevirtz, and Hubbard
(2006) demonstrated the importance of
patients’ understanding of the underlying
physiological mechanisms for better treat-
ment outcomes in a whiplash injury. Gluck
(2014) emphasized the importance of treat-
ment rationale for successful outcomes in
neurofeedback. Smeets et al. (2008) empiri-
cally demonstrated the importance of the
client’s view of treatment credibility in
improving outcomes of treatment for low
back pain.
Goals for Training and Practice
Stated broadly, goals of biofeedback
treatment and training are threefold:
• Awareness – improved awareness of
one’s physiological, cognitive, and
emotional processes is crucial in creating
meaningful change.
• Change – ability to self-regulate depends
on the ability to influence one’s physio-
logical state with conscious awareness.
• Generalization – long-lasting improve-
ment is only possible when the skills
learned in the therapist’s office are
generalized to the everyday environment.
More specific goals exist for each
modality of biofeedback. Reaching these
goals, otherwise known as training to
3
criterion, is extremely important for treat-
ment success. For example, in thermal
biofeedback, the training criterion is 95⁰F
for the hands. In EMG biofeedback, the
down-training criterion is 3 microvolts in
most cases. If these goals are not met during
biofeedback training, the client is unlikely to
derive full benefit from treatment.
In research, when study participants are
not successfully trained to criterion within
the modalities being investigated, the study
findings often lead to a conclusion that
biofeedback is not an effective treatment.
For example, a study by Middaugh et al.
(2001) did not find thermal biofeedback to
be an effective treatment for Raynaud’s
disease. The authors reported that only
34.6% of participants affected by Raynaud’s
learned to warm their hands to the 95⁰F
criterion. A similar issue occurred in a study
conducted by the Raynaud’s Treatment
Study Investigators (2000), which also
concluded that thermal biofeedback is not an
effective treatment for Raynaud’s disease,
with only 35% of its participants success-
fully training to criterion. In studies where a
majority of participants were successfully
trained to warm their hands to the 95⁰F
criterion, the results showed thermal bio-
feedback to be an effective treatment (e.g.,
Freedman et al., 1983, 1985, described by
Schwartz & Sedlacek, 2003).
Of course, when setting the final goal, it
is important to also set multiple intermediate
goals that are realistic for the client to
achieve within a short period of training (1-2
sessions). Setting realistic goals in training
facilitates client’s feelings of mastery and
satisfaction. A common rule of thumb for in-
session goal setting is the “70-30” rule
(Olton & Noonberg, 1980). This rule
suggests moving to a new challenge level
when the client is meeting the goal more
than 70% of the time, and lowering the
challenge if the client is not meeting the goal
more than 30% of the time.
Similarly, realistic goals for frequency
and duration of home practice are equally
 Evidence-Based Practice in Biofeedback and Neurofeedback
important. Most clients will not be able to
practice as frequently or for as long as the
therapist would wish for them to do right
away. A helpful approach is to discuss with
the client the duration and frequency of
home practice sessions that s/he thinks are
most realistic, and then take it down by
about a third, since most people tend to
overestimate their ability to set aside
practice time. As the client is meeting the
duration and frequency goals, goals may be
gradually increased until the client is
practicing at the level optimal to support in-
session training. It is also helpful to ask the
client to keep a log of symptoms and home
practice early on in the treatment. The logs
will help with learning about triggers for
symptoms, keeping track of progress, and
helping the client to be more consistent with
home practice assignments.
Altogether, positive reinforcement, client
buy-in to the proposed treatment, and
realistic goals for training and practice will
contribute to the clients’ feeling that they are
meeting or exceeding goals and expecta-
4
tions, which in turn is likely to increase their
motivation, willingness to learn and practice
new skills, and ultimately, improve treat-
ment outcome.
This text is designed to assist the
therapist in multiple aspects of biofeedback
treatment and training in the following
ways:
1. Assist in deciding whether biofeedback
is an empirically supported treatment for
the presenting problem
2. Assist in deciding which biofeedback
modality or modalities are empirically
supported as treatment for the disorder
3. Assist the therapist in providing the
client with clear and accurate rationale
for treatment based on empirical
evidence
4. Provide the therapist with guidelines for
treatment duration, and optimal frequen-
cy and duration of home practice
5. Provide the therapist with guidelines for
treatment goals and measures of success.
 Clinical Efficacy of Biofeedback Therapy: Explanation of Efficacy Levels
Chapter 2 – Clinical Efficacy of Biofeedback Therapy:
Explanation of Efficacy Levels
Carolyn Yucha, PhD,1 and Doil D. Montgomery, PhD, BCB Emeritus2
1
University of Nevada, Las Vegas
2
Nova University
Biofeedback therapy has matured over the
last 40 years, and today there are myriad
disorders for which biofeedback therapy has
been used. Large research grants have funded
prospective studies on biofeedback therapy
for a variety of disorders, such as headache
(migraine, mixed, and tension), essential
hypertension, and urinary incontinence.
These studies consistently report positive
results.
On the other hand, several reports of
unsuccessful biofeedback training have
appeared in the research literature since the
inception of biofeedback training four
decades ago. Many of the unsuccessful
studies conducted in the early development
of the field reflect failure to thoroughly train
patients. For example, some unsuccessful
studies provided only minimal training with
the biofeedback instrumentation (often one
to four sessions of short duration), provided
little coaching, involved no home practice,
and failed to train to clinical criteria.
In 2001, a Task Force of the Association
for Applied Psychophysiology and Biofeed-
back and the Society for Neuronal Regula-
tion developed guidelines for the evaluation
of the clinical efficacy of psychophysio-
logical interventions (Moss & Gunkelman,
2002). The board of directors of both
organizations subsequently approved these
guidelines. These Criteria for Levels of
Evidence of Efficacy, described below, were
used to assign efficacy levels for the vast
number of conditions for which biofeed-
back has been used.
Level 1: Not Empirically Supported
Supported only by anecdotal reports and/or
case studies in non-peer-reviewed venues.
Not empirically supported.
5
Level 2: Possibly Efficacious
At least one study of sufficient statistical
power with well-identified outcome mea-
sures but lacking randomized assignment to
a control condition internal to the study.
Level 3: Probably Efficacious
Multiple observational studies, clinical
studies, wait-list controlled studies, and
within-subject and intrasubject replication
studies that demonstrate efficacy.
Level 4: Efficacious
a. In a comparison with a no-treatment con-
trol group, alternative treatment group,
or sham (placebo) control utilizing ran-
domized assignment, the investigational
treatment is shown to be statistically
significantly superior to the control con-
dition, or the investigational treatment is
equivalent to a treatment of established
efficacy in a study with sufficient power
to detect moderate differences, and
b. The studies have been conducted with a
population treated for a specific problem,
for whom inclusion criteria are delineat-
ed in a reliable, operationally defined
manner, and
c. The study used valid and clearly
specified outcome measures related to the
problem being treated, and
d. The data are subjected to appropriate data
analysis, and
e. The diagnostic and treatment variables
and procedures are clearly defined in a
manner that permits replication of the
study by independent researchers, and
f. The superiority or equivalence of the
investigational treatment has been shown
in at least two independent research
settings.
 Evidence-Based Practice in Biofeedback and Neurofeedback

Level 5: Efficacious and Specific on every possible disorder, but rather is

Evidence for Level 5 efficacy meets all of meant to provide rationale for efficacy
the criteria for Level 4. In addition, the ratings of biofeedback.
investigational treatment has been shown to
be statistically superior to credible sham Note: This article is also available as a
therapy, pill, or alternative bona fide document online at www.aapb.org and
treatment in at least two independent www.isnr.net.
research settings.
This monograph is not meant to be an
inclusive review of all literature published

6
 Biofeedback Certification International Alliance
Chapter 3 – Biofeedback Certification International Alliance
(BCIA)
Judy Crawford,1 and Fredric Shaffer, PhD, BCB2,3
1
BCIA Executive Director
2
BCIA Chair and 3Center for Applied Psychophysiology, Truman State University
The Biofeedback Certification International
Alliance (BCIA) is an autonomous nonprofit
corporation that was created in January 1981
as the Biofeedback Certification Institute of
America. In 2010 the name was changed to
recognize an international scope, and as of
2015, BCIA certifications are held in 32
countries.
The mission is simply stated: “BCIA
certifies individuals who meet education and
training standards in biofeedback and progres-
sively recertifies those who advance their
knowledge through continuing education.”
BCIA is recognized as the certification
body for the clinical practice of biofeedback
by the Association for Applied Psychophysi-
ology and Biofeedback (AAPB), the
Biofeedback Federation of Europe (BFE),
the International Society for Neurofeedback
and Research (ISNR), and many other
organizations.
BCIA policies and procedures are set by
an independent board of directors, which is
comprised of a rotating group of distinguish-
ed biofeedback clinicians, researchers, and
educators.
Three certification programs are
currently offered:
1. BCB – Board Certified in Biofeedback
(providing the basics of biofeedback,
including electrodermal, EMG, HRV,
thermal, and brief introduction to EEG),
2. BCN – Board Certified in
Neurofeedback (for those who wish to
specialize in EEG biofeedback), and
3. BCB-PMD – Board certified in Pelvic
Muscle Dysfunction Biofeedback
(designed specifically for licensed health
care professionals who use biofeedback
7
and behavioral interventions to treat
elimination disorders and pelvic pain
syndromes).
BCIA saw the need to establish science-
based educational criteria in heart rate
variability biofeedback (HRVB) and has
offered a Certificate of Completion in HRVB
since 2012. This credential documents
completion of 15 hours of didactic education,
3 hours of ethics/professional standards
coursework, and passing an objective exam.
There are no degree prerequisites or personal
biofeedback, case conference, or patient/client
treatment requirements.
BCIA has developed an affiliate program
in countries where there is an established and
respected biofeedback community and
membership organization. This membership
group joins with BCIA to form a local
regional affiliate that upholds the educational
and training standards, but takes a stronger
role in ensuring that the prerequisites are
appropriate for that area. Affiliates help to
redefine certification requirements and
review applications from their country. BCIA
has affiliates in Australia (BCIA-A) and
Mexico (BCIA-M).
BCIA certification is the mark of
distinction for providers of biofeedback
services. Names of certified practitioners
may be found in the “Find a Practitioner”
area of its website at www.bcia.org. A
BCIA-certified practitioner must meet the
following qualifications:
1. Prerequisite educational degree of a
BA/BS or higher from a regionally
accredited academic institution in a
BCIA-accepted clinical health care field
 Evidence-Based Practice in Biofeedback and Neurofeedback
such as counseling, medicine, nursing,
psychology, rehabilitation, or social
work. Credentialed special education
teachers may also become certified in
neurofeedback to work in school
environments.
2. Didactic training by completing a BCIA-
accredited 3-semester-hour university
course from a regionally-accredited
academic institution or its equivalent, or
completing a BCIA-accredited training
program covering the Blueprint of
Knowledge statements specific to that
certification program.
3. Evidence of a human anatomy, human
biology, or human physiology course for
biofeedback and neurofeedback, or a
neuroanatomy, neuroscience, or physio-
logical psychology course for neurofeed-
back from a regionally accredited
academic institution or from a BCIA-
accredited program.
4. Practical training to teach the application
of clinical skills provided by a BCIA-
approved mentor using contact hours to
8
review personal biofeedback, case
conference, and patient/client treatment
sessions.
5. Successful completion of a written
certification exam covering all relevant
blueprint areas.
6. Adherence to the BCIA Professional
Standards and Ethical Principles of
Biofeedback (PSEP).
When treating a diagnosed medical or
psychological disorder, BCIA certificants are
required to carry a valid state-issued license
in a BCIA-approved health care field or to
work under appropriate supervision.
Although BCIA certification ensures that an
individual has met entry-level education and
training requirements for the clinical practice
of biofeedback, certification is not a
substitute for a state-sanctioned license or
other credential to practice one’s profession.
The public and interested professionals
may visit www.bcia.org to read about
certification requirements or search for a
practitioner.
 BCIA Professional Standards and Ethical Principles of Biofeedback
Chapter 4 – The Biofeedback Certification
International Alliance Professional Standards and
Ethical Principles of Biofeedback
Preamble
For the purposes of this document, the term
BCIA professionals refers to BCIA
certificants and those who have filed a
formal application for BCIA certification.
Because the Biofeedback Certification
International Alliance (BCIA) and its profes-
sionals are committed to the protection of
human rights, they strive to maintain the
dignity and worth of the individual while
rendering service, conducting research, and
teaching others. They operate within the
BCIA Professional Standards and Ethical
Principles (PSEP). They strive to provide
the highest quality of service and carefully
differentiate between empirically validated
and experimental procedures. They hold
themselves responsible for their actions and
make every effort to protect their clients’
welfare. Finally, they limit their services to
those areas in which they have expertise and
exemplify the values of competence,
objectivity, freedom of inquiry, and honest
communication.
The PSEP is intended to guide all BCIA
professionals who commit themselves to
adhere to these Principles as well as to the
Principles stated in their licensing act. A
copy of the PSEP will be provided to all
BCIA certification applicants and will be
available on the BCIA website. The PSEP
are intended to educate and guide profes-
sionals to prevent ethical misconduct and
should be applied with professional
maturity.
The term biofeedback refers to all
modalities for which we provide certifica-
tion including, but not limited to, BVP, EEG
or neurofeedback, electrodermal, EMG,
HRV, respiration, and thermal biofeedback.
“Biofeedback is a process that enables
an individual to learn how to change
9
physiological activity for the purposes of
improving health and performance. Precise
instruments measure physiological activity
such as brainwaves, heart function, breath-
ing, muscle activity, and skin temperature.
These instruments rapidly and accurately
feed back information to the user. The
presentation of this information—often in
conjunction with changes in thinking,
emotions, and behavior—supports desired
physiological changes. Over time, these
changes can endure without continued use of
an instrument.”1
Purpose and Scope
1. The PSEP consist of guidelines for
professional biofeedback practice that
are not exhaustive and do not limit BCIA
professionals’ ethical responsibilities.
They highlight areas in which ethical
concerns often arise. For BCIA profes-
sionals who practice under a state and/or
national licensing act, the PSEP are not
meant to replace, but to confirm and
reinforce, professional ethical guidelines.
2. The PSEP should be followed by BCIA
certificants, applicants, and their staff
who help provide biofeedback and
related services.
3. BCIA professionals’ ethical conduct is
measured by the PSEP, state and/or
national licensing acts, and the ethical
guidelines of their professional member-
ship organizations where applicable.
4. A violation of the PSEP may lead to
disciplinary action or decertification. In
some instances, such as sexual contact
with a client, a criminal charge may
result from breach of the PSEP and other
professional guidelines for ethical
practice.
 Evidence-Based Practice in Biofeedback and Neurofeedback
A. Responsibility
In utilizing biofeedback, BCIA professionals
adhere to the highest standards of their
profession. They behave responsibly; accept
responsibility for their behavior and its
consequences; ensure that biofeedback is
used appropriately; and strive to educate the
public concerning the responsible use of
biofeedback in treatment, training, and
research. BCIA professionals are responsible
for adhering to the ethical principles of their
profession; the local, state and national laws
relevant to their professional activities; and
the PSEP.
1. As practitioners, BCIA professionals
recognize their obligation to help clients
acquire knowledge and skill through
training that represents the best profes-
sional practice and that is delivered in
the most cost-effective manner.
2. As teachers, BCIA professionals are
committed to the advancement of know-
ledge. They encourage the free pursuit of
learning by their students and present
information objectively, accurately, and
completely.
3. BCIA professionals guard against mis-
use of their influence since they realize
that their professional services impact
the lives of their clients and others.
4. BCIA professionals should only
continue biofeedback services as long as
their clients benefit from training. If
their clients require an intervention that
they are not qualified to provide, they
should help them obtain these services
and should never abandon them.
B. Competence
BCIA professionals recognize the bound-
aries of their competence and only use those
biofeedback and adjunctive techniques in
which they have expertise. They also recog-
nize the proper limitations of biofeedback
and inform all concerned parties about the
clinical utility of particular procedures,
possible negative effects, and whether the
procedures are experimental or clinically
10
verified. BCIA professionals maintain
current knowledge of relevant basic and
applied biofeedback research.
1. BCIA professionals should operate
within applicable local, state, and
national laws as well as in accordance
with the ethical principles of their
profession. BCIA certification is not a
license to practice independently.
2. BCIA professionals who treat medical
or psychological conditions must
demonstrate professional competence as
defined by applicable local, state, and
national licensing/credentialing laws.
BCIA certification becomes invalid
when a license is suspended, revoked, or
not renewed due to an investigation of a
complaint, and the individual is not
allowed to provide services under super-
vision. A professional may only apply
for recertification after the license has
been reinstated.
3. It is illegal to treat medical or
psychological conditions without appro-
priate supervision if you are not licensed
or credentialed to do so. BCIA certifica-
tion becomes invalid when a certificant
loses and cannot replace appropriate
supervision. An individual may only
apply for recertification after document-
ing that appropriate supervision has been
reestablished.
4. BCIA professionals who are not
appropriately licensed or credentialed,
and who wish to treat medical or
psychological conditions, must acquire
appropriate supervision according to
applicable state and national laws and
professional codes/ regulations.
5. BCIA professionals must accurately
describe their qualifications, training,
experience, and/or specialty. They must
only list degrees in an approved health
care field earned from a regionally
accredited academic institution when
applying for BCIA certification. BCIA
only certifies individuals who hold these
degrees and only lists these credentials
 BCIA Professional Standards and Ethical Principles of Biofeedback
in its directory. When BCIA practitioners
list BCIA certification in advertisements,
business cards, directories, websites, and
similar professional publications, that
listing cannot include an unaccredited
degree nor can it list a degree not related
to health care.
C. Ethical Standards
BCIA professionals are sensitive to
prevailing community norms and recognize
that the violation of these standards may
jeopardize the quality of their services,
completion of professional responsibilities,
and public trust in biofeedback.
1. BCIA professionals will only charge for
services actually provided by them or by
those under their legal supervision. In
billing third-party payers, practitioners
will comply with the rules and regula-
tions of the third-party payer, including
clearly specifying which services the
practitioner provided directly and which
were supervised, and providing informa-
tion regarding their qualifications (e.g.,
degree, license, and certification).
2. BCIA professionals will clarify any
potential or actual conflict of interest
that exists when serving clients, conduct-
ing training or research, or when en-
gaged in any other professional activity
(such as a workshop in which presenters
recommend their own product).
3. BCIA professionals will obtain written
informed consent from clients for all
assessment and treatment procedures,
billings and fee collections, and proce-
dures to protect confidentiality, as well
as conditions that limit confidentiality.
4. BCIA professionals will obtain written
informed consent from clients for all
experimental treatment procedures. To
distinguish experimental and clinically
validated procedures is difficult and
requires familiarity with related
documents.2
11
D. Multiculturalism and Diversity
1. BCIA professionals are encouraged to
recognize that, as cultural beings, they
may hold attitudes and beliefs that can
detrimentally influence their perceptions
of and interactions with individuals who
are different from themselves ethnically,
racially, in sexual orientation, or gender
identity.
2. BCIA professionals are encouraged to
recognize the importance of multi-
cultural sensitivity/responsiveness to,
knowledge of, and understanding about
individuals who are different ethnically,
racially, in sexual orientation, or gender
identity.
3. As educators, BCIA professionals are
encouraged to employ the constructs of
multiculturalism and diversity in
education.
4. Culturally sensitive researchers are en-
couraged to recognize the importance of
conducting culture-centered and ethical
research among persons from different
ethnic, linguistic, racial, sexual orienta-
tion, or gender identity backgrounds.
5. BCIA professionals are encouraged to
apply culturally appropriate skills in
clinical and other biofeedback practices.
6. BCIA professionals are encouraged to
use positive motivational change pro-
cesses to support culturally informed
organizational (policy) development and
practices.
7. BCIA professionals regularly engage in
professional reading and education (both
online and face to face) on multicultural-
ism and diversity, keeping up to date on
current standards and research.
E. Public Statements
BCIA professionals recognize that all public
statements, announcements of services and
products, advertising, and promotional activ-
ities concerned with biofeedback should
help the public make informed choices.
Statements about biofeedback must be based
on scientifically verifiable information,
including recognition of the limits and
 Evidence-Based Practice in Biofeedback and Neurofeedback
uncertainties of such data. BCIA profes-
sionals must accurately represent their
qualifications, affiliations, and positions,
and must not mislead the public.
1. BCIA professionals shall accurately
represent the efficacy of biofeedback
procedures for all disorders or conditions
being treated.
2. BCIA professionals must use accurate
information in statements about biofeed-
back when providing services, marketing
a product, and in all other professional
activities. They consider the context and
source requesting information when
making a public statement and guard
against misrepresentation.
3. BCIA professionals recognize that they
may have personal interests when they
promote biofeedback activities and agree
that these interests must be superseded
by professional objectivity, concern for
clients’ welfare, and the PSEP and the
standards of other professional societies
to which they belong. When a question
arises as to their objectivity, they seek
professional guidance from appropriate
professional sources like BCIA and their
professional associations.
4. Announcements and listing of services
and training offered by BCIA profes-
sionals, such as service directory
listings, letterheads, business cards, and
marketing brochures and websites,
should be accurate and designed in a
professional manner, and should adhere
to the guidelines of their professional
associations.
F. Confidentiality
BCIA professionals protect the confidential-
ity of their clients’ data. They may only
release information with the written consent
of the client or the client's legal
representative, or when nondisclosure would
endanger the client or others.
1. BCIA professionals specify in advance
the legal limits of confidentiality to
clients, particularly when collecting fees
12
and complying with mandated reporting
laws that concern abuse or neglect.
Confidentiality applies to clients in
treatment, students in training, and
research participants.
2. Client records are stored and destroyed
in ways that maintain confidentiality.
BCIA professionals will keep records for
the time required by applicable national
and state laws.
G. Protection of Client Rights and Welfare
BCIA professionals protect the welfare of
clients, students, research participants, and
other groups with whom they work. They
inform all consumers of their rights, provide
them with a written statement of these
rights, fully inform them as to the purpose
and nature of procedures to be implemented,
and assure that clients’ rights are not
abridged.
1. Sexual intimacy with current clients,
trainees, supervisees, and research sub-
jects is prohibited. BCIA professionals
should follow the applicable guidelines
of state/national law and their profes-
sional associations regarding when sex-
ual intimacy is permissible after termina-
tion of a professional relationship.
2. Professionals adhere to the highest stan-
dards of infection mitigation to protect
clients and staff. Practitioners are
responsible to learn and follow reason-
able disinfection standards applicable to
biofeedback instruments, sensors, and
office environments. 4
3. In attaching biofeedback sensors, profes-
sionals assure that the privacy and rights
of the client are protected and respect the
feelings and sensitivities of their clients.
Caution and common sense are required
whenever an applicant or certificant has
physical contact with clients. Any
physical contact requires the permission
of the client. Touching of sensitive body
parts, such as breasts or genitals, is not
acceptable in biofeedback practice, with
the exception of a medical exam or
 BCIA Professional Standards and Ethical Principles of Biofeedback
medical treatment provided by a licensed
medical practitioner.
4. Special care is taken to protect the rights
of children when providing biofeedback
training or conducting research. Wher-
ever possible, BCIA professionals should
seek children’s agreement to participate
in these activities.
5. BCIA professionals do not discriminate
against or refuse services to anyone on
the basis of sex, sexual orientation,
gender identity, race, religion, disability,
or national origin.
H. Professional Relationships
BCIA professionals recognize the interdis-
ciplinary nature of biofeedback and respect
the competencies of colleagues in all
professions. They strive to act in accordance
with the obligations of the organizations
with which they and their colleagues are
associated. They:
1. should only treat medical disorders if
clients have first received a medical
evaluation and/or are under the care of a
physician.
2. should strive to be objective in their
professional judgment of colleagues and
to maintain good professional relation-
ships even when opinions differ.
3. should avoid multiple relationships with
their clients that could impair their
professional judgment or increase the
risk of exploitation, and must never
exploit clients, students, supervisees,
employees, research participants, or third
party payers.
I. Research with Humans and Animals
BCIA professionals conduct research to
advance understanding of human behavior,
to improve human health and welfare, and to
advance science. They carefully consider
alternative research methods and assure that
in the conduct of research the welfare of
research participants (human and animal) is
protected. All researchers will adhere to state
and national regulations and the professional
13
standards of their profession with regard to
the conduct of research. Research involving
humans may be subject to regulation by
local institutional review boards and to state
and/or national regulations.2
Animal research may be subject to local
institutional animal care and use committees
and must comply with state and national
policies on use of animals.3
1. The results of research will be released
in a manner which accurately reflects
research results and only when the
findings have satisfied widely-accepted
scientific criteria. Any limitations re-
garding factors such as sampling bias,
small samples, and limited follow-up,
will be explicitly stated. All descriptive
materials distributed regarding clinical
practice will be factual and straight-
forward.2
2. The individual researcher is responsible
for the establishment and maintenance of
acceptable ethical practice in research.
The investigator is also responsible for
the ethical treatment of research partici-
pants by collaborators, assistants,
students, and employees, all of whom
also incur similar obligations. Informa-
tion obtained about research participants
during the course of an investigation
should be confidential. When the
possibility exists that others may obtain
access to such information, ethical
research practice requires that this
possibility, together with the plans to
protect confidentiality, be explained to
the participants as part of the procedure
for obtaining informed consent.
3. Ethical practice requires that the
investigator inform participants of all
features of the research that might be
reasonably expected to influence their
willingness to participate and to explain
all other aspects of the research about
which the participant inquires. BCIA
professionals protect participants from
physical and psychological discomfort,
harm, and danger. If the risk of such
 Evidence-Based Practice in Biofeedback and Neurofeedback
consequences exists, investigators are
required to inform the participant of that
fact, secure informed consent before pro-
ceeding, and take all possible measures
to minimize distress. A research proced-
ure may not be used if it is likely to
cause serious and lasting harm to partic-
ipants. As participants’ risk increases, so
does the responsibility of the researcher
to protect the research participants.
Written informed consent or a verbal and
written summary of the research is
customary for most kinds of non-survey
research (including a signature by the
research participant in both cases).
4. The investigator must respect an
individual’s freedom to decline to partic-
ipate in research or to discontinue par-
ticipation at any time. The obligation to
protect this freedom requires special
vigilance when the investigator has
power over the participant. When a
prospective participant is a minor, inves-
tigators should seek the child’s assent.
5. After research data are collected, the
investigator must fully debrief partici-
pants about the nature of the study.
When scientific or human values justify
delaying or withholding information, the
investigator acquires a special responsi-
bility to assure that the participant is not
harmed.
Adherence to Professional Standards
BCIA professionals should be knowledge-
able about efficacious interventions and
adhere to the professional standards
associated with these techniques.5
Additional Standards
BCIA professionals who hold a state or
national license/credential should adhere to
the guidelines of the relevant professional
licensing act. Additional guidance can be
found in the ethical standards of organ-
izations like the American Psychological
Association, American Psychiatric Associa-
tion, the American Nurses Association, the
American Physical Therapy Association, the
14
American Medical Association, the
American Dental Association, the American
College of Sports and Rehabilitation, the
American Academy of Physical Medicine
and Rehabilitation, and their international
counterparts.
Ethics Complaint Procedures
When BCIA receives a written complaint
about the ethical conduct of a BCIA cert-
ificant or applicant, BCIA’s Executive
Director will record the complaint and will
write a letter to the complainant that will
describe BCIA's role in ethics cases, direct
the complainant to directly discuss the
complaint with the provider (certificant or
applicant), and if requested by the complain-
ant, identify state and/or national regulatory
agencies with jurisdiction. Since BCIA’s
approach to ethical issues is educational,
BCIA will not recommend that complainants
contact these agencies, nor will it represent
complainants before these agencies.
BCIA will not intervene in complaints
about manufacturer or vendor products,
services, or sales practices as these issues do
not concern certification and corporations
are not BCIA professionals.
While BCIA encourages certificants to
first discuss ethical concerns with their
colleagues, certificants may directly contact
appropriate regulatory agencies. If an
agency declares that a complaint lacks merit,
is frivolous, or is malicious, BCIA will defer
to the agency to discipline the complainant.
The BCIA Board of Directors will
periodically review and update the PSEP.
Thereafter, BCIA professionals shall be
required to adhere to the revised PSEP.
Comment is invited. Individuals desiring
more information about these Principles
may contact BCIA.
Related Documents and Acknowledgments
1
Biofeedback Alliance and Nomenclature
Task Force (2008).
2
Regulations for the protection of human
research subjects (45 CFR46 and 56 FR
28003) (Federal Regulations).
 BCIA Professional Standards and Ethical Principles of Biofeedback
3
Humane care and use of animals (A 2nd revision prepared and adopted by the
343401) (Federal Regulations). BCIA Board of Directors, March 24, 2002.
4
Hagedorn, D. (2014). Infection risk 3rd revision prepared and adopted by the
mitigation for biofeedback providers. BCIA Board of Directors, April 5, 2004.
Biofeedback, 42(3), 93-95.
5
G. Tan, F. Shaffer, R. Lyle, & I. Teo (Eds.). 4th revision prepared and adopted by the
Evidence-based practice in biofeedback BCIA Board of Directors, April 1, 2005.
and neurofeedback (3rd ed.). Wheat Ridge, 5th revision prepared and adopted by the
CO: Association for Applied Psychophys- BCIA Board of Directors, August 26, 2009.
iology and Biofeedback.
6th revision prepared and adopted by the
We thank the Association for Applied BCIA Board of Directors, May 18, 2015.
Psychophysiology and Biofeedback, whose 7th revision prepared and adopted by the
Ethical Principles were modified and BCIA Board of Directors, October 6, 2015.
adapted for these Principles.
8th revision prepared and adopted by the
Original version adopted by BCIA Board of BCIA Board of Directors, January 29, 2016.
Directors, August 26, 1990.
1st revision prepared by John G. Carlson,
Adopted by the BCIA Board of Directors,
October 14, 1999.

15
 Evidence-Based Practice in Biofeedback and Neurofeedback
Chapter 5 – Adult Headache
Level 4: Efficacious
Tracy Brown, BS, and Patrick R. Steffen, PhD, BCB
Brigham Young University, Department of Psychology
Headaches are a major public health prob-
lem associated with individual suffering,
varying levels of disability, and societal
economic burden (Leonardi, Steiner, Scher,
& Lipton, 2007). Much research has been
done on headache treatment targeting both
biological and psychosocial risk factors.
Previous editions of this reference have
provided the results of several earlier studies
showing the effectiveness of biofeedback
measures on headache reduction (Yucha &
Montgomery, 2008). For example, a meta-
analysis by Nestoriuc and Martin (2007)
examining the effectiveness of biofeedback
treatment on migraine headaches found a
medium effect size that was maintained over
a 17-month period. In this analysis, blood
volume pulse was found to be more
effective than EMG or thermal feedback.
Additionally, a review article by Silberstein
(2000) concluded that utilizing peripheral
skin temperature or EMG biofeedback in
conjunction with relaxation training was
generally effective for migraine reduction
and recommended as a treatment option.
Meta-analyses have provided evidence
supporting the utility of biofeedback in the
management of both migraine and tension
type headache (Nestoriuc & Martin, 2007;
Nestoriuc, Rief, & Martin, 2008). Integrated
outcome data from 53 studies assessing the
efficacy of biofeedback treatment (primarily
EMG biofeedback and temperature biofeed-
back) in patients with tension type headache
showed a medium-to-large effect size
corresponding to reduction in headache
frequency that remained stable over 15
months (Nestoriuc et al., 2008). Moderator
analyses suggested that combining biofeed-
back with relaxation training was more
16
effective than either alone, especially in
children and adolescents.
A comprehensive efficacy review on
biofeedback treatment for headaches
combining data from 3,500 migraine and
tension headache patients with chronicity of
over 14 years revealed a medium average
effect size for biofeedback when compared
to a control group with no treatment
(Nestoriuc, Martin, Rief, & Andraski, 2008).
While biofeedback was found to be effica-
cious for migraines, the evidence for
treatment specificity was weak. In the
tension type headache groups, a large
average effect size was found when
comparing EMG feedback to untreated
control groups. They also found medium
and small effect sizes (respectively) when
comparing biofeedback to placebo and
relaxation groups. Based on their findings,
the authors concluded that biofeedback is an
efficacious and specific treatment for
tension type headaches.
Verhagen et al. (2009) completed a
systematic review on behavioral treatments
for chronic tension type headaches and
found that most trials lacked adequate power
to show statistically significant differences.
Of the 44 randomized controlled trials
included in the review, 11 studies compared
EMG biofeedback to a control group that
received a pseudo or placebo treatment, no
treatment, or were placed on a wait-list. An
additional three studies examined EMG
biofeedback plus relaxation compared to
either a placebo or no treatment control
group. Based on their findings, the authors
concluded that there is little evidence to
support that behavioral treatment, including
EMG biofeedback, is better than no
treatment, placebo, or wait-list groups.
 Adult Headache
However, this review was limited by the fact
that many of the studies were underpowered
and a large number of the EMG biofeedback
studies did not provide data on outcome
measures. Of the approximately 24 studies
assessing EMG biofeedback alone or in
conjunction with relaxation, only 9 studies
had sufficient outcome data to be used in the
review. Therefore, results could not be
statistically pooled to create an effect size
estimate. Comparisons were made between
one or two EMG studies with sufficient data
based on heterogeneity and the authors
appear to have based their conclusions off of
these comparisons.
Kang, Park, Chung, and Yu (2009) found
a significant reduction in headache severity
in a Korean female migraine population that
received eight sessions of active autogenic
biofeedback-assisted training compared to a
monitoring group whose headache activity
was simply measured using biofeedback
parameters. In addition to reduced headache
activity, a corresponding reduction in
anxiety and depression scores were seen
post-biofeedback treatment.
A study by Stokes and Lappin (2010)
explored the effects of combining neuro-
17
feedback consisting of EEG and passive
infrared hemoencephalography and thermal
biofeedback on headache pain in 37
migraineurs. They found that the combina-
tion of biofeedback treatments reduced the
frequency of migraines by 50% or more in
70% of the sample. In addition, failure to
improve at all was seen in only 16% of the
population. This study was limited by the
fact that neurofeedback was not assessed
alone. Thermal biofeedback is known to be
effective for migraines and including this
modality confounded the results. Another
study examined the effectiveness of QEEG
neurofeedback on recurrent migraines in a
sample of 71 migraine patients (Walker,
2011). They initially assessed abnormalities
in QEEG and then implemented neuro-
feedback protocols to reduce high frequency
beta activity in the 46 patients who chose to
participate in the treatment. Of this group,
54% reported remission of migraines and
39% reported a reduction in migraine
frequency (>50%) that was maintained at 1-
year follow-up. In contrast, the majority of
the control group (68%) made up of the 25
remaining patients, reported no change in
number of headaches experienced.
 Evidence-Based Practice in Biofeedback and Neurofeedback

Chapter 6 – Attention Deficit Hyperactivity Disorder (ADHD)

Level 5: Efficacious and Specific
Martijn Arns, PhD,1,2,3 Hartmut Heinrich, PhD,4,5 and Ute Strehl PhD, MSc6
1
Research Institute Brainclinics, Nijmegen, The Netherlands
2
Utrecht University, Dept. Experimental Psychology, Utrecht, The Netherlands
3
neuroCare Group, Nijmegen, The Netherlands
4
Dept. of Child and Adolescent Mental Health, University Hospital of Erlangen, Erlangen, Germany
5
Heckscher-Klinikum, München, Germany
6
University of Tübingen, Tübingen, Germany

At present, stimulant medication and
behavior therapy are the most often applied
and accepted treatments for attention deficit
hyperactivity disorder or ADHD. However,
recent large-scale studies and meta-analyses
have demonstrated limitations of these
treatments. For example, limited long-term
effects of stimulant medication (possibly the
result of an up-regulation of the Dopamine
Transporter [DAT] [Wang et al., 2013]) and
behavior therapy have been reported
(Molina et al., 2009; Riddle et al., 2013). It
hence becomes obvious there is a need for
new treatments for ADHD with better long-
term effects, which also explains the recent
research interest in neurofeedback as a
treatment for ADHD. In the following,
neurofeedback as a treatment for ADHD will
be reviewed in more detail, specifically with
regard to its current evidence base level
using the APA/AAPB criteria.
A Brief History
Several years after Sterman’s first demons-
tration of anticonvulsant effects of sensori-
motor rhythm (SMR) neurofeedback
(Sterman & Friar, 1972), Lubar and Shouse
(1976) described the application of this same
SMR neurofeedback in a child with hyper-
kinetic syndrome. Employing an ABA
design, they reported improvements in
hyperactivity and distractibility when SMR
was uptrained, and found that symptoms
worsened when reversal training was
employed (Lubar & Shouse, 1976). Several
years later, these findings were replicated in
a larger study (Shouse & Lubar, 1979).
These reports can now be considered the
first demonstrations of clinical effects after
neurofeedback in what we today refer to as
ADHD.
Walter et al. in 1946 were the first to
describe the Contingent Negative Variation
(CNV). The CNV is very slow electrophysi-
ological brain activity, characterized by a
negative shift, in anticipation of an expected
event such as waiting for a traffic light to
turn green. Interestingly, in the same era
when the earlier-mentioned frequency
neurofeedback was first described,
McAdam, Irwin, Rebert, and Knott (1966)
were the first to describe that subjects could
exert voluntary control over their CNV
(McAdam et al., 1966), and this technique
was further pioneered by Elbert and
Birbaumer (Elbert, Rockstroh, Lutzenberger,
& Birbaumer, 1980; Lutzenberger, Elbert,
Rockstroh, & Birbaumer, 1979). Later in
1993, it was found that this slow cortical
potential, or SCP, neurofeedback had
anticonvulsive properties (Rockstroh et al.,
1993) and in 2004, Heinrich and colleagues
were the first to report clinical effects of this
protocol in ADHD (Heinrich, Gevensleben,
Freisleder, Moll, & Rothenberger, 2004). In
these early days of neurofeedback, other
neurofeedback protocols such as alpha en-
hancement were also investigated, however,
this alpha enhancement protocol failed to
show effects in hyperkinetic syndrome
(Nall, 1973) and in epilepsy (Rockstroh et
al., 1993), suggesting some specificity in the

18
 Attention Deficit Hyperactivity Disorder
EEG parameter trained in neurofeedback.
For a more detailed overview of the history
of neurofeedback, also see Arns, Heinrich,
and Strehl (2014).
Evidence Level
In the last decade, an increasing number of
well-controlled studies have been conducted
to evaluate the effects of neurofeedback in
the treatment of ADHD. Most studies have
investigated theta/beta (TBR), SMR, and/or
SCP protocols in the treatment of ADHD.
Since these three protocols are well
investigated in ADHD and have well-
established efficacy in ADHD, this review
will only focus and apply to the application
of these protocols in the treatment of
ADHD. For these three neurofeedback
protocols, theoretical models have been
developed that explain their efficacy in
ADHD (for review see: Arns & Kenemans,
2012; Gevensleben et al., 2013). Given the
many recent studies, we will only deal with
randomized controlled trials (RCTs). For a
review and meta-analysis beyond RCTs, the
reader is referred to Arns et al. (2009) and
Arns, Heinrich, and Strehl (2014).
Randomized Controlled Trials (RCTs)
The first two RCTs compared neurofeed-
back to a waiting list control group and
found improvements on attention and hyper-
activity (Lévesque, Beauregard, & Mensour,
2006; Linden, Habib, & Radojevic, 1996).
More recently, four RCTs have been
published either using a cognitive training
(Gevensleben et al., 2009; Holtmann et al.,
2009; Steiner et al., 2014) or an
electromyogram (EMG)-based biofeedback
training (Bakhshayesh et al., 2011) as a
control condition. These control conditions
aimed at controlling for non-specific effects
of neurofeedback such as the time of
computer interaction, amount of client-
therapist interaction, etc. Finally, one other
RCT compared SCP with TBR neurofeed-
back, and found similar effects for both
treatments on ADHD symptoms.
19
In all studies, except Holtmann et al.
(2009), neurofeedback training effects were
greater than for the control condition with
respect to ADHD symptoms (typically
medium effect size [ES]) according to parent
and also largely teacher ratings. Note that
these control groups are considered semi-
active control groups, and thus the reported
medium ES are rather conservative, due to
these control groups possibly having clinical
effects with a small ES. In Holtmann et al.
(2009), where an inhibition-related effect of
reduced impulsivity errors for neurofeed-
back was obtained (but no effects for
inattention and hyperactivity), the neuro-
feedback training consisted of 20 training
sessions, which is generally considered a
low number of sessions, known to have
smaller effects (Arns et al., 2009). In three
of these RCTs, follow-up was performed
and the clinical effects were maintained at 6-
month follow-up (Gevensleben et al., 2010;
Steiner et al., 2014; Strehl et al., 2006) and 2
years (Gani, Birbaumer, & Strehl, 2008).
Two of these RCTs were multicentre studies
with large sample sizes of N = 102 and N =
104, respectively (Gevensleben et al., 2009;
Steiner et al., 2014).
Neurofeedback Compared to
Methylphenidate
Several studies have compared the efficacy
of neurofeedback to stimulant medication.
Older nonrandomized studies (Fuchs et al.,
2003; Monastra et al., 2002; Rossiter, 2004;
Rossiter & La Vaque, 1995), reported
comparable effects of neurofeedback and
methylphenidate for measures of inattention,
impulsivity, and hyperactivity. However, all
these were nonrandomized studies, and
families self-selected their preferred treat-
ment, maximizing effects of expectancy in
both groups. Recently, two RCTs have been
published where neurofeedback was com-
pared to methylphenidate using a random-
ized group assignment (Duric, Assmus,
Gundersen, & Elgen, 2012; Meisel et al.,
2013). In both studies, methylphenidate was
 Evidence-Based Practice in Biofeedback and Neurofeedback
not superior to neurofeedback training,
confirming the findings from the earlier
nonrandomized studies. In Meisel et al.
(2013), significant pre–post academic per-
formance improvements were obtained only
in the neurofeedback group. The low sample
sizes from these studies do not allow firm
conclusions about the equivalence of
medication with neurofeedback. However,
the consistency of results of these six studies
comparing methylphenidate to neurofeed-
back is promising and suggestive of a
similarity in clinical effects.
Placebo-Controlled Studies
Only one small placebo-controlled study
used SMR neurofeedback with a sample size
of nine children (Perreau-Linck et al., 2010).
This study did not find clinical effects of
neurofeedback; however, the small sample
size (a result of recruitment issues due to the
double blind nature of the study and thus a
premature termination of the study)
precludes us from evaluating specific effects
of neurofeedback in this study (Perreau-
Linck et al., 2010).
Three other placebo-controlled studies
have been performed; however, the proto-
cols and EEG locations trained in those
studies deviate to such an extent that they
cannot be generalized to SCP, TBR, or SMR
neurofeedback protocols (for a more detail-
ed overview, see Arns, Heinrich, & Strehl,
2014; Arns & Kenemans, 2012). Based on
these studies we may conclude that
neurofeedback protocols like Engagement
Index (Arnold et al., 2012; DeBeus &
Kaiser, 2011), alpha enhancement neuro-
feedback (Nall, 1973), and bilateral frontal
and parietal SMR training (Lansbergen, van
Dongen-Boomsma, Buitelaar, & Slaats-
Willemse, 2011; van Dongen Boomsma,
Vollebregt, Slaats-Willemse, & Buitelaar,
2013) probably have no or at best limited
clinical effects in the treatment of ADHD,
particularly when applied with automatically
updated thresholds and/or with exciting
computer games (see Sherlin et al., 2011, for
20
a review of learning principles and
neurofeedback efficacy).
Meta-Analyses
The results of neurofeedback studies con-
ducted up to 2009 (including nonrandom-
ized studies) were rather coherent, as
confirmed in a meta-analysis by Arns and
colleagues (2009). This meta-analysis
incorporated 15 studies (of which 5 were
RCTs: Bakhshayesh, Hänsch, Wyschkon,
Rezai, & Esser, 2007; Gevensleben et al.,
2009; Holtmann et al., 2009; Leins et al.,
2007; Lévesque, Beauregard, & Mensour,
2006), and found that neurofeedback
resulted in large and clinically relevant
effect sizes for inattention and impulsivity
and a medium effect size for hyperactivity.
Recently, Sonuga-Barke and colleagues
published a systematic review and meta-
analysis on randomized controlled trials in
the treatment of ADHD that also included
neurofeedback (Sonuga-Barke et al., 2013).
For so-called most-proximal ratings
(typically from parents), they demonstrated
comparable ES to the meta-analysis by Arns
and colleagues (2009), whereas for
“probably blinded” ratings (primarily
teacher ratings), there was a tendency
towards significance (p = .07). Arns and
Strehl (2013) reflected critically on the
procedure and criteria of this meta-analysis
(e.g., change of medication status not taken
into account, selection of control condition,
not focusing on standard training protocols).
If only RCTs are considered where TBR or
SCP training was applied and cognitive
training or EMG biofeedback training was
used as control conditions, a significant
effect is also obtained for teacher ratings
(Arns & Strehl, 2013). Therefore, it may be
concluded that these two meta-analyses
substantiate at least the medium effects for
TBR, SMR, and SCP neurofeedback proto-
cols on ADHD symptoms.
For RCTs that also performed follow-up
to 6 months or 2 years, it was demonstrated
that the effects did not disappear with time,
 Attention Deficit Hyperactivity Disorder
and a tendency for further improvement
across time for hyperactivity/impulsivity
was found (Gani, Birbaumer, & Strehl, 2008;
Gevensleben et al., 2010; Leins et al., 2007;
Steiner et al., 2014; Strehl et al., 2006).
The ES for neurofeedback on symptoms
of inattention appear to be comparable to the
ES reported for methylphenidate (see Arns
et al., 2009; Faraone & Buitelaar, 2009;
Sherlin, Arns, Lubar, & Sokhadze, 2010).
These results tend to be in line with the
earlier referenced studies that compared
neurofeedback to stimulant medication and
suggest that at least for inattention the
effects are similar.
Other Aspects
Beyond the criteria for determining efficacy
level for biofeedback interventions regard-
ing a specific condition or clinical disorder,
two further points are worth mentioning.
Support for the specificity of effects induced
by SCP and TBR neurofeedback protocols
mentioned above is also provided by
significant associations between effects at
the neurophysiological level (learned self-
regulation, EEG, and event-related poten-
tials) and clinical improvements, particularly
differential patterns for different neuro-
feedback protocols (see Arns, Heinrich, &
Strehl, 2014 for review). Finally, up to now,
safety (adverse events) of neurofeedback in
ADHD has not been systematically
documented (Lofthouse et al., 2010). To our
knowledge, side effects have only been
systematically documented in two studies
that used other than TBR and SCP protocols
(Arnold et al., 2012; Lansbergen et al.,
2011). Future studies should more
21
systematically assess adverse events and
other safety aspects of neurofeedback.
Conclusion
Neurofeedback in the treatment for ADHD,
limited to SCP, TBR, and SMR protocols,
can thus be considered a Level: 5 Effica-
cious and Specific treatment. This is based
specifically on the following evidence:
• At least two independent multicenter
RCTs with large sample sizes (N >100)
where neurofeedback was compared to
cognitive training (a credible sham:
Gevensleben et al., 2009; Steiner et al.,
2014) and the effects were maintained
for at least 6 months (Gevensleben et al.,
2010; Steiner et al., 2014).
• At least two independent RCTs where
methylphenidate was not superior to
neurofeedback in the treatment of
ADHD (Duric et al., 2012; Meisel et al.,
2013), and overall comparable effect
sizes of neurofeedback and methylphe-
nidate from recent meta-analyses (Arns
et al., 2009; Faraone & Buitelaar, 2009).
This conclusion is further supported by
one meta-analysis (Arns et al., 2009), and
indirectly supported by another meta-
analysis when restricted to standard
protocols (Arns & Strehl, 2013; Sonuga-
Barke et al., 2013).
Acknowledgement
This work has been adapted from Arns, M.,
Heinrich, H., and Strehl, U. (2013). Evalua-
tion of neurofeedback in ADHD: The long
and winding road. Biological Psychology.
doi:10.1016/j.biopsycho.2013.11.013
 Evidence-Based Practice in Biofeedback and Neurofeedback
Chapter 7 – Alcohol/Substance Use Disorders
Level 3: Probably Efficacious
Estate M. Sokhadze, MD,1 and David Trudeau, MD2
1
University of Louisville
2
ISNR Research Foundation
Neurofeedback has been employed in the
treatment of substance use disorder (SUD)
and alcoholism over the last four decades,
but it still remains less than a mainstream
intervention. SUD is a complex series of
disorders with frequent comorbidities and
EEG abnormalities of several types. Neuro-
feedback has been employed in conjunction
with other therapies and may be useful in
enhancing certain outcomes of SUD therapy.
The treatment of addictive disorders by
neurofeedback was first popularized by the
work of Eugene Peniston (Peniston &
Kulkosky, 1989, 1990, 1991) and became
popularly known as the Peniston alpha-theta
protocol, hereafter the Peniston protocol.
This approach employed independent audi-
tory feedback of two slow brainwave
frequencies, alpha (8–12 Hz) and theta (4–8
Hz) in an eyes-closed condition to produce a
hypnagogic state. The patient was taught
prior to neurofeedback to use what amounts
to success imagery (being sober, refusing
offers of alcohol, living confidently and
happily) as they drifted down into an alpha-
theta “reverie” state. Repeated sessions
reportedly resulted in long-term abstinence
and changes in personality testing. Because
the method seemed to work well for
alcoholics, it has been tried in subjects with
cannabis dependence and stimulant depend-
ence, but with limited success until the work
of Scott and Kaiser (Kaiser et al., 1999;
Kaiser & Othmer, 2000; Scott & Kaiser,
1998; Scott et al., 2002, 2005). They
described treating stimulant-abusing sub-
jects with ADHD type neurofeedback
protocol, followed by the Peniston protocol,
with substantial improvement in program
retention and long-term abstinence rates.
22
This approach has become known widely as
the Scott-Kaiser modification of the
Peniston protocol, or the Kaiser-Scott
protocol.
In the first reported randomized and
controlled study of alcoholics treated with
alpha-theta neurofeedback, Peniston and
Kulkosky (1989) described positive outcome
results. Their subjects were inpatients in a
VA hospital treatment program, all males
with established chronic alcoholism and
multiple past failed treatments. Following a
temperature biofeedback pretraining phase,
Peniston's experimental subjects (n = 10)
completed fifteen 30-min sessions of eyes-
closed occipital alpha-theta biofeedback.
Compared to a traditionally treated alcoholic
control group (n = 10), and nonalcoholic
controls (n = 10), alcoholics receiving
brainwave biofeedback showed significant
increases in percentages of EEG recorded in
the alpha and theta rhythms, and increased
alpha rhythm amplitudes (single-lead
measurements at international 10-20 site
O1). The experimentally treated subjects
showed reductions in Beck Depression
Inventory (BDI) scores compared to the
control groups. Control subjects who
received standard treatment alone showed
increased levels of circulating beta-
endorphin, an index of stress, whereas the
neurofeedback group did not. Follow-up
data at 13 months indicated significantly
more sustained prevention of relapse in
alcoholics who completed alpha-theta
brainwave training as compared to the
control alcoholics, defining successful
relapse prevention as “not using alcohol for
more than 6 contiguous days” during the
follow-up period. In a further report on the
 Alcohol/Substance Use Disorders
same control and experimental subjects,
Peniston and Kulkosky (1990) described
substantial changes in personality test results
in the experimental group as compared to
the controls. The experimental group show-
ed improvement in psychological adjustment
on 13 scales of the Millon Clinical
Multiaxial Inventory compared to the
traditionally treated alcoholics who
improved on only two scales and became
worse on one scale. On the 16-PF
personality inventory, the neurofeedback
training group demonstrated improvement
on seven scales, compared to only one scale
among the traditional treatment group. This
small sample study employed controls and
blind outcome evaluation, with actual
outcome figures of 80% positive outcome
versus 20% in the traditional treatment
control condition at 4-year follow-up.
The protocol described by Peniston is
similar to that initially employed by
Twemlow and colleagues (1976, 1977ab) at
the Topeka VA and Elmer Green (e.g.,
Green, Green, & Walters, 1975) at the
Menninger Clinic, with two additions, i.e.,
1) temperature training, and 2) script.
Peniston introduced temperature biofeed-
back training with autogenic training
elements as a preconditioning relaxation
exercise, along with an induction script to be
read at the start of each session. Subjects are
first taught deep relaxation by skin
temperature biofeedback, for a minimum of
five sessions, that additionally incorporate
autogenic phrases. Peniston also used the
criterion of obtaining a temperature of 94 °F
before moving on to neurofeedback. Partici-
pants are then instructed in neurofeedback
and in an eyes-closed and relaxed condition,
receive auditory signals from an EEG
recorded from the left occipital EEG site
(O1). A standard induction script employing
suggestions to relax and “sink down” into
reverie is read. When alpha (8–12 Hz)
brainwaves exceed a preset threshold, a
pleasant tone is heard, and by learning to
voluntarily produce this tone, the subject
23
becomes progressively relaxed. When theta
brainwaves (4–8 Hz) are produced at a
sufficiently high amplitude, a second tone is
heard, and the subject becomes more relaxed
and according to Peniston, enters a hypna-
gogic state of free reverie and high suggest-
ibility. Following the session, with the
subject in a relaxed and suggestible state, a
therapy session is conducted between the
subject and therapist where the contents of
the imagery experienced is explored and
“abreactive” experiences are explored
(Peniston & Kulkosky, 1989, 1990, 1991).
In a following study, Saxby and Peniston
(1995) reported on 14 chronically alcohol
dependent and depressed outpatients using
this same protocol of alpha-theta brainwave
biofeedback. Following treatment, subjects
showed substantial decreases in depression
and psychopathology as measured by
standard instruments. Twenty-one-month
follow-up data indicated sustained abstin-
ence from alcohol confirmed by collateral
report. These male and female outpatients
received twenty 40-minute sessions of
feedback.
Bodenhamer-Davis and Calloway (2004)
reported a clinical trial with 16 chemically
dependent outpatients, 10 of whom were
probationers classified as high risk for re-
arrest. Subjects completed an average of 31
alpha-theta biofeedback sessions. Psycho-
metrics demonstrated improvements in
personality and mood. Follow-up at 74 to 98
months indicated 81.3 % of the treatment
subjects were abstinent. Re-arrest rates and
probation revocations for the probation
treatment group were lower than those for a
probation comparison group (40% versus
79%). The Peniston protocol’s singular
emphasis on augmenting posterior alpha and
theta waves appears in most cases to reduce,
but not eliminate, the excessive high
frequency beta at central sites (Callaway &
Bodenhamer-Davis, 2008).
The issue of alpha-theta biofeedback in
culturally sensitive groups that have not
responded to traditional modes of addiction
 Evidence-Based Practice in Biofeedback and Neurofeedback
treatment (such as confrontational group
therapies) has been considered in an open
case series reported by Kelly (1997). This 3-
year follow-up study presented the treatment
outcomes of 19 Navajo alcohol-abusing
clients. Four participants (21%) achieved
“sustained full remission,” 12 (63%) achiev-
ed “sustained partial remission,” and 3
(16%) remained “dependent.” The majority
of participants also showed a significant
increase in “level of functioning.”
Several other studies using the Peniston
protocol and its modifications reported cases
with positive clinical effects (Burkett et al.,
2003, 2005; DeBeus et al., 2002; Fahrion,
2002; Fahrion et al., 1992; Finkelberg et al.,
1996). These studies suggest that an applied
psychophysiological approach based on an
alpha-theta biofeedback protocol is a valu-
able alternative to conventional substance
abuse treatment (Walters, 1998; White,
2008).
A critical analysis of the Peniston
protocol is discussed at length in prior
reviews (Sokhadze, Cannon, & Trudeau,
2008; Sokhadze, Trudeau, & Cannon, 2014;
Trudeau, 2000, 2005ab; Trudeau, Sokhadze,
& Cannon, 2009). Several controlled studies
of the Peniston protocol for addictions and
reviews completed by Lowe (1999), Moore
and Trudeau (1998, 2000), Rosenfeld
(1992), and Taub and Rosenfeld (1994),
suggest that alpha-theta training for
addictions may be nonspecific in terms of
effect when compared to suggestion, sham
or controlled treatment, or meditational
techniques. In an in-depth critical analysis
that examines inconsistencies reported in the
original Peniston papers, Graap and Freides
(1998) raise serious issues about the
reporting of original samples and procedures
in these studies. In their analyses, the results
may have been due as much to the intense
therapies accompanying the biofeedback as
due to the biofeedback itself. The subjects
may have been comorbid for a number of
conditions, which were not clearly reported,
particularly PTSD, which may have been the
24
focus of the treatment. In his reply to these
criticisms, Peniston (1998) acknowledges
that it “remains unknown whether the
temperature training, the visualizations, the
alpha-theta brainwave neurotherapy, the
therapist, the placebo, or the Hawthorne
effects are responsible for the beneficial
results.” The criticism raised above by
Graap and Friedes (1998) regarding
Peniston's papers could also be applied to
earlier replication studies. Neither Peniston's
studies nor the replication studies provide
sufficient detail regarding the specifics of
the types of equipment used for alpha-theta
feedback, including filtering methods for the
EEG signal or other technical information,
to permit exact reproduction of the feedback
protocols with other equipment. Outcome
criteria also vary in the replication studies,
with varying measures of abstinence and
improvement.
The Guidelines for Evaluation of
Clinical Efficacy of Psychophysiological
Interventions (LaVaque et al., 2002), which
have been accepted by AAPB and ISNR,
specify five types of classification for the
effectiveness of biofeedback procedures,
ranging from “Not empirically supported” to
“Efficacious and Specific.” Level 3:
Probably Efficacious defines treatment
approaches that have been evaluated and
shown to produce beneficial effects in
multiple observational studies, clinical
studies, wait-list control studies, and within-
subject and between-subject replication
studies.
Using these criteria, and based on
studies reported to date, neurofeedback
(specifically the Peniston alpha-theta train-
ing protocol), can be classified as Level 3
Probably Efficacious when combined with
an inpatient rehabilitative treatment modal-
ity in subjects with long-standing alcohol
dependency. This classification is based on
the original randomized and controlled study
of the Peniston protocol (Peniston &
Kulkosky 1989, 1990, 1991; Saxby &
Peniston, 1995) and multiple observational
 Alcohol/Substance Use Disorders
and uncontrolled studies that preceded
(Twemlow & Bowen, 1977; Twemlow,
Sizemore, & Bowen, 1977) and followed
these studies (Bodenhamer-Davis &
Calloway, 2004; Burkett et al., 2003, 2005;
Callaway & Bodenhamer, 2008; DeBeus et
al., 2002; Fahrion, 1995, 2002; Fahrion et
al., 1992; Finkelberg et al., 1996; Kelly,
1997; Saxby & Peniston, 1995).
It should be noted that psychostimulant
(cocaine, methamphetamine) addictions may
require approaches and neurofeedback
protocols other than alpha-theta training.
Persons who are cocaine-dependent are
cortically under-aroused during protracted
abstinence (Roemer et al., 1995). QEEG
changes, such as a decrease in high beta
(18–26 Hz) power are typical for withdrawal
from cocaine (Noldy et al., 1994). Cocaine
abusers who are still taking this drug often
show low amounts of delta and excess
amounts of alpha and beta activity (Alper,
1999; Prichep et al., 1999), whereas chronic
methamphetamine abusers usually exhibit
excessive delta and theta activity (Newton et
al., 2003). Thus, cocaine and methamphet-
amine users may warrant a different
neurofeedback protocol, at least at the
beginning stages of neurofeedback therapy.
Scott and Kaiser (1998) describe
combining a protocol for attentional training
(beta and/or SMR augmentation with theta
suppression) with the Peniston protocol
(alpha-theta training) in a population of
subjects with mixed substance abuse, rich in
stimulant abusers. The beta protocol is
similar to that used in ADHD (Kaiser &
Othmer 2000; Kaiser et al., 1999) and was
used until measures of attention normalized,
and then the standard Peniston protocol
without temperature training was applied
(Scott et al., 2002, 2005). The study group is
substantially different than that reported in
either the Peniston or replication studies.
The rationale is based in part on reports of
substantial alteration of QEEG seen in
stimulant abusers associated with early
treatment failure (Prichep et al., 1996;
25
Prichep et al., 2002) likely associated with
marked frontal neurotoxicity (Alper, 1999).
Additionally, preexisting ADHD is assoc-
iated with stimulant preference in adult
substance abusers, and is independent of
stimulant associated QEEG changes. These
findings of chronic EEG abnormality and
high incidence of preexisting ADHD in
stimulant abusers suggest they may be less
able to engage in the hypnagogic and auto-
suggestive Peniston protocol (Trudeau,
Thuras, & Shockley, 1999). Furthermore,
eyes-closed alpha feedback as a starting
protocol may be deleterious in stimulant
abusers because the most common EEG
abnormality in crack cocaine addicts is
excess frontal alpha (Prichep et al., 2002).
The Peniston protocol is less feasible in
opiate addicts, as in eyes-closed conditions
they tend to struggle to maintain wakeful-
ness, and became drowsy even during
withdrawal.
In their initial report, Scott and Kaiser
(1998) described substantial improvement in
measures of attention and also of personality
(similar to those reported by Peniston and
Kulkosky, 1990). Their experimental sub-
jects underwent an average of 13 SMR-beta
(12–18 Hz) neurofeedback training sessions
followed by 30 alpha-theta sessions during
the first 45 days of treatment. Treatment
retention was significantly better in the
neurofeedback group and was associated
with the initial SMR-beta training. A subse-
quent published paper (Scott et al., 2005)
reported on an expanded series of 121 in-
patient drug program subjects randomized to
condition, followed up at 1 year. Subjects
were tested and controlled for the presence
of attentional and cognitive deficits, person-
ality states, and traits. The experimental
group showed normalization of attentional
variables following the SMR-beta portion of
the neurofeedback, while the control group
showed no improvement. Experimental
subjects demonstrated significant changes (p
< .05) beyond the control subjects on 5 of
the 10 scales of the MMPI-2. Subjects in the
 Evidence-Based Practice in Biofeedback and Neurofeedback
experimental group were also more likely to
stay in treatment longer and more likely to
complete treatment as compared to the
control group. Finally, the 1-year sustained
abstinence levels were significantly higher
for the experimental group as compared to
the control group.
The approach of beta training in
conjunction with alpha-theta training has
been applied successfully in a treatment
program aimed at homeless crack cocaine
abusers in Houston, as reported by Burkett
et al. (2003, 2005), with impressive results.
Two hundred seventy (270) male addicts
received 30 sessions of a protocol similar to
the Scott-Kaiser modification. One-year
follow-up evaluations of 94 treatment
completers indicated that 95.7% of subjects
were maintaining a regular residence; 93.6%
were employed/in school or training, and
88.3% had no subsequent arrests. Self-report
depression scores dropped by 50%, and self-
report anxiety scores by 66%. Furthermore,
53.2% reported no alcohol or drug use 12
months after biofeedback, and 23.4% used
drugs or alcohol only one to three times after
their stay. This was a substantial improve-
ment from the generally expected 30% or
less recovery in this population. The remain-
ing 23.4% reported using drugs or alcohol
more than 20 times over the year. Urinalysis
results corroborated self-reports of drug use.
The treatment program saw substantial
changes in length of stay and completion.
After the introduction of the neurofeedback
to the mission regimen, length of stay
tripled, beginning at 30 days on average and
culminating at 100 days after the addition of
neurotherapy. In a later study, the authors
reported follow-up results on 87 subjects
after completion of neurofeedback training
(Burkett et al., 2005). The follow-up
measures of drug screens, length of resi-
dence, and self-reported depression scores
showed significant improvement. It should
be noted that this study had limitations,
because neurofeedback was positioned only
as an adjunct therapy to all other faith-based
26
treatments for crack cocaine-abusing home-
less persons enrolled in this residential
shelter mission and was an uncontrolled
study.
Conclusion
Using the efficacy criteria and based on
reported studies to date, the Scott-Kaiser
modification of the Peniston Protocol can
also be classified as Level 3: Probably Effi-
cacious when combined with residential re-
habilitation modalities in stimulant abusers.
This rating is based on one controlled study
of 121 subjects in which Peniston’s out-
comes of both psychometric improvement
and abstinence improvement were replicated
(Scott et al., 2005) and on an observational
study of Burkett et al. (2003, 2005).
Alpha-theta training protocols do not
completely meet the criteria for the Level 4:
Efficacious classification. Although there are
sufficient studies that show statistically
significant superiority of randomly assigned
treatment groups to no-treatment control
groups, and studies have been conducted
with populations treated for a specific
problem from whom inclusion criteria are
delineated in a reliable, operationally de-
fined manner, and the studies cited use valid
and clearly specified outcome measures
related to the problem being treated with
data subjected to appropriate data analysis,
there remains the shortcoming cited by
Graap and Freides (1998) for the initial
reports of Peniston and Kulkosky (1989,
1990, 1991). We recall the qualifying
limitations of LaVaque et al. (2002), who
stated that “the diagnostic and treatment
variables and procedures are not clearly
defined in a manner that permits replication
of the study by independent researchers” (p.
280). However, the Scott et al. (2005) report
does appear to clearly delineate treatment
variables and procedures. More independent
studies showing the superiority of modified
alpha-theta training to control condition
would be needed to meet the stated criteria
for a Level 4: Efficacious classification for
this neurotherapy method.
 Anxiety and Anxiety Disorders
Chapter 8 – Anxiety and Anxiety Disorders
Level 4: Efficacious
Donald Moss, PhD, BCB, BCN
Saybrook University
Treatment of Anxiety and Anxiety
Disorders with General Biofeedback
Anxiety can be categorized into several
interrelated phenomena. Anxiety is a normal
dimension in human experience, often
accompanying anticipated life transitions,
new experiences, and challenges. David
Barlow has defined anxiety as a future-
oriented mood state that is concerned with
anticipation of possible upcoming negative
events (Barlow, 2002). This everyday
experience of anxiety is not abnormal, and
should not be perceived as something to be
treated or eliminated.
Anxiety can also become a life problem,
as in test anxiety that becomes so habitual
that it undermines test performance and
academic learning, or in the anxiety that
accompanies medical procedures or medical
conditions and sometimes inhibits coopera-
tion with life preserving interventions. Con-
siderable research is devoted to remediation
of test anxiety and the anxiety accompany-
ing medical conditions and procedures.
Finally, anxiety qualifies as an anxiety
disorder when it becomes habitual, relative-
ly chronic (at least 6 months in duration),
significantly impairs everyday life function-
ing, and meets the diagnostic criteria in the
DSM-5 or ICD-10. The anxiety disorders in
the DSM-5 include Panic Disorder,
Agoraphobia, Specific Phobia, Generalized
Anxiety Disorder, Social Anxiety Disorder,
Separation Anxiety Disorder, and Selective
Mutism. This review will include available
research studies on the just-mentioned
categories of the Anxiety Disorders. Anxiety
accompanying life transitions and medical
events can persist and become sufficiently
disruptive of life functioning to warrant
diagnosis of an anxiety disorder.
27
Research in biofeedback has focused on
both anxiety as a life problem (test anxiety
and anxiety at medical conditions and
procedures) and on anxiety disorders. There
are relatively few well-constructed studies
on the diagnosable anxiety disorders, using
clear diagnostic criteria. This section will
review the research on general biofeedback
for anxiety; research on neurofeedback with
anxiety will be considered in a separate
section.
Biofeedback for Anxiety as a Life Problem
Student anxiety. Ratanasiripong, Sverduk,
Prince, and Havashino (2012) randomly
assigned 30 undergraduate students in a
university counseling center to either a
counseling only control group or a
counseling plus heart rate variability
biofeedback (HRVB) group. The counseling
and biofeedback were provided for four
weekly sessions, and the Beck Anxiety
Inventory was administered prior to and
following the intervention. Both groups
showed significant improvements in anxiety
scores following treatment, and the group
receiving biofeedback showed significantly
larger change scores. The effect size,
measured by Cohen's d, was 0.77, or a
moderate effect size.
Prato and Yucha (2013) used
biofeedback-assisted relaxation training with
14 nursing students, and administered the
Spielberg Test Anxiety Inventory (TAI) prior
to and after training. The intervention
included training in diaphragmatic breath-
ing, progressive muscle relaxation and
autogenic training, and the students monitor-
ed their peripheral skin temperature, heart
rate, and respiration rate during the training.
A digital thermal biofeedback unit was
 Evidence-Based Practice in Biofeedback and Neurofeedback
provided for home biofeedback practice.
The intervention produced a significant
reduction in respiration rate and a significant
increase in peripheral temperature, but no
significant change in the TAI.
Anxiety in gifted children. Roome and
Romney (1985) randomly allocated 30
gifted children to either a progressive
relaxation, a surface EMG condition, or a
no-treatment control. The children in the
EMG condition showed a significant
decrease in state anxiety (but not trait
anxiety), and both intervention groups
showed increases in internal locus of
control.
Patients undergoing coronary
angiography. Patients undergoing coronary
angiography (CA) regularly show elevated
anxiety, and often increased blood pressure.
Mikosch, Hadrawa, Laubreiter, Brandl, Pilz,
Stettner, and Grimm (2010) randomly
assigned 212 patients scheduled for CA to a
treatment as usual (Control) or a
psychological support group with training in
abdominal breathing and one session of
HRVB (Intervention). The psychologist
revisited participants in the Intervention
group and reinforced the HRV/breathing
skills. All participants completed the
Spielberger State-Trait Anxiety Inventory
(STAI) pre- and post-intervention. Both
groups showed a reduction in STAI once the
CA was complete, but those participants in
the Intervention group showed a much
greater decrease in the STAI, reaching an
anxiety-free level. In addition, those
participants in the intervention group who
actively used abdominal breathing tech-
niques during the CA showed a greater
reduction on the STAI than those who did
not. The researchers also found a significant
reduction in systolic blood pressure (BP) in
the Intervention group at the time of the CA
and after, and a significantly greater
reduction in diastolic BP in the intervention
group after the CA.
28
Patients with alcohol abuse and co-
morbid anxiety. Clark and Hirschman
(1990) identified 36 males with elevated
anxiety in a larger group of 168 patients
hospitalized for alcohol abuse or depend-
ence, and randomly assigned them to a
paced breathing or a control condition.
Participants completed the STAI prior to and
following the intervention. The patients in
the paced breathing condition were given
two sessions with an auditory pacer to train
their respiration to a 10 breaths/minute rate.
Respiration rates, skin conductance (SCL),
and HR were also monitored during the
training sessions. The participants in the
paced breathing group showed greater
reductions in self-rated tension and in state
anxiety than those in the control condition.
Reductions in SCL were also greater in the
paced breathing group. The authors also
concluded that there were indications that a
longer period of training was needed to
enable the participants to become indepen-
dent of the auditory pacer.
Patients with anxiety accompanying
eating disorder. Scolnick, Mostofsky, and
Keane (2014) reported on an uncontrolled
study providing HRVB to 25 inpatients in
treatment for eating disorder. The research-
ers used a self-report questionnaire and not a
well-normed psychometric instrument to
measure anxiety level prior to or following
training. Nineteen individuals completed the
study, and of these, 47% agreed strongly that
“biofeedback decreased my anxiety,” and
35% rated this statement somewhat true.
Women with perinatal depression.
Beckham, Greene, and Meltzer-Brody
(2013) recruited 15 women in an inpatient
unit for severe perinatal depression, in a
study with no control group. The partici-
pants were assessed with the STAI, the
Warwick-Edinburgh Mental Well-Being
Scale, and Linear Analog Self-Assessment
pre- and post-intervention. The women were
provided with two sessions of HRVB using
the emWave® Desktop unit. The women
 Anxiety and Anxiety Disorders
showed significant improvements on all
three questionnaires following the biofeed-
back intervention. The greatest statistical
effect was in reducing the anxiety that
accompanies perinatal depression. Over
80% of the participants continued to use the
HRV techniques at least once weekly
following the study. The effects were
somewhat less for women with more severe
depression on baseline, but there was still
significant benefit for these women. The
availability of a nonpharmacological inter-
vention for pregnant women or postpartum
women who are breastfeeding is a critical
advantage.
Biofeedback for Anxiety Disorders
Unspecified anxiety disorder. Scandrett,
Bean, Breeden, and Powell (1986) randomly
assigned a total of 88 adults with anxiety in
two studies to a surface EMG condition, a
progressive muscle relaxation condition, or a
control group. Participants completed the
McReynolds anxiety checklist and verbally
reviewed anxiety symptoms with re-
searchers. Neither intervention produced a
significant reduction in anxiety symptoms.
Generalized anxiety disorder (GAD).
Rice, Blanchard, and Purcell (1993) publish-
ed a randomized controlled study of 45
individuals with generalized anxiety (38
with GAD as defined by the DSM-III),
treated with frontal electromyographic
(EMG) biofeedback, neurofeedback to
increase alpha activity, neurofeedback to
decrease alpha, or a pseudo meditation con-
trol condition. Participants completed eight
twice-weekly training sessions, and made up
any missed sessions. The participants com-
pleted the STAI, the Welsh A (anxiety)
Scale, and the Psychosomatic Symptom
Checklist, at baseline, 2 weeks posttreat-
ment, and 6 weeks posttreatment. The
researchers also monitored the participants
with HR, in a relaxation trial and in two
stress conditions. The results showed
significant decreases on the STAI in all four
treatment conditions, and not in the control
29
group. Only the EMG and alpha-increase
groups showed significant reduction on the
Welsh-A Scale, and only the alpha-increase
group showed a reduced reactivity of HR to
stress in the post-intervention assessment.
The authors concluded that additional
research is needed, but proposed that the
EMG relaxation training and alpha-increase
training modalities appear most promising
for treating GAD.
Agnihotry, Paul, and Sandhu (2007)
randomly assigned 45 persons with GAD to
a surface EMG relaxation group, an increase
alpha-EEG group, and a control group.
Training was conducted daily for 12 consec-
utive days. The EMG and EEG groups
showed significant improvements posttrain-
ing on the STAI State and Traits scales.
Galvanic skin resistance was measured as a
physiologic index of relaxation, and
increased posttraining in both groups, with
the greatest increase in the EMG group. At
2-week follow up, the EMG group showed
the greatest sustained improvements in GSR
levels, state anxiety, and trait anxiety.
Pallavicini, Algeri, Repetto, Gorini, and
Riva (2009) conducted a study with 13
individuals with GAD randomly assigned to
a virtual reality group, a virtual reality group
with biofeedback, and a waiting list group.
The biofeedback group received training
with virtual reality (VR) in which changes in
the VR images were contingent on control
of HR and SCL. A mobile phone also
provided a non-navigable version of the
virtual reality environment for home
relaxation. Both the virtual reality with
biofeedback (VRB) and virtual reality
without biofeedback group showed some
significant improvements in the course of
the study, but the VRB group showed
significantly greater improvement on the
STAI, BAI, Hamilton Anxiety scale, and the
GAD-7 questionnaire. The biofeedback
group also achieved greater, but not
significantly greater, changes in HR and
SCL than the nonbiofeedback group. The
study was limited by a small sample, but
 Evidence-Based Practice in Biofeedback and Neurofeedback
showed support for the value of virtual
reality and mobile phone technology in
anxiety treatment, and the value of
biofeedback in augmenting the VR training.
Panic disorder (PD). Barlow, Cohen,
Waddel, Vermilyea, Klosko, Blanchard, and
Di Nardo (1984) conducted a study of 11
individuals with panic disorder and 9 with
GAD. The participants were randomly
assigned to a treatment group or a wait list
control group. The treatment group received
18 sessions over 14 weeks of progressive
muscle relaxation, surface EMG biofeed-
back, and cognitive behavioral therapy. The
treatment group achieved statistically signi-
ficant improvements on the STAI-State
scale, the Psychosomatic Symptom Check-
list, and a Clinicians Rating Scale, and the
wait list group showed no significant
improvements. All but one member of the
treatment group maintained improvements at
the follow-up (between 3 months and 1 year
posttreatment), and several participants
showed further improvement on follow-up.
Although the study showed significant
differences between GAD and PD respon-
dents on symptom patterns, both groups
showed comparable improvement. There
was no significant correlation between
amount of change on surface EMG and
clinical improvement.
Meuret, Wilhelm, and Roth (2004)
published a composite case narrative
showing how capnometric biofeedback can
be utilized to train a patient with panic
disorder to normalize “aberrant” breathing
patterns and reduce anxiety symptoms. Their
single case, a 48-year-old woman, showed
improved respiratory rates and CO2 levels,
and a cessation of panic disorder.
Kim, Wollburg, and Roth (2012)
randomly assigned 74 patients with
diagnosed PD to one of three conditions:
Group one was trained with a hand-held
capnometer to increase its end-tidal CO2,
group two was trained similarly to decrease
its end-tidal CO2, and the third group served
as a wait-list control. Both breath-training
30
groups achieved significant improvements
on the Panic Disorder Severity Scale and
maintained treatment effects at 6-month
follow-up. The effect size for the raise-CO2
group was 1.34 and for the lower-CO2 group
was 1.53. The authors concluded that the
clinical effect must be due to some aspect of
the breath training/self-regulation training
other than the actual CO2 levels.
Reiner (2008) conducted a study with 24
individuals diagnosed with an anxiety
disorder (including generalized disorder,
panic disorder, specific phobia, social
phobia, OCD, IBS, or insomnia) using a
portable HRVB device for home practice.
The researchers measured anxiety using the
STAI, anger using the Spielberger State-
Trait Anger Expression Inventory (STAEI),
and sleep quality using the Pittsburgh Sleep
Quality Index (PSQI). Nineteen participants
completed the study and achieved statistical-
ly significant reductions in state anxiety,
trait anxiety, trait anger, and the PSQI total
score, as well as a significant increase in
total sleep time. The results also supported
that those individuals who used the portable
device more frequently for training
produced greater improvements in trait
anxiety, anger, and sleep.
Additional resource. Schoenberg and
David (2014) published an exhaustive and
comprehensive review, with careful inclu-
sion and exclusion criteria, of empirical
studies applying biofeedback to psychiatric
disorders. This study is a valuable resource,
although it applied the AAPB/ISNR efficacy
template in an idiosyncratic fashion. Instead
of rating the overall evidence for efficacy of
biofeedback for a disorder or a group of
disorders, they assessed whether the
individual published articles they reviewed
met the efficacy standards, and concluded
that only 50.8% of articles met the Level 4:
Efficacious standard.
Conclusion
Thirty years of research studies have shown
therapeutic benefits for general biofeedback
 Anxiety and Anxiety Disorders
with student's anxiety, anxiety accompany-
ing medical disorders and conditions, and
anxiety disorders. Many studies have
suffered from small samples, a lack of
randomized controls, a failure to specify
diagnostic standards, or failure to include
accepted psychometric measures. Neverthe-
less, there is more than adequate evidence to
support that general biofeedback meets the
Level 4: Efficacious standard for clinical
efficacy for student anxiety, anxiety ac-
companying medical disorders, and anxiety
disorders.
The choice of modality for intervention
has shifted over time, with a preponderance
of early studies utilizing surface EMG and
more recent studies favoring respiratory or
heart rate variability training. There is also a
growing literature on the use of neuro-
feedback for anxiety, and that literature will
be addressed in a separate section.
31
The benefits of self-regulation training
for anxiety disorders appear to be well-
established; the mechanisms are not. The
Rice, Blanchard, and Purcell (1984) EMG
study and the Kim, Wolburg, and Roth
(2012) breath training study both show that
the magnitude improvement is not necessari-
ly correlated with or explained by the
physiological change achieved. It remains
possible that providing any intervention
involving voluntary self-control with a
plausible hypothesis about efficacy is suf-
ficient to enhance the person’s self-efficacy
and reduce symptoms. Future research
should employ clear diagnostic criteria,
include credible controls or comparison
condition, utilize well-documented psycho-
metric measures prior to and following the
intervention, and implement well-construct-
ed designs with randomization and well-
defined control conditions.
 Evidence-Based Practice in Biofeedback and Neurofeedback
Chapter 9 – Arthritis
Level 3: Probably Efficacious
Mary C. Wood, MA,1 and Christopher L. Edwards, PhD1
1
Department of Psychiatry and Behavioral Sciences, Duke University Medical Center
Arthritis is a term describing several types
of inflammatory disorders of the joints.
Osteoarthritis, an active inflammatory
disease (or multiple diseases) that causes
cartilage to break down, and rheumatoid
arthritis, an autoimmune disorder that targets
the lining of the joints, are two major
arthritic types that have shown some
symptom improvement with biofeedback
training. The main goal of arthritis treat-
ments is to reduce symptoms and improve
quality of life. To address the symptoms of
arthritis, biofeedback training incorporates
the modalities of peripheral temperature,
muscle activation, pulse rate measures,
respiration rates, and skin conductance to
allow the patient to better control and
promote the autonomic healing processes.
Incorporated into the training are individ-
ualized educational interventions that may
increase the patient’s understanding of the
disease, and of his or her individual
situation, and thus to better manage and
cope with the symptoms, both physical and
emotional. Arthritis is a complex disease
that may be affected by genetics, weight and
BMI, injuries and excessive stress on the
joints, gender, age, blood sugar levels,
physical activity, and sleep. Biofeedback
training that includes cognitive behavioral
therapy (CBT) targets lifestyle changes and
balance in order to promote optimal success
for the participating individual.
Two studies that involve rheumatoid
arthritis are Dissanaynake and Bertouch
(2010) and Tamhane et al. (2014).
Dissanaynake and Bertouch conducted a
computer-aided search and manual screen-
ing of identified papers of randomized
controlled trials published in English in
peer-reviewed journals between 1981 and
32
2009, assessing for the use of psychological
interventions in adult patients with rheuma-
toid arthritis (RA). They sought to identify
the psychological interventions for which
there was consistent, high quality evidence
of efficacy in the treatment of patients with
RA. There was limited evidence regarding
relaxation therapy (two studies) as
efficacious for pain reduction. Methodo-
logical limitations of the reviewed literature
included failure of allocation concealment,
blinding and conduction of intention-to-treat
analysis as well as the heterogeneity and
choice of outcome measures.
Tamhane et al. studied racial/ethnic
differences with specific details of Comple-
mentary and Alternative Medicine (CAM)
used by African Americans with rheumatoid
arthritis. Data were collected from African
Americans with RA enrolled in a multicenter
registry regarding their use of CAM,
including food supplements, topical applica-
tions, activities, and alternative care provid-
ers. Factors associated with CAM use by sex
and disease duration were assessed using t-
test, Wilcoxon's rank sum test, chi-square
test, and logistic regression analyses. Of the
855 participants, 85% were women and
mean age at enrollment was 54 years. As
compared to men, women were significantly
(p < 0.05) more likely to use biofeedback,
but were less likely to smoke tobacco. CAM
use was highly prevalent in this cohort, even
in individuals with early disease. This was
deemed important within this cohort of
African Americans, where racial disparities
are known to affect access to conventional
care.
Several recent studies have been
conducted for osteoarthritis. Morone and
Greco (2007) conducted a structured review
 Arthritis
of eight mind-body interventions for older
adults with chronic nonmalignant pain. They
evaluated evidence for pain reduction via
mechanisms and interventions like biofeed-
back, progressive muscle relaxation, medita-
tion, and guided imagery. A manual search
of references from retrieved articles was also
conducted. Of the 381 articles retrieved
through search strategies, 20 trials that
included older adults with chronic pain were
reviewed. Controlled trials were based on 14
articles with participants aged 50 years and
above, while only 2 of these focused
specifically on persons aged 65 years or
older. They found some evidence for the
efficacy of progressive muscle relaxation
when added with guided imagery for
osteoarthritis pain. In an uncontrolled
biofeedback trial that stratified subjects by
age, both older and younger adults had
significant reductions in pain following the
intervention. The mind-body interventions
reviewed were found to be feasible and safe
in an older population, often with only slight
modifications of standard protocols. The
authors cautioned that there was not yet
conclusive evidence that such interventions
reduce nonmalignant pain in older adults.
Wasielewski, Parker, and Kotsko (2011)
reviewed evidence for the effectiveness of
electromyographic biofeedback (EMGB)
and evaluated only clinical randomized
controlled trials in which EMGB of the
quadriceps femoris was used for various
knee conditions of musculoskeletal origin.
Twenty specific data points were abstracted
from each clinical trial under the broad
categories of attributes of the patient and
injury, treatment variables for the EMGB
group, treatment variables for the control
group, and attributes of the research design.
Eight trials yielded a total of 319
participants with patellofemoral pain
syndrome (n = 86), anterior cruciate liga-
ment reconstruction (n = 52), arthroscopic
surgery (n = 91), or osteoarthritis (n = 90).
The average methodologic score of the
included studies was 4.6/10 based on the
33
Physiotherapy Evidence Database (PEDro)
criteria. Pooled analyses demonstrated
heterogeneity of the included studies,
rendering the interpretation of the pooled
data inappropriate. The EMGB appeared to
benefit short-term postsurgical pain or
quadriceps strength in three of four post-
surgical investigations, but was ineffective
for chronic knee conditions such as patello-
femoral pain and osteoarthritis in all four
studies. Findings were based on limited data.
Baird, Muroski, and Wu (2010)
evaluated the efficacy of guided imagery
with relaxation (GIR) created especially for
osteoarthritis in a longitudinal randomized
experiment design. Outcome variables
included pain, mobility, and medication use.
Thirty older adults were randomly assigned
to participate in the 4-month trial by using
either guided imagery relaxation or planned
relaxation. Repeated-measures ANOVA
revealed a significant reduction in pain from
baseline to month 4 and significant improve-
ment in mobility from baseline to month 2.
Evaluation of the data using the Poisson
technique indicated that, compared with
those who used the sham intervention,
participants who used GIR had a significant
reduction in over-the-counter (OTC) medi-
cation use from baseline to month 4,
prescribed analgesic use from baseline to
month 4, and total medication (OTC,
prescribed analgesic, and prescribed arthritis
medication) use from baseline to month 2
and month 4. Results of this study support
the efficacy of GIR in reducing symptoms,
as well as in reducing medication use.
Yilmaz et al. (2010) investigated
additive effect of EMG biofeedback in 40
patients aged 45-70 with knee osteoarthritis
who were randomly assigned in two
groups—one group (n = 20) had 3 weeks of
strengthening exercises paired with
biofeedback; the other group (n = 20) had
the same exercise program but without
EMGB. Clinical outcomes were measured
with visual analogue scale (VAS) and
Western Ontario and McMaster Universities
 Evidence-Based Practice in Biofeedback and Neurofeedback
(WOMAC) Osteoarthritis Index, strength
was measured with Cybex isokinetic
dynamometer, and quality of life with the
Nottingham Health Profile (NHP). There
was no statistically significant difference
between groups. Muscle strength, mobility,
and NHP pain scores improved; however,
sleep and energy improved with EMGB
additive (p < 0.05).
One study reported inconclusive
evidence for the effectiveness of biofeed-
back training for arthritis sufferers. Zijlstra,
Mancini, Chiari, and Zijlstra (2010) evalu-
ated feasibility and effectiveness of biofeed-
back-based training for balance/mobility in
older adults with two reviewers indepen-
dently screening publications of controlled
studies in adults ages >60. PEDro scale for
ineffectiveness identified if two or more
studies reported nonsignificance for the
same outcome. Positive training experiences
in the studies evaluated demonstrated that
biofeedback is applicable with older adults.
Effectiveness in 21 studies was indicated by
auditory and visual feedback training of
balance in frail participants by postural
sway, weight-shifting and reaction time in
standing with Berg Balance Scale. The
review produced inconclusive evidence to
answer the question of whether biofeedback
methods can be successfully applied in older
adults with disabling health conditions such
as osteoarthritis. However, some evidence
shows that training-specific aspects of
balance and mobility improve with
biofeedback.
34
Barsky et al. (2014) conducted a study in
which 168 arthritis patients were random-
ized into either CBT treatment, Jacobsen
technique relaxation response (RR), or
arthritis education (AE). Pain and the role of
impairment and psychological distress were
measured. Pain improved significantly at 12-
month follow-up with RR and AE. There
was no improvement in overall disease
severity, depression or anxiety. Effect sizes
were small (0.26-0.35). A true no-treatment
control group was not included. Effects of
the treatment appeared immediately after
treatment and remained through follow-up.
Recent work that supports a possible change
in gene expression resulting from relaxation
training may explain how short-term inter-
ventions like biofeedback translate to long-
term physiological changes.
A case study involving an 80-year-old
woman with 50-year history of arthritis in
her right hand was followed for six sessions
of biofeedback training. Subsequently, she
was able to demonstrate voluntary control,
and reported decreased pain and stiffness
according to Boczkowski (1983).
Most recently, Giggons, Perrson, and
Caulfield (2013) reported that virtual reality
and exergaming technology can be imple-
mented as a form of biofeedback. There is
some evidence recently that this type of
biofeedback is effective in improving
exercises in populations with musculo-
skeletal disorders like osteoarthritis, but
more studies are needed to validate the
reliability of this new technology.
 Asthma
Chapter 10 – Asthma
Level 3: Probably Efficacious
Paul M. Lehrer, PhD
Department of Psychiatry Rutgers – Robert Wood Johnson Medical School
Alone, the technique of heart rate variability
biofeedback (HRVB) meets criteria for
Level 4: Efficacious with one exception:
controlled studies have been done only in
our laboratory.
Assessment criteria and results from
published studies are as follows:
In comparison with both no treatment
and a placebo treatment (a version of
neurofeedback) in a study of 94 volunteers,
with random assignment to groups, patients
receiving HRVB took significantly less
asthma medication, showed significantly
fewer asthma symptoms, had significantly
lower respiratory resistance and significantly
fewer asthma exacerbations over the course
of a 3-month trial (Lehrer et al., 2004). In a
smaller study (N = 17), HRVB produced
significantly lower levels of respiratory
resistance than training in relaxed breathing
or a no-treatment control over the course of
a 3-month trial (Lehrer et al., 2004).
Additionally, Lehrer collaborated in writing
up results from a Russian multiple case
(uncontrolled) study of 30 consecutive cases
at an asthma clinic that showed significant
improvements in pulmonary function over
the course of 15 approximately daily
biofeedback sessions (Lehrer, Smetankin, &
Potapova, 2000).
In all the studies mentioned above,
asthma was verified by abnormal pulmonary
function results, and presence of asthma
symptoms. In the two studies by Lehrer et
al., subjects had showed evidence of a
therapeutic response in airway function to
asthma medications prior to study entry
(Lehrer et al., 1997, 2004). The outcome
measures in all studies were objective
measures of pulmonary function, as well as
(secondarily) asthma symptoms.
35
Although Lehrer was an investigator in
all three studies, he only analyzed data and
wrote the manuscript for one of the studies
(Lehrer et al., 2000). Data for that study
were collected in Russia. Nevertheless,
because Lehrer was involved in all reported
asthma studies, HRVBmust be considered
Level 3: Probably Efficacious, rather than
Level 4: Efficacious, which requires pub-
lished results from more than one center.
There are no long-term follow-up data
for effects of HRVB on asthma, an
important omission, since asthma is a
disease with usually only intermittent
symptoms. At present, the mechanism by
which HRVB helps asthma is not known.
Results do not seem to correlate with
changes in baseline levels of HRV or
baroreflex gain, although decreases in
respiratory impedance have been noticed
during biofeedback training sessions. It is
possible that strategic use of biofeedback
during occurrence of asthma exacerbations
may stop the progression of these
exacerbations, thus improving the overall
asthma condition. Other possible
mechanisms, for which no data are yet
available, include decreased airway
inflammation through stimulation of the
vagus nerve by biofeedback, and mechanical
stretching of the airways during deep
breathing, which is known to improve
performance on bronchial challenge tests
(Jackson, Murphy, Rassulo, Celli, & Ingram,
2004; Sundblad & Larsson, 2002).
Other nonbiofeedback breathing exercise
methods producing similar respiratory
patterns to HRVB have also been studied.
Pranayama yoga breathing exercises (Singh,
Soni, Singh, & Tandon, 2012), which often
produce respiratory rates similar to those in
 Evidence-Based Practice in Biofeedback and Neurofeedback
HRVB, the Buteyko method (Bowler, Green,
& Mitchell, 1998; Cowie, Conley,
Underwood, & Reader, 2008; Opat, Cohen,
Bailey, & Abramson, 2000), involving
regular shallow breathing, and the Papworth
method (Holloway & West, 2007), involving
training in relaxed breathing, have shown
improvements in asthma symptoms but not
improvements in pulmonary function. Sys-
tematic comparisons with drug effects have
not been done. Several studies did find
improvements in pulmonary function among
36
asthma patients using yoga (Kligler et al.,
2011; Singh et al., 2012; Sodhi, Singh, &
Dandona, 2009). Because yoga methods
differ considerably from place to place and
teacher to teacher, it is not possible to
determine the yoga components that led to
significant pulmonary function effects.
Controlled studies of relaxation training,
including surface electromyographic train-
ing, have shown marginal effects in treating
asthma (Lehrer et al., 1994; Vazquez &
Buceta, 1993; Vazquez & Buceta, 1993).
 Autism
Chapter 11 – Autism
Level 3: Probably Efficacious
Robert Coben, PhD,1 and Rachel Ricca, BA1
1
Integrated Neuroscience Services
There have been numerous case and group
pilot studies conducted with clients
diagnosed with autistic spectrum disorders
(ASD). In general, these studies have shown
that neurofeedback improved symptom-
atology and these improvements were
maintained at follow-up. For a more
thorough review of these, please see Coben,
Linden, and Myers (2008). While the stated
case studies are beneficial in finding support
of the efficacy of neurofeedback in patients
with ASD, without comparison to a control
group, their results are unable to fully rule
out other potential causes for improved
symptomatology.
To discover further support of the
positive effects of neurofeedback in relation
to ASD, several controlled group studies
were conducted as well. Two general
approaches have been made toward
researching neurofeedback and ASD:
examining the effects of power training and
those of coherence training. Jarusiewicz
(2002) conducted the first controlled study
of neurofeedback for autism using power
training, symptom-based approaches. She
examined 24 children on the autistic
spectrum. She divided the group in half with
12 serving as the experimental group
receiving neurofeedback, and the other 12
serving as the control group. Subjects in the
experimental group underwent between 20
and 69 sessions of neurofeedback. The
different protocols were selected based on
the child’s specific needs, such as desired
improvements in socialization, vocalization,
communication, etc., and determined by the
Othmer Assessment (1997). She evaluated
the efficacy of treatment by the child’s
responses to the Autism Treatment
Evaluation Checklist (ATEC), examining
37
autistic symptoms as well as parental
assessments in behavioral categories of
socialization, vocalization, anxiety, school-
work, tantrums, and sleep. After treatment,
Jarusiewicz compared both groups, and
results showed a 26% average reduction in
total autism symptoms with a range of 8-
56% as reported by the ATEC in the experi-
mental group, with only a 3% decrease in
the control group. The experimental group
also showed improvement in all behavioral
categories as reported by parents.
Several years later, Kouijzer, de Moor,
Gerrits, Congedo, and van Schie (2009)
investigated the effects of neurofeedback in
children with autism. It included 14 children
from 8 to 12 years old with a pervasive
developmental disorder—not otherwise
specified (PDD-NOS)—diagnosis. Excluded
were children with an IQ score below 70,
children using medication, and children with
a history of severe brain injury or
comorbidity such as ADHD or epilepsy.
Participants were divided into treatment and
wait-list control group according to the order
they applied. During baseline (Time1), all
participants were evaluated using QEEG and
a range of executive function tasks, and
parents completed behavior questionnaires
(CCC and Auti-R). After neurofeedback
training (Time2), or a comparable time
interval for the wait-list control group,
QEEGs and data on executive functions and
social behavior were re-collected. One year
after ending treatment (Time3), follow-up
data including QEEGs, executive function
tasks, and behavior questionnaires were
collected in the treatment group. Participants
in the treatment group had neurofeedback
training twice a week, until 40 sessions were
completed. In each session, participants
 Evidence-Based Practice in Biofeedback and Neurofeedback
were rewarded when inhibiting theta power
(4–8 Hz) and increasing low beta power
(12–15 Hz) at scalp location C4 according to
a protocol including seven 3-minute
intervals of neurofeedback, 70% of the
participants in the treatment group had
effectively decreased theta power and
increased low beta power. Repeated
measures MANOVA on the executive
functions data collected at Time1 and Time2
revealed a significant interaction between
treatment and control group, indicating
improvement of participants in the treatment
group on tasks measuring attention skills,
cognitive flexibility, set shifting, concept
generation/inhibition, and planning. Using
repeated measures MANOVA to compare
questionnaire data collected at Time1 and
Time2 revealed a significant interaction
effect between treatment and control group,
indicating improvement in nonverbal
communication and general communication.
Time2 Auti-R questionnaire data evaluating
changes in behavior over the last 6 months
showed significant improvement in social
interactions, communication skills, and
stereotyped and repetitive behavior for the
treatment group, but not for the control
group.
In a second study by Kouijzer and
colleagues (2010), several methodological
improvements were implemented to better
identify the effects of neurofeedback. A
randomized wait-list control group design
was used, and the study was conducted at
the schools of the participants (N = 20).
Participants were 8–12 years old and had
diagnoses of autism, Asperger’s disorder, or
PDD-NOS. Participants in the treatment
group had 40 individual neurofeedback
sessions using an individualized treatment
protocol based on an initial QEEG.
However, all treatment protocols included
theta inhibition at fronto-central scalp
locations. Treatment response was evaluated
by QEEG measures taken during rest and
task conditions with a range of executive
function tasks, and social behavior question-
38
naires filled out by parents and teachers. All
data were collected before (Time1) and after
treatment (Time2) and at 6-month follow-up
(Time3). Results of the study showed that
60% of participants decreased theta power
within 40 sessions of neurofeedback.
Additionally, repeated measures MANOVA
on QEEG data revealed a significant
interaction between treatment and control
group, indicating a decrease in theta power
in the treatment group in two out of four
QEEG conditions. Repeated measures
MANOVA on Time1 and Time2 executive
function data showed a significant inter-
action between treatment and control group
for cognitive flexibility, indicating improve-
ment in cognitive flexibility in the treatment
group compared to the control group.
Repeated measures MANOVA showed a
significant interaction effect for social
interactions and communication skills,
indicating that parents of participants in the
treatment group reported significant
improvement in social interactions and
communication skills, whereas less or no
improvement was reported by parents of
children in the control group.
Mu rhythm abnormalities are a sign of
mirror neuron dysfunction, which is thought
to be impaired in many children with autism
(Oberman et al., 2005). Two electrophysio-
logical studies conducted by Pineda et al.
(2007) sought to improve symptoms and
behavior of children with ASD by admin-
istering neurofeedback to renormalize mu
suppression and therefore correct mirror
neuron dysfunction. In Study 1, the 8 high-
functioning ASD participants were assigned
to either placebo or experimental groups.
Results showed that participants in the
experimental group showed increased
sustained attention ability and decreased mu
power and coherence when compared to
participants in the placebo group. In Study
2, there were 19 high-functioning ASD
children that underwent a modified double-
blind experiment with training of the high
mu band. Both studies showed improve-
 Autism
ments in sustained attention and in the
Autism Treatment Evaluation Checklists
(ATEC) scores. There were no improve-
ments in imitation following training, but
combined results suggest that training mu
rhythm can change behavior in high-
functioning ASD patients. Two years later,
two more studies by Pineda et al. (2009)
focused on reducing abnormal mu rhythms
in children with autism and found that,
according to parents, participants showed a
small but significant reduction in symptoms
but increased ratings of Sensory/Cognitive
awareness. This was the only study to
actually show an increase in symptoms in
trained subjects and raises some concern
with this approach in terms of safety and
efficacy.
A fifth study completed by Pineda et al.
(2013) similarly targeted participants’ mirror
neuron system through manipulating mu
rhythms. Thirteen ASD children and 11
typically developing (TD) children ranging
from 7 to 17 years old participated in this
study. All participants underwent 30 hours
of neurofeedback in both eyes-open and
-closed EEG sessions complete with mu
suppression before and after training.
Parents of the children filled out behavioral
questionnaires before and after treatment
and reported improvements predominantly
in children with ASD and not as much in TD
children. In another study related to mu
rhythms, Coben and Hudspeth (2006)
studied 14 children with ASD who were
identified as having significantly high levels
of mu activity and a failure to suppress mu
during observational activity. They all
received assessment-guided neurofeedback,
with a strong focus on aspects of mu power
and coherence. The participants were non-
randomly assigned to an interhemispheric
bipolar training (n = 7) or a coherence
training (n = 7) group designed to increase
connectivity between central regions and the
peripheral frontal cortex. All patients were
given neurobehavioral, neuropsychological
testing, and QEEG assessment. Both groups
39
of patients improved significantly on
neurobehavioral and neuropsychological
measures. However, only in the coherence
training treatment group was mu activity
significantly reduced. Increased coherence
was associated with diminished mu and
improved levels of social functioning.
Coben and his colleagues began
researching the effects of coherence/
connectivity training on autistic symptoms
more than 7 years ago. Coben and Padolsky
(2007) published a study investigating the
effects of neurofeedback treatment for
autistic disorders. The study included 49
children on the autistic spectrum, with 37
participants in the experimental group and
12 in a wait-list control group. Treatment
included 20 sessions performed twice per
week. The control group was matched for
age, gender, race, handedness, other treat-
ments, and severity of ASD. According to
the parents, there was an 89% success rate
for neurofeedback and an average of 40%
reduction in core ASD symptomatology.
There were significant improvements on
neuropsychological measures of attention,
visual-perceptual skills, language functions,
and executive functioning. Importantly,
reduced cerebral hyperconnectivity was
associated with positive clinical outcomes,
and in all cases of reported improvement,
positive outcomes were supported by
neurophysiological and neuropsychological
assessment.
Coben (2007) conducted a controlled
neurofeedback study focused on intervention
for prominent social skill deficits based on a
facial/emotional processing model. Fifty
individuals with autism were included in
these analyses and all had previously had
some neurofeedback training. All patients
underwent pre- and post-neuropsycholog-
ical, QEEG and parent rating scale
assessments. Twenty-five individuals were
assigned to either an active neurofeedback
or a wait list control group, in a randomized
fashion. The two groups were matched for
age, gender, race, handedness, medication
 Evidence-Based Practice in Biofeedback and Neurofeedback
usage, autistic symptom severity, social skill
ratings, and visual-perceptual impairment
levels. Neurofeedback training was QEEG
connectivity guided and included coherence
training (along with amplitude inhibits)
between maximal sights of hypocoherence
over the right posterior hemisphere. The
group that received the coherence training
showed significant changes in symptoms of
autism, social skills and visual-perceptual
abilities such that all improved. Regression
analyses showed that changes in visual-
perceptual abilities significantly predicted
improvements in social skills. EEG analyses
were also significant, showing improve-
ments in connectivity and source localiza-
tion of theta power related to brain regions
(fusiform gyrus, superior temporal sulcus)
associated with enhanced visual/facial/
emotional processing.
In an attempt to target multiple age
groups rather than just children to discover
effects of neurofeedback on individuals with
ASD, Thompson et al. (2010) examined
patients with Asperger’s Syndrome (AS) and
ASD over a 15-year period, including
children, adolescents, and adults. Partici-
pants received 40-60 sessions of
neurofeedback paired with training in
metacognitive strategies such as social
understanding, spatial reasoning, reading
comprehension, and math. Older adolescent
and adult participants also received
biofeedback of respiration, electrodermal
response, and heart rate variability. Results
showed improvements on measures of
attention, core symptoms, achievement and
intelligence. On the Full Scale IQ test,
participants averaged a 9-point increase. Not
only was a decrease found in negative
symptoms such as difficulties with attention,
anxiety, aprosodias, and social functioning,
but an increase in academic and intellectual
functioning was also found. However, there
are concerns here regarding control groups,
randomization and other methodological
limitations.
40
Given such methodological limitations
present in some, if not most, studies, it could
be argued that the positive increases in
performance could be attributed to non-
specific factors surrounding the treatment
and not the treatment itself. Heinrich et al.
(2007) speculate that significant improve-
ments in symptomatology are related to
factors such as treatment expectancy and/or
other nonspecific factors such as the
patient’s routine encounters with their
therapist. Thus, to dispute this claim and
overcome the methodological shortcomings,
Kouijzer and colleagues (2013) designed a
third study to control for nonspecific factors.
Researchers used a pretest-posttest randomly
assigned control group design. They divided
a group of 38 children into three different
groups: an EEG-biofeedback group, a skin
conductance biofeedback group, and a wait-
list group that received no treatment. The
addition of a skin conductance-biofeedback
group eliminates nonspecific factors because
now two groups are exposed to two different
treatments as well as the wait list group with
no treatment. Those in the EEG-biofeedback
group received monopolar neurofeedback
training on area Cz or FCz. Skin
conductance biofeedback was measured via
electrodes attached to participants’ index
and ring fingers. Kouijzer then judged
improvements by measuring cognitive
flexibility, inhibition, planning, attention,
and working memory, and lastly recorded an
EEG with a full measurement of
physiological brain functioning. Her results
showed similar levels of improvements
between the EEG and skin conductance
groups with the exception of cognitive
flexibility, but did not conclude that EEG
neurofeedback significantly reduced symp-
toms of ASD. This would seem to question
the previously mentioned research; however,
the issue with Kouijzer’s results lies with the
way the study was designed. The main
training sites Cz and FCz are minimally
affected by autism and would therefore not
produce significant results. It is believed that
 Autism
had she constructed the experiment dif-
ferently and focused on an area of the brain
more significantly related to ASD and/or
trained for improved coherence that she
would have found significant results leading
toward the positive effects of neurofeedback
on autism (Coben & Ricca, 2014).
Coben (2009) conducted a study of the
effects of an entire course of connectivity-
guided neurofeedback treatment on autistic
children. This included 110 subjects on the
autistic spectrum, with 85 in the experi-
mental group and 25 in the control (wait list)
group. The mean age of these subjects was
9.7 years (range = 4-20). Most (77%) of
these subjects were not on medication at the
time, while 14% were on one medication,
7% on two medications, and 1% on three
medications. The mean IQ of this group was
93 (range = 50–130). The mean ATEC score
was 50 (range = 40–170). There were no
significant differences between the experi-
mental and control groups for age, gender,
handedness, race, medications, IQ, or ATEC
scores. The experimental group underwent
an average of 74 neurofeedback sessions.
They were assessed using QEEG, neuro-
psychological testing, and parent rating
scales before treatment and then again after
treatment. In order to evaluate the efficacy
of neurofeedback treatment for reducing
ASD symptomatology, the subjects’ scores
on the ATEC and neuropsychological testing
were compared before and after treatment. A
univariate analysis of variance (ANOVA)
revealed that ATEC scores changed signif-
icantly after treatment (F = 117.2; p = .000).
Furthermore, 98.8% of parents reported a
reduction in ASD symptoms on the ATEC
after treatment. On objective neuropsycho-
logical testing, 100% of subjects demon-
strated some degree of improvement. An
ANOVA revealed improvements on tests of
visual-perceptual skills (F = 53.6, p = .000),
language abilities (F = 31.2, p = .000),
attentional skills (F = 54.0, p = .000), and
executive functioning (F = 15.7, p = .000).
In fact, visuoperceptual skills improved
41
43%, language abilities improved 47%,
attentional skills improved 56%, and execu-
tive functioning improved 48%. Over the
entire course of treatment, there was an
average decrease of 68% in autistic
symptoms.
Once it was determined that the therapy
was efficacious, the next question investi-
gated was whether it had greater efficacy
depending on level of functioning or sever-
ity of autistic symptoms. They investigated
the effects of pretreatment ATEC and IQ
scores on treatment outcome by dividing the
groups into quartiles based on ATEC and IQ
scores and re-analyzing the data. There were
no significant differences for any of these
analyses. This revealed that: 1) ASD symp-
tomatology improved with treatment regard-
less of IQ; and 2) severity of ASD symptoms
did not affect treatment outcomes. These
results suggest that neurofeedback is an
effective treatment regardless of the child’s
intellectual ability or severity of symptoms,
at least within the parameters of the subjects
that were included in this study.
Coben and Meyers (2010) compared
power and coherence training to determine
differential efficacy by comparing results of
Jarusiewicz’s (2002) study to Coben and
Padolsky’s data (2007). First, to equalize
sample sizes and symptom severity of the
two studies, 25 children from Coben and
Padolsky’s (2007) study with the lowest
scores in the ATEC were removed because
their sample size was larger and displayed
less severe autistic symptomatology. Coben
and Meyers (2010) examined group
differences in both pre- and posttreatment
ATEC subset scores and total scores through
utilizing an independent groups t-test. The
difference in scores, the percent change
scores, and the amount that changed per
session (the change between pre–post
neurofeedback divided by the number of
sessions administered) were also examined.
Both studies originally reported significant
improvements in their results based on
ATEC scores. Although the sample from
 Evidence-Based Practice in Biofeedback and Neurofeedback
Jarusiewicz’s group was significantly older,
Coben and Meyers (2010) found no
statistically significant differences in age
when the groups were equated. When
examining pretreatment impairment levels,
Jarusiewicz’s study showed more impair-
ment than Coben and Padolsky’s (2007)
samples [t (41) = 2.48, p = .017]. There were
no significant group differences when
comparing pretreatment scores; however,
when comparing posttreatment scores [t (22)
= 3.07, p = .006], difference scores [t (22) =
-2.249, p = .035], and percent change scores
[t (22) = -2.44, p = .023] on the
Sensory/Cognitive Awareness scales, signifi-
cant differences were found. There were also
significant differences found when compar-
ing both the total ATEC difference scores [t
(22) = -3.03, p = .006] and percent scores
for Sensory/Cognitive Awareness [t (22) =
-2.44, p = .023], Health/Physical/ Behavior
[t (22) = -2.10, p = .047], and total scores [t
(22) = -2.85, p = .009]. Another factor
contributing to the efficacy of the two
studies is the number of sessions.
Jarusiewicz (2002) used a significantly
greater number of sessions per subject when
compared to Coben and Padolsky (2007).
Examining the change per session showed
significantly greater change on all subscales
and total score of the ATEC in Coben and
Padolsky (2007) than in Jarusiewicz (2002).
Coben and Meyers (2010) discovered a
threefold improvement per session (ATEC
Total percent change per session; 0.84 vs.
2.31%) in the coherence-driven study
compared to the power training study,
demonstrating more efficacious results can
be achieved in fewer treatment sessions.
Added to these initial findings is
preliminary evidence that the effects of
neurofeedback on the symptoms of autism
are long-lasting (1-2 years) (Coben, 2009;
Kouijzer et al., 2009a).
42
Currently, there are few interventions
with proven efficacy for children with
autism. Behavioral modification interven-
tions currently have the most empirical
support, while pharmacologic interventions,
hyperbaric oxygen and vitamin supplemen-
tation have shown some potential. It is
therefore, our opinion that neurofeedback is
an intervention that may prove to be
efficacious in the treatment of symptoms of
autism. At present, it should be viewed as
demonstrating Level 3: Probably Efficacious
based on the criteria put forth by La Vaque
et al. (2002) and the previously stated
research designs.
While overall these findings are
encouraging, there are still many methodo-
logical limitations as reviewed above.
Although some of these studies include
randomized samples, it is possible that an
unknown selection bias could exist that
would have impacted the findings. In terms
of generalizing these findings to the larger
population of individuals who are autistic,
very young children and adults have not
been sufficiently represented in these group
studies. Lastly, there is the question of
whether neurofeedback may be applicable to
persons who are lower functioning or who
have more severe symptoms associated with
autism. Additional well-designed, more-
rigorous studies and longer follow-up
periods should be included. Clearly, more
research is needed and we would
recommend that this include a randomized,
double-blinded, placebo-controlled study
and/or research comparing neurofeedback to
other treatments for autism that have
demonstrated efficacy or are the “standard
of care.” We further suggest measuring
brain-related changes that may occur as a
result of neurofeedback as one way of
demonstrating its efficacy and mechanism of
action.
 Cerebral Palsy
Chapter 12 – Cerebral Palsy
Level 2: Possibly Efficacious
Jeffrey Bolek, PhD
Private Practice and Cleveland Clinic Staff Emeritus
Cerebral palsy (CP) has been defined as a
group of permanent disorders of the
development of movement and posture that
cause activity limitations and are attributed
to nonprogressive disturbances that occurred
in the developing fetal or infant brain
(Rosenbaum, Paneth, & Leviton, 2006).
Despite the abundance of literature on the
subject, there is little in the way of basic
descriptions of children with CP (Olney &
Wright, 1994), with some observing that the
diagnosis is one of exclusion of other
possible diagnoses, causing extreme hetero-
geneity in the resulting population. Spastic
motor involvement is characteristic of most
with CP (Dursun, Dursun, & Alican, 2004).
Unfortunately, spasticity is an impairment
that is poorly defined and measured
(Malhotra, Pandyan, Day, Jones, & Hermes,
2009). Therefore, we have a disorder that is
not well described with a characteristic
(spasticity) that is poorly defined. These two
facts make designing a study to judge the
efficacy of interventions with CP very
difficult. Physical and occupational therapy
interventions are used to help those with CP
gain motor control.
EMG biofeedback has been
acknowledged as effective in the retraining
of muscles and inducing relaxation of
spastic muscles (Moreland, Thomson, &
Fuoco, 1998; Schleenbaker & Mainous,
1993; Wolf & Binder-MacLeod, 1983). The
Cochrane Library only has two citations on
the topic of biofeedback and cerebral palsy.
Scianni, Butler, Ada, and Teixeira-Salmela
(2009) conducted a comprehensive review
on the effect of muscle strengthening on CP.
The quality of included studies was assessed
by extracting PEDro scores from the
Physiotherapy Evidence Database (Maher et
43
al., 2003). Of 57 full papers extracted, 5 met
the inclusion criteria and were included in
the review. The authors concluded that
strengthening interventions (progressive
resistance exercises, electrical stimulation)
do not increase strength or improve activity
in CP. If one of the targets in the use of
biofeedback in the treatment of CP is to
increase strength by facilitating exercises
such as progressive resistance, then
according to the Scianni et al. study, the
treatment is unlikely to be effective; not
because of the treatment modality (biofeed-
back), but because even traditional treat-
ments such as progressive resistance do not
increase strength. As it is, the Scianni et al.
study is contrary to previous systematic
reviews that found progressive resistance to
be effective (Dodd, Taylor, & Graham,
2003). The other study was the Van Dijk et
al. (2005) article reviewed below.
There are no comprehensive reviews on
the effectiveness of biofeedback in the
treatment of motor disorders in CP. Van
Dijk, Jannink, and Hermens (2005)
conducted a systematic review of random-
ized controlled trials on the effect of
augmented feedback on motor function of
the affected upper extremity in rehabilitation
patients. “Augmented feedback” was defin-
ed as biofeedback, kinetic feedback,
kinematic feedback, and knowledge of
results. “Biofeedback” was defined in the
study as feedback related to the activity of
physiological processes. No firm evidence
was found of effectiveness of augmented
feedback to improve motor function.
Essentially, the study looked at a diversity of
therapeutic interventions. Bloom, Przekop,
and Sanger (2010) found that chronic daily
use of surface EMG by children with CP
 Evidence-Based Practice in Biofeedback and Neurofeedback
showed significant clinical improvement in
all 10 children that completed the study.
Dursun et al. (2004) evaluated the effective-
ness of EMG biofeedback on gait function
in 21 children with CP. The biofeedback
group displayed statistically significant
improvements in plantar flexor muscle tonus
and active range of motion of the ankle
joints compared to the 15 children who
received conventional exercise. In an
attempt to decrease the rates of drooling,
Koheil, Sochaniwskyj, Bablich, Kenny, and
Milner (1987) investigated the effectiveness
of EMG auditory feedback training of the
orbicularis oris, of making the act of
swallowing a conscious one, and of
providing an auditory signal to cue
swallowing. After biofeedback training,
there was a significant decrease in drooling
rates and a small increase in swallowing
rates of the 12 children with CP.
James (1992) conducted a review of
biofeedback treatment in children and
adolescents with CP. He found that, overall,
the reviewed studies demonstrated that
biofeedback is effective in supporting self-
regulation of several problem areas for
children with cerebral palsy. Bolek (2003,
2006) found that 14 of 16 treatment-resistant
children with CP improved in their ability to
sit, walk, and stand, their upper extremity
use and head control using EMG
biofeedback. The Agency for Healthcare
44
Research and Quality posted the following
recommendation in 2010:
It is recommended that biofeedback be
considered by a physical therapist as
an adjunct to other forms of traditional
physical therapy. Physical therapists
may use surface electromyogram
(EMG) biofeedback to facilitate im-
provements in strength, coordination,
muscle control, and peak muscle
power during gait as well as to
improve gait parameters such as
velocity, cadence and stride length
(Schleenbaker & Mainous, 1993;
Dursun, Dursun, & Alican, 2004;
Bolek, 2006; Bolek, 2003; James,
1992) (p. 4).
Conclusion
Based on these findings, the use of
biofeedback in the treatment of patients with
CP warrants a rating of Level 2: Possibly
Efficacious. Indeed, even traditional therapy
techniques (progressive resistance) were
found wanting in some studies. Without
well-designed, blind, randomized studies, it
is difficult to sort out which treatments are
most effective. There is enough evidence to
support further study, but the challenges
mentioned earlier (definition of CP,
spasticity, poorly defined progressive
resistance exercises) will need to be
addressed.
 Chemobrain
Chapter 13 – Chemobrain
Level 3: Probably Efficacious
Sarah Prinsloo, PhD
MD Anderson Cancer Center
Complaints of cognitive difficulties is one of
the most widely recognized consequences of
cancer and its treatment. The phenomenon
known as chemofog or chemobrain has been
confirmed via subjective report, obser-
vational studies, clinical trials, and neuro-
imaging modalities. Brain regions affected
by exposure to chemotherapy can be
widespread and may include the left inferior
frontal cortex, superior and middle frontal
gyri, parahippocampal gyrus, cingulated
gyrus, and precuneus, to name a few, with
specific alterations being associated with
cognitive function (Inagaki et al., 2007;
Silverman et al., 2007). Single regions of
interest as well as network hubs have been
reported to be affected by chemotherapy
(Bruno et al., 2012). Most studies have been
done in breast cancer survivors with
common chemotherapy regimens, including
cyclophosphamide, doxorubicin, paclitaxel,
methotrexate, and 5-fluorouracil, and have
reported neuropsychological deficits that
include the domains of intelligence,
processing speed, verbal memory, executive
functioning, and fine motor skills. The
extent to which neurofeedback can be
utilized to help cancer survivors suffering
with this issue is yet to be determined. To
date, there is only one study measuring the
effects of neurofeedback on post-chemo-
therapy cognitive impairment directly;
however, neurofeedback studies to address
similar cognitive deficits in other
populations are more prevalent.
While there is limited availability of
randomized, controlled trials to treat
chemobrain, several studies with a control
group design or a placebo treatment have
45
been published that address efficacy of
neurofeedback to treat cognitive impair-
ment. Alvarez (2013) examined 23 breast
cancer survivors who underwent twice-
weekly neurofeedback sessions for 10 weeks
for a total of 20 sessions. Significant
improvements were found in self-reported
cognitive function, fatigue, sleep quality,
and psychological well-being (Alvarez et al.,
2013). Improvements in overall cognitive
performance as well as improvements in
working memory were found across several
studies of EEG neurofeedback (Escolano et
al., 2011; Hanslmayr et al., 2005; Zoefel et
al., 2011). Bacerra randomly assigned
healthy seniors to a treatment or a control
group that received placebo feedback. The
treatment group participants improved in
verbal comprehension and verbal IQ,
attention, executive function, and memory
(Becerra et al., 2012). Finally, Hoedlmoser
et al. (2008) found that increasing the
sensorimotor rhythm (12-15 HZ) resulted in
improvement in declarative memory
performance after 10 neurofeedback
sessions in a group of 27 healthy subjects.
Conclusion
These studies and others support a rating of
Level 3: Probably Efficacious for neuro-
feedback to treat cognitive decline after
chemotherapy. Future research should
address the question of whether or not
predictions of cognitive decline can be made
by type of chemotherapy treatment, and
RCTs should be implemented to increase the
level of efficacy of neurofeedback in this
population.
 Evidence-Based Practice in Biofeedback and Neurofeedback

Chapter 14 – Chronic Pain

(excluding fibromyalgia, headache, irritable bowel syndrome, Raynaud’s disease)

Richard A. Sherman, PhD, BCB, BCB-PMDB,1 Gabriel Tan, PhD, BCB, BCN,2 Lai Wei Wei, BSc (Hons),2
and Tina Tin, BSc (Hons)2
1
Saybrook University
2
National University of Singapore

Efficacy Ratings of Chronic Pain Disorders

Level 4: Efficacious
a. Muscle-related orofacial pain (Crider, Glaros, & Gevirtz 2005; Glaros, & Lausten, 2002).
b. Noncardiac chest pain (DeGuire, Gevirtz, Hawkinson, & Dixon, 1996; Gevirtz, 2001)
c. Posture-related pain problems such as forward head thrust (Middaugh, 1994)

Level 3: Probably Efficacious

a. Muscle-related low back pain (Flor & Birbaumer, 1994; Morley, Eccleston, & Williams,
1999; van Tulder et al., 2006)
b. Cramping and burning phantom limb pain (Belleggia & Birbaumer, 2001, Flor, 2002;
Harden et al., 2005; Sherman, Devore, Jones, Katz, & Marbach, 1996)
c. Pelvic floor pain syndromes (Glazer, Rodke, Swencionis, Hertz, &Young, 1995; Tries &
Eisman, 1995; Yucha & Gilbert, 2004)
d. Subluxation of the patella and patellofemoral pain (Crossley, Bennell, Green, Cowan, &
McConnell, 2002, Dursun, Dursun, & Kilic, 2001)
e. Cancer pain (Tsai et al., 2007)

Level 2: Possibly Efficacious

a. Pain from carpel tunnel syndromes related to upper arm and neck muscle tension
(Donaldson, Nelson, Skubick, & Clasby, 1998; Skubick, Clasby, Donaldson, & Marshall,
1993)
b. Myofascial pain syndrome/trigger point-related pain (Gevirtz, 1995; Headley, 1991;)
c. Whiplash
d. PMS and dysmenorrhea (Breckenridge, 1983)
e. Pain from spastic muscles and muscle spasms (Kasman, 1998)

Level 1: Not Empirically Supported

a. Pain and spasticity due to not taking micro-breaks among sign language translators,
musicians, factory workers, computer workers, etc.
b. Reflex sympathetic dystrophy
c. Trigeminal neuralgia (Sime, 2004)

Introduction pain, once pain becomes chronic, it becomes

A common accepted definition of chronic
pain is pain that has lasted more than 3 or 6
months that continues to persist beyond an
expected course of outcome. Thus, any acute
pain could become chronic. It has also been
observed that regardless of the source of the
a syndrome (a collection of signs and symp-
toms that are observed in, and characteristic
of, a single condition) (Grichnik & Ferrante,
1991). Traditional treatments include
surgery, medication, injections, and physical
medicine and rehabilitation (PM & R)

46
 Chronic Pain
treatments. Chronic pain often does not
respond positively to treatment used for
acute pain.
Biofeedback is used for chronic pain in
three main ways. First, it is aimed directly at
rectifying the problem causing the pain—as
when muscle tension biofeedback is used to
teach people having jaw area pain due to
sustained jaw area muscle tension to
recognize and control their muscle tension to
prevent the pain from starting. Second, it is
directed toward changing the underlying
patterns of responses that lead to the pain—
as when heart rate variability feedback is
used to quiet the autonomous system, so the
intestinal problems leading to the pain of
irritable bowel syndrome will not get
started. Third, it is used to reduce anxiety
and stress responses magnifying pain
sensations. For a more detailed analysis of
the above, see Pain Assessment and
Intervention from a Psychophysiological
Perspective (2012).
This chapter excludes headaches and
fibromyalgia, which are reviewed in other
chapters of this text. The outcome and
conclusions of the review have been
presented above as a table showing the level
of efficacy for different chronic pain
conditions and the supporting research.
There has been increasing evidence that
pain is processed and modulated in the brain
and the central and peripheral nervous
systems (CNS and ANS), which play a
major role in the etiology and maintenance
of many chronic pain conditions (i.e., the
phenomena of hyperalgesia and allodynia).
The neurobiology of chronic pain indicates
that repetitive stimulation of peripheral
nerve could activate C-fibers, resulting in
progressive build-up of response in second-
order dorsal horn neurons (“wind up”), and
that persistent peripheral stimulation could
lead to disproportionate up-regulation of the
CNS. This phenomenon is often referred to
as central sensitization, a major etiology and
contributor to the maintenance of chronic
pain (Bennett & Robert, 1999). Fibromyal-
47
gia could be an example. Another discovery
is non-nociceptive pain arising from
augmented sensory processing (Bennett &
Robert, 1999). The discovery that pain is
processed and modulated in the brain and
that a myriad of infrastructures are involved
have given rise to the introduction of new
treatments for chronic pain. Thus,
neurofeedback holds a great deal of promise
for pain management.
Partly due to the history of biofeedback,
treatments for chronic pain have focused on
muscle-related pain (e.g., using SEMG to
treat tension headaches, posture-related pain,
pain associated with TMJ), or pain resulting
from ANS dysregulation, stress, and anxiety
(e.g., IBS, migraine and Raynaud’s
Syndrome). Much of the research to date
and evidence of efficacy have been related
to these conditions.
Evidence of neurofeedback use in pain
has been quite limited partly due to its newer
history. Some examples are using slow
cortical potential training to alleviate
symptoms of migraine, using EEG-driven
neurofeedback in conjunction with EMG
biofeedback to treat fibromyalgia (Caro &
Winter, 2001), treating pain associated with
trigeminal neuralgia with biofeedback and
neurofeedback (Sime, 2004), and treating
complex regional pain syndrome (CRPS)
type 1 with neurofeedback as part of a
treatment regime (Jensen, Grierson, Tracy-
Smith, Bacigalupi, & Othmer, 2007). Targets
for neurofeedback include: failure modes in
the anterior cingulate, such as excess alpha,
excess of slow wave activity, and beta
spindling (Arns, Gunkelman, Breteler, &
Spronk, 2008; Johnstone, Gunkelman, &
Lunt, 2005; Shafritz, Kartheiser, & Belger,
2005; Woodward, Ruff, & Ngan, 2006), and
somatosensory areas for pain perception,
thalamic relays for modulating pain
sensation and cortical reorganization (Flor et
al., 1995).
The following sections will review the
efficacy of biofeedback and neurofeedback
therapies for patients who experience
 Evidence-Based Practice in Biofeedback and Neurofeedback
chronic pain. When considering these
studies, it is important to note that chronic
pain can have a myriad of origins,
symptoms, patterns, and intensities. Iden-
tical symptoms can have varied causes, yet
science’s ability to tease out particular
underlying mechanisms is still in its infancy.
Thus, a particular treatment could be highly
efficacious for alleviating a set of symp-
toms, but less effective for other sufferers
with the same symptoms. The reviews will
be presented by efficacy levels rather than
by specific chronic pain conditions.
Biofeedback and Neurofeedback Studies
Level 4: Efficacious. Evidence
supporting biofeedback treatment affords
confidence in its use among patients with
chronic pain that is induced by various
physiological conditions. Paired with relax-
ation exercises, breathing practice or
strength training focusing on specific muscle
groups, biofeedback treatments are effective
in alleviating pain as associated with
recurrent abdominal pain (Humphreys &
Gevirtz, 2001), posture-related muscle
tension (Middaugh, Kee, & Nicholson,
1994; Newton-John, Spence, & Schotte,
1995; Vlaeyen, Haazen, Schuerman, Kole-
Snijders, & van Eek, 1995), and noncardiac
arrest chest pain (DeGuire, Gevirtz,
Hawkinson, & Dixon, 1996; Del Pozo,
Gevirtz, Scher, and Guarneri, 2004). In
combination with secondary treatment
modes, biofeedback therapy worked well
with Cognitive Behavioral Therapy (CBT)
for patients with temporomandibular
disorders (Crider, Glaros, & Gevirtz, 2005)
and psycho-educational training that
includes challenging automatic thoughts
about heart disease among patients with
noncardiac arrest chest pain (Potts, Lewin,
Fox, & Johnstone, 1999). Several review
studies also supported the use of
biofeedback therapy for muscle-related
orofacial pain (Crider et al., 2005), chronic
abdominal pain (Weydert, Ball, & Davis,
2003), and noncardiac arrest chest pain
(DeGuire et al., 1996; Gevirtz, 2002).
48
Studies that examined biofeedback
treatment for chronic pain have adopted
well-designed methodologies for efficacy
evaluation, including the use of wait-list or
sham-treatment control groups, samples
being treated for a specific pain-inducing
condition, and well-defined treatment out-
come measures. In comparison with con-
trols, biofeedback techniques are reportedly
superior in reducing patient-reported pain
either as a treatment on its own to modulate
physiological reactions or in combination
with a secondary treatment mode such as
psychological therapy or relaxation exercise.
Based on the efficacy guidelines by the
Association for Applied Psychophysiology
and Biofeedback (AAPB) and the Inter-
national Society for Neuronal Regulation
(ISNR) (Lavaque et al., 2002), biofeedback-
based treatments are efficacious (Level 4) in
ameliorating chronic pain symptoms report-
ed by patients with noncardiac arrest chest
pain, posture-related pain, and muscle-
related orofacial conditions.
The above studies provide evidence that
psychophysiological approaches such as 1)
respiration training, 2) relaxation training, 3)
resonant frequency training (heart rate
variability biofeedback [HRVB]), and 4)
respiration/relaxation/HRV training com-
bined with psychological or educational
intervention should all produce at least some
success in treating chronic pain. The current
understanding of biofeedback treatment for
chronic pain is not complete. More can be
done to build on recent data, such as
determining success rates in relation to
initial severity, establishing effectiveness
duration, or generalizing to samples with co-
morbid conditions.
Level 3: Probably Efficacious There is
some evidence supporting the use of
biofeedback treatment for patients with
chronic bodily pain and cancer. Using wait-
list controls and other nonbiofeedback
treatments (e.g., CBT, standard medical
treatment, operant conditioning) as compar-
ison, patients with chronic low back pain
 Chronic Pain
reported fewer pain symptoms following
biofeedback treatment that included
assistance from muscle tension relaxation
exercises (Ferrari, Fipaldini, & Birbaumer,
2006; Flor & Birbaumer, 1993; Vlaeyen et
al., 1995). Relative to controls receiving
conventional treatment, patients with cancer
pain also experienced relief from
biofeedback-assisted relaxation exercises
(Tsai, Chen, Lai, Lee, & Lin, 2007).
Although biofeedback-assisted muscle
tension release techniques and thermal
biofeedback are effective in reducing
phantom limb pain, specific effects depend
on the nature of the pain’s underlying
physiological correlates (Harden et al.,
2005; Sherman et al., 1996). Sherman et al.
(1996) proposed that varying types of
phantom pain respond virtually only to
interventions that alter its underlying
mechanisms (Sherman et al., 1996).
Integrating biofeedback techniques with
isometric exercises or electrical stimulation
was effective for patients with knee pain
(Durmus, Alayli, & Canturk, 2005; Qi &
Ng, 2007). Despite the positive outcomes,
results from these studies should be read
with caution as control or placebo groups
were not included. There are also studies
claiming success in using biofeedback-based
techniques to ameliorate pelvic floor-related
pain disorders including chronic pelvic pain
of unknown origin (Hoebeke et al., 2004;
Nadler, 2002), vulvar vestibulitis (Glazer,
Rodke, Swencionis, Hertz, & Young, 1995),
and constipation-related pain (Turnbull &
Ritvo, 1992). In a similar context, gender
differences in treatment responses were
observed (Hetrick et al., 2006). However,
similar to studies on knee pain, biofeedback
treatment studies examining pelvic pain
syndromes suffer from lack of control or
placebo comparisons, substantial sample
sizes, and long-term follow-up results, and
thus, should be read with caution.
Only some studies focusing on the
treatment of chronic pain in patients with
muscle-related low back problems, phantom
49
limb pain, cancer pain, pelvic floor pain
syndromes, and patella and patelofemoral
pain have been evaluated using wait-list or
placebo controlled studies and patient
samples with varied etiologies of pain
symptoms reported. In some studies, sample
sizes were small (N < 10) and diagnostic
methodology of sampled populations was
not clearly explained or was unavailable.
Thus, the use of biofeedback therapy for the
above conditions is at best probably
efficacious (Level 3). Further efforts to
specify treatment sample profiles and to
introduce sham treatment conditions may be
worthwhile.
Level 2: Possibly Efficacious Some
attempts to use controlled study designs
were observed in studies examining chronic
pain related to premenstrual syndrome
(PMS) and/or dysmenorrhea, whiplash
condition (Voerman, Vollenbroek-Hutten, &
Hermens, 2006), and repeated muscle strain
injuries (Moore & Wiesner, 1996).
Specifically, using wait-list controls as
comparison, hypnosis combined with
biofeedback and autogenic training appeared
effective for patients with repetitive muscle
strain injuries (Moore & Wiesner, 1996) and
biofeedback treatment was successful in
reducing symptoms among women with
primary dysmenorrhea (Balick, Elfner, May,
& Moore, 1982). Based on self-controlled
designs, women with primary dysmenorrhea
improved in reported symptoms upon
completion of skin conductance and EMG
biofeedback treatments (Hart, Mathisen, &
Prater, 1981), and chronic whiplash patients
reported reductions in pain intensity
following completion of ambulatory electro-
myographic biofeedback training (Voerman
et al., 2006).
There are some case series describing
changes in chronic pain ratings following
the completion of treatments based on
biofeedback techniques. Temperature bio-
feedback was successful in reducing
symptoms among women with primary
dysmenorrhea (Balick, Elfner, May, &
 Evidence-Based Practice in Biofeedback and Neurofeedback
Moore, 1982; Breckenridge, Gates, Hall, &
Evans, 1983; Mathew, Claghorn, Largen, &
Dobbins, 1979) and pain from endometriosis
(Hawkins & Hart, 2003). Frontal EMG
biofeedback, fingertip temperature biofeed-
back, and progressive relaxation exercises
were effective in reducing symptom severity
among female soldiers with PMS and
primary dysmenorrhea (Hamblen, Sherman,
& Powell, 1996). Myofascial technique
physical therapy combined with psycho-
physiologic procedures and trigger point
injections relieved resistant myofascial pain
when conventional treatments did not work
(Sorrell & Flanagan, 2003; Sorrell,
Flanagan, & McCall, 2003). A case series by
Skubick et al. (1993) provided some
evidence for using surface EMG techniques
for pain due to muscular dysfunction in
patients with carpal tunnel syndrome (CTS).
For an in-depth review on the etiology of
muscular dysfunctions leading to CTS, see
Donaldson Donaldson, Nelson, Skubick, and
Clasby (1998).
There is preliminary evidence supporting
the use of neurofeedback approaches for
pain and chronic pain problems. Compared
to healthy controls, deCharms et al. (2005)
reported 50% reduction in patient-rated pain
following real-time fMRI biofeedback
treatment. Recently, based on uncontrolled
case series data, Jensen et al. (2013)
demonstrated modest effects of EEG
neurofeedback in improving spinal cord-
related pain and these effects were
maintained at 3-month follow-up.
Biofeedback treatment for PMS, primary
dysmenorrhea, chronic whiplash, and
repeated muscle strain injuries has achieved
some positive outcomes. Neurofeedback
50
treatment approaches also offer promising
advances in relieving chronic pain and pain
related to spinal cord injury. These treatment
methods are possibly efficacious (Level 2).
Reviewed studies are lacking well-
controlled experimental designs that are
supported by sham or placebo treatment
conditions. Sample sizes are also small and
with limited generalizability beyond the
particular condition. Greater focus is needed
in developing larger studies with better
controls and with long-term follow-ups.
Level 1: Not Empirically Supported.
Biofeedback or neurofeedback treatments
are not empirically supported (Level 1) for
pain related to complex regional pain
syndrome (CRPS; Jensen et al., 2007;
McMenamy, Ralph, Auen. & Nelson, 2004),
trigeminal neuralgia (Sime, 2004), and pain
and spasticity due to not taking micro-breaks
(e.g., among sign language translators,
musicians, factory workers, computer
workers, etc.). Although Jensen et al. (2007)
reported lower pain ratings among patients
with CRPS posttreatment, differences in
pre–post ratings were not statistically
significant. Furthermore, study participants
were administered a package of several
other non-biofeedback-related treatments,
which make specifying treatment effects due
to biofeedback alone challenging. In a case
study, Sime (2004) reported the positive
effects of biofeedback and neurofeedback
treatments combined in a patient who
experienced pain resulting from trigeminal
neuralgia. However, these findings are still
preliminary and controlled designs with
more specific treatments could help to
validate these results.
 Constipation
Chapter 15 –Constipation
Level 4: Efficacious
Irene Teo, PhD
University of Texas MD Anderson Cancer Center
Functional constipation, or chronic idio-
pathic constipation, is characterized by
persistent difficult and/or infrequent
defecation that is not readily explained by
known causes that is present for at least 3
out of 6 months (World Gastroenterology
Organisation, 2010). Functional constipation
is an umbrella term that includes slow transit
constipation and dyssynergic defecation.
Slow transit constipation is associated with
abnormal rate in fecal material progressing
through the colon. Dyssynergic defecation
(also known as pelvic floor dyssynergia,
spastic pelvic floor syndrome, paradoxical
puborectalis contractions, or anismus) refers
to problems with evacuation of stool where
there may be paradoxical anal contraction,
involuntary anal spasm/relaxation, or
inadequate push effort (Bleijenberg, 1994;
Gilliland, 1997; Koustsomanis, 1995).
Dyssynergic defecation is the most common
pathogenesis that affects about 40% of
patients with functional constipation,
although about two-thirds of these patients
typically also present with slow colonic
transit (Rao, 2008).
Types of biofeedback therapies that are
typically utilized in treatment of functional
constipation include EMG biofeedback,
manometry biofeedback, and sensory
training (Bassotti, 2004). Out of these
biofeedback methods, EMG biofeedback has
been studied the most, although none have
been shown to be consistently more
effective than any other method (Enck, Van
Der Voort, & Klosterhalfen, 2009;
Woodward, Norton, & Chiarelli, 2014).
Recent studies report biofeedback to be
more effective for patients with dyssynergic
defecation compared to those with slow
transit constipation (Bassotti et al. 2004;
51
Battaglia et al. 2004; Chiarioni, Salandini, &
Whitehead, 2005). A number of reviews
have been conducted examining the
effectiveness of biofeedback in treating
constipation (Enck et al., 2009; Heymen,
Jones, Scarlett, & Whitehead, 2003; Palsson,
Heymen, & Whitehead, 2004). These review
studies reported the superiority of
biofeedback therapy to other treatments. A
more recent Cochrane review conducted by
Woodward et al. (2014) identified 17
randomized trials that reported patient
improvement from biofeedback therapy for
chronic constipation and dyssynergic
defecation with effects sizes ranging from
40–100%. The authors concluded that the
methodological quality of the studies
reviewed was poor and that many of the
studies were subject to bias. The following
are summaries of findings of randomized
controlled trial studies that have full reports
published in peer-reviewed literature.
Biofeedback vs. Other Treatments for
Functional Constipation
Simon et al. (2009) compared EMG
biofeedback to behavioral counselling
sessions in treating elderly patients with
dyssynergic defecation who were unre-
sponsive to diet modification. Patients who
received biofeedback treatment were found
to have significant improvements in number
of bowel movements, difficulty and
completion of evacuation, perianal pain, as
well as straining compared to the patients
who received behavioral counseling. The
improvements were maintained at 2-month
follow-up.
Chiarioni, Whitehead, Pezza, Morelli,
and Bassotti (2006) randomized patients
with severe levels of constipation with
 Evidence-Based Practice in Biofeedback and Neurofeedback
dyssynergic defecation into groups receiving
either EMG biofeedback or laxatives and
educational treatment. Patients in both
groups reported increased stool frequency;
however, patients being treated with
biofeedback reported more satisfaction with
treatment (80% vs. 22%), greater reductions
in blocked on incomplete bowel movements,
straining, abdominal pain, and use of
enemas at 6 and 12 months.
Rao et al. (2007) randomized patients
with dyssynergic defecation to receiving
treatment in the form of manometry
biofeedback (showing visual display of anal
sphincter pressure), sham biofeedback, or
standard care. The patients who received
sham biofeedback were taught progressive
muscle relaxation and received balloon
distensions to match those received by
patients receiving biofeedback. Standard
care comprised of diet and lifestyle
education, laxatives, and scheduled evacua-
tions. Patients who received biofeedback
treatment reported significantly increased
complete spontaneous bowel movements in
comparison to the other groups at 3-month
follow-up. The group who received
biofeedback treatment also reported
increased satisfaction in bowel movements.
One-year follow-up of the patient groups
that received manometry biofeedback and
standard care indicated that those who
received manometry biofeedback continue
to do better than those who received
standard therapy (Rao et al., 2010).
Heymen and colleagues (2007)
compared the effectiveness of EMG
biofeedback to oral diazepam or placebo in
patients who continued to have dyssynergic
defecation following 4 weeks of diet and
lifestyle education. At 3-month follow-up,
patients who received EMG biofeedback
training reported improvement in constipa-
tion symptoms compared to the group
receiving diazepam and placebo (70% vs.
23% and 38%). Patients who received EMG
biofeedback reported significantly more
unassisted bowel movements compared to
52
those receiving placebo, and less straining
compared to those who were administered
diazepam.
You and colleagues (2001) reported that
biofeedback treatment was superior to
botulinum toxin-A injections and posterior
myomectomy of the internal anal sphincter
and puborectalis muscles in treatment of
patients with outlet obstruction constipation.
In the study, patients receiving biofeedback
therapy reported satisfactory improvements
compared to those receiving surgery (88%
vs. 85%). Patients who received biofeedback
treatment reported no relapse in constipation
at 2-year follow-up.
Farid and colleagues (2009, 2010) con-
ducted a study in Egypt comparing sensory
training biofeedback, botulinum toxin-A
injections, and bilateral open partial division
of puborectalis treatment in patients with
anismus (nonrelaxing anal sphincter) that
were unresponsive to laxatives or enemas.
This study reported that the group receiving
surgery and botulinum toxin-A reported
improvements compared to the biofeedback
group initially (95% and 71% vs. 50%). At
1 year, the number of patients who report
continued improved bowel functioning was
70% in the surgery group, 35% in the
botulinum toxin-A group, and 30% in the
biofeedback group. Satisfaction with
treatment was highest for the group
receiving surgery despite 7 out of 20
patients experiencing some form of adverse
reaction (i.e., infection, incontinence, and
intussusception).
Lehur et al. (2008) conducted a trial
across nine European clinics and random-
ized 119 female patients with outlet obstruc-
tion to receiving either EMG biofeedback
training or a stapled transanal rectal resec-
tion (STARR) procedure. More patients in
the group who received STARR procedure
compared to the EMG biofeedback reported
decreased obstructed defecation (82% vs.
33%). Although this surgical technique ap-
pears to have higher success rates than bio-
feedback, it is important to note that surgical
 Constipation
procedures are associated with higher risk of
adverse events including wound infection,
fecal incontinence, pain, etc.
Differences in Method of Biofeedback in
Treating Constipation
Bleijenberg et al. (1994) randomized
patients with chronic dyssynergic defecation
to receive either EMG biofeedback or
balloon-assisted training. This study found
EMG biofeedback to be more effective than
balloon-assisted training. Pourmomeny et al.
(2010) also randomized patients with
chronic dyssynergic defecation to receive
either EMG biofeedback or balloon-assisted
training. This study also found EMG bio-
feedback to be more effective than balloon-
assisted training.
Koutsomanis et al. (1995) utilized a
randomized cross-over design where
patients with functional constipation were
administered EMG biofeedback with or
without visual display. Patients were placed
into the alternate arms if improvements were
not observed in two sessions. No significant
differences were observed between the two
groups.
Heymen et al. (1999) randomized
patients with dyssynergic defecation into
different variations of EMG biofeedback
training: 1) weekly 1 hour of EMG biofeed-
back, 2) EMG biofeedback + sensory
training, 3) EMG biofeedback with home-
trainer, and 4) EMG biofeedback + sensory
training + home trainer. The study conclud-
ed that adding the home training component
and/or sensory training improved outcomes
over EMG biofeedback training alone.
Glia et al. (1997) compared manometry
biofeedback to EMG biofeedback. No
statistical significant difference was found in
53
effectiveness of the interventions. Chang et
al. (2003) randomized patients with
functional constipation to receive either
EMG biofeedback training or electrical
stimulation therapy (EST). No statistical
difference was observed between the two
groups in bowel functioning satisfaction
scores. Hart and colleagues (2012) examined
patients with dyssynergic defecation who
were not responsive to lifestyle modifica-
tions and medical interventions. Patients
were randomized to receive either anorectal
EMG biofeedback training or trapezius/
temporalis EMG biofeedback training. The
group receiving the anorectal EMG biofeed-
back training reported a lower constipation
severity score mean compared to the group
receiving trapezius/temporalis EMG bio-
feedback training, although this finding was
nonsignificant. Quality of life scores for
both groups were comparable.
Conclusion
A review of the literature indicates
biofeedback to warrant a rating of Level 4:
Efficacious in treatment of functional
constipation. Biofeedback has been shown
to be superior to the standard of care
treatments (typically defined as prescription
of laxatives and patient education), however,
recent studies comparing biofeedback to
novel surgical techniques have mixed find-
ings at this time. Biofeedback seems to be
more effective for patients with dyssynergic
defecation compared to those with slow
transit constipation. There appears to be
most support for EMG biofeedback,
although the overall literature does not
report a particular method to be better than
another.
 Evidence-Based Practice in Biofeedback and Neurofeedback

Chapter 16 – Chronic Obstructive Pulmonary Disease (COPD)

Level 2: Possibly Efficacious
Christopher Gilbert, PhD, BCB

Kaiser Permanente Chronic Pain Program, San Francisco

A small, randomized study demonstrated and audio biofeedback of breathing vari-

those persons receiving breathing-pattern
training had a 22% increase in forced
expiratory volume (FEV1) and a 19%
increase in forced vital capacity (FVC), but
no significant increases in the control group
(Esteve, Blanc-Gras, Gallego, & Benchetrit,
1996). An uncontrolled study showed that
five sessions of HRVB and walking with
pulse oximetry feedback improved the
distance walked in 6 minutes and quality of
life in patients with COPD (Giardino, Chan,
& Borson, 2004).
A 4-week study compared outcomes of a
standard rehabilitation program for COPD
with the same program plus extensive visual
ables (van Gestel et al., 2012). Biofeedback
training goals were slower, steadier
breathing with more abdominal and less
thoracic movement, plus avoidance of
hyperinflation. Each group contained 20
subjects. Though reaching training criteria
was not assessed, the two groups after
1 month did not differ in exercise tolerance,
quality of life, or pulmonary functions. Both
groups had improved cardiac autonomic
functioning, suggesting that the breathing
biofeedback’s effect was similar to the effect
of intense exercise, which both groups
performed.

54
 Coronary Artery Disease
Chapter 17 – Coronary Artery Disease
Level 2: Possibly Efficacious
Christine S. Moravec, PhD, and Michael G. McKee, PhD, BCB
Department of Cardiovascular Medicine, Cleveland Clinic
Evidence suggests that biofeedback may be
efficacious in coronary artery disease
(CAD), but studies suffer from two
significant limitations. Early studies suggest
clinical improvement, but are small,
uncontrolled and nonrandomized. More
recent studies, which are adequate in size
and study design, provide only indirect
evidence for efficacy, showing that
biofeedback can augment HRV, but failing
to link improved HRV with CAD severity or
prognosis.
Palomba and colleagues worked with
four postmyocardial infarction patients,
training them to control heart rate, and
showing little, if any, change in HRV,
accompanied by anecdotal reports of
minimal clinical improvement in individual
patients (Palomba, Stagagno, & Zanchi,
1982). Johnston and Lo trained seven angina
patients using guided relaxation as well as
EMG and HRVB. After training, six of
seven patients reported less angina and
demonstrated an increase in exercise
tolerance (Johnston & Lo, 1983). In 1990,
Cowan and colleagues used respiratory sinus
arrhythmia (RSA) biofeedback training to
increase HRV in six survivors of cardiac
arrest, demonstrating both increased power
spectral density at the high frequency level
and decreased density at low frequency,
suggesting improvement in autonomic
balance (Cowan, Kogan, Burr, Hendershot,
& Buchanan, 1990).
In larger, randomized trials, work by
Cowan and colleagues demonstrated that a
psychosocial intervention that included
biofeedback training that was aimed at
improving autonomic tone decreased the
risk of cardiac death in a randomized trial of
133 cardiac arrest survivors. Death in the
55
control group was due to ventricular
arrhythmias, which did not occur in the
treated group. Risk of cardiovascular death
was decreased by 86% by the intervention,
with a 62% reduction in all-cause mortality
(Cowan, Pike, & Budzynski, 2001). In spite
of these impressive results, the study
provided no evidence that patients in the
intervention group were able to change
HRV. They were able to change their
breathing rate significantly, but the effects
on breathing rate were not sustained at 6-
month or 1-year follow-ups.
Gevirtz’s group conducted a ran-
domized, controlled trial of biofeedback in
63 patients with established CAD. Bio-
feedback consisted of abdominal breathing
training and cardiorespiratory feedback.
HRV improved in the biofeedback group
between baseline and Week 6, and continued
to improve through the last follow-up at
Week 18, although formal training stopped
at Week 6 (DelPozo, Gevirtz, Scher, &
Guarneri, 2004). Nolan’s group also
conducted a randomized controlled trial of
biofeedback in 46 CAD patients, using five
sessions of HRVB. They found that patients
who were able to modulate high frequency
HRV, which is believed to be associated
with enhanced vagal heart rate control,
showed improved psychosocial adjustment
to disease, including reduced levels of
reported stress and decreased depression
(Nolan et al., 2005). Conducting a review of
HRV therapies in cardiovascular disease in
2008, Nolan and colleagues concluded that
there was an overall moderate improvement
in HRV with biofeedback (absolute increase
in SDNN = 9 ms; relative increase =
15.9%), and they used data from the
reviewed studies to calculate that between
 Evidence-Based Practice in Biofeedback and Neurofeedback
1,018 and 1,520 patients would need to be
enrolled for a rigorous assessment of
biofeedback efficacy (Nolan, Jong, Barry-
Bianchi, Tanaka, & Floras, 2008). Mikosch
and colleagues (2010) studied the utility of
biofeedback in treating anxiety in CAD
patients undergoing coronary angiography,
and showed that respiratory sinus
arrhythmia training successfully decreased
56
anxiety associated with the procedure
(Mikosch et al., 2010), but did not assess the
effects on CAD itself.
Summary
In conclusion, the evidence for the
effectiveness of biofeedback in coronary
artery disease can only be classified as Level
2: Possibly Efficacious.
 Depressive Disorders
Chapter 18 – Depressive Disorders
Level 4: Efficacious
Fredric Shaffer, PhD, BCB,1 and Christopher L. Zerr1,2
1
Truman State University, Center for Applied Psychophysiology
2
Department of Psychology, Washington University
Major depressive disorder (MDD) is
diagnosed when five or more depressive
symptoms, including sadness or loss of
pleasure, are present for 2 weeks. Depressed
patients may sleep too much or too little,
display psychomotor retardation or agita-
tion, show change in weight or appetite,
experience loss of energy, feel worthless or
guilty, report an inability to concentrate,
think, or make decisions, and think
repeatedly about death or suicide (Beidel,
Bulik, & Stanley, 2014).
The main interventions evaluated in this
chapter include neurofeedback (EEG and
fMRI) and biofeedback (EMG and HRV).
While the majority of published reports have
been case studies or single-group pretest/
posttest designs, there have been several
RCTs and studies where participants
assigned themselves to conditions. None of
the RCTs utilized a double-blind control.
Neurofeedback Studies
Neurofeedback interventions for depres-
sion have included EEG protocols to correct
frontal alpha asymmetry or enhance parietal-
occipital upper alpha, and fMRI protocols to
up-regulate targeted regions that mediate
positive emotion.
EEG Protocols
The rationale for alpha asymmetry
neurofeedback for mood disorders is that the
left frontal cortex mediates positive affect,
while the right mediates negative affect.
Clinical depression is associated with
less activation of the left frontal lobe than
the right. Since alpha is an “idling
frequency,” this asymmetry is seen when
alpha amplitude is greater in the left (F3)
57
than the right frontal lobe (F4). The goal of
alpha asymmetry neurofeedback for depres-
sion is to correct this imbalance, decreasing
left frontal alpha with respect to right frontal
alpha.
Rosenfeld (2000) summarized a series of
case studies involving patients diagnosed
with depression. Before neurofeedback
sessions, patients were trained to breathe
diaphragmatically for 15-30 minutes and to
warm their hands to a criterion of 95 °F.
Active electrodes at F3 and F4 were both
referenced to Cz. Training sessions, which
were conducted twice a week, were divided
into 50% neurofeedback and 50% psycho-
therapy. In four cases, as the alpha
asymmetry score improved, Beck
Depression Inventory (BDI) and Minnesota
Multiphasic Personality Inventory (MMPI)
depression scores declined.
Baehr, Rosenfeld, and Baehr (2001)
reported follow-up data on three of six
unipolar depression patients who had
completed an average of 27 neurofeedback
sessions using a right hemisphere alpha
asymmetry protocol for depression. The
patients were evaluated from 1-5 years post-
therapy in a single session that used the
same alpha asymmetry measure and the
BDI. At follow-up, the three patients
maintained nondepressed alpha asymmetry
scores and normal BDI scores. None of the
patients experienced clinical depression
since terminating treatment.
An experiment by Raymond, Varney,
Parkinson, and Gruzelier (2005) featured 12
second-year medical student participants
with high scores on the Personality
Syndrome Questionnaire’s (PSQ-80) With-
drawal scale, which measures avoidant
 Evidence-Based Practice in Biofeedback and Neurofeedback
behavior. The investigators randomly
assigned the participants to either auditory
alpha/theta neurofeedback or sham neuro-
feedback. An active Pz electrode was
referenced to the ear. Participants received
two weekly 20-minute sessions of eyes-
closed neurofeedback or sham neurofeed-
back for 5 weeks. The PSQ-80 and Profile
of Mood States (POMS) were administered
to assess personality and mood changes,
respectively. Alpha-theta ratios significantly
increased with time within sessions for the
neurofeedback group, but did not change
across sessions. While PSQ-80 Withdrawal
scores did not change in either group,
participants in neurofeedback sessions felt
more energetic, composed, agreeable,
elevated, and confident, while those in sham
neurofeedback sessions felt more tired, yet
more composed, as measured on the POMS.
Choi et al. (2011) conducted a pilot
study of 24 right-handed depressed patients
who had not received psychoactive drugs
within 2 months of the study. While they
randomly assigned participants to either
alpha asymmetry neurofeedback or
psychotherapy placebo conditions, neither
the patients nor the evaluators were blind to
their condition. A clinical psychologist
evaluated depression using the Hamilton
Depression Inventory (HAM-D) and Beck
Depression Inventory II (BDI-II). The
researchers placed active electrodes at F3
and F4, referenced to Cz, and utilized
Rosenfeld’s asymmetry protocol. Training
sessions comprised six 4-minute trials
separated by 30-second rest periods. They
trained participants twice a week for 5
weeks. Following neurofeedback training,
participants received self-training to
reproduce the mental state they experienced
during neurofeedback without equipment
twice a week for 1 month. The
psychotherapy placebo sessions were also
conducted for 5 weeks and involved
psychological assessment and interpretation,
and education about the trajectory and
treatment of affective disorders. Following
58
these sessions, they were referred to other
therapists who provided traditional psycho-
therapy for depression as required. Only the
neurofeedback group increased right frontal
alpha power and asymmetry scores and
demonstrated significant improvement on
the HAM-D and BDI-II scales. Six (50%) of
the neurofeedback participants and none of
the psychotherapy placebo participants
achieved a clinical response.
Peeters et al. (2014) reported a pilot
study of alpha asymmetry neurofeedback in
nine participants (five male and four female)
diagnosed with major depressive disorder.
Active F3 and F4 electrodes were referenced
to the earlobes (A1 and A2). Participants
received a maximum of 30 sessions, three
per week, which consisted of three 8-minute
feedback blocks, with 5 minutes of rest
between each block. Mean baseline alpha
asymmetry significantly declined across
sessions. One participant showed a clinical
response and four achieved remission based
on Quick Inventory of Depressive
Symptoms self-report version (QIDS-SR16)
scores.
neurofeedback to enhance upper alpha in
the occipital-parietal region represents an
alternative neurofeedback protocol to treat
depression. While this intervention has suc-
cessfully increased cognitive performance in
healthy individuals, there is limited evidence
of its efficacy for patients diagnosed with
major depressive disorder.
Kumano et al. (1996) reported a case
study of an inpatient diagnosed with
depressive disorder who received 34
sessions of EEG-driven photic stimulation to
increase occipital alpha in addition to
psychotherapy and antidepressant medica-
tion. The investigator monitored the EEG
from O2 with a reference at A1 and a
forehead ground. While the patient increased
alpha amplitude, improved autonomic
balance, and reduced depressive symptoms,
the authors could not determine the relative
contributions of the treatment components to
his improved mood.
 Depressive Disorders
Escalano et al. (2013) conducted an
uncontrolled study of 49 participants
diagnosed with major depressive disorder.
Participants received eight neurofeedback
sessions (two sessions per week) to increase
upper-alpha power. Each session consisted
of 6 minutes of prescreening, 20 minutes of
five 4-minute trials, and 6 minutes of post-
screening. The investigators monitored 16
sites, including FP1, FP2, F3, Fz, F4, C3,
Cz, C4, P7, P3, Pz, P4, P8, O1, Oz and O2,
with the ground at FPz and the reference on
the left earlobe. The upper-alpha band
ranged from the individual alpha frequency
(IAF), the frequency bin between 7 and 13
Hz with the greatest power, to the IAF + 2
Hz. They computed upper-alpha power and
provided visual feedback from an average of
values detected by electrodes P3, Pz, P4,
O1, and O2. Participants increased upper-
alpha power within and across training
sessions. Their cognitive performance
improved on the Paced Auditory Serial
Addition Task (PASAT), which assesses
information processing speed and working
memory, the Rey Auditory Verbal Learning
Test (RAVLT), which measures verbal
memory, the Stroop Color-Word Test
(STROOP), which gauges attention and
concentration, the Trail Making Test (TMT),
which evaluates executive functioning, and
the Fluency Verbal Test (FAS), which
appraises verbal fluency. These results must
be considered preliminary since there was
no control condition.
fMRI Protocols
Real-time functional MRI neurofeedback
(rtfMRI NF) interventions are designed to
increase the metabolism of brain regions that
mediate positive affect.
Linden et al. (2012) reported an open-
label pilot study of fMRI NF for 16
participants diagnosed with recurrent
depressive disorder. In the fMRI NF
condition, the researchers trained 8
participants during four sessions to up-
regulate brain regions responsive to positive
59
emotions using a visual display that was
updated every 2 seconds. Each session
consisted of three 7-minute trials. In the
control condition, the researchers instructed
8 participants to utilize positive imagery
techniques employed by the fMRI NF
subjects during four sessions conducted
outside the scanner. The fMRI NF group
successfully up-regulated the target areas
(left or right ventromedial prefrontal cortex,
insula, dorsolateral prefrontal cortex, medial
temporal lobe, or the orbitofrontal cortex).
While the fMRI NF group improved on the
Hamilton Depression Rating Scale (HDRS),
the control group did not change. The
authors recognized the need to follow up
with randomized controlled studies where
subjects are blind to their condition. A more
credible control condition would have
improved the control of demand
characteristics.
Young et al. (2014) randomly assigned
unmedicated participants diagnosed with
major depressive disorder to either receive
rtfMRI-nf from the left amygdala
(experimental; n = 14) or the left intra-
parietal sulcus (control; n = 7). Training
sessions consisted of seven 8.5-minute runs.
These included a resting run, practice run,
three training runs, and a concluding transfer
run. During resting runs, participants were
instructed to not focus on anything while
attending to the display. Practice runs,
training runs, and transfer runs were divided
into resting (five 40-second blocks),
counting backward from 300 (four 40-
second blocks), and recalling positive
autobiographical memories (AMs) (four 40-
second blocks). Practice runs were intended
to familiarize participants with the training
paradigm. Training runs were designed to
teach participants to increase the activation
of the target structure. Finally, the transfer
run was included to evaluate control of
activation without neurofeedback. The
experimental group increased left amygdala
activation when recalling positive AMs
within the first training session. This
 Evidence-Based Practice in Biofeedback and Neurofeedback
training effect was maintained during
transfer runs in which participants did not
receive neurofeedback. In contrast, the
control group did not increase the activation
of the intraparietal sulcus. While the
experimental group decreased Profile of
Mood States (POMS) depression scores, it
was not superior to the control group. The
experimental group decreased State-Trait
Anxiety Inventory (STAI) state and trait
scores; the two groups only differed on state
anxiety. Finally, the experimental group
increased Visual Analog Scale (VAS)
happiness ratings and this gain was greater
than in the control group.
Biofeedback Studies
Biofeedback interventions for depression
have included biofeedback-assisted iso-
metric exercise and HRVB.
Fifty women between 42 and 74 years
old who were diagnosed with knee
osteoarthritis participated in a study by
Durmus, Alayli, and Canturk (2005). The
researchers randomly assigned patients to
either biofeedback-assisted isometric
exercise or electrical stimulation. For both
groups, 20 minutes of therapy was applied 5
days a week for 4 weeks. Patients were
evaluated before and after therapy. Both
treatment groups showed significant
improvements in pain, measured by the
Western Ontario McMaster Universities
Osteoarthritis Index (WOMAC), and
physical function scores, and demonstrated
significant improvements in anxiety and
depression scores on the Hospital Anxiety
Depression (HAD).
Hassett et al. (2007) conducted a single-
group, open-label study with 12 women
diagnosed with fibromyalgia. Participants
received 10 weekly sessions of HRVB, with
assessments taken at Sessions 1 and 10, and
at a 3-month follow-up. Baseline BDI-II
scores revealed that 8 of 12 (67%)
participants had mild depression, while three
(25%) had severe depression. BDI-II scores
significantly decreased from Session 1 to 10
60
and persisted for 3 months after training.
The Fibromyalgia Impact Questionnaire
(FIQ), which assesses overall functioning by
measuring items such as physical function-
ing, fatigue, anxiety, and depression, showed
significant improvements in participants’
scores from Session 1 to the 3-month
follow-up period. By the end of training,
patients had significantly increased their
HRV, high-frequency HRV, and low-fre-
quency blood pressure variability (BPLF).
Karavidas et al. (2007) conducted a
single-group study of 11 participants
diagnosed with major depressive disorder
(MDD) using 10 weekly sessions of HRVB.
Hamilton Depression Scale (HAM-D) and
Beck Depression Inventory (BDI-II) scores
significantly declined by Session 4. There
was a 50% reduction in depressive symp-
toms with an effect size comparable to
antidepressants. While the standard devia-
tion of normal cardiac interbeat intervals
(SDNN) returned to baseline values by the
end of treatment and during follow-up, the
clinical improvement in depressive symp-
toms persisted for the duration of the study.
Siepmann et al. (2008) conducted an
open-label controlled pilot study with 38
participants. They placed 14 depressed
individuals in the HRVB condition.
Additionally, they randomly assigned 12
healthy individuals each to HRVB and
active control (watch the same HRVB
display without instructions) conditions. The
decision to assign all of the depressed
individuals to the HRVB condition and none
to the active control condition undermined
the internal validity of this design for these
subjects. All participants received three
treatment sessions per week for 2 weeks.
While depressed individuals significantly
reduced Beck Depression Inventory (BDI)
scores, decreased Spielberger State-Trait
Anxiety Inventory (STAI) scores and heart
rate, and increased HRV compared to
baseline, healthy participants who received
HRVB or the active control treatment did
not change.
 Depressive Disorders
Zucker et al. (2009) conducted a
controlled pilot study with 38 participants
recruited from a residential therapeutic
community for substance use disorder who
were diagnosed with PTSD symptoms. They
randomly assigned individuals to either
HRVB (StressEraser) or progressive muscle
relaxation (PMR) recording. They instructed
subjects to practice 20 minutes per day and
complete weekly logs. The HRVB group
achieved lower Beck Depression Inventory
(BDI-II) scores and increased HRV (SDNN)
compared to the PMR group. Both groups
significantly reduced PTSD symptoms on
the Posttraumatic Stress-Total (PTS-T) scale
and PTSD Checklist-Civilian Version (PCL-
C). Increased HRV predicted improvement,
even when respiration rate was statistically
controlled.
Patron et al. (2013) studied 26
individuals with depressive symptoms
following cardiac surgery. They randomly
assigned participants to either five 45-
minute sessions of HRVB or treatment as
61
usual (TAU). HRVB was superior to TAU in
increasing respiratory sinus arrhythmia
(RSA), which is heart rate speeding and
slowing across the breathing cycle, and
decreasing the Centre for Epidemiologic
Studies of Depression (CES-D) values from
pre- to posttreatment. Improvement was
correlated with increased RSA.
Conclusion
Both neurofeedback and biofeedback
interventions have earned a rating of
Level 4: Efficacious in treating depression.
For neurofeedback, both alpha-asymmetry
(Choi et al., 2011) and fMRI (Young et al.,
2014) protocols have been validated by
RCTs using depressed participants. For
biofeedback, HRV protocols have been
supported by RCTs for participants
diagnosed with substance abuse and PTSD
(Zucker et al., 2009) and depression
following heart surgery (Patron et al., 2013).
 Evidence-Based Practice in Biofeedback and Neurofeedback
Chapter 19 – Diabetes Mellitus
Glycemic Control – Level 4: Efficacious
Intermittent Claudication – Level 2: Possibly Efficacious
Diabetic Ulcers – Level 3: Probably Efficacious
Fredric Shaffer, PhD, BCB, and Zachary M. Meehan
Truman State University, Center for Applied Psychophysiology
Diabetes mellitus involves the failure to
produce and/or utilize insulin. This systemic
disorder involves hyperglycemia (elevated
blood sugar), microvascular lesions of the
retina, kidneys, and peripheral nerves, and
disorders like cardiovascular disease
(Rhoades & Bell, 2013). The studies
reviewed in this chapter evaluated the
efficacy of biofeedback or biofeedback-
assisted relaxation (BART) to improve
glycemic control, reduce intermittent
claudication (painful cramping), and heal
diabetic ulcers.
Glycemic Control (Level 4)
Four case studies (Bailey, McGrady, & Good,
1990; Fowler, Budzynski, & VandenBergh,
1976; McGrady & Gerstenmaier, 1990;
Seeburg & DeBoer, 1980), one uncontrolled
study (Rosenbaum, 1983), and six RCTs
(Jablon, Naliboff, Gilmore, & Rosenthal,
1997; Lane, McCaskill, Ross, Feinglos, &
Surwit, 1993; McGinnis, McGrady, Cox, &
Grower-Dowling, 2005; McGrady, Bailey, &
Good., 1991; Miley, 1989; Surwit &
Feinglos, 1983) evaluated the efficacy of
biofeedback or BART to improve glycemic
control, and they provided persuasive
evidence that BART deserves a rating of
Level 4: Efficacious.
Fowler et al. (1976) reported a case
study of EMG BART for a 20-year-old
woman diagnosed with insulin-dependent
diabetes mellitus (IDDM). During a 6-week
baseline, daily insulin averaged 85 units.
Following a 6-week baseline, researchers
assigned 6 weeks of frontalis muscle
relaxation training with a portable EMG
biofeedback unit while listening to recorded
62
progressive muscle relaxation and breathing
instructions. They instructed her to practice
twice daily for 30-40 minutes per session
and during stressful events. Her daily insulin
averaged 59 units during this period. At
follow-up 6 months after training ended,
daily insulin declined to 52 units. The design
of this case study prevented isolation of the
unique effects of EMG biofeedback on the
patient’s insulin requirement.
Seeburg and DeBoer (1980) treated a 24-
year-old woman diagnosed with juvenile-
onset IDDM with frontalis EMG
biofeedback. She received 8 weeks of three
25-minute sessions per week. During this
time, frontalis EMG scores declined during
each session and she twice reduced insulin
dosage. Hypoglycemic symptoms forced
early termination of biofeedback training
and her glucose values showed dangerous
swings for several weeks. Following a 6-
month suspension of training, she resumed
EMG biofeedback following restabilization
of her blood sugar. However, reductions in
EMG scores were followed by severe insulin
side effects, which were not alleviated by
reducing insulin dosage. Turkat (1982)
argued that EMG biofeedback is an
appropriate intervention for IDDM when
stress reduces carbohydrate metabolism. He
questioned the appropriateness of Seeburg
and DeBoer’s EMG intervention since their
subject did not report excessive psycho-
logical distress, enjoyed excellent health,
and was stabilized on a conventional insulin
dosage of 22-24 units.
Rosenbaum (1983) treated six patients
diagnosed with IDDM with 15-20 minutes
of family therapy, preceding or following 60
 Diabetes Mellitus
minutes of frontal EMG biofeedback, hand
temperature biofeedback, and skin
conductance biofeedback. After six weekly
sessions, subsequent sessions were
scheduled monthly or as needed. She
assigned home relaxation practice that
combined autogenic training, progressive
relaxation, systematic desensitization, and
the quieting reflex. The author followed
several patients up to 4 years. All patients
learned to control two or more physiological
measures (EMG, skin conductance, and skin
temperature) and increased their ability to
cope with stressors. At least one diabetic
index (plasma glucose levels, glycemic
variability, or insulin dosage) improved in
five of six patients. The patients reported no
side effects. The design of this uncontrolled
study prevented isolation of the unique
effects of the three biofeedback modalities
on the three diabetic indices.
Surwit and Feinglos (1983) studied 12
non-insulin-dependent diabetics (NIDDM),
nine female and three male, in a RCT
conducted within a hospital setting. Their
diet was designed to control blood sugar and
prevent weight loss. The researchers
measured glucose and insulin tolerance at
the start and end of this study. They
randomly assigned patients to relaxation or
control groups. The relaxation group (n = 6)
practiced a recorded progressive relaxation
exercise twice daily for 5 days and received
five 50-minute frontalis BART sessions. The
control group (n = 6) only received
treatment as usual (TAU). Glucose tolerance
and 2-hour postprandiol (post-meal) blood
glucose measurements improved for the
relaxation group; insulin tolerance did not
change. This RCT had two important
limitations. First, the researchers did not
demonstrate that the relaxation group
learned to lower frontalis EMG. Second,
since the relaxation group received EMG
biofeedback with progressive relaxation, the
researchers could not isolate EMG
biofeedback’s unique contributions to
glucose control.
63
Miley (1989) reported an RCT with 21
inpatients diagnosed with Type 2 IDDM and
a poor prognosis of full recovery. The
researchers randomly assigned seven
patients each to one of three conditions:
BART, insight therapy, or TAU. The BART
group received three weekly 45-minute
frontalis EMG biofeedback training
sessions. The insight therapy group received
three weekly 45-minute sessions of
nondirective psychotherapy. The TAU group
read or rested in their rooms for three
weekly 45-minute periods. The investigators
measured blood glucose before and after
each of the three sessions and shared these
values with the patients, so that all patients
received blood glucose feedback. The BART
group achieved greater within-session blood
glucose reductions than the insight therapy
or TAU group for Weeks 1 and 2. During
Week 3, the BART and insight therapy
groups achieved comparable reductions.
While this RCT showed that EMG
biofeedback can reduce blood glucose
within sessions, it suffered several limita-
tions. The authors limited BART and insight
therapy to three sessions, the BART group
did not learn to reduce frontalis EMG, and
the BART group only reduced pretraining
blood glucose from the second to third
sessions.
Bailey et al. (1990) treated a 27-year-old
woman diagnosed with IDDM with BART.
This patient had controlled her blood
glucose for 2½ years using a subcutaneous
insulin infusion pump. The diabetes nurse
educator, biofeedback therapist, and client
collaborated on the development of a
treatment plan that included relaxation
training, home relaxation practice, EMG and
temperature biofeedback, counseling to
identify and manage stressors, diabetes
education, and assessment of blood glucose
readings. The client measured blood glucose
four times daily and following hypo-
glycemic symptoms. At the end of 30
sessions over 10 months, forehead EMG
scores had decreased by about 30%, hand
 Evidence-Based Practice in Biofeedback and Neurofeedback
temperature had increased by 10 °F (5.6 °C),
and glycemic control had improved. This
case study underscores the importance of a
team approach to diabetes treatment and the
potential contribution of a multimodal
intervention that includes biofeedback-
assisted relaxation and stress management.
McGrady and Gerstenmaier (1990)
treated a 36-year-old woman diagnosed with
unstable Type 1 IDDM. The patient had
used a cutaneous subcutaneous insulin
infusion pump for 2 years prior to the case
study. The investigators provided 33
sessions over 10 months of EMG and
temperature BART, and stress management.
The patient practiced autogenic training or
progressive relaxation while she received 20
minutes of auditory EMG or temperature
biofeedback. She was instructed to practice
autogenic phrases twice a day for 15
minutes each time and record finger
temperature using a handheld thermometer.
Stress management training focused on
relaxing during stressful situations, using
cues like increased muscle tension or cool
fingers. Forehead EMG scores decreased
from 3.9 to 1.3 microvolts and hand
temperature increased from 87 °F (30.6 °C)
to 93.4 °F (34.1 °C). Mean glucose values
decreased from 154.1 to 128.6 mg/dl from
pretreatment to posttreatment. At 1-year
follow-up, 75% of her readings fell below
150 mg/dl, insulin doses decreased, and
hypoglycemic reactions declined to 4 per
month compared to 11 per month before
treatment. This case study also demonstrated
the promise of a multimodal intervention
that incorporates BART and stress
management.
McGrady, Bailey, and Good (1991)
conducted an RCT that studied the
effectiveness of BART in 18 adults
diagnosed with Type I IDDM. The
investigators randomly assigned participants
to experimental or control groups. The
experimental group (n = 10) received 10
weekly 20–30-minute sessions of BART.
Subjects practiced progressive relaxation in
64
1–2 sessions and autogenic training in 7–8
sessions. They received approximately 5
sessions of frontal EMG biofeedback and 5
sessions of hand temperature biofeedback.
Following each session of biofeedback-
assisted relaxation training, they received
15–30 minutes of counseling to improve
glycemic control. A clinical nurse specialist
reviewed home records of blood glucose
values and insulin use, suggested strategies
to identify and control stressors, and
supplied a relaxation recording and
handheld thermometer with instructions to
practice relaxation 30–60 minutes daily. The
control group (n = 8) also received 15–30
minutes of diabetes counseling per week.
They did not receive BART until they ended
their participation as control subjects. With
statistical control for pretest values, the
experimental group achieved significantly
lower frontal EMG than the control group at
posttest, while finger temperature increase
did not reach statistical significance. The
experimental group attained lower blood
glucose levels, a lower percentage of blood
glucose values over 11.2 nmol, and a higher
percentage of fasting blood glucose values at
target than the control group at posttest.
There was no significant difference between
the two groups in insulin usage at posttest
when pretest insulin dosage was controlled.
This RCT provided convincing evidence
that BART can be an important adjunctive
treatment to traditional medical management
of Type 1 diabetes.
Lane et al. (1993) investigated the
effectiveness of BART in 38 patients
diagnosed with NIDDM. Following initial
metabolic assessment, the researchers placed
patients into weight classes and then
randomly assigned members of each class to
BART or control conditions. The BART
group (n = 19) received intensive
conventional diabetes treatment and weekly
50-minute auditory forehead EMG sessions
with recorded progressive relaxation
instructions during the first 8 weeks of the
study. The investigators instructed them to
 Diabetes Mellitus
relax twice each day at home using the
progressive relaxation recording throughout
the 12 months of the study. Patients received
follow-up EMG BART sessions during
which practice was reviewed at 3, 4, 5, and 6
months. The control group (n = 19) only
received intensive conventional diabetes
treatment. Both groups significantly reduced
GHb values (mean blood glucose), but not
glucose tolerance, after 8 weeks of intensive
conventional diabetes treatment and during
the follow-up period. There were no group
differences on either measure. Since the
authors did not measure changes in EMG
levels or relaxation, there is no evidence that
this RCT fairly tested its EMG BART
component.
Jablon et al. (1997) conducted a study of
20 NIDDM outpatients that compared EMG
BART with a wait-list control. The treatment
condition (n = 10) started with oral glucose
tolerance testing (OGTT), EDR and EMG
monitoring, and state anxiety measurement.
Subjects received eight 60-minute EMG
BART sessions with progressive relaxation
training over 4 weeks. The researchers
instructed them to practice with three 20-
minute progressive relaxation recordings
twice a day and to perform 30-60-second
mini-relaxations 10-20 times each day, and
to document their practice. Following
treatment, OGTT was repeated. The control
group (n = 10) received OGTT during initial
assessment, after 4 weeks of no treatment,
and at the end of 4 weeks of EMG BART.
The treatment group decreased EDR, EMG,
and state anxiety from pre- to post-
assessment, while the control group did not
change on these measures. However, the
treatment group did not increase glucose
tolerance or improve on three diabetic
metabolic control measures (fasting blood
glucose, 2-hour postprandial blood glucose,
and fructosamine). The authors concluded
that EMG BART might not improve the
glycemic control of NIDDM patients who
report mild stress.
65
McGinnis et al. (2005) performed an
RCT involving 30 patients with Type 2
diabetes to examine whether BART can
lower HbA1c (A1C). The researchers
obtained 4 weeks of morning and evening
blood glucose values and then evaluated
patients on forehead EMG, finger temp-
erature, anxiety and depression, and A1C
during pretest assessment. They assigned
these patients to either experimental or
control groups. The experimental group (n =
16) received 10 weekly 45-minute sessions
of EMG and temperature BART. The
researchers provided audiovisual EMG
biofeedback (five sessions) and temperature
biofeedback (5 sessions). They encouraged
patients to discover ways to control their
stress response through improved stress
management and self-care. They instructed
patients to practice relaxation twice a day
using a 15-minute audiotape. The control
group (n = 14) received three individual 60–
75-minute diabetes education sessions,
every 3 or 4 weeks. Four weeks after the last
experimental and control group sessions, the
researchers repeated the assessment. The
experimental group received two monthly
booster sessions, which involved discussion
of diabetes and stress management, and
BART if requested. The researchers repeated
the psychophysiological assessment during
the second booster session. The experi-
mental group achieved greater reductions in
blood glucose, A1C, and forehead EMG (but
not finger temperature) than the control
group 4 weeks following completion of
initial training and control sessions. The
experimental group maintained reductions of
blood glucose and A1C at the 3-month
follow-up. Both groups decreased anxiety
and depression scores. Pretest anxiety and
depression scores were correlated with
posttest A1C values.
Intermittent Claudication (Level 2)
Two case studies (Aikens, 1991; Saunders,
Cox, Teates, & Pohl, 1994) and one within-
subjects study (Rice & Schindler, 1992)
examined whether BART can reduce the
 Evidence-Based Practice in Biofeedback and Neurofeedback
frequency of intermittent claudication
(cramping leg pain triggered by exercises
like walking). The limited number of studies
and methodological limitations of the RCT
warrant a rating of Level 2: Possibly
Efficacious at this time.
Aikens (1991) treated a 60-year-old
woman diagnosed with Type 2 diabetes and
intermittent claudication with temperature
biofeedback for the toe. The patient received
five sessions that provided 18 minutes of
temperature biofeedback for the ventral
aspect of her great toe. The researcher
instructed her to practice foot warming skills
at home at least five times each week
without feedback. She increased toe
temperature from baseline by 1.7–3.1 °F
(0.9–1.7 °C). The patient achieved 90%
compliance with home practice. Lower
extremity blood pressure, walking impair-
ment, distance, and speed, and stair climbing
improved after five temperature biofeedback
sessions. This case study demonstrated that
brief temperature biofeedback training can
improve foot perfusion and walking in
diabetic patients.
Rice and Schindler (1992) evaluated the
effect of relaxation training and temperature
biofeedback on lower extremity circulation
in 40 adults diagnosed with diabetes.
Twenty-one subjects were diagnosed with
IDDM and 19 with NIDDM. The
experimenters divided this within-subjects
experiment into two 4-week phases. In
phase 1, subjects relaxed using their prefer-
red method for 15-20 minutes per day, 5
days a week. They recorded temperature
from their great toe before and after each
practice session. At the end of this phase,
subjects returned for blood volume pulse
(BVP) and temperature measurement before
and after they relaxed using their chosen
method for 16 minutes. In phase 2, subjects
were informed about temperature BART,
had a temperature sensor placed on their
great toe, and were told to relax using
recorded instructions. Following each
session, they provided subjects with the
66
relaxation recording and asked them to
practice 5 days a week and to continue
recording temperature from their great toe.
At the end of this phase, subjects returned
for BVP and temperature measurement
before and after they listened to the
relaxation recording for 16 minutes. While
subjects achieved greater increases in toe
temperature and BVP during Phase 2 than
Phase 1, this study suffered serious limita-
tions. First, this design was confounded by
order, since all subjects received BART
during the last 4 weeks. Second, this study
did not test BART because subjects never
received temperature biofeedback during the
Phase 2 training sessions. Instead, the
researchers only monitored temperature
while subjects listened to relaxation
instructions. Temperature was only a
dependent variable. Despite its limitations,
this flawed study showed that 8 weeks of
relaxation practice was associated with
increased perfusion of diabetic patients’
lower extremities.
Saunders et al. (1994) reported a case
study of temperature BART of a 48-year-old
patient diagnosed with NIDDM, vascular
disease, and intermittent claudication. The
researchers monitored temperature from the
left little finger and great toe during 21
treatment sessions. They played a
progressive muscle relaxation recording
during Session 1, a differential relaxation
recording during Session 2, and autogenic
training recordings during subsequent
sessions. The investigators provided
auditory and visual temperature biofeedback
from the hand during Sessions 1-5 and from
the foot during Sessions 6-21. They
instructed the patient to practice the self-
regulation skills learned during BART
sessions, continue walking, and treat
claudicating pain with voluntary hand and
foot warming. The researchers assessed the
patient at 12 and 48 months. From Session
12 on, the patient reported no episodes of
intermittent claudication. At both follow-up
points, the patient increased walking
 Diabetes Mellitus
distance to 4.5 miles per day. At the 48-
month visit, he demonstrated a 3.8 °F (2.1
°C) increase in within-session foot temp-
erature. This case study demonstrated the
potential of temperature BART to reduce
intermittent claudication and increase
walking distance in NIDDM patients.
Diabetic Ulcers (Level 3)
A series of case studies (Shulimson,
Lawrence, & Iacono, 1986), an uncontrolled
study (Fiero, Galper, Cox, Phillips, &
Fryburg, 2003), and an RCT (Rice, Kalker,
Schindler, & Dixon, 2001) showed that
BART can increase lower extremity
perfusion and heal diabetic ulcers, and
warrants a rating of Level 3: Probably
Efficacious.
Shulimson et al. (1986) treated three
men with nonhealing diabetic ulcers located
on the toe, ankle, and leg with temperature
BART sessions. In the initial training
session, patients listened to a 20-minute
recorded relaxation script without feedback.
The researchers began the first two patients’
training with 9 or 12, 30-minute hand
temperature biofeedback sessions. The next
10 or 11 biofeedback sessions targeted their
ulcer sites. The investigators only provided
biofeedback sessions at the ulcer site for the
third patient. Subject A’s toe ulcer healed
following 21 training sessions conducted
over 11 weeks. Subject B’s ankle ulcer
almost completely healed after 20 sessions
over 15 weeks. Tragically, gangrene that
originated at another site on the foot
required below-the-knee amputation.
Subject C’s calf ulcer did not heal following
24 sessions over 8 weeks. This series of case
studies showed that temperature BART can
be a useful adjunctive treatment for lower
extremity ulcers.
Rice et al. (2001) performed an RCT that
examined the effectiveness of BART in
treating nonhealing foot ulcers. The
researchers assigned 32 patients with
chronic nonhealing lower-extremity ulcers
to either an experimental group or a control
group. Experimental subjects (n = 16)
67
received instruction in vascular physiology
and sensations associated with peripheral
vasodilation. They participated in one
session of BART that included progressive
muscle relaxation, breathing instruction,
autogenic training, thermal biofeedback and
visualization, and encouragement. The
researchers assigned relaxation practice 5
days a week with a 16-minute recording
while monitoring the temperature of a great
toe with an alcohol thermometer. The
investigators assigned control subjects (n =
16) to use their preferred relaxation method
(e.g., enjoying music) while reclining.
Experimental subjects significantly increas-
ed toe temperature and BART was
responsible for 64% of the variability in
temperature. Fourteen of 16 ulcers (88%)
healed, compared with 7 of 16 (44%) in the
control group. The authors speculated that
research with larger sample sizes may be
able to identify variables that predict ulcer
healing, such as ulcer duration, strength of
pedal pulses, and degree of neuropathy. This
RCT provided a powerful demonstration of
the potential of temperature BART to heal
foot ulcers.
Fiero et al. (2003) studied the effect of
neuropathy on the acquisition of thermal
biofeedback-trained foot-warming by 24
diabetics (5 Type 1 and 19 Type 2). Training
consisted of two hand-warming and four
foot-warming sessions. Despite mild-to-
moderate neuropathy, participants increased
foot temperature an average 2.2 °F (1.2 °C)
across six weekly thermal biofeedback
sessions. However, lower extremity sympa-
thetic-autonomic and sensory neuropathies
accounted for 41% of the variance in foot-
warming and limited skill acquisition. This
study's findings were weakened by the
absence of a control group.
Conclusion
BART is a promising adjunctive treatment
for both IDDM and NIDDM patients. The
reviewed case studies, uncontrolled studies,
and RCTs support a rating of Level 4:
Efficacious for glycemic control, Level 2:
 Evidence-Based Practice in Biofeedback and Neurofeedback

Possibly Efficacious for intermittent inexpensive portable EMG, heart rate

claudication, and Level 3: Probably
Efficacious for healing of diabetic ulcers.
The reviewed studies may have been limited
by the relatively primitive devices (e.g.,
alcohol thermometers) available for home
BART sessions. The availability of
variability, and temperature biofeedback
devices that can provide engaging real-time
displays increases the opportunity for more
effective home practice than was previously
possible.

68
 Epilepsy
Chapter 20 – Epilepsy
Level 4: Efficacious
Gabriel Tan, PhD, and Chin Yi Wong, BSocSci (Hons)
National University of Singapore
Introduction
Approximately 50 million people in the
world today suffer from epilepsy, with an
estimated 2.4 million new cases occurring
each year globally (World Health Organiza-
tion, 2009). Common treatments for
epilepsy involve medication and neuro-
surgery if that does not succeed. However,
the former is only effective for around two
out of every three epilepsy patients
(Iasemidis, 2003), and potential side effects
and health risks exist. The latter is limited in
its success (Witte, Iasemidis, & Litt, 2003).
Neurofeedback provides an alternate and
inexpensive treatment method, with minimal
side effects, that is especially applicable for
drug-resistant epilepsy. Research findings
support the efficacy of neurofeedback
treatments, with the potential for enhanced
effectiveness and usage in the future.
Research Synopsis
The earliest studies establishing the
efficacy of EEG-based feedback methods
for the treatment of epilepsy in humans date
back to the 1970s, beginning with Sterman
and Friar (1972) in a single-subject study.
Subsequent studies with larger sample sizes
as well as control conditions replicated the
positive findings of this pioneer study.
Research in the United States has
historically focused on the augmentation of
sensorimotor rhythm (SMR) with or without
simultaneous inhibition of slow frequency
rhythms, whereas research in Europe has
focused on the self-regulation of slow
cortical potentials (SCP). Other approaches
studied include the inhibition of theta
activity combined with reinforcing beta
activity and the use of quantitative EEG
(QEEG) to individualize neurofeedback
69
training. However, to date, these approaches
have involved small sample sizes and only
one participant group, with no control group
or randomization possible. The different
neurofeedback approaches, all utilizing
operant conditioning of EEG, have reported
success in targeting uncontrolled epilepsy.
Sensorimotor rhythm up-training.
With SMR training, the 12 to 15 Hz EEG
rhythm that is localized to the sensorimotor
cortex is reinforced. Simultaneously, theta
activity, at 4 to 7 Hz, is inhibited. Through
operant conditioning, the SMR is increased.
SMR is thought to enhance cortico-
thalamico inhibition. It increases the occur-
rence of sleep spindles and improves the
quality of sleep. According to Sterman
(2000), this causes the reduction of seizures.
Traditionally, most SMR studies used a
bipolar or sequential montage, although this
protocol has also been utilized with mono-
polar training recently, where there is one
active electrode site on the head that is
usually referenced to the earlobe (Tan,
Hammond, Walker, Broelz, & Strehl, 2010).
Results from most studies have
suggested that SMR feedback leads to a
reduction in seizure frequency. Andrews and
Schonfeld (1992), for instance, in a retro-
spective study found that SMR neurofeed-
back, along with a combination of other
treatments such as diaphragmatic breathing
and identifying precursors and triggers for
seizures, leads to control over their seizures
for 83% of the 89 patients targeted.
Earlier studies on neurofeedback in
epilepsy treatment also utilized SMR
feedback. Following the initial one-subject
study by Sterman and Fair (1972), Sterman,
Macdonald, and Stone (1974) conducted a
 Evidence-Based Practice in Biofeedback and Neurofeedback
similar study with improved methodology
and more participants, and decreases in
seizure rates were observed in both studies.
Similar findings of decreased seizure
frequency were derived from a host of other
subsequent studies (Kuhlman & Allison,
1977; Lubar & Bahler, 1976; Tozzo, Elfner,
& May, 1988).
Studies with comparison groups were
also carried out in validating the efficacy of
neurofeedback for the treatment of epilepsy.
Lubar et al. (1981) conducted a double-blind
crossover study with eight subjects suffering
from drug-refractory seizures with multiple
phases of training. Five out of the eight
subjects experienced a decrease in seizure
frequency. Lantz and Sterman (1988) also
conducted a between-groups study with 24
participants, in which a median seizure
reduction of 61% occurred with patients
receiving SMR training but not with control
group patients. This effect was observed
during the 18 weeks of the study period.
Slow cortical potential (SCP) feed-
back. SCP feedback targets event-related
positive and negative shifts in slow potential
brain activity. To combat the problem of
restraining the hyperactivation of neurons
and increased cortical negativity contribut-
ing to the onset of epileptic seizures, SCP
feedback utilizes a bi-directional training
task to promote learned suppression of
negative shifts and promote positive shifts to
attenuate epileptic discharges, reduce
seizure frequency, and increase paroxysmal
activity thresholds.
To date, three controlled studies have
investigated the use of SCP feedback for the
treatment of epilepsy (Elbert et al., 1991;
Kotchoubey et al., 2001; Rockstroh et al.,
1993). In the initial pilot investigation,
utilizing a double-blind between-subjects
pre–post study design, Elbert and colleagues
(1991) assessed 14 patients with drug
refractory epilepsies through 1-hour sessions
of either bi-directional SCP feedback (n = 7,
experimental) or bi-directional alpha train-
70
ing (9.5-15 Hz, n = 7, control) at the vertex
(Cz). A majority of SCP feedback patients
demonstrated learned self-regulation of SCP
activity and reduced seizure frequency rates
at treatment termination (6, 85%) and at 4-
month follow-up (4, 57%). Only one patient
from the alpha training group demonstrated
differentiation in the enhancement and
suppression of alpha activity. Treatment
effects were sustained at 12-month follow-
up for all patients in the SCP group, but for
only one patient in the alpha training group.
Later, Rockstroch and colleagues (1993)
extended the investigation and, similarly,
found a significant reduction in seizure
frequency rates at 12 months posttreatment.
Mean differentiation between positive and
negative trials also increased in feedback
and transfer trials across the 28 sessions,
which is linked to greater seizure remission.
In their work on SCP feedback for
treatment-resistant epilepsy, Kotchoubey
and colleagues (2001) reported improved
self-regulation abilities and reduced seizure
frequency rates in patients who completed a
multimodal treatment program combining
SCP feedback with behavioral therapy
sessions (focusing on perceptual sensitivity
and identification of seizure signs and
triggers, and emotional self-regulation
skills). While SCP feedback training was
superior to respiration training in improving
patient outcomes, its effects were on par
with those of anticonvulsant therapy.
Posttreatment, patients who received SCP
feedback training also reported a significant
improvement in cognitive and psychological
variables measured (e.g., decrease in self-
reported depression symptoms, improved
ability to use relaxation for coping with
stress, and improved locus of control and
full-scale IQ scores).
Overall, the data indicate that patients
with epilepsy are able to learn self-
regulation of SCP activity. Stability of SCP
self-regulation was observed at 4-6 month
follow-up (Elbert et al., 1991; Strehl,
Kotchoubey, Trevorrow, & Birbaumer,
 Epilepsy
2005) and seizure reduction was maintained
at 12-month follow-up (Elbert et al., 1991;
Kotchoubey et al., 2001; Rockstroh et al.,
1993; Strehl et al., 2005). A 10-year follow-
up study confirmed sustained reduction of
seizures and self-regulation performance
(Strehl et al., 2014). The use of multisite,
comparison designs that are measured across
time also supports the efficacy of using SCP
feedback training for epileptic seizures with
good confidence.
Inhibiting theta, reinforcing 15–18 Hz.
Ayers (1988, 1995) took a different
approach in the treatment of uncontrolled
epilepsy, emphasizing the inhibition of theta
activity. Mild reinforcement of beta activity
was done at 15 to 18 Hz, utilizing a low
reward threshold. Successful cases were
reported with this method, with reduction of
seizure rates as well as normalization of
EEG activity.
Under this approach, the significant
reinforcement of beta activity was believed
to possibly lead to negative effects. Addi-
tionally, treatment was provided in both
hemispheres, as opposed to only the
hemisphere with a seizure focus. This
method is supported by the mirror
phenomenon (Hughes, Taber, & Fino, 1991).
Utilizing QEEG to guide and
individualize neurofeedback treatment.
Technological innovations in neurofeedback
are providing even further potential for the
future of neurofeedback with epilepsy.
Quantitative EEG (QEEG) can provide a
scientifically objective evaluation of
abnormal brain (EEG) functioning, as well
as providing a physiological measure of pre–
post neurofeedback changes in brain
function. The QEEG-guided neurofeedback
treatment for epilepsy allows training to be
individualized, targeting both statistical
abnormalities and specific areas of the
cortex where abnormal functioning is
occurring (Walker & Kozlowski, 2005).
71
Reviews and Meta-Analyses
Although studies based on SMR self-
regulation are more common than those
utilizing other approaches, experimental
designs lack consistency and are often not
controlled, involving only pre- and post-
treatment effects. Furthermore, sample sizes
tend to be small out of necessity. Thus,
reviews have sought to aggregate findings
across the literature, and suggest that the
positive results consistently hold up across a
variety of conditions and contexts.
Sterman (2000) conducted a review of
research from 1972 to 1996, and identified
18 peer-reviewed studies. It was concluded
that 82%, or 142 out of the 174 patients,
showed a significant (>30%) reduction in
seizures, with a more than 50% reduction on
average. Sixty-six percent of patients
displayed significant effects in terms of EEG
changes, with a shift towards normalization.
Following that, Monderer et al. (2002)
reviewed the existing literature on efficacy
of neurofeedback in reducing seizure rates.
Six studies were identified that were
completed over three decades, with at least
five participants and positive findings. A
further four inconclusive or alternate studies
were identified as well. This review suggest-
ed a positive effect of neurofeedback on
controlling seizures in epilepsy, but could
not draw a conclusion on the extent, particu-
larly in lieu of large-scale randomized
controlled studies.
Through a meta-analytic review, Tan et
al. (2009) identified that the majority of
controlled studies on treatment of uncon-
trolled epilepsy with positive outcomes
involved SMR reinforcement. The review
concluded that SMR and SCP training
“consistently decreased seizure rate among
severe cases of epilepsy which [sic] could
not otherwise be controlled” (p.177). In this
review, 63 published studies from 1970 to
2005 were identified, with 9 studies on SMR
training and one on SCP training eventually
being included in a meta-analysis. For the
meta-analysis, 79% of patients who under-
 Evidence-Based Practice in Biofeedback and Neurofeedback
went SMR treatment had a statistically
significant reduction in the frequency of
their seizures.
It is essential to note that in most of the
studies on SMR and SCP feedback, the
patients suffer from uncontrolled epilepsy
and have largely not been able to benefit
from other forms of epilepsy treatment for
years.
Conclusion
Neurofeedback for the treatment of epilepsy,
in terms of SMR and SCP protocols, can be
considered a Level 4: Efficacious treatment
(LaVaque et al., 2002). This is based on the
following evidence:
• In at least one comparison with a no-
treatment control group, the SMR
treatment was shown to be statistically
significantly superior to the control
condition (Lantz & Sterman, 1988).
• In at least one comparison with two
alternate treatment groups, the SCP
treatment was shown to be equivalent to
the alternate treatment with established
efficacy and superior to another
feedback modality (Kotchoubey et al.,
2001).
The conclusion is further supported by a
meta-analysis (Tan et al., 2009) and a
thorough review of literature (Sterman,
2000).
Other Comments
In this chapter, a review on the efficacy of
neurotherapy for epilepsy has been
provided. Neurofeedback is a safe and
promising technique with minimal side
effects for reducing seizure frequency in
drug-resistant patients. It offers a
72
noninvasive treatment alternative to surgery
for drug-resistant patients, as well as for
women wishing to become pregnant who are
concerned about being on medication during
pregnancy.
However, this technique is still not been
widely used in mainstream epilepsy treat-
ment. To increase acceptance and confi-
dence for neurofeedback, larger-scale
studies involving randomized control
designs, multiple treatment comparisons,
treatment response prediction or learning
curves, and the establishment of the
rationale for QEEG-guided and other
approaches to neurofeedback (e.g., infra-
slow training and Live Z-score neurofeed-
back training) are needed to build up
establish an empirical basis for its efficacy.
Comparisons to traditional pharmacotherapy
could also be drawn to provide support for
neurofeedback as an alternate treatment, as
opposed to a back-up treatment.
Acknowledgement
1. This work is based on, revised and
adapted from: Tan, G., Hammond, D. C.,
Walker, J., Broelz, E., & Strehl, U. (2010).
Neurofeedback and Epilepsy. In R. Coben,
& J. Evans (Eds.), Neuromodulation and
Neurofeedback: Emerging Scientific
Evidence (pp. 183-203). London, UK:
Elsevier.
2. Drs. Sarah Wyckoff and Ute Strehl are
responsible for the content relating to the
SCP portion of this chapter and have
also substantially contributed the
drafting of the chapter as well.
3. Dr. Cory D. Hammond has contributed
for editing the final version.
 Erectile Dysfunction
Chapter 21 – Erectile Dysfunction (ED)
Level 4: Efficacious
Fredric Shaffer, PhD, BCB, and Steven Shearman
Truman State University, Center for Applied Psychophysiology
Radical prostatectomy (RP), a common
surgical procedure for localized prostate
cancer, causes erectile dysfunction (ED) in
26–100% of patients (Burnett et al., 2007;
Walsh et al., 1987) due to neurovascular
bundle injury and other mechanisms
(Dubbelman et al., 2006). The etiology of
non-iatrogenic ED is complex and poorly
understood. In men, the ischiocavernosus
muscle (ICM) and bulbospongiosus pelvic-
floor muscle are active during sexual
intercourse. Contraction of the ICM pro-
duces rigidity during the muscular phase of
erection. An impressive and growing body
of research, including several RCTs have
shown encouraging results for pelvic-floor
biofeedback training (PFBT) that combines
pelvic-floor muscle exercises, EMG
biofeedback, and electrical stimulation.
Van Kampen and colleagues (2003)
evaluated the effectiveness of pelvic-floor
exercises, electromyographic (EMG) bio-
feedback of pelvic-floor muscle activity, and
electrical stimulation of perineal muscles for
ED using a pretest/posttest design. Fifty-two
patients received 4 months of weekly PFBT
training sessions administered by a physical
therapist. After participants completed train-
ing, 47% were able to achieve a normal
erection, 24% improved, and 12% did not
change. Eighteen percent did not complete
training. ED etiology was a powerful
predictor of clinical response. Seventy-five
percent of patients diagnosed with venous-
occlusive ED recovered erectile function,
compared with none of the nine patients
diagnosed with a psychological etiology.
The absence of random assignment to a
control condition prevented the researchers
from demonstrating that PFBT was
73
responsible for the positive clinical
outcomes.
Dorey and colleagues (2004, 2005)
reported an RCT for 55 men diagnosed with
ED. The researchers randomly assigned 28
patients to a PFBT intervention group,
which received pelvic-floor muscle exer-
cises, biofeedback, and recommendations
for lifestyle changes, and 27 patients to a
control group, which only received lifestyle
counseling. Outcome measures included the
International Index of Erectile Function
(IIEF), anal pressure, and blinded assess-
ments. After 3 months, the intervention
group achieved better erectile function than
the control group. The investigators then
switched the control subjects to the PFBT
intervention and they also improved erectile
function after 3 months of pelvic-floor
muscle exercises and biofeedback.
Following 6 months, blind assessment
revealed that 40% were able to achieve a
normal erection, 35.5% improved, and
24.5% did not change.
Sighinolfi and colleagues (2009)
evaluated a case series of three RP patients
treated with PFBT that combined exercises
to strengthen pelvic-floor muscles, EMG
biofeedback, electrical stimulation, lifestyle
advice, and home practice of pelvic-floor
muscle contractions without feedback.
Patients received weekly sessions for 4
months. Following training, all three
patients improved erectile function (EF)
from an International Index of Erectile
Function (IIEF-15) score of 17 to 22, and
regained urinary continence. Since treatment
consisted of multiple components, the
investigators could not isolate PFBT’s
unique contribution to the recovery of
erectile function.
 Evidence-Based Practice in Biofeedback and Neurofeedback
Prota and colleagues (2012) reported an
RCT of PFBT for ED following RP. The
experimental group (n = 26) received
weekly 30-minute PFBT using EMG
biofeedback with an electrode inserted
within the anus and another on the ankle,
and home exercises for 3 months. The
control group (n = 26) only received verbal
directions to guide pelvic floor contraction.
Twelve months following RP, more
experimental subjects (47%) than control
subjects (12.5%) recovered potency. Urinary
continence following RP predicted recovery
of potency, as continent patients were 5.4
times more likely to regain erectile function.
Lavoisier and colleagues (2014)
conducted an observational historical cohort
study of 122 men diagnosed with isolated
ED and 108 men diagnosed with isolated
premature ejaculation (PE). Patients with
neuromuscular disorders or prior perineal
treatment were excluded from this study.
Participants received 20 sessions of PFBT
that involved 30 minutes of voluntary ICM
contractions assisted by electrical stimula-
74
tion to increase muscle strength. ED patients
received phosphodiesterase type 5 inhibitors
(PDE5-Is) and PE patients received
paroxetine or clomipramine. Intercavernous
pressure (ICP) indexes vascular pressure
within the penis. The maximum change in
ICP increased (87% and 88%, respectively)
for ED and PE patients with positive trends.
The maximum ICP baseline also increased
(99% and 72%, respectively) for ED and PE
patients with positive trends. While PE
patients increased ICP, improvement of PE
symptoms could not be assessed without
methodologically complex clinical trials.
Conclusion
Two independent RCTs, one for RP patients
(Prota et al., 2012) and one for non-
iatrogenic ED (Dorey et al., 2004, 2005)
demonstrated that interventions that
combine pelvic-floor muscle exercises,
EMG biofeedback, and electrical stimulation
can restore or improve erectile function.
Therefore, biofeedback for ED warrants a
rating of Level 4: Efficacious.
 Facial Palsy
Chapter 22 – Facial Palsy
Level 3: Probably Efficacious
Elena Dalla Toffola, PhD,1,2 Silvia Mandrini, PhD,1 Rosella Togni, PhD2
1
Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
2
University of Pavia, Pavia, Italy
Facial paralysis represents the end result of
a wide array of disorders and heterogeneous
aetiologies, including infectious, traumatic,
neoplastic, congenital and metabolic causes.
Functional outcome is related to the degree
of neurologic damage. Idiopathic facial
paralysis or Bell’s palsy is the most common
peripheral facial palsy. Most patients with
Bell’s palsy recover spontaneously, but
about 30% have less than complete
functional and aesthetic recovery because of
persisting motor deficit and the onset of
synkinesis, which involves involuntary
movements that accompany intentional ones
(Dalla Toffola et al., 2005).
Biofeedback is a procedure that allows
the patient with facial palsy to gain
functional control of a muscle or muscle
groups by monitoring motor unit activity.
With available feedback, each patient can
first learn to activate a few motor units and
subsequently produce partial movement.
Conversely, one study has shown it also
possible to train inhibition of motor unit
activity in cases of hypermotor muscle
behavior (Brown et al., 1978). Muscle
exercises carried out with the aid of EMG-
biofeedback were initially proposed for the
treatment of postparalytic synkinesis and for
retraining after reinnervation surgery of the
VIIth cranial nerve. Recently the use of
EMG-biofeedback and mirror biofeedback
techniques during the first stages of recovery
have produced good results in the control
and prevention of synkinesis (Dalla Toffola
et al., 2005). Preventing synkinesis is more
effective than treating an established one.
Indeed, it was shown that when patients with
facial palsy begin facial biofeedback
rehabilitation before synkinesis has
75
developed, the outcome of the treatment is
much better (Azuma et al., 2011).
Multiple case studies have demonstrated
clinically significant improvement in facial
function in patients affected by facial palsy
treated with electromyography (EMG)/elec-
tronystagmography (ENG) or mirror bio-
feedback. Brown et al. (1978) reported the
successful use of auditory and visual EMG
biofeedback in increasing functional facial
control in two cases of postsurgical facial
palsy after a 3-month training period. Balliet
et al. (1982) described an improvement in
selective motor control of facial muscles
combining EMG sensory biofeedback,
behavioral therapy and specific exercises
after a 7- to 8-month treatment period in
four cases of posttraumatic facial paralysis
undergone following surgical anastomosis.
In a retrospective case-series review,
Dalla Toffola et al. (2005) evaluated clinical
recovery from Bell's palsy in 65 patients
following two different rehabilitation
protocols. The first 28 patients were treated
with kinesitherapeutic techniques (KT)
(mean of 24 sessions, range 6–60), while the
latter 37 patients were treated with EMG
biofeedback (mean 17 sessions, range 6–50).
All patients were clinically evaluated within
1 month and after 12 months from the onset
of palsy using the House-Brachmann scale.
Particular attention was paid to presence and
severity of synkinesis, assessed by an
examiner. EMG/ENG was performed 4
weeks after paralysis; only patients with
axonotmesis were included in the study.
Patients with post-herpes zoster or
posttraumatic paralysis were excluded. At
12-month follow-up, the biofeedback group
had a higher number of cases with complete
recovery or mild dysfunction at House-
 Evidence-Based Practice in Biofeedback and Neurofeedback
Brachmann evaluation and fewer with
synkinesis than in the KT group. EMG
biofeedback seemed to be more effective
than KT in Bell’s palsy, perhaps because it
allows a better modulation in voluntary
recruitment of motor units.
Few observational studies demonstrate
positive results of various forms of
biofeedback training. In a cohort study,
Dalla Toffola et al. (2012) evaluated the
motor recovery of patients with Bell's palsy,
considering the severity of neurological
lesions assessed by EMG/ENG, and
compared EMG biofeedback and mirror
biofeedback in 102 patients. All patients
were clinically evaluated within 1 month
and after 12 months from the onset of palsy
with the House-Brachmann scale. Severity
of synkinesis was assessed with a
nonstandardized scale. An EMG/ENG
evaluation was performed 20-30 days after
the onset of facial paralysis to classify
patients according to neurogenic findings.
Twenty-nine patients with an EMG pattern
of neuroapraxia did not undergo any
rehabilitation treatment. The first 38 patients
with an EMG pattern of axonotmesis were
treated with EMG biofeedback, while the
latter 35 patients were treated with mirror
biofeedback. All patients with neuroapraxia
made a spontaneous full recovery, regardless
of the degree of paralysis. At 12-month
follow-up, EMG biofeedback and mirror
biofeedback group did not differ either
clinically nor in terms of presence of
synkinesis. The two biofeedback methods
used to treat patients with axonotmesis
resulted in a similar rehabilitation outcome.
In a prospective clinical study, Azuma et
al. (2011) investigated the effects of a 10-
month rehabilitation period with mirror
biofeedback at home in a group of 13
patients (8 with Bell’s palsy, 5 with Ramsay
Hunt) after the temporary relief of oral-
ocular synkinesis obtained with a single-
dose administration of botulinum A toxin.
Median grading of facial palsy was IV on
the House-Brackmann scale. The interval
76
between the onset of facial palsy and
botulinum A toxin administration ranged
from 6 to 96 months with a mean of 23
months. The outcome measured was the
percentage of asymmetry of eye opening
width during three designated mouth
movements (lip pursing, cheek puffing, and
teeth baring) assessed with a nonstan-
dardized method by blinded examiners. The
combination therapy resulted in a long-
lasting decline of oral–ocular synkinesis,
unlike the rapid and temporary therapeutic
effects of botulinum A toxin. The authors
added that botulinum A injection contributed
to further motivate patients to continue the
rehabilitation exercises at home. However,
five patients presented negative effects with
a worsening of synkinesis. The authors
attributed these individual differences to
neural plasticity, although in our opinion the
period from the onset of facial palsy was
very different among subjects and this may
have caused different responses to
biofeedback therapy.
There are few randomized clinical trials
regarding the efficacy of biofeedback
therapy in facial palsy. In a multicenter
randomized clinical trial, Pourmomeny et al.
(2013) compared two groups of subjects, the
first (n = 16) treated with EMG biofeedback
(five sessions of 30-45 minutes per week in
the first month, then one session per week in
the following 11 months) and the second (n
=13) treated with general physical therapy
performed by therapists, for a period of 12
months. Sixty-nine percent of subjects had
Bell’s palsy, the others had posttraumatic or
neoplastic aetiologies; only patients with
ENG-EMG evidence of partial or severe
lesion at the facial nerve were included in
the study. Before and after the rehabilitation
period all patients were evaluated with the
Sunnybrook Facial Grading System and
with a nonstandardized scale in which a
blinded examiner reported the presence and
the grade of synkinesis. Although both
methods had positive effects on patient
outcomes, a comparison of quantitative
 Facial Palsy
variables showed that the efficacy of
biofeedback therapy was strongly superior
to that of the comparison modality.
Moreover, biofeedback therapy alone was
enough for the treatment of facial nerve
palsy, with the advantages of high sensitivity
in detecting voluntary and involuntary
movement and in promoting the active
participation and motivation of patients.
In a randomized clinical trial, Nakamura
et al. (2003) investigated the efficacy of
mirror biofeedback in a group of 27 patients
(10 Bell’s palsy, 17 Ramsay Hunt) with
complete facial nerve palsy who had no
response to electrical stimulation. Patients in
the treatment group (n = 12) were instructed
to keep their eyes open symmetrically
during three designated mouth movements
(pursing lips, baring teeth, and puffing out
cheeks) for 30 minutes a day at home for 10
months. The control group (n = 15) did not
undergo any training. All patients were
assessed by blinded examiners who
measured with Adobe Photoshop the right
and left eye opening widths during the three
mouth movement mentioned above. The
treatment group was assessed after the 10-
month rehabilitation period, the control
group after 12 months. This might introduce
a bias in the results because of the possible
worsening of synkinesis in the control
group. Neither measures of central tendency
of the asymmetry nor intention-to-treat
analysis were mentioned. However, the
results showed a lesser degree of synkinesis
in the training group than in the control
group, so the authors concluded that their
method of mirror biofeedback was very
effective for preventing the development of
synkinesis.
Only one study examined the efficacy of
EMG biofeedback versus mirror
biofeedback. In a prospective, randomized,
controlled trial, Ross et al. (1991) examined
the efficacy of EMG biofeedback versus
mirror biofeedback in long-standing
peripheral facial nerve paresis. Thirty-one
patients were recruited; 24 patients were
77
randomly assigned to EMG biofeedback
associated with mirror training (n = 11) or
mirror training alone (n = 13), and 7 patients
served as controls. The training consisted of
two sessions of 60 minutes per week for 2
weeks; one session per week for 6 weeks;
and two sessions per month for 10 months,
for a total treatment duration of 1 year. Only
4 patients had Bell’s palsy; other aetiologies
included postoperative and post-herpes
zoster palsy. Patients with upper motor
neuron injuries, bilateral facial nerve
paralysis, and lack of facial muscle activity
were excluded. Facial motor function was
evaluated before the treatment and at a
follow-up of 6 and 12 months using linear
measurement of facial movement, blinded
visual assessment of voluntary movement
with a standardized videotape protocol, and
facial nerve response to maximal stimulation
by standardized electroneurography. Bio-
feedback training, either with mirror
biofeedback alone or with the addition of
EMG biofeedback, led to a significant
beneficial effect, increasing excursion of
facial movement, when compared to the
control group. Findings suggested that
appropriate mirror biofeedback training with
or without EMG biofeedback can be useful
in patients with incomplete facial recovery
(weakness and/or synkinesis).
In a systematic review, Cardoso et al.
(2008) selected all randomized controlled
trials between 1958 and 2007 that evaluated
facial exercises associated either with mirror
or EMG biofeedback to examine their
effects on patients with Bell’s palsy with
respect to complications or delayed
recovery. They found four studies that met
inclusion criteria. The studies described
mime therapy versus control (n = 50), mirror
biofeedback exercise versus control (n =
27), “small” mirror movements versus
conventional neuromuscular retraining (n =
10), and EMG biofeedback associated to
mirror training versus mirror training alone.
The treatment length varied from 1 to 12
months. Because of the small number of
 Evidence-Based Practice in Biofeedback and Neurofeedback
randomized controlled trials, it was not
possible to analyze whether the exercises
associated either with mirror or EMG
biofeedback were effective. The main
problems observed in the researched studies
were the use of nonstandardized outcome
measures, the inclusion of patients with
different aetiologies of facial palsy, the
differences between protocols of treatment,
the impossibility of blinding between
therapist and patient, short times of follow-
up, and the scarcity of intention-to-treat
analysis. However, the authors suggested the
use of mirror biofeedback due to its low cost
78
and easy access compared with EMG
biofeedback.
In a second review of facial exercises
associated or not with mirror biofeedback,
Pereira et al. (2011) found 132 studies, but
only 6 met the inclusion criteria. They
reported the same problems observed by
Cardoso et al., recommending the
CONSORT Statement for the future
randomized controlled trials on facial palsy.
Nevertheless, they concluded that facial
exercise therapy was effective to improve
functional outcomes.
 Fecal Incontinence
Chapter 23 – Fecal Incontinence
Level 4: Efficacious
Irene Teo, PhD
University of Texas MD Anderson Cancer Center
Fecal or bowel incontinence refers to the
inability to control bowel movement, which
leads to involuntary passage of stool. Fecal
incontinence can range from the occasional
leak of stool and gas to complete loss of
bowel control. There are numerous possible
causes of fecal incontinence, including
structural abnormalities, physiological
disturbances, and psychological factors
(Norton & Cody, 2012; Rao, 2004). Organic
fecal incontinence describes incontinence
due to known physical abnormality (e.g.,
abnormality of the anal sphincter or pelvic
floor muscles), while functional fecal
incontinence refers to incontinence due to
movement of the bowel (e.g., constipation,
loose stool).
Biofeedback as treatment for functional
fecal incontinence allows training of the
perianal muscles so that patients can achieve
greater control in tightening or relaxing
these muscles that are typically not
distinguished during defecation. For patients
who have known physical abnormalities that
cause fecal incontinence, surgery is
sometimes an option; however, biofeedback
may be used as part of postsurgical
treatment. Biofeedback training for fecal
incontinence can incorporate balloon
manometers, electromyographs (EMG), and
ultrasound as sensors. Rectal sensitivity
training, strength training, and coordination
training are the three main modalities used
(Norton & Cody, 2012).
Several reviews examining biofeedback
for the treatment of fecal incontinence in
adults in the last 5 years have included up to
12 RCTs, which are discussed below (Enck
et al., 2009; Norton & Cody, 2012;
Vonthein, Heimerl, Schwandner, & Ziegler,
2013). The reviews examine biofeedback as
79
treatment on its own as well as in
conjunction with other treatments for fecal
incontinence. A Cochrane Systematic
Review concluded that the limited number
of trials and their methodological weak-
nesses do not allow definitive conclusions to
be drawn (Norton & Cody, 2012). There is
some evidence suggesting biofeedback can
be useful, with a small number of more
recent trials providing better evidence.
However, as another review pointed out, the
quality of the RCTs varied and better quality
studies with larger sample sizes predicted
significant findings (Vointhen et al., 2013).
Biofeedback is shown to produce better
rates of continence in patients compared to
no treatment (Miner, Donnelly, & Read,
1990), sphincter exercise (Ilnyckyj, Fachnie,
& Tougas, 2005), and pelvic floor exercise
(Heymen et al., 2009). Miner (1990), who
conducted a small crossover trial (N = 25),
reported that the group receiving sensory
feedback had significantly fewer inconti-
nence episodes per week and improved
rectal sensory threshold. Ilnyckyj (2005),
who examined 23 women and compared
anal sphincter exercise to biofeedback,
reported that although resting and squeeze
manometric pressures were not significantly
different, squeeze duration and rates of
patients with continence based on
participant diaries were significantly better
in the biofeedback group. Heymen et al.
(2009), who compared pelvic floor exercise
with and without biofeedback, showed
significantly better continence in the group
receiving biofeedback. In contrast, a study
consisting of 171 patients that compared
four arms of treatments (education alone,
education with sphincter exercise, sphincter-
pressure biofeedback, and biofeedback plus
 Evidence-Based Practice in Biofeedback and Neurofeedback
home EMG biofeedback) reported no
significant differences between the groups in
manometric measurements, continence
scores, and quality of life (Norton,
Chelvanayagam, Wilson-Barnett, Redfern,
& Kamm, 2003). Additionally, a study
comparing surgical anal sphincter repair
with and without subsequent biofeedback in
38 female patients with obstetric-related
injuries reported no statistically significant
difference in continence between the two
groups (Davis, Kumar, & Poloniecki, 2004).
Another study that compared biofeedback
with and without pelvic floor muscle
training reported both treatments to be
equally effective in modifying continence
scores, although secondary outcomes
measuring patient perceived effects and
quality of life favored the treatment with
added biofeedback (Bols, 2011).
Reports examining biofeedback
combined with other treatments show the
superiority of continence scores when EMG
biofeedback was facilitated in conjunction
with electrical stimulation (otherwise known
as triple target treatment) compared to either
monotherapy (Fynes, 1999; Schwandner,
2010; Schwandner, 2011). In their meta-
analysis, Vonthein et al. (2013) indicated
that two times more patients became
continent when biofeedback was combined
with electrical stimulation instead of
biofeedback only. RCTs comparing EMG
biofeedback with EMG biofeedback and
electrical stimulation for treatment of fecal
incontinence associated with obstetric
trauma showed conflicting results. Mahony
et al. (2004) reported both groups had
improved continence scores, while Naimy et
al. (2007) reported neither group showed
improvement in continence scores. This
contrast could be related to the type or
etiology of fecal incontinence.
Two separate meta-analysis studies
(Enck et al., 2009; Norton & Cody, 2012)
80
indicate that there are no differences in
outcomes among biofeedback modalities.
For instance, in Solomon, Pager, Rex,
Roberts, and Manning (2013), 120 randomly
assigned patients in three biofeedback
treatment groups—biofeedback with anal
manometry, biofeedback with transanal
ultrasound, and pelvic floor exercises with
feedback from digital examination—showed
a 70% improvement in continence with no
difference between groups. In another study,
the addition of home biofeedback has also
been reported to not contribute to
statistically significant improvement in
incontinence scores, manometric measure-
ments, and quality of life (Norton et al.,
2003). More recently, however, Vonthein et
al. (2013) noted that different modes of
biofeedback reported remission rates that
varied between 20–54% (Fynes et al., 1999;
Heymen et al., 2000; Ilnyckyj et al., 2005;
Schwandner et al., 2011).
It was generally agreed across the
reviews that study eligibility criteria for
patients, biofeedback modalities, and study
outcome evaluations add to the difficulty in
comparing the studies in this population.
Norton and Cody (2012) reported that
studies that had recruited participants who
had failed to respond to first-line treatments
such as diet and education (e.g., Bols, 2011;
Heymen, 2009), noted biofeedback to
produce significantly better results than
control treatments. Vonthein et al. (2013)
and Enck et al. (2009) discuss the lack of
consensus and standardization in measuring
study outcomes. Notably, a debate is
ongoing specifying whether patient-reported
quality of life indices or remission rates of
incontinence should be the primary
outcomes. The authors agree that, for now,
both outcomes are important in this area of
research.
 Fibromyalgia
Chapter 24 – Fibromyalgia
Level 3: Probably Efficacious
Stuart Donaldson, PhD
Myosymmetries, Calgary
Introduction
Fibromyalgia is characterized by chronic
widespread muscle and joint pain, and body
tenderness, that are accompanied by
cognitive issues (e.g., brain fog), numerous
other medical conditions (i.e., irritable
bowel syndrome) and a wide variety of
psychological complaints (Ablin & Buskila,
2013; Arnold, Clauw, & McCarberg, 2011).
The American College of Rheumatology’s
classification criteria includes diffuse soft
tissue pain of at least 3 months duration,
pain on palpation in at least 11 of 18 tender
points that are made worse by exertion,
stress, lack of sleep, and weather changes
(Wolfe et al., 2010).
The nature of the definition of
fibromyalgia has led to the development of
various theories of causation, and
consequently, numerous types of treatment.
Developments in pharmacological treat-
ments are aplenty without success, leading
to the growth of alternative techniques
targeting symptom reduction (Holdcraft,
Assefi, & Buchwald, 2003). Recent
literature is proposing fibromyalgia as a
central nervous system processing dysfunc-
tion (Clauw, Arnold, & McCarberg, 2011).
Biofeedback Treatment for Fibromyalgia
The diffuse nature of the disease does not
readily lend itself to treatment with
biofeedback techniques as these techniques
are usually organ-specific. Another problem
in researching biofeedback is that it involves
learning. Thus, it is difficult to do a double-
blind study. Sham studies have been
attempted, but are contaminated by indi-
viduals recognizing they are receiving false
information. Randomized double-blind
studies are therefore few in number.
81
Since the 2008 review, the field has seen
some growth involving one major study (a
meta-analysis study; see Glomobiewski,
Bernardy, & Hauser, 2013) and one system-
atic review (Meeus, 2013). Clinical trials
involving biofeedback as a main/supple-
mental treatment option also suggest pro-
mising evidence on using biofeedback to
treat fibromyalgia symptoms. These studies
will be discussed in detail in the following
sections.
Meta-Analysis and Review Studies
Glombiewski, Bernardy, and Hauser (2013)
reviewed numerous search engines, finding
123 unique citations for biofeedback
efficacy and fibromyalgia. Of these, 116
were rejected due to methodological issues
(i.e., no control group). Based on 7 studies
(totalling to 321 patients), the authors found
that biofeedback significantly reduced pain
intensity with a large effect size when
compared to control groups. Subgroup
analyses revealed that only Surface Electro-
myography (SEMG)-assisted biofeedback,
and not neurofeedback, significantly
reduced pain intensity. The authors also
noted that sleep problems, depression,
fatigue, or health quality of life issues were
not reduced. While the review found
numerous articles that indicated positive
results or outcomes for SEMG and EEG
neurotherapy, the review team also noted
that all studies pertaining to SEMG and
EEG treatments suffered from various types
of methodological issues. SEMG and EEG
neurotherapy studies are limited due to a
number of confounding issues, in particular,
the use of different types of treatment
techniques.
Meeus et al. (2013) performed a
systematic review of the literature for heart
 Evidence-Based Practice in Biofeedback and Neurofeedback
rate variability. They reported on 10 studies
that followed the PRISMA guidelines,
examining the results of clinical studies
comparing heart rate variability of
fibromyalgia patients to controls. The
majority of the studies, as noted by the
authors, shows decreased HRV, increased
sympathetic activity. and a blunted
autonomic response to stressors for
fibromyalgia sufferers. Resistance training
improved HRV in the fibromyalgia patients
with an average decrease of 39% in pain,
decreased constipation and depression.
Biofeedback Studies
Several studies based on SEMG biofeedback
technology such as Babu et al. (2007) and
Ferraccioli et al. (1987) produced positive
results. Babu et al. (2007) demonstrated
improvements through decreased pain in
tender points in 15 patients who received 6
days of SEMG biofeedback when compared
to 15 fibromyalgia patients who received
sham biofeedback. However, in this study,
no demonstration was made for learning,
and hence the specific nature of treatment
cannot be defined. Outcomes assessment of
EMG treatment studies also varies, as some
studies included psychological outcome
measures such as the Minnesota Multiphasic
Personality Inventory (MMPI; e.g., Drexler
et al., 2002), and others did not (e.g.,
Ferraccioli et al., 1987).
Buckelew et al. (1998) found that
biofeedback, when combined with relax-
ation training, was effective in reducing
symptoms, while van Santen et al. (2002)
demonstrated no significant effects of EMG
in the treatment of fibromyalgia symptoms.
Neurofeedback Studies
The use of neurofeedback in treating
fibromyalgia has shown mixed results.
Several studies have found variants of
neurotherapy to be useful in improving a
variety of fibromyalgia symptoms (Kayiran
et al., 2007; Mueller et al., 2001). A recent
82
study by Caro and Winter (2011) found
significant improvements in visual attention,
pain, tenderness, and fatigue in 15
fibromyalgia patients who completed 40
sessions of neurofeedback on preexisting
attention deficit problems and various
physical symptoms, as compared to 63
fibromyalgia control patients. On the other
hand, Nelson and colleagues (2010) did not
report significant differences in the number
of tender points, levels of cognitive
dysfunction and fatigue, or global distress
between 17 female fibromyalgia patients
who completed 22 low-energy
neurofeedback system (LENS) sessions and
17 others who did not undergo the treatment.
Efficacy Level
Given the above findings, particularly from
the meta-analysis and systematic review
studies, biofeedback can be considered as a
Level 3: Probably Efficacious treatment for
fibromyalgia symptoms. This is based on the
following evidence and observations in the
existing literature:
• In at least one comparison with placebo
and/or control groups, neurofeedback/
biofeedback training has been shown to
be effective in improving psychological
and/or physiological symptoms related
to the fibromyalgia syndrome.
• In at least one study evaluating the
effectiveness of neurofeedback/biofeed-
back training for treating fibromyalgia
symptoms, patient homogeneity was
attempted in sample selection (e.g.,
Nelson et al., 2010).
The field is restricted by the lack of a
concise definition of fibromyalgia, by the
lack of a standardization of the numerous
biofeedback methods, and the lack of
explicit demonstration of biofeedback/
neurofeedback-assisted learning in most
studies. Additional efforts to specify and
standardize treatment nature will be useful.
 Functional/Recurrent Abdominal Pain
Chapter 25 – Functional/Recurrent Abdominal Pain
Level 2: Possibly Efficacious
Robert A. F. Guiles, MA, BCB, Mark J. Stern, MA, BCB, Carolyn Huntley, MA, BCB, and
Richard Gevirtz, PhD, BCB
Alliant University
Functional abdominal pain (FAP) is
classified as a functional gastrointestinal
disorder (FGID) (Drossman, 2006). Though
it has often been referred to in the literature
and by clinicians as Recurrent Abdominal
Pain (RAP), RAP is not acknowledged as a
standardized diagnosis and can obscure
research and clinical outcomes (von Baeyer
& Walker, 1999). Rome criteria for FAP are
the recommended standard label for patients
with specific chronic abdominal pain
(Baber, Anderson, Puzanovova, & Walker,
2008). Therefore, it is important to note in
this review that only one study used FAP as
the diagnostic criteria, while the rest of the
studies used RAP.
The rationale for the use of biofeedback
in the treatment of FAP relies on a centrally
mediated etiology of pain associated with
limbic dysregulation amplifying or
disinhibiting afferent sympathetic signals of
visceral pain (Grover & Drossman, 2010;
Sperber, & Drossman, 2010). There is also
evidence of low vagal tone and high spectral
domain low frequency/high frequency ratios
(Sowder, Gevirtz, Shapiro, & Ebert, 2010).
Humphreys and Gevirtz (2000)
compared three different treatment groups,
all including thermal biofeedback, to a fiber-
only control group in 47 pediatric patients
with RAP. All three treatment groups
showed greater improvements in self-
reported pain than the fiber-only group, but
83
no significant treatment superiority. Using a
combination of HRV and thermal
biofeedback, Masters (2006) was successful
in reducing pain symptoms in a pediatric
female patient with RAP. Sowder et al.
(2010) demonstrated that HRVB was
successful at reducing FAP in 20 children
diagnosed by a pediatric gastroenterologist.
Analysis revealed a large effect size, and
pain reductions were significantly mediated
by restored vagal tone. A recent clinical
replication series with 11 pediatric FAP
patients found that HRVB improved
abdominal pain in all of the patients in an
average of 10 sessions. Sixty-four percent
achieved full remission and 36% achieved
partial remission (Stern, Guiles, & Gevirtz,
2014). However, no control or comparison
group was utilized for treatment outcomes in
either of these HRV studies.
Conclusion
Thermal biofeedback may be more cost-
effective than more complex therapies, but
there is not enough evidence to show
treatment superiority. HRVB also shows
promising results and mediational
compatibility, but is lacking in randomized
controlled trials. Larger sample sizes and
randomized controlled trials utilizing HRVB
for FAP according to Rome III criteria are
recommended to establish stronger efficacy.
 Evidence-Based Practice in Biofeedback and Neurofeedback
Chapter 26 – Hyperhidrosis
Level 2: Possibly Efficacious
Fredric Shaffer, PhD, BCB, and Matthew Mannion
Truman State University, Center for Applied Psychophysiology
Hyperhidrosis involves excessive sweating.
While it is normal to perspire when excited
or following physical exertion, these
individuals constantly perspire, often
without obvious triggers, from their palms
and soles, and less frequently from their
armpits, chest, and back.
Generalized hyperhidrosis may be
caused by autonomic dysregulation or it may
be due to a metabolic disease, fever-
inducing illness, or cancer. Localized hyper-
hidrosis may be due to abnormal regrowth
of damaged sympathetic axons, an abnormal
number or arrangement of eccrine sweat
glands, or other vascular abnormalities.
Where generalized hyperhidrosis often starts
in adulthood, localized hyperhidrosis is
often first seen in childhood or adolescence.
Both forms of hyperhidrosis can severely
embarrass these individuals and produce
occupational disability.
Conventional therapies for this disorder
include antiperspirants, Botox® injections,
lotions, oral medications, and in extreme
cases, endoscopic transthoracic sympathec-
tomy (ETS).
The rationale for using electrodermal
biofeedback to treat hyperhidrosis is that
sympathetic activation can increase sweat-
ing, which raises skin conductivity, and that
decreasing skin conductivity can both
reduce sympathetic arousal and resultant
perspiration. Also, in cases where hyper-
hidrosis is triggered or exacerbated by
stressors, a biofeedback-assisted interven-
tion could improve patient symptoms
through better stress management. The
evidence of biofeedback efficacy in hyper-
hidrosis is weak, based on small pretest-
posttest studies without control groups and
case studies.
Preliminary studies (Duller & Gentry,
1980; Singh & Singh, 1993) and a single
case study (Rickles, 1978) showed that
84
biofeedback may decrease hyperhidrosis
symptoms.
Duller and Gentry (1980) provided
visual water vapor pressure biofeedback to
14 adults diagnosed with hyperhidrosis.
They trained patients from twice a day
(hospitalized) to twice a week (outpatients)
in 30-minute sessions. Three patients who
failed to reduce sweating after 10 sessions
were removed from the study. The authors
evaluated all patients 6 weeks after the end
of treatment. Based on clinical observation
or patient self-report, 11 of 14 patients
reduced excessive sweating. Relaxation may
have contributed to symptom reduction.
Singh and Singh (1993) reported that a
program of skin conductance (SC)
biofeedback-assisted relaxation helped 6 of
10 male patients significantly reduce their
sweating. The authors reported that clinical
improvement was strongly correlated with
reductions in skin conductivity.
Rickles (1978) trained a patient
diagnosed with hyperhidrosis with auditory
and visual vapor pressure biofeedback for 8
months, followed by desensitization for 5
months. The treatment outcomes were
mixed. While the patient could alternatively
increase or decrease sweating within 5
minutes within the clinical setting, this
control did not generalize to stressful events
in everyday life. However, the patient
reported increased comfort in coping with
stressful situations, which the author
attributed to desensitization training.
The limited evidence from uncontrolled
studies and a single case study only warrants
a rating of Level 2: Possibly Efficacious. In
both the Singh and Singh (1993) and Rickles
(1978) reports, electrodermal biofeedback
was administered with a behavioral
intervention, so the specific contribution of
biofeedback could not be isolated.
 Hypertension
Chapter 27 – Hypertension
Level 4: Efficacious
Angele McGrady, PhD
University of Toledo
A meta-analysis of 23 studies completed
between 1975 and 1996 compared bio-
feedback-based training with active inter-
ventions (those thought to be effective, such
as relaxation and meditation) and with
inactive interventions (those representing a
control group, such as clinic blood pressure
[BP] measurement or sham biofeedback).
While both biofeedback and other active
treatments resulted in a reduction in BP,
there were no differences in the magnitude
of the reduction in either systolic blood
pressure (SBP) or diastolic blood pressure
(DBP) when biofeedback was compared
with active treatments. However, when
biofeedback was compared to inactive
control treatments, there was a significantly
greater reduction in both SBP (6.7 mmHg)
and DBP (4.8 mmHg) (Yucha et al., 2001).
A second meta-analysis of 22 ran-
domized controlled studies (comprising a
total of 905 essential hypertensive persons)
published between 1966 and 2001 supported
these findings (Nakao, Yano, Nomura, &
Kuboki, 2003). In comparison with non-
intervention controls, biofeedback resulted in
significantly greater reductions in SBP (7.3
mmHg) and DBP (5.8 mmHg). Compared
with other behavioral interventions, the net
reductions in SBP and DBP were not
statistically different.
The review of more than 100
randomized controlled trials conducted by
Linden and Moseley (2006) showed that
behavioral treatments reduce BP to a modest
degree (but in some studies as much as 14
mmHg for SBP and 11 mmHg for DBP). The
decrease in BP was larger than that seen in
wait-list or other inactive controls. These
authors noted that BP effects are greater
when baseline blood pressure is high and
when treatment is individualized to each
85
person’s needs, which makes direct
comparison among studies difficult.
Sharma, Frishman, and Gandhi (2011)
reviewed the literature on device-guided
slow breathing. Four studies, including two
matched case control studies and two
randomized control trials, were reviewed;
controls either performed home BP mea-
surements or listened to calming music. The
results of the four studies were positive for
the device-guided slow breathing; breathing
rate slowed and reductions in SBP and DBP
were observed.
Biofeedback has shown efficacy in
persons with white-coat hypertension,
similar to the studies of essential hyper-
tension (Nakao, Nomura, Shimosawa,
Fujita, & Kuboki, 2000). Laboratory training
followed by home training appears to be
particularly effective (Henderson, Hart, Lal,
& Hunyor, 1998). Workplace stress reduc-
tion programs for hypertensive employees
have been reported to decrease BP
(McCraty, Atkinson, & Tomasino, 2003).
Prehypertension was defined in the Joint
National Committee guidelines (Chobanian
et al., 2003) as BP values of greater than
120/80 and lower than 140/90 mm Hg.
These individuals are often recommended to
use lifestyle change prior to beginning
therapy with antihypertensive medication
(Eckel et al., 2013). The lifestyle change
guidelines include weight loss, increasing
activity and reducing salt and fat in the diet,
but do not mention stress management.
Nonetheless, the potential confound of BP
lowering by antihypertensives is avoided in
biofeedback studies in prehypertension.
Surface electromyograph biofeedback
(SEMG) with relaxation training was
associated with significant decreases in SBP
and DBP in comparison to controls in a
 Evidence-Based Practice in Biofeedback and Neurofeedback
group of students diagnosed with prehyper-
tension (Xu, Gao, Ling, & Wang 2007).
Similar improvements in BP were reported
by Wang et al. (2010) in women with
prehypertension and by Lin et al. (2012). In
the three studies, lowered BP was correlated
with greater heart rate variability and shifts
to vagal dominance.
It is not clear exactly how biofeedback
exerts its BP-lowering effect or how to
differentiate biofeedback effects from the
other interventions that are commonly
coupled with biofeedback in clinical practice
(Linden & McGrady, 2016). In most studies,
direct BP feedback is less powerful than
other forms of feedback. However, Tsai,
Chang, Chang, Lee, and Wang (2007)
showed a significant advantage for direct BP
feedback compared to sham biofeedback
after controlling for starting BP. Thermal
biofeedback seems to work by helping
patients to dilate peripheral blood vessels, an
indicator of sympathetic adrenergic activity,
thereby lowering total peripheral resistance.
Because baroreceptor sensitivity is reduced
in hypertension, increasing the response of
the baroreceptors with baroreceptor feedback
(Overhaus, Ruddel, Curio, Mussgay, &
Scholz, 2003) or respiratory training (Reyes
del Paso et al., 2006) may result in BP
reduction. Other trials of HRVB compared to
slow breathing or relaxation alone produced
significant decreases in BP and correlated
increases in HRV controls (Nolan et al.,
2010).
Long-term data on the effects of biofeed-
back in essential hypertension is sparse and
few studies continue with follow-up for 1
year or more. Most studies provided training
of 10–12 sessions, offered follow-up several
months later, and then expected patients who
have learned self-regulation to maintain the
lowered BP without additional training. This
approach is in sharp contrast to recom-
mendations from JNC (Chobanian et al.,
86
2003) that medication be prescribed long
term, based on the assumption that BP
increases over time in most hypertensive
patients.
Unfortunately, the degree of BP response
to biofeedback training has varied widely.
This may be because of the starting level of
BP (the higher the initial level, the better the
response), the variety of modalities used
(thermal, SEMG, heart rate, BP, heart rate
variability biofeedback), the length of the
training (4 to 20 sessions), the site and the
outcome measures (clinic, place of employ-
ment, laboratory, or ambulatory monitoring)
and the evidence that the patient can apply
self-regulation to normal daily stressors
(Linden & Moseley, 2006; Yucha, 2002).
Current literature suggests that thermal,
device-guided breathing and HRVB are
usually more effective than EMG or direct
BP feedback, but this finding is not
consistent (Linden & Moseley, 2006). While
it is difficult to predict which hypertensive
individuals will be helped to lower BP and
their antihypertensive medications with
training, those with high resting sympathetic
activity (low skin temperature, high heart
rate, high BP) appear to benefit more with
biofeedback-assisted relaxation training
(Weaver & McGrady, 1995). Further,
patients whose BP is stress-sensitive may
greatly benefit from combining biofeedback
and relaxation therapy with medical
management (Frank, Khorshid, Kiffer,
Moravec, & McKee, 2010).
Based on the review of published studies,
the evidence for biofeedback in essential
hypertension and prehypertension meets the
criteria for Level 4: Efficacious. The future
of this research may depend on the ability of
investigators to study long-term effects and
to design trials in which multimodal therapy
is used, since the latter is most clinically
relevant.
 Immune Function
Chapter 28 – Immune Function
Level 2: Possibly Efficacious
Fredric Shaffer, PhD, BCB, and Zachary Bartochowski
Truman State University, Center for Applied Psychophysiology
The human body utilizes both nonspecific
and specific immune mechanisms to protect
itself against invading organisms, damaged
cells, and cancer. The main nonspecific, or
innate, mechanisms are relatively rapid in
response and include anatomical barriers
(skin and mucous membranes), phagocytosis
(ingestion of microorganisms) by macro-
phages and neutrophils, destruction of
infectious agents by natural killer cells and
neutrophils, release of antimicrobial agents
(hydrochloric acid, interferons, and
lysozyme), signaling to other immune re-
sponders, and local inflammatory responses
that confine microbes, allowing white blood
cells and other immune cells to attack them.
In contrast, specific, or adaptive, immune
mechanisms are generally slower and aim to
selectively target invaders and diseased
cells. The specific immune response
involves the production and proliferation of
antibodies by B cells, targeted destruction of
foreign material by T cells, and preparation
for future infiltrations of the same antigen.
Six RCTs (McGrady et al., 1991; Taylor,
1995; Coen, Conran, McGrady, and Nelson,
1996; Birk, McGrady, MacArthur, and
Khuder, 2000; Kern-Buell, McGrady,
Conran, and Nelson, 2000; Nolan et al.,
2012) examined whether interventions that
included a biofeedback component (SEMG
and temperature) could increase immunity.
Lehrer et al. (2010) tested whether HRVB
training could protect subjects from the
effects of an endotoxin lipopolysaccharide
(LPS) injection. Finally, Schummer, Noh,
and Mendoza (2013) investigated whether
neurofeedback could increase CD4+ (or
helper T) cell counts. Collectively, these
studies show that biofeedback and
neurofeedback have promise in increasing
87
immune function, especially in patients with
compromised immunity.
McGrady et al. (1991) performed an
RCT of biofeedback-assisted relaxation on
immunological indicators in 31 healthy
adults. The investigators measured T-
lymphocyte blastogenesis (conversion into
larger cells that can undergo cell division),
white cell count, cortisol levels, anxiety, and
forehead SEMG. The experimental group (n
= 14) completed four 30-minute sessions of
biofeedback-assisted relaxation (BART)
over a 4-week period. These sessions
combined SEMG and temperature biofeed-
back with imagery, progressive relaxation,
and autogenic phrases. The control group (n
= 17) received no training and was only
assessed at the start and conclusion of the 4-
week period. The two groups were compar-
able on all measures at the initial baseline.
Following training, the BART group was
shown to have increased blastogenesis and
reduced white cell count by decreasing
neutrophils in comparison to the control
group. The groups did not differ on plasma
cortisol levels. This RCT was limited by a
weak control condition, short study duration,
and an inability to identify the separate
contributions of biofeedback and relaxation
to changes in immune function.
Taylor (1995) conducted an RCT of a
multimodal stress management intervention
on T-cell count in 10 HIV-positive men who
were asymptomatic except for T-cell count
below 400. The treatment group (n = 5)
received 20 twice-weekly sessions of EMG
BART, progressive relaxation, meditation,
and hypnosis supplemented with home
practice. The control group (n = 5) received
no treatment. The experimental group
achieved greater gains compared to the
 Evidence-Based Practice in Biofeedback and Neurofeedback
control group on state anxiety, trait anxiety,
overall mood, self-esteem, and T-cell count.
They maintained these improvements at 1-
month follow-up. Limitations of this study
included a small sample size (N = 10),
failure to establish that the groups were
equivalent at preassessment, inability to
measure the separate contribution of
biofeedback to increased T-cell count, and a
weak control condition.
Coen et al. (1996) performed an RCT
that evaluated the effects of BART on
psychophysiological arousal and immune
measures in 20 patients aged 12–22 years
who were diagnosed with mild asthma and
did not require steroid medication.
Following an interview regarding asthma
symptoms and medication, psychological,
psychophysiological, and immune function
assessment, the experimenters randomly
assigned subjects to experimental or control
groups. The experimental group received
eight relaxation training sessions, which
incorporated autogenic relaxation, deep
breathing instruction, imagery, and finger
temperature biofeedback. The investigators
emphasized facial muscle relaxation and
taught subjects to drop their jaw.
Participants were provided a cassette
recording of a relaxation script and a
cassette player for home practice, twice
daily for 15 minutes. The researchers
instructed subjects to complete weekly
asthma logs through the 8-week study. The
wait-list control group received pretest and
posttest assessment. At posttest, the
experimental group reduced asthma severity,
medication use, and forehead muscle
tension, but did not increase finger
temperature. Reduced forehead SEMG was
correlated with an improvement in asthma
symptoms. The experimental group also
showed an increased number of CD4+ and
CD8+ (cytotoxic T) cells. CD4+ cells signal
immune cells, like CD8+ cells, to destroy
infected cells. Study limitations included a
small sample size, weak control condition,
and the inability to measure the separate
88
contributions of biofeedback and relaxation
to changes in asthma symptoms, medication
use, forehead SEMG, and immune function.
Birk et al. (2000) reported an RCT that
compared the effects of massage therapy,
massage with aerobic exercise, massage
with biofeedback-assisted stress manage-
ment, and a control condition over a 12-
week period on immunity and quality of life
in 31 patients diagnosed with HIV. The
massage group received a weekly 45-minute
whole-body massage. The massage with
exercise group participated in two weekly
supervised aerobic exercise sessions
(progressing from 20-45 minutes) in
addition to weekly massage. The massage
with stress management group received
weekly massage and 12 sessions of SEMG
and temperature biofeedback combined with
diaphragmatic breathing and autogenic
relaxation. The control group, which had
one of the highest starting CD4+/CD8+
lymphocyte ratios, only received standard
care. The authors did not demonstrate that
participants who received biofeedback
successfully reduced SEMG or increased
hand temperature. None of the experimental
groups showed gains, compared to the
control group, in CD4+, CD8+, and natural
killer cell counts. The massage with stress
management group utilized less medical
care than the massage only or control group.
The small number of subjects in each group,
failure of random assignment to control for
CD4+/CD8+ lymphocyte ratio, and the
absence of a manipulation check to
demonstrate mastery of biofeedback skills
limited the value of this study.
Kern-Buell et al. (2000) conducted an
RCT of BART on psychophysiological
arousal and immune measures in 16
nonsmoking patients diagnosed with mild
asthma that did not require steroid medica-
tion. Following an interview regarding
asthma symptoms and medication, psycho-
logical, psychophysiological, and immune
function assessment, the experimenters
randomly assigned subjects to experimental
 Immune Function
or control groups. The experimental group
received eight relaxation training sessions,
which incorporated autogenic relaxation and
progressive relaxation. The last four sessions
incorporated forehead SEMG biofeedback to
down-train facial muscle tension. Partici-
pants were instructed to practice autogenic
relaxation twice daily for 15 minutes using a
recorded exercise. The wait-list control
group received pretest and posttest assess-
ment. Both groups were instructed to
monitor asthma symptoms, peak flow
measurements, and medication usage every
2 weeks. From pretest to posttest, the
experimental group significantly lowered
forehead SEMG, while hand temperature did
not change. Compared to the control group,
the experimental group’s asthma severity
and use of bronchodilator medication were
lower at posttest. The FEV1/FVC index,
which measures the percentage of vital
capacity that an individual can exhale during
the initial second of forced expiration, was
higher. Finally, the percentage of neutrophils
declined and the percentage of basophils
increased, suggesting reduced inflammation.
Study limitations included a small sample
size, weak control condition, and no means
of measuring the separate contributions of
biofeedback and relaxation to changes in
asthma symptoms, medication use, forehead
SEMG, and immune function.
Lehrer et al. (2010) examined whether
HRVB training would protect subjects from
the effects of an inflammation-triggering
endotoxin LPS injection. The researchers
randomly assigned participants to HRVB or
control groups. The HRVB group (n = 6)
received four 1-hour sessions in which they
were taught to breathe at their resonance
frequency. The resonance frequency
corresponds to the respiration rate that
maximizes HRV. These training sessions
were supplemented with twice-daily 20-
minute breathing practice at home. The
control group (n = 5) was trained to breathe
near their resting respiration rate. After
completion of training, the researchers
89
injected subjects with LPS and then coached
them to breathe at their assigned rate for 10
minutes at five hourly points in time. While
the HRVB group showed less HRV
reduction and reduced headache and eye
photosensitivity compared to the control
group, proinflammatory cytokine levels,
nausea, muscle aches, and feverishness were
not significantly different. Despite the small
sample size, this ingenious experiment
provided preliminary evidence of HRVB’s
potential for modulating inflammation.
Nolan et al. (2012) reported a re-analysis
of a previous RCT of 45 subjects diagnosed
with hypertension who were randomly
assigned to either four weekly and two
biweekly sessions of HRVB or autogenic
relaxation training supplemented by home
practice. The training sessions for both
groups included a 10-minute review of
cognitive-behavioral strategies for managing
daily stress. The goal of HRVB training was
to teach subjects to integrate cognitive-
behavioral skills with self-regulation of
HRV to reduce cardiovascular stress
responses. The goal of autogenic relaxation
training was to teach subjects to use passive
relaxation to reduce hypertensive stress
responses. Unfortunately, the authors did not
report evidence of whether the HRVB group
increased HRV or lowered blood pressure in
comparison with the autogenic relaxation
group. After adjustment for baseline values,
the two groups did not differ in changes in
the proinflammatory markers hsCRP and IL-
6. However, the researchers did find an
inverse relationship between changes in
hsCRP (but not IL-6) and high frequency
power, baroreflex sensitivity, and the RR
(interbeat) interval. Since the authors did not
demonstrate HRV increase in the experi-
mental group, this archival study provided
an inconclusive test of HRVB’s potential for
reducing inflammation.
Finally, Schummer et al. (2013)
conducted an RCT on the effect of
neurofeedback and cranial electrotherapy
interventions on CD4+ cell counts in 40
 Evidence-Based Practice in Biofeedback and Neurofeedback
HIV-positive volunteers over a 4-month
period. They randomly assigned HIV-
positive, AIDS-negative participants to a
neurofeedback, cranial electrotherapy, com-
bined neurofeedback and cranial electro-
therapy, or a wait-list control group (each n
= 10). Participants in the neurofeedback
group received 20-minute, twice-weekly
sessions to increase eyes-closed alpha
amplitude for 16 weeks. At the conclusion of
training, only the neurofeedback and
combined groups significantly increased
CD4+ counts. While the authors did not
measure EEG changes in the control group,
they demonstrated that subjects in the
neurofeedback and combined groups
satisfied their target alpha amplitude for 20
minutes by the end of the 16 weeks. This
90
RCT provided compelling evidence that
alpha neurofeedback can increase CD4+
counts in HIV-positive patients.
The six studies that combined
biofeedback with other treatment compo-
nents were incapable of isolating bio-
feedback’s contribution to changes in
immunity. Moreover, several of these
experiments failed to demonstrate biofeed-
back training success in lowering SEMG or
increasing hand temperature. In contrast, the
experiments that featured HRVB (Lehrer et
al., 2010) or neurofeedback (Schummer et
al., 2013) demonstrated modulation of
immunity. Due to the limitations of this
body of evidence, biofeedback and
neurofeedback warrant a rating of Level 2:
Possibly Efficacious.
 Insomnia
Chapter 29 – Insomnia
Level 3: Probably Efficacious
Emilie Dessy,1 Aisha Cortoos,1,2 Olivier Mairesse,1,4 and Nathalie Pattyn1,3
1
VIPER Research Unit, Royal Military Academy, Brussels, Belgium
2
Department of Pneumology – Sleep Unit, Universitair Ziekenhuis Brussel, Brussels, Belgium
3
Department of Biological Psychology, Vrije Universiteit Brussel, Brussels, Belgium
4
Sleep Laboratory and Unit for Chronobiology, Brugmann University Hospital, Brussels, Belgium
Although pharmacotherapy is the most
common treatment modality for insomnia
(Kupfer & Reynolds, 1997), it is not
recommended for chronic insomnia (>6
months) because of drug tolerance, drug
dependence, or the occurrence of rebound
insomnia when the treatment is stopped.
Therefore, consideration of nonpharmaco-
logical options is warranted. According to
the American Academy of Sleep Medicine
(1999), a number of behavioral and cogni-
tive behavioral treatments have been found
to be effective for treating insomnia. A
structured, multicomponent program called
cognitive behavioral therapy for insomnia
(CBT-I) is even regarded as the gold
standard treatment for chronic insomnia.
Indeed, the National Institutes of Health
Consensus and State of the Science
Statement (NIH, 2005) concluded after a
review of the literature that CBT-I is “as
effective as prescription medications are for
short-term treatment of chronic insomnia”
(NIH, 2005, p. 14). Moreover, a recent
meta-analysis (Riemann & Perlis, 2009)
demonstrates that pharmacotherapy with the
use of benzodiazepine receptor agonists
(BZRAs) and CBT-I have both a comparable
effectiveness during periods of active
treatment (4 weeks for BZRAs and up to 8
weeks for CBT-I). This review also
concludes that CBT-I produces significant
beneficial long-term effects beyond the
initial 4-8 weeks of therapist contacts.
Improvements were still present after 6
months, which was not the case for pharma-
cotherapy. Although CBT-I and behavioral
strategies are very efficient for the treatment
91
of chronic insomnia, they require discipline
and manageable anxiety levels to implement
in a successful way. Moreover, approxi-
mately 20% of insomnia patients do not
respond very well to these interventions, and
sleep complaints remain after training
(Harvey & Tang, 2003). As such, other
nonpharmacological treatment modalities
need to be evaluated in order to broaden the
treatment options.
Regarding the use of biofeedback, the
American Academy of Sleep Medicine
(1999) rated this treatment modality as a
“probably efficacious” treatment for
insomnia. Moreover, in an update by the
American Sleep Disorders Association
(2006), a task force of content experts was
appointed by the American Academy of
Sleep Medicine to perform a comprehensive
review of the scientific literature since 1999
and to grade the evidence regarding
nonpharmacological treatments of insomnia
(Morgenthaler et al., 2006). Recommenda-
tions were developed based on this review
using evidence-based methods. The task
force described biofeedback as an individ-
ually effective therapy in the treatment of
chronic insomnia (guideline) along with
sleep-restriction therapy, multicomponent
therapy (without cognitive therapy), and
paradoxical intention. Biofeedback training
involves the monitoring and use of
physiologic information to teach patients to
modify specific physiologic functions. There
are different modalities for biofeedback such
as electromyographic (EMG) biofeedback,
HRVB, and skin surface temperature
biofeedback. Neurofeedback has become a
 Evidence-Based Practice in Biofeedback and Neurofeedback
separate area of study and application
(McKee, 2008).
The possibility of using biofeedback in
the field of sleep became known through the
pioneering study of Sterman, Howe, and
Macdonald (1970), who showed that cats
learning to enhance 12–14 Hz activity
(SMR) in their waking EEG through operant
conditioning, also showed changes in their
sleeping EEG. Since that time, three types of
biofeedback, namely electromyography
(EMG) biofeedback, theta biofeedback, and
sensorimotor rhythm (SMR) biofeedback
have been the subject of research in the field
of insomnia.
Several studies have evaluated the use of
EMG biofeedback in insomnia patients and
have shown significant decreases in sleep
latency, number of night-time awakenings,
time awake after sleep onset (WASO), and
an increase in the total sleep time (Bootzin
& Rider, 1997; Freedman & Papsdorf, 1976;
Haynes, Sides, & Lockwood, 1977;
Nicassio, Boylan, & McCabe, 1982;
Sanavio, 1988; Sanavio, Vidotto, Bettinardi,
Rolleto, & Zorzi, 1990; VanderPlate & Eno,
1983). Neurofeedback as a treatment option
for insomnia, on the other hand, has only
been evaluated in a few controlled studies.
In 1981, Hauri compared three
biofeedback modalities and one control
group. Forty-eight patients diagnosed with
psychophysiologic insomnia were randomly
assigned to one of the following groups:
frontalis EMG feedback, frontalis EMG
feedback followed by theta feedback, SMR
feedback, or no treatment (control). Sleep
evaluations by home logs and polysom-
nography (PSG) in the laboratory were done
before and after biofeedback training, as
well as 9 months later. Results showed no
significant differences in sleep improvement
between biofeedback groups and the control
group, although the SMR group showed a
positive correlation between the amount of
SMR learning session and improvements in
laboratory measured sleep. In a post-hoc
analysis, results showed that a high initial
92
tension level of the insomniacs correlated
positively with sleep improvement for the
EMG and theta groups, but negatively with
sleep improvement for the SMR group. On
the other hand, the relaxed insomnia patients
(low initial tension) responded only to SMR
feedback. In a replication study (Hauri et al.,
1982), patients with psychophysiologic
insomnia were randomly assigned to either
theta feedback or SMR feedback. However,
because of methodological issues, they
performed both trainings with eyes open,
while in the first study the theta was trained
in an eyes-closed condition receiving only
auditory feedback. The results of the home
sleep logs showed an equal improvement in
sleep for both feedback training modalities:
total sleep time (TST) per night increased,
while the sleep latency decreased. The para-
meter “number of awakenings per night”
seemed to decrease for the theta group while
it stayed stable for the SMR. The results of
sleep laboratory evaluations indicated that
neither theta nor SMR training had con-
sistently been superior in the treatment of
insomnia. They have also investigated if an
appropriate biofeedback may be effective for
a specific subgroup of insomniacs. They
have split subjects in two groups: high
tension level (tense) and low tension level
(relaxed) insomniacs. Some patients re-
ceived clinically appropriate feedback (theta
training for tense insomniacs and SMR
training for relaxed insomniacs) while others
received clinically inappropriate feedback
(SMR training for tense insomniacs and
theta for relaxed). Results of the laboratory
evaluation of sleep demonstrated that
appropriate feedback increased sleep
efficiency and latency, while inappropriate
feedback had a significant negative effect on
sleep efficiency and sleep latency during the
biofeedback training. In summary, those
results indicate that insomnia patients with a
high tension level are better treated with
theta neurofeedback while insomnia patients
with a low tension level are better treated
with SMR neurofeedback.
 Insomnia
A recent exploratory study (Cortoos, De
Valck, Arns, Breteler, & Cluydts, 2010) has
randomly assigned 17 insomnia patients to
either a tele-neurofeedback or an electro-
myography tele-biofeedback. Researchers
used a different form of biofeedback training
in this study: participants were trained at
home over an internet connection while they
were trained in a lab in the other studies.
Polysomnography was performed pre- and
posttreatment and participants were also
asked to fill in a sleep diary for 2 weeks
prior to training and during training. The
neurofeedback group was trained to increase
SMR, while inhibiting theta and high beta
activity. The training consisted of 20
sessions for a total period of 8 weeks.
Results indicated that the sleep onset latency
decreases for both feedback modalities, but
only SMR tele-neurofeedback resulted in a
significant increase of total sleep time.
In 2011, Hammer, Colbert, Brown, and
Ilioi assessed whether two distinct Z-score
neurofeedback protocols, a modified
sensorimotor (SMR) protocol, and a
sequential, quantitative EEG (sQEEG)-
guided individually designed (IND)
protocol, would improve sleep and
associated daytime dysfunctions of
participants with insomnia. In this study, the
authors used a statistical computation
derived from a database, to determine in real
time the deviation from normal (Z-score)
while the EEG is being recorded. The IND
training protocol was based on the selection
of the four sites with the greatest amplitude
deviations from the norm observable on the
sQEEG obtained during the baseline mea-
surement. Participants were asked to train
the EEG brainwaves at these locations. The
training rewarded the correct enhancement
or inhibition of those elements of the
sQEEG. The SMR treatment protocol, on the
other hand, required placement of two active
electrodes, one at Cz and another at C4. The
training rewarded the enhancement of SMR
(12–15 Hz), and the inhibition of excessive
theta (4–8 Hz) and high beta (25–30 Hz). As
93
the IND protocol, the SMR training used
instantaneous Z-scores to determine reward
condition. Participants were randomly
assigned to one of the two protocols. This
exploratory pre–post comparison study
revealed an improvement in sleep and
daytime functioning. Both Z-score
neurofeedback groups showed an improve-
ment in the following primary measures: the
global score of insomnia severity index, the
global score of the Pittsburgh Sleep Quality
Inventory (PSQI), and the measure of the
sleep efficiency (SE) of the PSQI. Daily logs
also showed amelioration in TST. They
found that both the SMR and the IND
protocol reduced symptoms of insomnia,
however, the SMR protocol is easier to
administer to the patient.
Finally, Schabus et al. (2014) tested in a
pilot study whether the SMR biofeedback
can enhance sleep and cognitive perfor-
mance in insomnia. Twenty-four subjects
with clinical symptoms of primary insomnia
were tested in a counterbalanced within-
subjects design. Each patient has taken part
in an SMR and a sham-conditioning training
block. They were arbitrarily selected to
receive either SMR training (10 sessions) or
sham training (five sessions) first.
Polysomnographic sleep recordings were
conducted before and after each training
block. Results indicated a decrease in the
number of awakenings and an increase in
the slow-wave sleep after a training of 10
SMR neurofeedback sessions while sham
training did not have any effect on those
variables and led to important negative sleep
quality changes.
Conclusion
The studies reviewed suggest that the use of
biofeedback in patients with insomnia may
provide a promising treatment. SMR neuro-
feedback seems to be the most appropriate
biofeedback training to improve sleep
behavior of insomnia subjects, such as a
decrease in the frequency of nighttime
awakenings and in sleep onset latency, and
an increase in slow-wave sleep and TST.
 Evidence-Based Practice in Biofeedback and Neurofeedback
Insomnia patients with high tension levels,
on the other hand, are better treated with
theta neurofeedback.
However, we can only classify
biofeedback as Level 3: Probably
Efficacious. Indeed, many of the studies are
outdated and the methodological quality of
several of the studies is low (i.e., small
sample size, a lack of control and sham
groups, or a convincing demonstration of
94
proposed EEG changes after training).
Certainly, more research is needed for a
better understanding of the mechanisms
underlying biofeedback intervention for the
treatment of insomnia. Therefore, future
studies should include strong and rigorous
methodology and a consensus on the
procedure of treatment should be
highlighted.
 Irritable Bowel Syndrome
Chapter 30 – Irritable Bowel Syndrome
Level 4: Efficacious for HRVB
Mark J. Stern, MA, BCB, Robert A. F. Guiles, MA, BCB, Carolyn Huntley, MA, BCB,
and Richard Gevirtz, PhD, BCB
Alliant University
Irritable bowel syndrome (IBS) is classified
as a functional gastrointestinal disorder
(FGID) (Drossman, 2006). Rationale for the
use of biofeedback in the treatment of IBS
stems from autonomic control over healthy
digestive processes (Janig, 2006) as well as
pathophysiology showing autonomic dys-
regulation impacting motility dysfunctions,
as evidenced by low basal HRV (Mazur et
al., 2007; Orr, Elsenbruch, & Harnish, 2000;
Pellissier, Dantzer, Canini, Mathieu, &
Bonaz, 2010).
Early research showed that increasing
relaxation and reducing distress through a
multicomponent psychological intervention
that included thermal biofeedback signifi-
cantly reduced global and motility-specific
symptoms compared to a wait-list symptom
monitoring control group (Neff &
Blanchard, 1987). Six out of 10 IBS patients
improved symptoms with clinical signifi-
cance (as defined by >50%), while only one
out of nine in the control group reached such
symptom reductions. Improvements in
diarrhea and flatulence accounted for most
of the variance in recovery. Though this
study had a small sample size, patients
maintained long-term symptom improve-
ment at 1-year, 2-year, and even 4-year
follow-ups (Blanchard, Schwarz, & Neff,
1988; Schwarz, Blanchard, & Neff, 1986;
Schwarz, Taylor, Scharff, & Blanchard,
1990). However, in 1992, Blanchard and
colleagues compared thermal biofeedback
plus progressive muscle relaxation (PMR) to
an attention-control group (EEG alpha
suppression) to find 60% clinically
improved, but yet no statistically significant
group differences. Improving on limitations
of the first study (i.e., small sample size,
95
within-cell variability, selection process,
number of therapists, manipulation checks,
and diagnosis from board-certified GI
specialists), they conducted a second
investigation that found that both groups
reported reductions of 86% of symptoms.
Previous conclusions regarding these find-
ings determined thermal biofeedback was
not more efficacious than a placebo-control
group. However, EEG alpha suppression has
been shown to be a credible treatment of
generalized anxiety (Rice, Blanchard, &
Purcell, 1983). Reducing anxiety is in itself
an important psychophysiological mech-
anism in IBS symptom remission. Both
groups may have influenced different (i.e.,
central and peripheral) psychophysiological
mechanisms of anxiety related to IBS.
Electrodermal biofeedback, administered
through a computerized game, has shown
clinically significant reductions in global
and stool symptoms in a sample of
treatment-resistant IBS patients (Leahy,
Clayman, Mason, Lloyd, & Epstein, 1998).
Patients who responded to treatment were
found to use the technique successfully for
symptom management at follow-up, indicat-
ing that the short-term computerized
biofeedback was effective in generalizing
for responders. However, this study did not
employ the use of a control group.
HRVB is more targeted to the autonomic
pathophysiology of IBS as it is shown to
improve autonomic regulation and restore
vagal tone (Lehrer, Vaschillo, & Vaschillo,
2000). A multiple case study of 8 women
with IBS showed that HRVB reduced
symptom severity and improved psycho-
logical health and measures of autonomic
balance (Thomas, 2011). A more recent
 Evidence-Based Practice in Biofeedback and Neurofeedback
clinical replication series using HRVB at a
managed care GI clinic, reported that of 13
pediatric IBS patients, 100% showed
clinically significant improvement and 70%
reported full remission (Stern, Guiles, &
Gevirtz, 2014). In a randomized controlled
trial, Thompson (2010) randomly assigned
IBS patients into either HRVB or cognitive
therapy. The HRV group showed equiva-
lence to the improvements seen in cognitive
therapy. However, this study was a non-
peer-reviewed, published dissertation. In a
more recent randomized controlled trial
comparing HRVB with hypnotherapy for
refractory IBS, researchers found that both
HRV and hypnotherapy improved IBS
symptoms on validated measures (Dobbin,
Dobbin, Ross, Graham, & Ford, 2013).
Though the group with HRVB was
significantly more improved initially post-
treatment, there were no group differences
found at 24-week follow-up. Both groups
showed long-term remission. HRVB shows
promise, particularly as equivalent to the
established efficacy of cognitive therapy and
hypnotherapy (Lee, Choi, & Choi, 2014; Li,
Xiong, Zhang, Yu, & Chen, 2014).
Conclusion
Methodological differences in the presented
studies limit the interpretability and possible
level of efficacy. IBS criteria ranged from
96
physician diagnosis to symptom checklists
and three of these studies used standardized
methods, such as Rome III Diagnostic
Criteria (Drossman, 2006). Due to the small
sample size and possibly mixed results,
thermal biofeedback earned a rating of Level
2: Possibly Efficacious when used in
combined treatments. However, since no
studies have yet shown efficacy with
thermal biofeedback alone, efficacy as a
stand-alone treatment cannot be established.
Electrodermal biofeedback was only
reported in one study without a control
group and therefore, is also Possibly
Efficacious. Multiple studies have investi-
gated HRVB, including two studies that
compared it to previously established
efficacious treatments using standardized
diagnostic and treatment methods. HRVB
meets criteria for a Level 4: Efficacious
treatment of IBS based on its equivalence to
a previously established therapy in a quality
study by Dobbin et al. (2013). As Thompson
(2010) was a non-peer-reviewed published
dissertation, HRVB cannot be established as
Level 5: Efficacious and Specific at this
time. Thus, while the rationale for using
HRVB to treat IBS is strong, further
research may help establish the highest
AAPB level of efficacy.
 Motion Sickness
Chapter 31 – Motion Sickness
Level 3: Probably Efficacious
Fredric Shaffer, PhD, BCB, and Nicholas Gravett
Truman State University, Center for Applied Psychophysiology
The body depends on coordination between
the vestibular, visual, and somatosensory
systems to determine our position in space.
Discrepant input from these integrated
systems can result in the physiologic
vertigo, nausea, and malaise that charac-
terizes motion sickness and space sickness
(Rhoades & Bell, 2013).
Three studies (Cowings, Suter, Toscano,
Kamiya, & Naifeh, 1986; Cowings, Naifeh,
& Toscano, 1990; Stout, Toscano, &
Cowing, 1995) demonstrated sympathetic
activation in autonomic responses to
Coriolis stimulation (angular acceleration)
produced by chair rotation, while one
(Graybiel & Lackner, 1980) found no
relationship between physiological measures
and the development of motion sickness
symptoms.
Cowings et al. (1986) continuously
monitored the autonomic responses of 127
subjects before, during, and after a motion
sickness-inducing rotating chair test. They
reported significant changes during this test
consistent with increased sympathetic
activation on all measures. Blood volume
pulse (BVP) and skin resistance (SR)
decreased, while heart rate (HR) and
respiration rate (RR) increased during chair
rotation. These findings contradicted an
earlier report by Graybiel and Lackner
(1980) of no relationship between auto-
nomic change and motion sickness, which
was flawed by a failure to monitor subjects
during the motion sickness stimulus.
Cowings et al. (1990) examined the
stability of autonomic responses in 58
subjects during two rotating chair tests. The
researchers measured BVP, HR, RR, and
skin conductance (SC) during Coriolis
stimulation. They found stable individual
97
autonomic response stereotypies during
motion sickness provocation, which
suggested the need for personalized training.
Stout et al. (1995) examined the
reliability of autonomic change and self-
rated malaise in 33 subjects (26 men and 7
women) across six weekly rotating chair
tests. The investigators monitored BVP, HR,
and RR for all subjects, and SC for 22
subjects. A standardized scale that measured
malaise included subjective estimates of
symptoms like dizziness, headache, drowsi-
ness, sweating, salivation, and nausea. The
researchers found that while the rate of
autonomic change across a single rotating
chair test was not reliable, averaging the
slopes of five motion sickness tests yielded a
moderately stable response pattern.
Increased HR and RR was correlated with
greater malaise, and increased BVP was
associated with reduced malaise.
The effectiveness of self-regulation
training in reducing motion sickness was
examined in three RCTs (Dobie, May, Elder,
& Kubitz, 1987; Jozsvai & Pigeau, 1996;
Russell, Hoffman, Stromberg, & Carlson,
2014), an archival study (Cowings &
Toscano, 2000), an uncontrolled study
(Levy, Jones, & Carlson, 1981), and two
case studies (Cowings, Toscano, Miller, &
Reynoso, 1994). The majority of these
reports supported the efficacy of behavioral
interventions in increasing resistance to
motion sickness induced by Coriolis
stimulation via a rotating chair, visually
induced motion (VM), and a virtual reality
(VR) experience.
Jozsvai and Pigeau (1996) compared the
effectiveness of true autogenic feedback
(TFB), false autogenic feedback (FFB), and
a no-treatment control (CTL) in increasing
 Evidence-Based Practice in Biofeedback and Neurofeedback
motion tolerance. They assigned the three
groups to six weekly sessions of Coriolis
stimulation to induce motion sickness.
Between the first and second Coriolis
sessions, the TFB group (n = 6) received
five 36-minute sessions of autogenic train-
ing with HR and skin temperature (ST)
feedback. The FFB group (n = 6) received
autogenic training with noncontingent HR
and ST feedback. The CTL group (n = 6)
received no training. While both the TFB
and FFB groups achieved significant
changes in HR and ST, this did not reduce
motion sickness during subsequent Coriolis
sessions. This RCT suffered from several
limitations. The researchers did not train
electrodermal activity, which is strongly
correlated with motion sickness. They failed
to train HR and ST to predefined criteria.
They provided massed practice over a
week’s time, which may have limited skill
acquisition. The failure of the TFB group to
achieve greater HR and ST control than the
FFB group indicted the effectiveness of their
biofeedback training. Finally, their sample
size was too small to detect a moderate
effect size. Despite these limitations, three
out of six TBF subjects, compared with one
out of six FFB subjects, demonstrated
improved motion tolerance.
Levy et al. (1981) reported an
uncontrolled study of 20 military aircrew
who were diagnosed with disabling chronic
motion sickness. The treatment protocol
included relaxation training that included
progressive relaxation, diaphragmatic
breathing, calming imagery, and audiovisual
galvanic skin reflex (GSR), electromyo-
graphic (EMG), and ST biofeedback. During
each of 19 twice-daily 45-minute training
sessions, patients were challenged 10-15
times by increasing motion stress. At each
level of difficulty, they were instructed to
observe changes in their physiological
measurements, anticipate resulting symp-
toms, prophylactically initiate relaxation,
and confirm whether this attempt was
successful. The goal of training was to teach
98
patients to self-monitor for early warning
signs of motion sickness and to abort each
episode within seconds. They also were
encouraged to practice relaxation skills in
diverse real-world settings. Of 19 eligible
patients, 16 resumed operational flying. This
study was limited by the lack of a control
group, failure to statistically verify
physiological change, and the inability to
isolate the unique contribution of bio-
feedback to motion sickness control.
Dobie et al. (1987) conducted an RCT
that compared two methods to increase
tolerance to VM. The researchers randomly
assigned 16 subjects susceptible to motion
sickness to one of four conditions. The
behavior therapy (BT) group (n = 4)
received 10 sessions that combined confi-
dence building with desensitization training.
The biofeedback (FB) group (n = 4)
received 10 sessions of EMG and temp-
erature biofeedback. The combined behavior
therapy and biofeedback (n = 4) group
(BTFB) received 10 BT and 10 FB sessions.
The control (C) group (n = 4) was not
treated. Only the BT and BTFB groups
increased VM tolerance from pretreatment
to posttreatment. While this study was
limited by its small sample size, it provided
evidence that behavioral interventions can
increase tolerance to a second cause of
motion sickness, VM. An unanswered
question is whether these outcomes would
have been stronger if the researchers had
replaced EMG with HR or SC biofeedback,
since these measures appear more strongly
correlated with motion sickness. Cowings et
al. (1994) reported two case studies of
successful treatment of motion sickness in
two military pilots using autogenic feedback
training (AFT). Subjects received 30-minute
sessions of individual training, 4 days each
week for 3 weeks, for a total of 6 hours.
During these sessions, subjects received
visual BVP, HR, RR, and skin conductance
level (SCL) feedback to learn to increase
and decrease these responses (bidirectional
control). Training incorporated autogenic
 Motion Sickness
training, progressive relaxation, systematic
desensitization, paced respiration, and
coaching that suggested alternative
strategies when necessary. They received
rotating chair motion sickness tests before
the start of training and at 1-week intervals
following the last training session of each
week. Following training, both pilots
reduced autonomic nervous system response
variability and increased their tolerance to
the rotating chair. They each successfully
controlled their airsickness during qualifi-
cation tests on their high-performance
military aircraft and returned to active duty
flight status.
Cowings and Toscano (2000) reported an
archival study that compared drug, auto-
genic feedback training exercise (AFTE),
and no-treatment control groups. The
researchers matched three groups of 11
subjects from a database on the number of
rotations tolerated during initial exposure to
a rotating chair, motion symptoms, and
physiological responses. All subjects
received the same motion sickness evalua-
tion procedures. They received rotating chair
motion sickness tests before the start of
training and at 1-week intervals following
the last training session of each week. The
drug group (n = 11) received baseline (no
injection), 25-mg IM promethazine, 50-mg
IM promethazine, and saline injection in
counterbalanced order under double-blind
conditions. The AFTE group (n = 11)
received 30-minute sessions of individual
training, 4 days each week for 3 weeks, for a
total of 6 hours. During these sessions,
subjects received visual BVP, HR, RR, and
skin conductance level (SCL) feedback to
learn to increase and decrease these
responses (bidirectional control). Training
incorporated autogenic training, progressive
relaxation, systematic desensitization, paced
respiration, and coaching that suggested
alternative strategies when necessary. The
control group (n = 11) received no treatment
and was used to measure physiological
habituation over four motion sickness tests.
99
A comparison of responses to the motion
sickness tests showed that only the AFTE
group decreased HR, both the AFTE and
drug groups decreased SCL, and only the
drug group increased RR. IM promethazine
(25-mg or 50-mg) did not increase motion
sickness tolerance when compared to a
saline injection or the control group. The
AFTE group tolerated the rotating chair two
to three times longer than the promethazine
or control groups. Five of 11 AFTE subjects
completed the maximum 1170 rotations
compared with none of the promethazine or
control subjects. While the authors carefully
matched subjects from their database, this
archival study lacked the protection against
confounding by extraneous variables
provided by an RCT.
Russell et al. (2014) conducted an RCT
that evaluated the effectiveness of
diaphragmatic breathing in reducing motion
sickness during a virtual reality (VR)
experience. The subjects were 60 healthy
motion sickness-susceptible individuals.
Following administration of a motion
sickness assessment questionnaire (MSAQ)
and physiological assessment of HR, HRV,
and RR, the investigators randomly assigned
subjects to either paced diaphragmatic
breathing (DB) or a control group. The DB
group (n = 30) was given a rationale for DB,
instructed in diaphragmatic breathing
techniques without feedback, and invited to
practice 3–7 breaths-per-minute DB, ask
questions about DB, and then demonstrate
DB. The control group (n = 30) was given a
rationale for focusing on environmental
awareness, and was invited to attend to
themselves and the laboratory environment,
ask questions about this procedure, and then
rest. A researcher explained the 10-minute
virtual reality experience, played a video of
ocean swells from the perspective of a
passenger on board a boat, and recorded
nausea ratings every minute. Following
completion of the video, subjects repeated
the MSAQ and physiological assessment,
and then rated the realism of the VR
 Evidence-Based Practice in Biofeedback and Neurofeedback
experience. The DB group achieved slower
RR, greater high-frequency power, and
lower nausea ratings than the control group
during the VR experience. The DB group
also reported lower MSAQ scores than the
control group following the VR experience.
While this study provided minimal DB
training due to the absence of RR feedback
and limited practice time, it demonstrated
that DB can reduce the severity of motion
sickness symptoms in a VR environment.
Conclusion
Motion stimulation produced by chair
rotation produces sympathetic activation of
autonomic responses (Cowings et al., 1986;
Cowings et al., 1990; Stout et al., 1995).
Monitoring patients during multiple expo-
sures to induced motion can identify
moderately stable individual response
stereotypies. These unique autonomic
response patterns can provide a roadmap for
personalized training to increase resistance
to motion sickness.
While the evidence from two RCTs
showed the promise of self-regulation in
100
preventing motion sickness, the Dobie et al.
(1987) study was limited by its small sample
size and the Russell et al. (2014) study did
not actually provide biofeedback.
Although the Cowings and Toscano
(2000) archival study, Levy et al. (1981)
uncontrolled study, and Cowings et al.
(1994) case studies lacked control for
extraneous variables, they provided consis-
tent support for the efficacy of biofeedback-
assisted relaxation for treating motion
sickness. The Cowings and Toscano (2000)
archival study deserves credit for its training
for bidirectional autonomic control, which
has the potential to increase psycho-
physiological awareness and autonomic self-
regulation. The Levy et al. (1981) study was
particularly impressive because of its
demonstration of 16 of 19 eligible aircrew
regaining flight status through successful
prevention of motion sickness.
Due to the limitations of these studies,
biofeedback for motion sickness warrants a
rating of Level 3: Probably Efficacious.
 Performance Enhancement
Chapter 32 – Performance Enhancement
Level 3: Probably Efficacious
Leslie Sherlin, PhD,1,2,3 and Noel Larson Ford, MA1,3
1
SenseLabs
2
Northern Arizona University
3
Southwest College of Naturopathic Medicine
Despite the growing popularity of all
biofeedback modalities and the often-stated
theory that more optimal physiological
states are likely to produce optimal
performances (e.g., Hellstrom, 2009;
Thompson et al., 2008), it remains unclear to
date how efficacious biofeedback training is
for improving performance. Most studies
examining the efficacy of biofeedback
training have been conducted among
athletes and performing artists (e.g., dancers,
musicians), while other studies tapped into
arenas such as corporate and academic
settings, and military applications (e.g.,
Cochran, 2011; Matte & van Otterdijk,
2012; Oded, 2011; Ros et al., 2009;
Srinivasan, 2011; Todd, 2011; Wahab &
Sinandurai, 2012). Although the applications
of biofeedback and neurofeedback are
expanding, many of the results are based
solely on self-reported measures or related
physiological variables (e.g., heart rate,
brain activity). Changes in physiology
associated with peak performance are
promising and lay the groundwork for
understanding the mechanism of action by
which biofeedback improves performance;
yet, only changes in performance metrics
can provide direct evidence for the efficacy
of biofeedback in enhancing performance.
Therefore, to understand the current
standing of the clinical efficacy of
biofeedback and neurofeedback in training
performance, this section will discuss the
most prominent and recent investigations
focusing on this topic, with an aim to
provide significant support or critique to the
utilization of self-regulation techniques in
performance.
101
Neurofeedback
Only a few experimental studies have been
conducted with the aim to determine if
neurofeedback can improve performance
(Thompson et al., 2008). Vernon (2005)
conducted a comprehensive review of the
literature describing how neurofeedback has
been used to improve performance and
observed that cortical differences between
novice and expert performers provided
compelling logic to use neurofeedback
training to improve performances of amateur
athletes. In detail, Vernon (2005) highlighted
a key study by Landers et al. (1991), which
demonstrated that successfully augmenting
alpha power at the electrode site T3 (deemed
the “correct” feedback) was significantly
correlated to better posttraining performance
among “pre-elite” archers, while the
increase in right hemisphere (T4) alpha
synchrony (i.e., the “incorrect” feedback)
was related to poorer performance on
posttraining assessment in the archers.
Importantly, performance of the control
group did not alter significantly. The results
offered evidence for applying learning
theory principles (Sherlin et al., 2011a) to
training parameters and also created
criterion-specific outcomes, which have
been suggested to augment the efficacy of
neurofeedback (Gould & Udry, 1994).
However, the study also highlighted possible
risk in training athletes without validated
protocols, as illustrated by the performance
decrement among the archers trained with
the “incorrect” protocol.
Since the work of Landers and
colleagues (1991), more evidence has been
published supporting the efficacy of
 Evidence-Based Practice in Biofeedback and Neurofeedback
neurofeedback in peak performance training.
Arns et al. (2008) demonstrated improved
putting accuracy among golfers using an
ABAB design for neurofeedback training
(i.e., no-feedback, feedback, no-feedback,
feedback). In particular, golfers scored up to
25% more putts when they reproduced their
own “successful” EEG profile while putting,
as compared to the no-feedback condition.
The authors proposed that this method of
training reduces the need for “over-training”
and that more personalized training
protocols based on baseline assessments can
help to enhance individual performance.
However, crucially, the study failed to
provide evidence that the golfers were able
to reproduce at will the “correct” EEG state.
On the other hand, in a study examining rifle
shooting performance, Rostami and
colleagues (2012) demonstrated that neuro-
feedback training could positively impact
rifle shooting performance among 24
national and provincial rifle shooters as
compared to study controls. Although post-
training shot result significantly improved
for the neurofeedback group but not for the
control group, the other study variables were
not impacted significantly posttraining.
Furthermore, the study lacked randomiza-
tion, a placebo-control group, and did not
report effect size. Considering evidences
from the above studies, there is room for
growth in using neurofeedback for
facilitation and assessment of peak
performance training.
Shaw, Zaichkowsky, and Wilson (2012b)
reported the use of both biofeedback and
neurofeedback training to improve balance
beam performance, as rated by independent
expert judges during competition. Study
participants improved on 60% of the
assessed beam performances posttraining;
however, this improvement was not
sustained when neurofeedback and
biofeedback training ended. While the
results are promising, the study did not have
a control group and the participant number
was low, variable, and single-gendered (i.e.,
102
female). The authors also noted the lack of
individualized training protocols, which did
not maximize the effectiveness of biofeed-
back and neurofeedback (Gould & Udry,
1994; Hammond, 2007). Efficacy of neuro-
feedback training in gymnastics is limited at
best. In addition to gymnastics, the
performing arts have also been studied using
neurofeedback and biofeedback training.
Gruzelier and colleagues (2006) demon-
strated that augmenting sensorimotor rhythm
(SMR) at C4 or beta 1 (15–20 Hz) at C3 in
conservatory students significantly reduced
commission errors on a continuous
performance task (CPT). P300 amplitude
increment was also detected with regard to
the beta 1 training. Although the authors
replicated similar findings in subsequent
studies (e.g., Egner & Gruzelier, 2003), no
studies have demonstrated that improve-
ments on a CPT are predictive of improve-
ments in competitive performance. There-
fore, it is still uncertain if neurofeedback
improved performance.
Biofeedback
Respiration muscle training. Respira-
tory muscle training (RMT), also referred to
as inspiratory muscle training (IMT) and
expiratory muscle training (EMT) depending
on the specificity of the training protocol, is
a form of biofeedback that utilizes a
breathing device capable of providing
resistance training for the respiratory
muscles. It is one of the most researched
biofeedback modalities with regard to
performance enhancement among endurance
athletes, demonstrating efficacy in improv-
ing performance among rowers (Griffiths &
McConnell, 2007; Voliantis et al., 2001),
cyclists (Gething, Williams, & Davies, 2004;
Johnson, Sharpe, & Brown, 2007; Romer,
McConnell, & Jones, 2002a; Romer,
McConnell, & Jones, 2002b; Sonetti et al.,
2001), and swimmers (Kilding, Brown, &
McConnell, 2010; Wells et al., 2005); and
improving swimming endurance and CO2
sensitivity among scuba divers (Lindholm et
 Performance Enhancement
al., 2007; Pendergast et al., 2006; Ray,
Pendergast, & Lundgren, 2008).
Specific to rowing, Voliantis et al.
(2001) conducted IMT among rowers to
identify if sport-specific rowing perfor-
mance could be improved. After 4 weeks of
training, there was a significant increase in
inspiratory muscle strength within the IMT
training group from baseline values, with the
increase sustained at 11 weeks. The IMT
group also showed more improvements in
distance covered and time spent in covering
a 5000-meter trial than the placebo-control
group. Griffiths and McConnel (2007) also
found that IMT training was associated with
significant increases in inspiratory mouth
pressure and in mean rowing power. For this
study, however, the EMT group did not
improve in rowing performance, and the
added 6 weeks of combined training did not
produce significant results (Griffiths &
McConnell, 2007). Providing further
support, Klusiewicz et al. (2008) found
improvements in inspiratory muscle strength
and increased maximal oxygen uptake
during exercise among elite rowers who
completed IMT as compared to controls.
Although rowing performance was not
directly assessed, the measured variables
have been linked to greater work capacity of
rowers by way of greater tidal volume,
reduced heart rate, and likely less
“concentrations of lactate in blood” (p. 283).
Finally, despite the positive findings,
Riganas and colleagues (2008) found that
IMT did not improve time and maximal
oxygen uptake in well-trained rowers even
though rowers completed full IMT. The
authors suggested possible limits to the
positive effects of training when the task is
near-maximal intensity. The insignificant
effects of the IMT have been demonstrated
by past studies (e.g., Morgan et al., 1987;
Fairbarn et al., 1991; Hanel & Secher, 1991;
Inbar et al., 2000; Kohl et al., 1997; Sonetti
et al., 2001; Williams et al., 2002). It is
proposed that slight variations in
methodology (e.g., intensity levels of
103
performance tests, training style, and
resistance setting on device and ergometers)
impacted the effects of IMT. Majority of
results strongly supported the use of IMT for
performance enhancement among rowers.
However, the effects of minimal resistance
training (such as that applied on control
groups) on performance gains as well as
methodological inconsistencies require
replication.
In terms of other sports, Romer, Connell,
and Jones (2002a) reported that cyclists
given the IMT not only completed simulated
races on cycle ergometers faster, but also
perceived less effort in completing the races,
than those in the placebo control group.
These results are consistent with many other
reported findings (Boutellier et al., 1992;
Gething, Williams, & Davies, 2004; Markov
et al., 2001; Stuessi et al., 2001; Volianitis et
al., 2001). On the other hand, Lindholm et
al. (2007) found that experienced and
current scuba divers who completed IMT
improved in their endurance of surface and
underwater swimming. However, this study
did not use a control group or report its
effect sizes.
Overall, RMT improves respiratory
function in lab settings, but its association
with competitive performance improve-
ments still remains elusive (Williams et al.,
2002). Future studies of biofeedback and
neurofeedback efficacy for peak perfor-
mance should evaluate competitive perfor-
mance metrics in addition to laboratory
assessments.
Heart rate variability. The use of HRV
training is often accompanied by stress
management or performance anxiety
programs to attain better control over
physiological arousal. A large body of
literature suggests that in order to achieve
peak performance, athletes must achieve the
optimal arousal state (e.g., Gould & Udry,
1994; Robazza, Bortoli, & Nougier, 1998).
This training almost always utilizes
breathing techniques, making it difficult to
distinguish at times between HRV and
 Evidence-Based Practice in Biofeedback and Neurofeedback
respiration biofeedback. Extensive research
has been conducted on arousal regulation
techniques of all kinds (Zaichkowsky &
Fuchs, 1988), but no study has indicated that
HRV or respiration regulation biofeedback
alone improves performance. Two key
studies examining HRV training among
competitive performers are reviewed below.
Paul and Garg (2012) reported the
effects of HRV training on basketball
performance in a randomized, double blind
design with basketball players (N = 30;
female = 13) of diverse skill levels. Results
implied that the experimental group learned
the training well as their breathing rate
decreased following training and at follow-
up, but the other two groups remained
stagnant in breathing rate. These results
strongly support the use of HRV for
basketball performance.
Among golfers, Lagos et al. (2008)
reported improvements in all performance
measures (i.e., total score, average driving
distance, longest driving distance, and
number of putts, birdies, and pars) and a
more stable heart rate (HR), following the
completion of HRV training over a 10-week
period. The authors speculated the observed
effects to be linked to golfers’ improved
ability to manage stress. However, it is noted
that study outcomes were assessed in a
virtual reality golf game setting and that
real-world competition may call for
additional demands not present in a well-
controlled environment.
Although there is some evidence
supporting the use of HRV training among
competitive performers, present work in this
area still lacks methodological considera-
tions necessary to push biofeedback into the
forefront of training options for improving
performance. There is promising evidence
on using HRV training to improve endur-
ance performance in cycling among
noncompetitive participants (Goudas et al.,
2007), but study effects require replication
beyond lab settings. Therefore, there
remains much room for further development
104
in using HRV training for competitive
performance enhancement.
Combinatory biofeedback modalities.
Shooting accuracy was assessed among a
small sample of Division I ice hockey
players (N = 4) after training breathing
patterns and skin conductance (Perry, Shaw,
& Zaichkowsky, 2011). Results showed that
the players were able to reduce respiration
rate and improve shooting accuracy.
Unfortunately, this is an uncontrolled study
with small sample sizes and no analyses
were reported to detect significance of the
improvements.
Galloway (2001) combined biofeedback
training (surface electromyography or
SEMG, and galvanic skin response or GRS,
temperature, and heart rate or HR) with four
specific psychology skills from the Wingate
Five-Step approach (Blumenstein, Bar-Eli,
& Collins, 2002) to train five junior elite
male tennis players and a sixth participant
acting as a control. The study scored in
terms of implementing a multifaceted
training protocol, but failed to provide any
statistical analyses of pre–post data.
In preparation for the Vancouver 2010
Olympics, Dupee and Werthner (2011)
utilized a combination of EEG, SEMG,
respiration rate, HR, HRV, skin conductance
(SC), and peripheral body temperature
(TEMP) to train athletes to cultivate their
own optimal state for competition. However,
similar to Perry et al. (2011) and Galloway
(2001), the study was missing a control
group and statistical analyses of pre–post
data were also not conducted.
Harvey et al. (2011) reported the use of a
biofeedback program with 10 male speed
skating athletes that included HRV, EMG,
HR, SC, TEMP, and EEG (alpha training) to
decrease reaction time. The authors based
their program on the work of Wilson,
Pepper, and Moss (2006). Study analyses
revealed an effect of time on the study
measure. Similarly, Beauchamp et al. (2012)
integrated neurofeedback and biofeedback
manipulations in training speed skaters and
 Performance Enhancement
found positive outcomes with regard to the
athletes succeeding in the Canadian
Olympics. Although results from both
studies suggest positive effects of combining
physiological feedback modalities, there is a
need to highlight that both studies did not
use control groups. It is then difficult to
determine if reaction time changes were due
to participants’ manipulation of their own
physique and not because of practice effects
on reaction time tasks.
Using a design with better methodologi-
cal rigor compared to those discussed above,
Raymond and colleagues (2005) conducted
a direct test of the relationship between
neurofeedback and performance by com-
paring the effects of alpha/theta neuro-
feedback training to a HRV training group as
well as a control group (no training). The
neurofeedback training group improved in
“overall execution” and “timing” domains;
the HRV training group improved in “over-
all execution,” and “technique” domains; the
control group made no significant changes.
The biofeedback and neurofeedback groups
did not differ significantly from each other
in study measures.
Not all studies examining the efficacy of
biofeedback observed positive results.
Evetovich and colleagues (2007) tested the
value of using mechanomyography as a
biofeedback method and failed to find that
training reduced fatigue and therefore to
increase number of repetitions on a forearm
flexion task. However, they did report that
this form of biofeedback effectively
increased muscle relaxation, relative to the
untrained group.
Most studies investigating the effects of
combined physiological feedback modalities
have employed poor designs such as the
absence of control groups and statistical
analyses of pre–post data, and demonstrated
limited generalizability to inform the field
with the small samples studied. The
implementation of a combined modality
protocol is promising, but the field strongly
needs further replication of present research
105
efforts before any claims for positive
outcomes can be made.
Other Comments
Proposed mechanism of action. Since
the 1970s, better performance has been
associated with systematic differences in the
physiology of experts and novices (e.g.,
Blumenstein, Bar-Eli, & Tenenbaum, 2002;
Deeny, Hillman, Janelle, & Hatfield, 2003;
Kirschenbaum, 1987; Milton, Solodkin,
Hlustik, & Small, 2007; Zaichkowsky &
Fuchs, 1988). Specific to neurofeedback,
more economical control of brain function is
the underpinning of the neural efficiency
theory (Haier et al., 1992), and when applied
to sport, indicates that there are consistent
cortical differences between novice and
expert performers (e.g., Kim et al., 2008;
Milton et al., 2007). In fact, Baumeister and
colleagues (2008) demonstrated that better
performance was associated with an increase
in theta and alpha power along the fronto-
midline sites. This view is also supported by
the research done by Shelley-Tremblay,
Shugrue, & Kline (2008), which observed
significant increases in global fast frequency
activity in novice putters when they are
observed by an audience versus being alone.
The boost in cortical activation assumes the
novices felt heightened self-consciousness
while being watched, which coincides with
their decrease in performance with an
audience. While a greater review of the
proposed mechanism of action is beyond the
scope of the current work, it is should
suffice to illuminate how neurofeedback
training could improve performance, par-
ticularly among aspiring sport novices (e.g.,
Deeny et al., 2003; Del Percio et al., 2009).
Methodological Concerns
In 1993, Gould and Udry reviewed the
evidence for using biofeedback for the
purpose of arousal regulation, which many
believe mediates the relationship between
biofeedback training and performance im-
provements. The methodological concerns
reported by the authors include the lack of
 Evidence-Based Practice in Biofeedback and Neurofeedback
standardization in training protocols, lack of
follow-up data to determine maintenance of
training effects, and lack of control groups
to differentiate training and mere expectancy
effects. Interestingly, Gould and Udry also
state that an important need for research in
biofeedback is to make training protocols
more comprehensive with regard to the
physiological systems in the body due to
individual response stereotypy. While this
concern is valid, response stereotypy can be
addressed directly by assessing the
individual prior to employing a standardized
protocol. Rather than actual performance
measures, some studies have considered
how neurofeedback training impacts
assessments like a CPT in athletes (Sherlin,
Larson, & Sherlin, 2012) or sport specific
variables like body fat percentage, focus,
reaction speed variability, and improved
impulse control (Larson, Sherlin, Talley, &
Gervais, 2012; Sherlin et al., 2011b).
Future directions. Due to the sensitivity
of gaining access to performance
populations, considerable efforts are
sometimes taken to frame any research
endeavors as peak performance opportuni-
ties rather than to evaluate any presence of
pathology. Most of the studies reviewed did
not utilize strict exclusion criteria with
regard to presence of current or historical
medical or psychological diagnosis. It is
unclear how the presence of a current or
historical diagnosis may contribute to the
overall response or outcomes in the high
performance populations. However, it is also
reasonable to expect that those circum-
stances will have benefited from the training
rather than being benign, due to the
significant evidence of biofeedback and
neurofeedback efficacy in clinical
populations.
Recently, Gruzelier has published a
series of articles reviewing the literature of
neurofeedback in performance populations.
This series provided a review of cognitive
106
and affective outcomes of neurofeedback
training (Gruzelier, 2013a), and subse-
quently focused on its validity in the
performing arts (Gruzelier, 2013b). It is not
our intent to expand upon the writings of
Gruzelier in this chapter; however, there is
significant evidence and discussion in the
series that further emphasizes and supports
the conclusions of this chapter. We suggest
that readers would additionally consult the
series by Gruzelier and anticipate the third
and final article of this series to address
theoretical and methodological issues
(Gruzelier, 2013a).
Conclusion
The use of biofeedback and neurofeedback
training in improving individual perfor-
mance can be considered a Level 3:
Probably Efficacious treatment. This is
based on the following evidence and
observations in the existing literature:
• In at least one comparison with placebo
and/or control groups, neurofeedback/
biofeedback training has been shown to
be effective in improving performance-
related outcomes
• In at least one study evaluating the
effectiveness of neurofeedback/biofeed-
back training for performance improve-
ment, random assignment and homo-
geneity was observed in sample
selection with attempts at reaching
consistency in protocol selection.
However, while the application of
neurofeedback/biofeedback in performance
training has become more popular, there is
no landmark evidence to date supporting the
use of this application. Most studies have
employed small sample sizes and are also
inconsistent in methodologies. The
application of neurofeedback/biofeedback
training in this area remains to be further
established.
 Preeclampsia
Chapter 33 – Preeclampsia
Level 4: Efficacious
Fredric Shaffer, PhD, BCB, and Zachary M. Meehan
Truman State University, Center for Applied Psychophysiology
Preeclampsia, also called pregnancy-induced
hypertension (PIH), is characterized by
elevated blood pressure and proteinuria
(abnormal levels of protein in the urine)
following the twentieth week of gestation.
This disorder affects 6–8% of pregnancies
and is one of the leading causes of fetal
morbidity and mortality in the United States
(Walling, 2004). Preeclampsia is associated
with the increased risk of acute renal failure,
cerebrovascular and cardiovascular compli-
cations, separation of the placenta from the
uterus, widespread formation of clots in
small blood vessels, and maternal death
(MacKay, Berg, & Atrash, 2001).
Three RCTs, one multigroup study with
a historical control, and a pretest/posttest
study provide evidence that biofeedback-
assisted relaxation is efficacious in the
treatment of preeclampsia. Researchers
incorporated electrodermal biofeedback
(galvanic skin response and skin con-
ductance), HRV biofeedback, or temperature
biofeedback in their relaxation interventions.
Little et al. (1984) conducted an RCT
that compared the efficacy of relaxation
training or biofeedback plus relaxation to a
control group that received treatment as
usual (TAU) in the management of women
with pregnancy-induced hypertension. Fifty
women participated in this 6-week study.
Eighteen were given relaxation therapy, 18
received relaxation combined with bio-
feedback, and 24 controls only received
TAU. Following referral, the researchers
sequentially assigned patients diagnosed
with PIH to one of the three conditions. The
relaxation-only group listened to relaxation
instructions based on Patel and North
(1975), and were told to listen to a recording
of these instructions once daily at home. The
biofeedback plus relaxation group listened
to the same relaxation instructions as the
107
relaxation-only group, received skin con-
ductance feedback, and were also told to
listen to a recording of the relaxation
instructions once daily at home. The control
group only received TAU. The experimental
groups were superior to the control group on
frequency of hospitalization, mean hospi-
talization length, diastolic blood pressure,
and proteinuria. The relaxation-only group,
alone, achieved lower systolic blood
pressure than the control group. An
important limitation of this study was the
researchers’ failure to confirm that the
biofeedback plus relaxation group learned to
lower skin conductance. The investigators
also speculated that the equivalence of the
two treatment groups on most measures
could be due to their failure to assign skin
conductance biofeedback home practice.
Somers et al. (1989) conducted an RCT
that involved 45 women (30-36 weeks’
gestation) diagnosed with mild PIH. The
researchers randomly assigned these women
to bed rest alone, compliance enhancement
training, or biobehavioral intervention. The
group on bed rest alone (n = 15) received
TAU, which included bed rest and compre-
hensive obstetrical monitoring. The compli-
ance enhancement training group (n = 15)
received the same TAU components as the
bed rest alone group, combined with 4 hours
of training to increase their compliance. The
biobehavioral intervention group (n = 15)
received TAU and 4 hours of training that
included elements of the bed rest alone and
compliance enhancement training protocols,
and blood pressure monitoring with
temperature biofeedback-assisted relaxation
training. The researchers assigned relaxation
skill practice twice a day, three relaxation
breaks a day, and a blood pressure and hand
temperature journal. The biobehavioral
intervention group raised hand temperature
 Evidence-Based Practice in Biofeedback and Neurofeedback
from their entry into the study to the final
practice sessions preceding delivery. They
reduced mean arterial pressure (MAP) and
their MAP measurements were lower than
the bed rest alone and compliance
enhancement training groups. Only 9 of 15
biobehavioral intervention group patients
exceeded 95 mm Hg at the final prenatal
visit compared with 14 of 15, in each of the
other groups. This RCT provided a powerful
demonstration of an inexpensive 4-hour
intervention for mild PIH.
El Kosery, Saleh, and Farouk (2005)
reported a pretest/posttest study of 25
women at 16 weeks’ gestation who were at
high risk for PIH. These patients received
autogenic training combined with galvanic
skin response biofeedback in 30-minute
sessions, twice a day, for 12 weeks.
Comparisons of before-treatment and after-
treatment values showed reductions in
systolic and diastolic blood pressure and
heart rate. Three women (12%) developed
PIH, while 22 (88%) did not. While the lack
of a control group precluded drawing causal
conclusions due to confounding by
extraneous variables, this study demon-
strated the potential of biofeedback-assisted
relaxation to prevent PIH in high-risk
pregnant women.
El-Kosery, Abd-El Raoof, and Farouk
(2005) reported an RCT of 35 women diag-
nosed with preeclampsia who were ran-
domly assigned to either a relaxation group
or control group. The relaxation group (n =
20) received three sessions of autogenic
training combined with galvanic skin
response biofeedback per week for 6 weeks
and continued to take the antihypertensive
drug methyldopa. The control group (n = 15)
only received methyldopa. The relaxation
group reduced heart rate, systolic and
diastolic blood pressure, proteinuria, and
methyldopa dosage. The control group also
reduced heart rate, systolic and diastolic
blood pressure, and proteinuria, but their
methyldopa doses increased. At the end of
the 6 weeks of training, the relaxation group
achieved greater reductions in systolic blood
108
pressure, methyldopa dosage, diastolic blood
pressure, heart rate, and proteinuria, respec-
tively, than the control group. While the
medication control group lacked the demand
characteristics and engagement of the relax-
ation group, this RCT provided strong evi-
dence of the effectiveness of GSR biofeed-
back-assisted relaxation in managing PIH.
Cullins et al. (2013) compared the
efficacy of respiratory sinus arrhythmia
(RSA) biofeedback with a historical control
group, external to the study, which received
treatment as usual (TAU). The authors did
not use random assignment. Volunteers
included 47 adult women, previously
diagnosed with PIH, within the gestational
range of 24 to 36 weeks. Subjects in the
RSA biofeedback group (n = 16) received
bed rest, antihypertensive medication, and
RSA biofeedback. The researchers used a
45-minute training session to instruct sub-
jects how to use a StressEraser portable RSA
biofeedback device while breathing from
4.5-7.0 breaths per minute, and to assign 20
minutes of daily practice for 2 weeks.
Subjects in the TAU group (n = 31) received
bed rest and antihypertensive medication.
Systolic and diastolic blood pressure did not
change for either group. The RSA biofeed-
back group had fewer labor and delivery
complications, and higher birth weight and
gestational age than the TAU group. While
statistical analysis showed that the RSA
biofeedback and TAU groups shared com-
parable demographics, the lack of random
assignment and different demand character-
istics risked confounding by extraneous
variables. While RSA biofeedback practice
did not lower diastolic or systolic blood
pressure, this group’s superior labor and
delivery outcomes were encouraging.
Three RCTs (El Kosery et al., 2005;
Little et al., 1984; Somers et al., 1989) and a
multigroup study with a historical control
(Cullins et al., 2013) have demonstrated that
biofeedback-assisted relaxation can reduce
preeclampsia, warranting a rating of Level 4:
Efficacious.
 Posttraumatic Stress Disorder
Chapter 34 – Posttraumatic Stress Disorder
Level 3: Probably Efficacious
Jay Ginsberg, PhD,1 Dale S. Foster, PhD, BCN,2 and Gabriel Tan, PhD, BCB, BCN3
1
Dorn VA Medical Center
2
Memphis Integral Neurofeedback Institute
3
National University of Singapore
At the request of the Department of Veterans
Affairs, the Institute of Medicine's Commit-
tee on Treatment of Posttraumatic Stress
Disorder (PTSD) undertook a systematic
review of the PTSD literature. After nearly
2,800 abstracts were identified, the applica-
tion of inclusion criteria narrowed the list
down to 90 randomized clinical trials, 37
pharmacotherapy studies, and 53 psycho-
therapy studies. The principal finding of the
committee is that the scientific evidence on
treatment modalities for PTSD does not
reach the level of certainty that would be
desired for such a common and serious
condition among veterans. Most studies
included in the committee's review were
characterized by methodologic limitations,
some serious enough to affect confidence in
the studies’ results. The committee reached a
strong consensus that additional high-quality
research is essential for every treatment
modality. Current behavioral treatments for
PTSD include prolonged exposure treatment
and cognitive processing/behavioral thera-
pies. Neurofeedback and biofeedback are
relative newcomers.
Neurofeedback
Early on, biofeedback was used to reward an
increase in alpha and theta activity in
treatment of anxiety. In this type of protocol,
neurofeedback for anxiety was likely to have
included reduction of high-frequency beta
because, typically, when alpha and theta are
rewarded, high-frequency beta activity is
inhibited. Currently, infra-low neurotherapy
is in the early stages of study for its efficacy
in decreasing symptoms of PTSD. One of
the newest forms of neurotherapy for PTSD
109
is Beta Reset, a trademarked protocol that is
commercially available, but has not been
described in the scientific literature
(Gisburne, 2014).
The first published study on neuro-
feedback and PTSD (Peniston & Kulkosky,
1991) reported remediation of PTSD
symptoms and improvements on MMPI
clinical scales among 15 combat veterans
who received occipital alpha-theta (A-T)
neurofeedback treatment in addition to
standard treatment, of which 14 control
participants experienced relapse while only
3 of the 15 veterans reported the same at 30-
month follow-up. In a second uncontrolled
study, Peniston, Marrinan, Deming, and
Kulkosky (1993) reported the elimination of
chronic PTSD symptoms at 26-month
posttreatment follow-up among 16 of 20
veterans with PTSD and comorbid alcohol
abuse, while the remaining four veterans
reported a range of only one to three
episodes of PTSD symptoms at follow-up.
Similar to works of Peniston and team,
Smith (2008) found significant decreases in
PTSD symptoms of depression and im-
provements in attention among 10 combat
veterans diagnosed with PTSD following 30
sessions of neurofeedback training including
A-T training.
While evidence on the efficacy of A-T
neurofeedback training looks promising,
Graap (1998) concluded in a review on the
works by Peniston and colleagues (focusing
on A-T neurofeedback treatment for
alcoholism and PTSD) that additional
clarifying information is needed before A-T
neurofeedback techniques are effective for
PTSD treatment. Peterson (2000) also
 Evidence-Based Practice in Biofeedback and Neurofeedback
recommended further guidelines and
cautions on the effectiveness of A-T neuro-
feedback treatment for PTSD and related
psychopathological conditions, citing the
strengths and shortcomings of using A-T
training and eye movement desensitization
reprocessing (EMDR) to treat PTSD
symptoms, and the possible integration of
the two treatment modalities in treating
disorders of extreme stress.
In 2012, studies focusing on multimodal
treatment and management of PTSD
symptoms provided positive evidence on the
use of integrated neurofeedback/biofeedback
methods (e.g., Hagedorn, 2012; Othmer,
2012; Rutter, 2012), suggesting advantages
in supplementing standard treatment such as
psychological therapy with neurofeedback/
biofeedback techniques (e.g., electrocardio-
graph for heart rate variability, event-related
potentials, live Z-score training). This is
assuming that a one-size-fits-all treatment
approach may not be feasible for war
veterans who develop PTSD symptoms
(Hagedorn, 2012).
On EEG-guided neurofeedback training,
Walker (2009) reported decreased anxiety
ratings that were self-reported by 19 PTSD
sufferers after completion of 5–7 sessions of
QEEG-guided neurofeedback training and at
1-month follow-up. Kelson (2013) also
reported a significant remediation of PTSD
symptoms in 5 veterans of mixed age and
race who completed 20 sessions of neuro-
feedback, in contrast to a control group (n =
5) that did not exhibit improvements in
PTSD symptoms following the study period.
Building upon previous research with
healthy normal subjects (Ross et al., 2013)
in which fMRI salience network changes
were noted to be caused by neurofeedback,
Kleutsch et al. (2013) observed decreased
alpha amplitude and self-reported improve-
ments in relaxation, calmness, and clear-
mindedness among 21 chronic PTSD
sufferers. Additionally, fMRI measures
quantified improved connectivity within
both the salience network and the default
110
mode network, both known to be
dysregulated in sufferers of PTSD.
Attempting an individualized treatment
approach, Foster and Veazey-Morris (2013)
utilized LORETA (low-resolution EEG
tomographic analysis) Z-score neurofeed-
back in conjunction with a functional neural
network symptom checklist match method
to train eight combat veterans diagnosed
with both PTSD and postconcussion
syndrome. They reported normalization of
the PTSD-affected neural networks trained,
and reduction in PTSD symptoms.
Heart Rate Variability Biofeedback
Published reports of the use of HRVB for
PTSD first appeared in 2009, and its
application in the treatment of PTSD is
receiving increasing attention among clinical
practitioners. HRVB for PTSD is particu-
larly widespread in VA hospitals as an
adjunctive treatment modality for combat
veterans with PTSD.
Ginsberg et al. (2010) noted some
positive findings in achieving cardiac
coherence, an increase in coherence ratio,
and improvements in information processing
abilities upon the completion of 4-week
HRVB training in five war veterans with
PTSD. In a pilot study focusing on
improving HRV in veterans with combat-
related PTSD symptoms, Tan et al. (2011)
also showed that HRVB treatment (in
addition to treatment as usual) significantly
increased HRV and reduced PTSD
symptoms among study participants. While
the study preliminarily supported HRVB
treatment as an effective and feasible
treatment for veterans, a larger randomized
control trial is needed for further validation.
Using a multimodal treatment approach,
Zucker et al. (2009) compared the effects of
respiratory sinus arrhythmia (RSA) biofeed-
back with a control group, using progressive
muscle relaxation training as adjunctive
interventions for 38 persons with PTSD
symptoms comorbid with a substance use
disorder. Both groups reported decreases in
depression symptoms, insomnia ratings and
 Posttraumatic Stress Disorder
substance use cravings, and increases in
HRV. Similarly, Tan et al. (2013) examined
the application of a novel intervention
combining group therapy with biofeedback
training via telemedicine and using a home
practice portable biofeedback device. They
reported improvements in self-reported pain
unpleasantness and interference, depressive
and PTSD symptoms, and sleep disturbance
in 34 female veterans presenting with
chronic pain comorbid with depression
and/or PTSD, with improvements sustained
at 6-week follow-up.
While the studies discussed above offer
promising evidence on using HRVB training
for PTSD, Lande et al. (2010) did not
observe a significant effect of HRVB
training on PTSD and depression symptoms
among active duty military service members
deployed to Iraq or Afghanistan who
received HRVB training in addition to usual
treatment. Additionally, McLay and Spira
(2009) reported that a military medical
provider improved in insomnia symptoms,
but not PTSD symptoms, following 1 week
of HRVB training.
Finally, in a review of the literature, Tan
et al. (2013) recommended HRVB training
as a promising treatment for alleviating
PTSD symptoms and in improving cognition
for PTSD sufferers. The review also
suggested HRVB as an effective comple-
mentary treatment to more traditional
psychotherapy methods such as cognitive
behavioral therapy (CBT), prolonged
exposure therapy (PET), and acceptance and
commitment therapy (ACT). However, at
this point, larger-scale and more rigorous
controlled trials are needed to affirm these
outcomes.
Other Biofeedback
The evaluation of biofeedback training
independent of other treatment modalities
has resulted in mixed findings. Supporting
the use of biofeedback exercises for post-
trauma treatment, Sadigh (1999) reported a
successful single-case study describing the
effects of standard autogenic exercises and
111
autogenic abreaction in reducing post-
traumatic nightmare frequency and intensity
in a car crash survivor. Follow-up data
suggested that the treatment effects persisted
after therapy completion. Wood et al. (2010)
also reported positive outcomes in using
virtual reality (VR) therapy to treat 30
soldiers presenting with combat-related
PTSD symptoms. Carlson et al. (1998)
provided partial evidence on the efficacy of
biofeedback treatments for combat veterans
with PTSD, citing positive treatment effects
for EMDR treatment, but did not report the
same for biofeedback-assisted relaxation and
routine clinical care. Similarly, Watson et al.
(1997) did not observe additional benefits of
including deep breathing and thermal
biofeedback training to simple relaxation
exercises for 90 Vietnam War veterans with
PTSD.
Multimodal treatments combining
biofeedback training with traditional PTSD
intervention methods have also been
evaluated. Hickling et al. (1986) evaluated
the use of biofeedback and relaxation
training on six patients with PTSD, in
combination with individual and group
therapy. Study participants improved in
anxiety and depression symptoms, reported
lower MMPI scores, and showed lower
electromyography (EMG) and subjective
tension ratings. Later, Silver et al. (1995)
evaluated the effects of a combination of
treatment modalities, which included eye
movement desensitization and reprocessing
(EMDR), relaxation, and biofeedback
training on Vietnam War veterans. Study
team reported positive effects of combined
treatment, with significant improvements in
anxiety, anger, depression, isolation,
thoughts of combat experiences, and
relationship problems. Finally, Greco et al.
(1997) provided evidence on the positive
effects of treating patients with chronic
temporomandibular disorder (TMD) with
trauma onset using a multimodal treatment
consisting of intraoral appliance, biofeed-
back, and stress management training. Both
 Evidence-Based Practice in Biofeedback and Neurofeedback
TMD patients, with and without trauma
onset, experienced improvements in muscle
pain, temporomandibular joint pain, and
mandibular opening. This study contrasted
with previous evidence indicating poor
treatment outcomes of TMD patients with
trauma onset.
Recently, Muller et al. (2009) evaluated
the feasibility and efficacy of a cognitive
behavioral biofeedback program for treating
chronic pain among 11 traumatized
refugees. Study participants reported
improved pain management and coping, and
pain-associated heart rate reactivity. In a
controlled trial, Liedl et al. (2011) reported
on the positive effects of including a
physical activity component to
biofeedback-based CBT (CBT-BF) program
in treating traumatized refugees. Treatment
groups (i.e., CBT-BF and CBT groups)
improved in coping strategies, pain and
mental health status, and physiological
reactivity as compared to wait-list controls.
CBT-BF group also reported greater
improvements in coping (particularly for
cognitive restructuring, counter-activities,
and perceived self-competence) than the
CBT group. In addition, Morina et al. (2012)
reported in a pilot study that a combination
of biofeedback training and narrative
exposure therapy (NET) is feasible and
effective for traumatized refugees suffering
from both persistent pain and PTSD
symptoms. Study participants reported
significant reduction in pain and PTSD
symptoms and improved quality of life.
Biofeedback also boosted motivation for
trauma-focused therapy among participants.
There are recent efforts to integrate
biofeedback technology with traditional
psychotherapies, such as using a wearable
sensor platform designed for monitoring
autonomic nervous system activity to
administer the delivery of empathetic or
therapeutic messages in the tradition of CBT
to patients, when specific arousal events are
detected. These sensors can be worn on the
ankles, with options to include a custom-
designed ECG heart monitor that can be
worn on the chest (Fletcher et al., 2011). The
use of these sensors is to be further
validated.
Conclusion
The use of biofeedback and neurofeedback
training in treating PTSD can be considered
a Level 3: Probably Efficacious treatment.
This is based on the following evidence and
observations in the existing literature:
• In at least one comparison with placebo
a and/or control groups, neurofeedback/
biofeedback training has been shown to
be effective in improving PTSD symp-
toms and associated psychological/
physical correlates
• In at least one study evaluating the
effectiveness of neurofeedback/biofeed-
back training for treating PTSD symp-
toms, random assignment and homo-
geneity was observed in sample
selection.
However, while the application of
neurofeedback/biofeedback in treating
PTSD symptoms has been well-received,
there is no landmark evidence to date
supporting the use of this application. Most
studies have employed small sample sizes,
including participants presenting with
comorbid conditions. In addition, much of
the research on biofeedback training was
completed in combination with other
treatment modalities, thus making it difficult
to confirm the direct effects of any form of
biofeedback treatment in singularity. The
application of neurofeedback/biofeedback
training as a treatment approach in this area
remains to be further established.
112
 Reynaud’s Disease
Chapter 35 – Raynaud’s Disease
Level 4: Efficacious
Carolyn Yucha, PhD
University of Nevada
There were several brief, relatively
uncontrolled studies published in the 1980s
that confirmed the rationale underlying
temperature biofeedback treatment of
primary Raynaud’s disease or phenomenon.
Peterson and Vorhies (1983) studied
temperature biofeedback-trained Raynaud’s
patients, observing the speed of hand
temperature return to baseline after hand
immersion in ice water, which was six to
seven times as fast after biofeedback
training (6 minutes average after training
versus 40 minutes before). Jobe, Sampson,
Roberts, and Kelly (1986) compared hand
temperature responses to whole-body
chilling before and after biofeedback
training and found it to be effective. When
Guglielmi, Roberts, and Patterson (1982)
compared temperature biofeedback with
EMG biofeedback and controls with a
double-blind procedure, all three groups had
comparable improvements, suggesting a role
of nonspecific factors. The results of this
study have limited generalization to clinical
practice because the patients did not have
adequate instructions about how to perform
the physiological changes, when and how to
utilize the training, and any motivational
guidelines for incorporating the training
daily to enhance the clinical training. Keefe,
Surwit, and Pilon (1980) found similar
results, in which other behavioral control
methods performed as well as temperature
biofeedback. However, Freedman et al.
(1988) compared simple temperature
biofeedback with autogenic training and
found the former to be more effective.
The largest study to date of Raynaud’s
involving biofeedback compared to use of a
calcium-channel blocker (nifedipine) with
temperature biofeedback, EMG feedback,
113
and a placebo (Raynaud’s Treatment Study
Investigators, 2000). In this study of 313
patients with primary Raynaud’s disease,
nifedipine seemed to be the superior agent
for reducing symptoms. Problems with
training the patients to an adequate level of
skill in handwarming, however, compro-
mised the final results (Middaugh et al.,
2001).
Two reviews were done in the late
2000s, one reporting that temperature
biofeedback is efficacious and the other
reporting that it is not, based on the
frequency of attacks. Karavidas, Tsai,
Yucha, McGrady, and Lehrer (2006)
reviewed studies using temperature biofeed-
back training in Raynaud’s phenomenon,
and identified whether patients were
adequately trained to increase finger
temperature. They included eight RCTs, one
nonRCT, and two follow-up studies. The
authors categorized the level of evidence for
temperature biofeedback as Level 4:
Efficacious. The rationale was based on
three randomized controlled trials conducted
in independent laboratories (Freedman et al.,
1988; Keefe et al., 1980; Surwit et al., 1978)
that demonstrated “superiority or equiva-
lence” of treatments that include tempera-
ture biofeedback. A more recent meta-
analysis (Malenfant, Catton, & Pope, 2009)
focused on determining effective non-
pharmacological treatments for Reynaud’s.
A number of treatments were considered,
but they found an insufficient number of
studies within some of the treatment options
(e.g., acupuncture, laser). They included five
biofeedback studies and, using the frequency
of attacks as the outcome measure without
considering whether patients had learned to
 Evidence-Based Practice in Biofeedback and Neurofeedback
raise finger temperature, reported that there
was no benefit of biofeedback over control.
Since then, little research has been
published on biofeedback for Reynaud’s. In
2012, Sporbeck et al. compared biofeed-
back, deep oscillation, and a control group
in 28 patients with Reynaud’s disease
secondary to systemic sclerosis. Those in the
biofeedback group reported greater
symptom improvement.
114
Conclusion
In summary, it appears that if temperature
biofeedback is sufficient to ensure that
Reynaud’s patients learn to increase their
finger temperature, temperature biofeedback
is effective in reducing the number of
attacks. If training is insufficient, temp-
erature biofeedback will not be effective in
reducing attacks. This is analogous to
expecting medications that are not taken to
be effective in alleviating symptoms.
 Repetitive Strain Injury
Chapter 36 – Repetitive Strain Injury (RSI)
Level 2: Possibly Efficacious
Fredric Shaffer, PhD, BCB
Truman State University, Center for Applied Psychology
The conventional view of repetitive strain
injury (RSI) is that repeated movement
while performing workplace tasks can
produce injury characterized by pain and
neurological symptoms (Peper, Gibney, &
Wilson, 2004). Peper and Gibney (2006)
cautioned that it is misleading to primarily
attribute pain experienced when working
with a computer to repetitive movement.
They proposed the adoption of the term
computer-related disorder (CRD) because
repetitive motion interacts with many other
factors to produce injury and pain. These
include limited breaks and movement, lack
of somatic awareness, poor ergonomics,
misaligned posture, stress experienced at
home and in the workplace, excessive
physiological reactivity, and muscle
overactivation in regions like the neck and
shoulders.
Investigators have used diaphragmatic
breathing instruction, ergonomic education,
hypnosis, relaxation training, surface
electromyographic (SEMG) biofeedback,
temperature biofeedback, and training to
reduce dysponesis (e.g., misplaced muscle
effort) to prevent or treat RSI. The evidence
supporting the use of biofeedback to treat
RSI is preliminary, involving a case study
and RCTs that were limited by the failure to
confirm effective SEMG biofeedback
training to separate the effects of SEMG
biofeedback from other components, to
study clinical samples, and to use credible
control conditions.
Reynolds (1994) reported a case study of
a 45-year-old female patient who had
received education about posture and
workstation ergonomics, and electromyo-
graphic (EMG) evaluation following surgery
for lateral epicondylitis (tennis elbow) and
115
radial tunnel syndrome (i.e., hand and wrist
weakness due to radial nerve compression).
The EMG evaluation focused on her wrist
and finger extensors. The author used EMG
monitoring to select the writing device (e.g.,
felt marker), resting forearm position (e.g.,
forearm supinated or resting in lap), and
keyboard angle (e.g., flat) that would
minimize EMG activity. The patient
returned to work 3 months following
surgery, increased work time from 4 to 6
hours per day, and reported reduced pain
with occasional episodes. While this case
report did not involve EMG biofeedback
training, it illustrated a role for EMG
evaluation as part of a rehabilitation
program.
Spence and colleagues (1995) conducted
an RCT that compared EMG biofeedback,
relaxation training, and combined treatment
with a wait-list control. They randomly
assigned 48 patients diagnosed with upper
extremity pain for 5–6 years to one of four
conditions. Patients in the three treatment
conditions were individually trained in
twice-weekly 1.5-hour sessions for 4–6
weeks. EMG biofeedback provided auditory
feedback to reduce EMG activity in the
forearm flexors of both arms, and in the
trapezius muscles, if they were associated
with pain. They were assigned home
practice without equipment to teach
discrimination and control of muscle
tension. The relaxation training group
learned relaxation techniques, including
progressive relaxation and imagery, and
were assigned the same home practice as the
EMG biofeedback group. The combined
treatment group integrated the previously
described relaxation training with auditory
EMG biofeedback, and were assigned the
 Evidence-Based Practice in Biofeedback and Neurofeedback
same home practice as the EMG
biofeedback and relaxation training groups.
The wait-list group only received preassess-
ment and postassessment evaluation.
All three treatment groups showed
greater reduction in Beck Depression
Inventory scores than the wait-list control
group and the treatment groups achieved
comparable improvement. Only the
relaxation and combined treatment groups
demonstrated greater reduction in state
anxiety than the wait-list group. Only the
relaxation group showed greater gains in
self-monitored distress than the wait-list
group. Six-month follow-up data were
reported for the three treatment groups, but
not the wait-list group. From posttreatment
to follow-up, state anxiety increased and
self-monitored pain decreased. The treat-
ment groups did not differ in changes on any
of the outcome measures during this period.
The authors’ failure to measure and report
within-session or between-session EMG
changes raised the question of whether EMG
biofeedback training was effective, and
limited this study’s value.
Moore and Wiesner (1996) randomly
assigned 30 patients diagnosed with upper
extremity RSI to six weekly 45-minute
sessions that combined relaxation training
(basic relaxation and autogenic training),
hypnosis, and temperature biofeedback to
produce vasodilation in their hands and
wrists, or to a wait-list control group. The
experimental subjects increased dorsal hand
temperature by 6.7 °F (3.7 °C) to 95.6 °F
(35.3 °C). The researchers did not report
temperature changes in the wait-list group.
The experimental group reduced visual
analog scale pain ratings more than the wait-
list group. The major limitations of this
study were that the wait-list control may
have produced different engagement and
expectancies than the active treatment, and
that the authors did not measure the wait-list
group’s temperature. Since the experimental
group received relaxation training, hypnosis,
and temperature biofeedback, we cannot
116
evaluate the contribution of biofeedback to
their pain reduction.
Peper et al. (2003) randomly assigned 27
participants into training and no-training
groups. The participants had not been
diagnosed with RSI. The researchers
monitored all participants’ forearm flexor,
forearm extensor, anterior deltoid, and upper
trapezius muscles during an initial session.
Following this assessment, the no-training
group left and the training group stayed. The
researchers explained the SEMG assessment
data to each experimental subject, provided
them with 20–30 minutes of SEMG biofeed-
back and diaphragmatic breathing instruc-
tion to teach relaxed mousing, and then
assigned them to practice these skills over
the next week while using a computer. The
investigators provided additional SEMG
biofeedback and training to take micro-
breaks during the next week’s training
session, and assigned diaphragmatic breath-
ing practice and a log of breathing and
dysponesis during computer work. The
researchers re-evaluated subjects in both
groups at the end of the third week.
Following training, the experimental sub-
jects’ RSI symptom ratings improved,
breathing became more diaphragmatic and
slower, and upper trapezius SEMG declined.
This study was limited by the different
demand characteristics of training and no-
training conditions and its nonclinical
sample. However, it provided an excellent
demonstration of how a brief intervention
using SEMG biofeedback and breathing
training could positively impact RSI
symptoms, trapezius SEMG, and breathing
pattern.
Peper, Gibney, and Wilson (2004)
randomly assigned 28 university employees
to either an experimental group or a wait-list
control group. The participants had not been
diagnosed with RSI. The control group
reported working more hours on the
computer. The experimental group received
six weekly 2-hour sessions that combined
education with training to increase SEMG
 Repetitive Strain Injury
awareness and down-train SEMG activity.
The researchers monitored activity in the
forearm flexor, forearm extensor, anterior
deltoid, upper trapezius, and trapezius-
scalene sites at several points in the study.
Experimental subjects practiced at their
worksites and at home with portable
electromyographs to reinforce SEMG
awareness and relaxation skills. They also
coached co-workers using SEMG biofeed-
back. Finally, they also completed logs of
microbreaks (e.g., placing hands on the lap
for 1–2 seconds), mesobreaks (e.g., stretch-
ing for 5–20 seconds), and macrobreaks
(e.g., taking a several-minute walk) while
working at a computer.
Following completion of the 6-week
training program, the experimental group
reported fewer symptoms associated with
the workplace (e.g., head, neck, and
shoulder muscle tension) and less tiredness.
The experimental group also increased the
use of breaks, diaphragmatic breathing, and
sound ergonomics. Measurement of SEMG
change in target muscles would have helped
to interpret improvement in workplace
symptoms and fatigue. This preliminary
study was limited by the different demand
characteristics of experimental and wait-list
117
conditions, and its nonclinical sample.
However, it provided a compelling proof of
concept for the potential of group training to
increase healthy computing practices and
prevent injury.
Peper and Harvey (2008) reported a 9-
month follow-up telephone survey
conducted by the university’s risk manage-
ment department. The risk management staff
found that the 16 experimental subjects they
interviewed had coached over 100
employees using SEMG biofeedback. The
staff also examined the frequency of
workers’ compensation claims by depart-
ment. Those departments with no claims
employed coaches and the three departments
with the most claims had no coaches. While
a survey cannot prove that coaching by co-
workers reduced workers’ compensation
claims, this exciting follow-up report
provided strong evidence that employees
can be trained as coaches of healthy
computing skills.
Conclusion
Due to the limitations of the case study and
RCTs examined in this section, biofeedback
for RSI only warrants a rating of Level 2:
Possibly Efficacious.
 Evidence-Based Practice in Biofeedback and Neurofeedback
Chapter 37 – Stroke
Level 2: Possibly Efficacious
Jeffrey Bolek, PhD, BCB
Private Practice and Cleveland Clinic Staff Emeritus
Stroke incidence is approximately 158 per
100,000 and is a leading cause of disability
in the United States (MMWR Morbidity
Mortality Weekly, 2005). The most common
and widely recognized impairment caused
by stroke is motor impairment, defined as a
loss or limitation of muscle control (Wade,
1992). There are three critical issues that
cloud the interpretation of any studies under
consideration. First, there is a lack of
consistency among professionals in the
terminology used to describe changes in
motor ability poststroke. Two articles
concluding different results of an
intervention may actually have had the same
result if consistent terminology were used
(Jorgensen, Nakayama, Raaschou, & Olsen,
1995). Second, most of the interventions did
not target a specific pathophysiological
process, thereby increasing the “noise” in
the research (Sanderock, Algra, & Anderson,
2009). Third, there is a big difference
between restoring motor control and motor
function. One may have an increase in motor
control, but lack an increase in function or
the ability to perform basic daily tasks of
self-care (Bolek, 2012).
Much of the research on this topic is
dated. It may be that the more recent studies
that failed to find effectiveness of biofeed-
back on stroke recovery outcome discour-
aged further work in this area. An often-
cited Cochrane review (Woodford & Price,
2007) concluded there was no treatment
benefit by incorporating EMG biofeedback
into “standard” physiotherapy, but the
reviewers did not distinguish between
studies that focused on the return of motor
function and those that did not. Pollock
(2007) did not find any one physiotherapy to
be more effective in promoting the return of
118
postural control following stroke. Barclay
(2009) found that standing balance training
using a force platform helped patients stand
more evenly, but did not transfer to
functional activities. In a review of the
literature on the efficacy of biofeedback on
stroke recovery, Nelson (2007) concluded
that biofeedback is a useful tool in the
recovery of function following stroke and
should be provided. In a review paper on
biofeedback applications, Horowitz (2006)
cited several studies with positive outcomes,
but made no statement regarding efficacy. In
a review of evidence-based physiotherapeu-
tic approaches, Woldag and Hummelsheim
(2002) reported that EMG-initiated electrical
muscle stimulation, but not electrical muscle
stimulation, improved motor function. In a
review similar to, but more recent than, the
Cochrane reviews cited earlier, Stanton,
Ada, Dean, and Preston (2011) used two
reviewers to independently rank the quality
and intervention of 46 potentially relevant
papers. The intervention was any type of
biofeedback (position, force, EMG). The
review provided evidence that biofeedback
has a moderate effect in improving activities
of the lower limb such as standing up,
standing, and walking compared with the
usual therapy or placebo. Dickstein (2008)
published a critical review of intervention
approaches on the rehabilitation of gait
speed, but it was basically a summary of
prior Cochrane reviews. In a review of
interventions to promote upper limb
recovery in stroke survivors, Hayward,
Barker, and Brauer (2010) found that robotic
therapy, EMG-stimulation, and a SMART
arm improved the paresis, but did not extend
to everyday tasks. Lastly, a meta-analysis of
biofeedback therapy in poststroke rehabilita-
 Stroke
tion did not support the efficacy of
biofeedback, but cautioned that the
possibility of a Type II error may have
masked important clinical benefits (Glanz et
al., 1995).
Conclusion
One may conclude that biofeedback
interventions, either alone or in conjunction
with other therapeutic modalities, may be
classified as Level 2: Possibly Efficacious
due to the limitations of the studies
conducted thus far. The question of which
treatment is superior is independent of the
question of whether biofeedback is worth
the time and money to invest in patient
treatment. A consistent finding is that no one
treatment is superior. For example, one may
119
explore the use of biofeedback as a tool to
use in muscle strengthening treatment of
children with cerebral palsy. In a contro-
versial systematic review, Scianni et al.
(2009) found that strengthening exercises
such as electrical stimulation and
progressive resistance exercises (but no
studies using biofeedback) were ineffective
in muscle strengthening. This means that if
the study had used only biofeedback and
concluded that biofeedback was ineffective,
it may be interpreted that other treatment
modalities should be used instead of
biofeedback. Future studies will need to ask
the question as to the efficacy of
biofeedback compared to other specific
interventions.
 Evidence-Based Practice in Biofeedback and Neurofeedback
Chapter 38 – Temporomandibular Muscle and Joint Disorder
(TMJD) Pain
Level 4: Efficacious
Alan G. Glaros, PhD
University of Missouri-Kansas City
Temporomandibular muscle and joint
disorders (TMJD) are a heterogeneous
collection of problems involving the
muscles of mastication, the hard tissues of
the temporomandibular joint (TMJ), and the
soft tissues (i.e., articular disc) of the TMJ.
When biofeedback is used as a treatment
modality for TMJD, it typically targets the
muscles of mastication.
Biofeedback can be used alone, or it can
be combined with other treatment
modalities. In clinical trials, alternative
treatments often include non-biofeedback-
containing psychosocial interventions, self-
care strategies (e.g., avoidance of hard,
chewy foods), common dental interventions
(e.g., mouth guards), use of nonsteroidal
anti-inflammatory medications, and placebo
or nontreatment groups. The National
Institute of Dental and Craniofacial
Research (2013) strongly advises against the
irreversible approaches such as tooth
grinding (occlusal adjustment) and
orthodontics to treat most forms of TMJD.
Used alone, biofeedback improves pain,
pain-related disability, and mandibular
functioning (Gardea, Gatchel, & Mishara,
2001). A meta-analysis of 13 studies of
EMG biofeedback treatment showed
biofeedback was superior to no treatment or
psychological placebo control for patient
pain reports, clinical exam findings, and/or
ratings of global improvement (Crider &
Glaros, 1999).
Biofeedback is frequently combined
with other psychosocial interventions.
Crider, Glaros, and Gevirtz (2005) reported
on 14 controlled and uncontrolled outcome
evaluations of biofeedback-based treatments
for TMJD published since 1978. The
120
literature examined in this review included
RCTs of three types of biofeedback treat-
ment: 1) surface electromyographic (SEMG)
training of the masticatory muscles, 2)
SEMG training combined with adjunctive
cognitive behavioral therapy (CBT)
techniques, and 3) biofeedback-assisted
relaxation training (BART). Based on a
detailed review of RCTs supplemented with
information from non-RCT findings, the
authors concluded SEMG training with
adjunctive CBT is an efficacious treatment
for TMJD, and both SEMG training as the
sole intervention and BART are probably
efficacious treatments. More recent reviews
also report that biofeedback combined with
CBT reduces pain and other pain-related
outcomes (Aggarwal, Lovell, Peters, Javidi,
Joughin, & Goldthorpe, 2011; Aggarwal,
Tickle, Javidi, & Peters, 2010; Orlando,
Manfredini, Salvetti, & Bosco, 2007).
Gatchel, Stowell, Wildenstein, Riggs,
and Ellis (2006) conducted a randomized
clinical trial to evaluate the efficacy of a
biopsychosocial intervention for patients
who were at high risk (HR) of progressing
from acute to chronic TMJD-related pain.
The authors assessed pain and psychosocial
measures at intake and at 1-year follow up.
Participants were randomized into one of
two conditions: a nonintervention group or
an early intervention group that received
CBT and biofeedback (frontales EMG and
finger temperature training). Of 101 subjects
who started the study, 98 completed the 1-
year follow-up study. Subjects’ self-reported
pain levels were measured on an analog
scale and in response to muscle palpation. At
1 year, the treatment group subjects reported
significantly lower levels of self-reported
 TMJD Pain
pain and depression, and the early inter-
vention group subjects had generated signif-
icantly lower health care costs for jaw-
related pain (Stowell, Gatchel, &
Wildenstein, 2008).
Biofeedback can also be used in
conjunction with dental and medical
interventions. Perhaps the most common
dental intervention for TMJD is the use of
an interocclusal appliance (i.e., splint, mouth
guard). Biofeedback-based treatments incor-
porating CBT showed the same efficacy for
pain reduction as a splint (Shedden Mora,
Weber, Neff, & Rief, 2013). One study
reported that patients receiving an
interocclusal appliance initially reported
better relief from pain. However, at the 6-
month follow-up, there was significant
relapse in pain in the interocclusal appliance
group while participants in the stress
management/biofeedback group continued
to improve (Turk, Zaki, & Rudy, 1993). A
second trial comparing interocclusal
appliance treatment, stress management/
121
biofeedback training, and the combination of
the two reported that the combined approach
was more efficacious in reducing pain at 6
months than either treatment alone (Turk et
al., 1993).
Medlicott and Harris (2006) reported the
results of a systematic review of the
effectiveness of exercise, manual therapy,
electrotherapy, relaxation training, and
biofeedback in the management of TMJD.
Thirty studies met four criteria: 1) subjects
were from one of three groups identified in
the first axis of the Research Diagnostic
Criteria for TMJD, 2) the intervention was
within the realm of physical therapy
practice, 3) an experimental design was
used, and 4) outcome measures assessed one
or more primary presenting symptoms were
found. Among other recommendations, the
authors stated that combinations of active
exercises, manual therapy, postural correc-
tion, and relaxation techniques often
combined with biofeedback may be
effective.
 Evidence-Based Practice in Biofeedback and Neurofeedback
Chapter 39 – Tinnitus
Level 3: Probably Efficacious for Biofeedback
Level 2: Possibly Efficacious for Neurofeedback
Fredric Shaffer, PhD, BCB, and Matthew Mannion
Truman State University, Center for Applied Psychophysiology
Tinnitus involves ringing in the ear when
noise is absent. This often-debilitating
symptom frequently is associated with
hearing loss. Tinnitus, which affects over 45
million people in the U.S., can impair
speech comprehension. Medical interven-
tions to treat tinnitus may focus on reducing
attention to this symptom by using back-
ground music, devices that generate a more
pleasant masking sound, and antidepressants
(Lalwani, 2014). Biofeedback and neuro-
feedback, along with cognitive behavioral
therapy (CBT), hypnosis, and relaxation
techniques, have been used to treat tinnitus.
The majority of studies of biofeedback
and neurofeedback for tinnitus reviewed in
this chapter utilized a single group pretest/
posttest design, which prevents drawing
causal conclusions. A single biofeedback
study (Weise, Heinecke, & Rief, 2008)
utilized an RCT design. The biofeedback
studies (House, 1978; Walsh & Gerley,
1985; Weise et al., 2008) provided surface
EMG and finger temperature biofeedback.
The neurofeedback studies (Crocetti, Forti,
& Del Bo, 2010; Dohrmann, Elbert, Schlee,
& Weisz, 2007) provided feedback to
modify power in the delta and tau bands of
the EEG, and to down-regulate real time
functional MRI (rtfMRI) activity in cortical
regions that process auditory information.
Biofeedback Studies
House (1978) conducted a pretest/posttest
study that trained 41 patients diagnosed with
severe tinnitus with frontalis EMG and
finger temperature biofeedback. The
majority of these patients suffered sensori-
neural impairment, while the rest experi-
enced conductive hearing loss or had normal
122
hearing. Following 10–12 one-hour training
sessions, the researcher followed the
participants for 6–12 months. Thirty-six of
these individuals improved, four dramati-
cally, while none worsened. Twenty-five of
the 41 patients reported using tranquilizers
before starting biofeedback. After biofeed-
back training, 3 stopped and 6 significantly
reduced their use of these drugs; none
increased their intake. Three limitations of
this study were that the author did not report
changes in frontalis EMG and finger
temperature, did not train participants to
criteria, and only reported descriptive
statistics for self-reported tinnitus symptoms
and medication use. Further, while the
results of this series were encouraging, the
lack of a control group prevented the
attribution of positive outcomes to biofeed-
back training.
Walsh and Gerley (1985) reported a
pretest/posttest study that provided 32
patients diagnosed with subjective tinnitus
(i.e., no pathophysiological findings) with
index finger temperature biofeedback while
they listened to recorded progressive relax-
ation instructions. The researchers measured
participants’ baseline dominant-hand finger
temperatures, Minnesota Multiphasic Per-
sonality Inventory (MMPI) scores, and
Annoyance and Loudness Scales at the start
of the study. Following an 8-week waiting
period, they measured these variables again.
They provided eight 1-hour temperature
biofeedback sessions over the next 8 weeks,
and recorded finger temperature during
presession and postsession baseline periods.
Following 8 weeks of training, they
readministered the MMPI and Annoyance
and Loudness Scales. Self-ratings of
 Tinnitus
loudness and annoyance only declined
during the treatment phase. Likewise, finger
temperature only increased during this time.
The authors found a significant correlation
between finger temperature and loudness
ratings, during both the waiting period and
following 8 weeks of biofeedback training.
Four limitations of this study were that the
authors did not report the mean values for
finger temperature change, they did not train
participants to a temperature criterion (e.g.,
95 °F/32.3 °C), they could not separate the
effects of temperature biofeedback from
progressive relaxation training, and most
importantly, there was no control group.
Weise et al. (2008) randomly assigned
130 patients diagnosed with tinnitus to either
treatment or wait-list control conditions. The
treatment group received 12 1-hour manual-
ized EMG training sessions that combined
muscle down-training for the most reactive
sites (e.g., frontalis, masseter, sternocleido-
mastoid, and trapezius muscles) and
autonomic feedback with CBT interventions
designed to treat tinnitus. Participants in the
wait-list condition were subsequently
crossed over into the treatment condition.
The treatment group improved on measures
of tinnitus annoyance, subjective loudness,
and perceptions of tinnitus controllability.
During a 6-month follow-up, both coping
cognitions and depressive symptoms im-
proved. The most serious limitation of this
study was the failure of the authors to
demonstrate that biofeedback training pro-
duced the intended pattern of physiological
change (e.g., muscle relaxation and reduced
autonomic reactivity). Without this manipu-
lation check, they could not attribute
improvements in primary and secondary
outcome measures to physiological change
in EMG skin conductance or skin temp-
erature. Second, the integration of
biofeedback with CBT prevented the authors
from isolating their separate contributions to
tinnitus improvement.
123
Neurofeedback Studies
Weisz, Moratti, Meinzer, Dohrmann, and
Elbert (2005) discovered that chronic
tinnitus patients exhibited increased delta
(1.5–4 Hz) and decreased tau (8–12 Hz)
EEG power, particularly in the temporal
lobe. Dohrmann et al. (2007) performed a
quasi-experiment that compared neurofeed-
back training with frequency discrimination
training (FDT) without random assignment
to conditions. The authors provided 21
patients with neurofeedback training to
normalize spontaneous EEG activity in these
bands. They evaluated the 21 patients who
reported chronic tinnitus (mean duration of
8.7 years) and provided 10 individual 30-
minute sessions of neurofeedback training
over 4 weeks. They assigned patients to one
of three protocols: reward for increasing the
tau/delta ratio, reward for increasing power
in the tau band, or reward for decreasing
power in the delta band. Sensors were
placed at fronto-central sites (F3, F4, FC1,
and FC2) with a right mastoid reference.
The researchers compared neurofeed-
back training with 10 sessions of frequency
discrimination training (FDT) for a separate
group of 27 chronic tinnitus patients (mean
duration 9.1 years). In this procedure,
patients wearing hearing aids to enhance lost
frequencies were rewarded for successfully
discriminating between two pure tones. The
tones were located within the lost frequency
range and they reduced the separation
between tones as the participants succeeded.
The neurofeedback group increased the ratio
of tau/delta power and reduced baseline-to-
post-neurofeedback training tinnitus inten-
sity. Regardless of the neurofeedback
training protocol, participants who simul-
taneously reduced power in the delta band
and increased it in the tau band achieved the
greatest reduction in tinnitus intensity or its
complete elimination. The neurofeedback
group achieved greater tinnitus improvement
and reduction in distress than the FDT
group. The changes in distress measured by
the Tinnitus Questionnaire were not
 Evidence-Based Practice in Biofeedback and Neurofeedback
correlated with changes in either delta or tau
band power or the tau/delta ratio.
The authors proposed that neurofeed-
back to decrease delta and increase tau
might be superior to training to increase the
tau/delta ratio, since change in only one
band could increase the ratio. Two major
limitations of this study were the failure to
randomly assign subjects to neurofeedback
or FDT groups and train participants to
performance criteria. Nonrandom assign-
ment made it impossible to rule out
confounding by extraneous variables.
Failure to train to criteria may have limited
the potential power of the FDT and
neurofeedback protocols.
Crocetti et al. (2011) conducted a
pretest/posttest study of 15 adults with
normal hearing and chronic sensorineural
tinnitus. They provided patients with 12
sessions of neurofeedback to increase the
tau/delta ratio over a period of 4 weeks.
Sensors were placed at fronto-central sites
(F3, F4, FC1, and FC2) with a right mastoid
reference. Each session provided 20 minutes
of audiovisual feedback for changes in the
tau/delta ratio. The Tinnitus Handicap
Inventory (THI) and the Visual Analogue
Scales (VAS) were administered before and
at the conclusion of neurofeedback training,
and at 1, 3, and 6 months posttreatment. The
tau/delta ratio did not change during
neurofeedback training sessions. Measure-
ments on the THI, intensity scale, annoyance
scale, tinnitus impact on life scale, and
overall problems improved from preassess-
124
ment to the end of neurofeedback training,
and these gains were maintained during
follow-up. The tau/delta ratio was correlated
with the THI score. The major limitations of
this study were lack of a control group and
failure to train to criteria. The failure to
increase the tau/delta ratio suggests that
neurofeedback training was ineffective.
Haller, Birbaumer, and Veit (2010)
reported a pretest/posttest real time
functional MRI (rtfMRI) feedback study of
six adult participants diagnosed with chronic
tinnitus. After locating the auditory cortex,
the researchers provided four 264-second
rtfMRI training sessions in which patients
received visual feedback to down-train
auditory activation. Five of the six
participants successfully reduced auditory
activations. Activations in left and right
hemisphere auditory areas decreased linearly
across training sessions. Two of six
individuals reported mild improvement 2
weeks post-rtfMRI training. This “proof of
concept” study was limited by lack of a
control group, failure to train to criteria, and
the brevity of training (four 4-minute
sessions).
The biofeedback studies warrant a rating
of Level 3: Probably Efficacious due to the
Weise et al.’s (2008) RCT that combined
biofeedback with CBT. The neurofeedback
studies warrant a rating of Level 2: Possibly
Efficacious due to several studies with
sufficient statistical power with well-
identified outcome measures.
 TBI and PTSD
Chapter 40 – Traumatic Brain Injury (TBI) and Posttraumatic
Stress Disorder (PTSD)
Level 3: Probably Efficacious
Dale S. Foster, PhD, BCN,1 and Robert W. Thatcher, PhD2
1
Memphis Integral Neurofeedback Institute
2
Applied Neuroscience Institute
A January 2014 internet search for studies
utilizing neurofeedback in the treatment of
traumatic brain injury (TBI) yielded 25 peer-
reviewed studies, involving 584 subjects, all
of which demonstrated positive outcomes.
Outcome measures included self-report of
improved symptoms (mood, fatigue, focus,
ability to return to work), neuropsycho-
logical test scores (objective tests of
attention, executive function, visual and
auditory memory), and quantitative EEG
metrics (increased beta, SMR and/or alpha
power; decreased theta, high beta, and/or
EMG power; and normalization of coher-
ence and/or phase). Five of the studies
employed control groups, of which three
utilized random assignment (N = 88) (Ayers,
1993, N = 12; Keller, 2001, N = 21;
Rostami, Mohajeri Aval, Shirani, &
Farahani, 2011, N = 12; Schoenberger, Shif,
Esty, Ochs, & Matheis, 2001, N = 12; Tinius
& Tinius, 2000, N = 31). Six studies
employed historical control (N = 91) (Foster
& Veazey-Morris, 2013, N = 8; Hoffman,
Stockdale, and Van Egeren, 1996, N=14;
Laibow, Stubblebine, Sandground, &
Bounias, 2001, N = 27; Walker, Norman, &
Weber, 2002, N = 26; Zelek, 2002, N = 10;
Zorcec, Demerdzieva, & Pop-Jordanova,
2011, N = 6) and 14 studies involved
uncontrolled individual case studies and
case series (N = 405) (Ayers, 1987, N = 250;
Bratic, Orsillo, Esslen, & Jancke, 2007, N =
2; Byers, 1995, N = 1; Grueling, Lloyd, &
Bowser, 1998, N = 1; Hammond, 2005, N =
2; Larson, Harrington, & Hicks, 2006, N =
100; Malkowicz & Martinez, 2009, N = 1;
Nash, 2005, N = 1; Reddy, Jamuna, Devi, &
Thennarasu, 2009, N = 1; Surmeli, 2007,
125
N =24; Thornton, 2000, N = 2; Thornton,
2002, N = 4; Thornton & Carmody, 2013,
N = 15; Wing, 2001, N = 1).
Two of the studies in this review
(Schoenberger, Shif, Esty, Ochs, & Matheis,
2001; and Larson, Harrington, & Hicks,
2006) utilized neuromodulation methods
other than operant conditioning by providing
pre-perceptual stimulation (photic or
electromagnetic) driven by the subject’s
EEG. These studies are included here
because the success of these alternative
neurofeedback methods provides additional
motivation for further basic research into the
scientific underpinnings of neurofeedback in
the treatment of TBI.
The three studies that utilized ran-
domized assignment to control groups
included Ayers (1993), Keller (2001), and
Schoenberger, Shif, Esty, Ochs, and
Matheis, (2001). Ayers (1993) conducted a
study in which 12 outpatients in ongoing
psychotherapy with right hemisphere closed-
head trauma and symptoms of emotional
dyscontrol were randomly assigned to either
neurofeedback inhibiting 4–7 Hz and
rewarding 15–18 Hz in the right hemisphere
(n = 6) or a psychotherapy-only control
group (n = 6). Only the neurofeedback
group showed decreased symptomatology
and progress in psychotherapy. A weakness
of Ayers’ report was the lack of information
regarding her data analysis techniques.
Keller (2001) treated 21 inpatients with
moderate traumatic brain injury an average
of 3.8 months postinjury, randomly assign-
ing them to either 10 sessions of neuro-
feedback training (n = 12) or 10 computer-
ized attention training sessions (n = 9).
 Evidence-Based Practice in Biofeedback and Neurofeedback
Focusing primarily on attention measures
and beta frequency (13–20 Hz) EEG power,
he found that both groups demonstrated
improvements in attention measures, but
only the neurofeedback group showed
improvement on a sustained attention task
and in time spent producing beta.
Schoenberger, Shif, Esty, Ochs, and
Matheis (2001) randomly assigned 12
subjects who had suffered mild to
moderately severe closed head injuries at
least 1 year previously to either a wait-list
control group or 25 sessions of neuro-
feedback utilizing the Flexyx Neurotherapy
System. The treatment group self-reported
improvements in mood and fatigue and
demonstrated improvements in working
memory. Improvements in social and
occupational function were also reported by
a majority of the treatment group including
reductions in need for medication and
increased ability to return to work.
Tinius and Tinius (2000) did not use
random assignment, but compared 16
outpatients diagnosed with mild traumatic
brain injury with 15 healthy controls and
demonstrated improvements on measures of
attention, response control, executive func-
tion, and self-reported symptom severity
after 20 sessions of neurofeedback training
combined with computerized cognitive re-
training exercises. The neurofeedback
training involved single-site power training
along the sensorimotor strip. A weakness of
this study is that the effects of neuro-
feedback were not differentiated from the
possible effects of the cognitive retraining
exercises.
Laibow, Stubblebine, Sandground, and
Bounias (2001) treated 27 brain-injured
subjects with neurofeedback training at Cz,
rewarding alpha and midrange beta while
inhibiting theta and high beta. Subjects were
classified according to symptom type,
number and severity. Improvements varied
according to these symptom variables, as did
the number of sessions, ranging from 23 to
132. They reported 59% to 87% rehabilita-
126
tion, based on the improvement ratings of
subject, physician and caregiver.
In a departure from the usual method of
training EEG power to remediate symptoms,
usually either at Cz or along the sensori-
motor strip, Walker et al. (2002) employed
QEEG-guided coherence training in the
treatment of 26 outpatients with persistent
posttraumatic symptoms 3–70 months after
mild traumatic brain injury. Training one
coherence measure at a time, they reported
that in an average of 19 sessions, 88% of the
patients reported greater than 50%
improvement in self-reported symptoms. In
addition, all patients employed prior to their
injury were able to return to work. They
added that these results were an
improvement over their unpublished data
analysis showing that beta training at Cz
required an average of 38 sessions to
achieve equivalent gains.
Thornton and Carmody (2013) trained
15 TBI patients to modify both power and
connectivity at multiple sites based on
functional neural network models, and
demonstrated improvements in both auditory
and visual memory as well as QEEG power
and connectivity measures. One of their
findings revealed a 0.64 correlation between
the amount of improvement in auditory
memory and the number of sessions
administered.
Foster and Veazey-Morris (2013)
utilized LORETA Z-score neurofeedback
employing a functional neural network,
symptom checklist match method in a case
series of eight veterans with both TBI and
PTSD who were an average of 8.8 years
post injury. They simultaneously trained
multiple power and connectivity (coherence
and phase) measures in multiple Brodmann
areas with real-time normative database
comparisons. Selection criteria for the
measures trained relied on a Symptom
Checklist developed from the cross-
validated functional neuroimaging literature
(Thatcher, 2013). Subjects demonstrated
improvements in both self-reporting of
 TBI and PTSD
symptoms and normalization of QEEG
measures. This neurofeedback method offers
the most specificity and personalization of
training to date. Additionally, this method
offers the added safety of decreased
likelihood of overtraining due to training
toward a normative database in real time
(live Z-score training) rather than training a
specific measure with offline normative
database comparisons or no normative
comparison.
Based on the data available, neuro-
feedback training is probably effective in the
treatment of traumatic brain injury.
However, the heterogeneity of traumatic
brain injuries creates the need for
individualized treatment, and the accumulat-
ing data indicate that the effectiveness of
neurofeedback in the treatment of TBI varies
according to appropriateness of the training
for the symptoms being treated. With the
cross-validation of QEEG with other func-
tional neuroimaging techniques, specific
symptoms are being correlated with specific
neural network abnormalities with increas-
127
ing accuracy. This ability to identify specific
neural network abnormalities behind the
identified symptoms and renormalize them
through operant conditioning with live
normative database comparisons (Z-score
training), and training multiple measures
simultaneously, appear to be the next steps
in the evolution of neurofeedback training
for TBI. It also appears evident that the
utilization of EEG tomography through
LORETA and the resulting increased
specificity of training that this allows is a
move toward the needed personalization of
training for such a varied problem as TBI.
Due to the fact that many of the sequelae of
TBI often remit in the 18 or so months
following the insult regardless of treatment,
in evaluating the cause of symptom
remission in cases of TBI, the natural course
of the disease must be considered and
controlled for. Further research involving
better controls is needed to further
demonstrate and clarify the efficacy and
specificity of neurofeedback in the treatment
of TBI.
 Evidence-Based Practice in Biofeedback and Neurofeedback
Chapter 41 – Urinary Incontinence in Children
Level 3: Probably Efficacious
Ingrid Harm-Ernandes, PT, WCS, BCB-PMD
Duke University Health System
Trials studying biofeedback for treatment of
urinary incontinence (UI) in children are
limited due to a few factors. Many studies
investigated dysfunctional voiding (DV)
rather than UI alone. Dysfunctional voiding
refers to an inability to fully relax the pelvic
floor, urinary sphincter or bladder neck (Bo,
Berghman, Morkved, & Van Kampen,
2015). Urgency dysfunctional voiding pat-
terns, nocturnal enuresis constipation, and
UI can all be symptoms of voiding
dysfunction, but UI is not always associated
with voiding dysfunctions. Additionally, few
high quality RCTs are available to review.
There are studies that are observational,
some are RCT, and some compared
animated biofeedback with more conven-
tional biofeedback that is normally
performed with adults.
Results of studies on UI in children vary
greatly. In one study investigating children
with DV, it was found that biofeedback did
improve UI (Van Gool & de Jonge, 1989). In
another study utilizing biofeedback for
treatment of DV in older children, the
authors demonstrated a reduction in all
symptoms, including daytime wetting. They
concluded that biofeedback is applicable in
older children with dysfunctional voiding
(Kibar et al., 2007). In yet another study,
biofeedback was beneficial in children with
dysfunctional voiding where daytime
wetting was improved in 59.2% of children.
The authors concluded that biofeedback
training is a simple, effective, and well-
tolerated treatment modality in children for
various parameters resulting from bladder
dysfunction (Yagci et al., 2005).
An RCT studied a treatment arm with
pelvic floor muscle training with
biofeedback and a pelvic floor muscle
128
training only arm. They concluded that both
methods are effective in treating UI and
urinary tract infections (Vasconcelos et al.,
2006). A literature review in the Journal of
Pediatric Urology included 27 studies, but
only one was an RCT. The 26 case studies
did show improvement in UI symptoms and
the RCT favored biofeedback, but there was
not a statistically significant difference
between the two groups. The overall
conclusion of the review was that biofeed-
back is an effective, noninvasive method of
treating dysfunctional elimination. They did
caution that most reports were of a low level
of evidence (Desantis et al., 2011).
A more recent RCT (Kajbafzadeh et al.,
2011) investigated the effectiveness of
animated biofeedback. Animated biofeed-
back utilizes visual aids to assist in the
biofeedback sessions (e.g., dolphins jumping
through hoops). There was an improvement
in all symptoms in this RCT. However,
improvement in UI symptoms as an
individual symptom was not mentioned. The
conclusion for this study was that animated
biofeedback does effectively treat voiding
dysfunction in children more efficiently than
nonanimated biofeedback. In another study,
animated biofeedback was compared with
nonanimated biofeedback. Children in the
animated group demonstrated symptom
reduction (included UI) in fewer sessions
than the nonanimated group. Their conclu-
sion was that the animated biofeedback
yielded similar results as the nonanimated,
but in a significantly shorter time frame
(Kaye & Palmer, 2007). Finally, in one more
study, animated biofeedback did not offer
improved results, but did reduce the number
of sessions required to achieve success. The
authors concluded that it was an effective in
 Urinary Incontinence in Children

treating “giggle incontinence” typical of often studied as an isolated symptom, but

girls age 5–7 (Palmer, 2010).
There are many limitations in deter-
mining the efficacy of biofeedback in
treating pediatric UI. This includes limits in
the number of RCTs, the fact that UI is not
rather part of a group of symptoms
associated with voiding dysfunction, and
that the effect of aging is difficult to study.
All of these factors need to be taken into
consideration in future studies.

129
 Evidence-Based Practice in Biofeedback and Neurofeedback
Chapter 42 – Urinary Incontinence in Men
Level 3: Probably Efficacious
Ingrid Harm-Ernandes, PT, WCS, BCB-PMD
Duke University Health System
The majority of trials regarding biofeedback
for urinary incontinence (UI) in men focus
on treatment surrounding prostatectomy.
Levels of quality vary greatly. Four RCTs
indicated that there was no significant
difference when adding biofeedback to
exercise alone or verbal instruction alone
(Florates et al., 2002; Mathewson-Chapman,
1997; Robinson et al., 2008; Wille et al.,
2003).
In another study, mean UI episodes
decreased significantly in the pelvic floor
muscle training (PFMT) group, as well as
the electrical stimulation, biofeedback, and
PFMT group. The authors concluded that
there was no additional benefit of adding
biofeedback and electrical stimulation to the
PFMT (Goode et al., 2011).
Continence was achieved earlier in the
group treated with PFMT, biofeedback, and
electrical stimulation than in the control
group who only received PFMT and oral
advice (Marchiori et al., 2010). In another
study, biofeedback and PFMT were utilized
preoperatively in the experimental group
and verbal instruction for pelvic floor
contraction only postoperatively in the
control group. There was a significant
decrease in the number of urinary leakage
episodes in the study group as compared to
the control group (Burgio et al., 2006).
Some trials indicate earlier recovery
with use of biofeedback. One RCT reported
130
that early biofeedback pelvic floor muscle
training not only hastens the recovery of
urinary continence after radical prostatec-
tomy, but also improves pelvic floor strength
and the severity of incontinence (Ribiero,
2010). In one RCT, a biofeedback and
electrical stimulation group had a significant
positive impact on the early recovery of
urinary continence after radical prostatec-
tomy (Mariotti, 2009).
In a 2011 Cochrane review for
conservative management for postprostatec-
tomy urinary incontinence, 50 trials were
reviewed, but only 8 studies included PFMT
with or without biofeedback. In the review,
they concluded that there are various
approaches to conservative management of
UI following prostatectomy and that the
evidence is conflicting (Anderson et al.,
2011). As with female UI, there is often no
consistency between protocols. In most
studies, no effort was made to assess pelvic
floor strength prior to surgery. As a result,
we cannot determine if men with weaker
pelvic floor muscles benefit more from
biofeedback and have greater improvement
than those with stronger pelvic floor
muscles. Many studies also had limited
training, so it is not known whether more
sessions could have yielded positive results
(Bo et al., 2015).
 Urinary Incontinence in Women
Chapter 43 – Urinary Incontinence in Women
Level 3: Probably Efficacious
Ingrid Harm-Ernandes, PT, WCS, BCB-PMD
Duke University Health System
There are many variables to consider when
studying urinary incontinence (UI). Even the
definition for UI can vary from study to
study. In some studies, urinary incontinence
is defined as the “complaint of complete loss
of urine,” (Haylen, 2010); other studies
define it as “a leakage occurring in the last
30 days” (Kinchen et al., 2003). Within
urinary incontinence, there are three
subgroups that can be studied: stress
incontinence (SUI), urge urinary inconti-
nence (UUI), and mixed urinary
incontinence (MUI). biofeedback can be
used to treat all of these types of
incontinence and it is important to realize
that different types of incontinence can have
various responses to biofeedback. In
addition, more trials now study the use of
biofeedback for incontinence both with and
without pelvic floor muscle training
(PFMT). Biofeedback and the associated
protocols are often variable and confusing,
creating difficulty in comparing studies. In
the majority of studies utilizing biofeedback
for urinary incontinence, either superficial
pads or internal sensors are used to record
the electrical activity of the pelvic floor
muscles. The patient can see the electrical
activity displayed on a screen or with a
device that has visual and/or auditory cues
(Herdershee et al., 2011).
In a Cochrane review studying bladder
training for urinary incontinence in adults,
only a few trials compared biofeedback to
pharmacological intervention. One particular
study concluded that the behavioral training
plus PFMT plus biofeedback group
demonstrated a significant reduction in UI
episodes, reported a higher quality of life,
and had greater treatment satisfaction
(Wyman, 1998). The authors of the
131
Cochrane review concluded that there is
limited evidence that bladder training and
biofeedback may be helpful for the
treatment of urinary incontinence, but trials
were of variable quality and small size
(Wallace et al., 2004).
There are very few RCTs on overactive
bladder (OAB) and biofeedback. One study
(Wang et al., 2004) did examine the effect of
biofeedback and PFMT on OAB. The study
indicated that biofeedback, PFMT, and
electrical stimulation had the highest sub-
jective improvement as compared to the
exercise-only group. One significant diffi-
culty in studying OAB is that there are no
current recommendations on the most
effective treatment methods in treating OAB
with biofeedback. In a Cochrane review for
biofeedback and feedback training for UI,
24 studies were reviewed (Herdeschee et al.,
2001). The majority of the studies included
SUI only or as one of the types of UI (21
studies), MUI alone or with other UI (11
trials), and UUI either isolated or with other
UI (4 studies). However, one particularly
strong trial (Burgio, 2002) did study women
with UUI and MUI. This study did
demonstrate positive results for both
biofeedback and feedback for improvement
in UI symptoms.
Another trial studying biofeedback and
SUI indicated that those in the biofeedback
arm achieved more rapid progress
(Berghmans, 1996). Only nine of the studies
had the same PFMT program in both the
control and experimental group (Berghmans,
1996; Burns, 1993; Laycock, 2001;
McClurg, 2006; Morkved, 2002, Schmidt,
2009; Shepherd, 1983; Sherman, 1997;
Smidt, 1997). The Cochrane study did
conclude that biofeedback and feedback
 Evidence-Based Practice in Biofeedback and Neurofeedback
may provide benefit in addition to PFMT in
women with UI (Herderschee et al., 2011).
There are many issues with the trials
concerning biofeedback and UI in the
Cochrane review as well. Only three studies
reviewed in the Cochrane report stated that a
proper pelvic floor (PF) contraction was
confirmed utilizing the Laycock scale
(Laycock, 2001b) by digital palpation
(Laycock, 2001a; Morkved, 2002; Pages,
132
2001). As a result, it is difficult to consider
the effect of the degree of contraction
strength and how it affects the benefit of
biofeedback. In addition, there is very little
consistency from trial to trial for biofeed-
back and treatment protocols. Further
research needs to be done to control these
effects and determine if benefits can be due
to other factors, such as increased contact
with practitioners (Herderschee et al., 2011).
 Vasovagal Syncope
Chapter 44 – Vasovagal Syncope
Level 2: Possibly Efficacious
Fredric Shaffer, PhD, BCB
Truman State University, Center for Applied Psychology
Vasovagal syncope (VVS), also called
neurocardiogenic syncope, involves a
temporary loss of consciousness (LOC),
often while standing. In VVS, skeletal
muscles abruptly relax, respiration is
depressed, and heart rate, cardiac output,
and systemic vascular resistance greatly
decrease during stressful events (Rhoades &
Bell, 2013). The use of a tilt-table test to
accurately diagnose this syndrome has been
recommended (Parry & Kenny, 1999).
A case series and randomized controlled
trial have examined the effectiveness of an
integrative program of relaxation, diaphrag-
matic breathing training, biofeedback, and
stress management to control VVS
symptoms. While preliminary, the findings
showed that psychophysiological interven-
tions are promising.
McGrady, Bush, and Grubb (1997)
reported a case series of 10 consecutive
VVS patients treated with biofeedback
(EMG and temperature), diaphragmatic
breathing, and relaxation (autogenic training
and progressive relaxation) interventions.
These patients presented with chronic
syncope or near-syncope (e.g., near-faint-
ing), and headache, and could not control
their symptoms with medication or tolerate
its side effects. Training consisted of an
average of 8.5, 50-minute sessions, divided
into 30 minutes of practice and 20 minutes
of education and counseling. The clinicians
started with progressive relaxation and then
integrated it with electromyographic (EMG)
biofeedback. Next, they introduced auto-
genic training and diaphragmatic breathing
combined with temperature biofeedback. Six
of seven patients who were diagnosed with
syncope before receiving treatment reported
at least a 50% reduction in episodes after
133
completing their training. Five of 10 patients
reported that each of their symptoms had
improved. While this case series was limited
by the absence of a control group and the
ability to evaluate the efficacy of individual
treatment components, it provided a
persuasive demonstration of the potential of
psychophysiological interventions to treat
syncope or near-syncope.
McGrady et al. (2003) conducted a
randomized controlled pilot study of
biofeedback-assisted relaxation training
(BART) for 22 VVS patients. Following a 2-
week pretest, the researchers randomly
assigned these patients to either treatment (n
= 12) or wait-list control (n = 10) groups.
The BART group received ten 50-minute
sessions that integrated BART with stress
management. The relaxation component
included autogenic training and progressive
relaxation. The biofeedback component
consisted of facial muscle EMG and finger
temperature biofeedback. Stress manage-
ment training consisted of encouragement to
use relaxation phrases when dealing with
everyday stressors. The researchers assigned
relaxation practice using audiotapes and
scripts twice daily for 10–15 minutes per
session. Following introductory relaxation
and biofeedback training, they suggested
symptom-specific skills (e.g., contracting
muscles when syncope threatened). Follow-
ing completion of 10 training sessions, the
researchers reassessed treatment and control
subjects on physiological and psychological
measures.
The BART group decreased EMG levels
and increased hand temperature from pretest
to posttest, while the control group did not
change on these measures. This demon-
strated that the BART group had learned
 Evidence-Based Practice in Biofeedback and Neurofeedback
these self-regulation skills. Seven patients
(three BART and four control) reported
frequent LOC during preassessment. The
BART group reduced LOC episodes from
pretest to posttest. The BART group did not
significantly reduce headache pain com-
pared to the control group (p = .05) and the
BART group’s pretest/posttest change in
headache index was also nonsignificant (p =
.08). Both groups improved on state anxiety
and depression. While this pilot study was
limited by the shortcomings of a wait-list
134
control and the inability to evaluate the
efficacy of individual treatment components,
it replicated the McGrady et al. (1997) case
series findings and confirmed that psycho-
physiological interventions could help
patients reduce the frequency of LOC.
While the evidence supporting the
efficacy of psychological interventions to
control VVS symptoms is preliminary, the
successful replication of a 10-patient case
series with an RCT warrants a rating of
Level 2: Possibly Efficacious.
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Chapter 2 – Clinical Efficacy of Biofeedback Therapy: Explanation of

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Chapter 5 – Adult Headache

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Chapter 6 – Attention Deficit Hyperactivity Disorder (ADHD)

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Lansbergen, M. M., van Dongen-Boomsma, M., Buitelaar, J. K., & Slaats-Willemse, D. (2011). ADHD
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Lofthouse, N., Arnold, L. E., & Hurt, E. (2010). A comment on Sherlin, Arns, Lubar, and Sokhadze,
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Chapter 7 – Alcohol/Substance Use Disorders

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Callaway, T. G., & Bodenhammer-Davis, E. (2008) Long-term follow-up of a clinical replication of the
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Dehghani-Arani, F., Rostami, R., & Nosratabadi, M. (2010). Effectiveness of Neurofeedback training as a
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Fahrion, S. L., Walters, D., Coyne, L., & Allen, T. (1992). Alterations in EEG amplitude, personality
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rehabilitation of the patients with pathological addictions. Biofeedback and Self-Regulation, 21, 364.
Graap, K., & Freides, D. (1998). Regarding the database for the Peniston alpha-theta EEG biofeedback
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Graap, K., Ready, D. J., Freides, D., Daniels, B., & Baltzell, D. (1997). EEG biofeedback treatment for
Vietnam veterans suffering from posttraumatic stress disorder. Journal of Neurotherapy, 2, 65–66.
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Huang-Storms, L., Bodenhamer-Davis, E., Davis, R., & Dunn, J. (2007). QEEG-guided neurofeedback
for children with histories of abuse and neglect: neurodevelopmental rationale and pilot study.
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Kaiser, D. A., & Othmer, S. (2000). Effect of neurofeedback on variables of attention in a large multi-
center trial. Journal of Neurotherapy, 4(1), 5–15. doi:10.1300/J184v04n01_02
Kaiser D. A., Othmer, S., & Scott, B. (1999). Effect of neurofeedback on chemical dependency treatment.
Biofeedback and Self-Regulation, 20(3), 304–305.
Kelly, M. J. (1997). Native Americans, neurofeedback, and substance abuse theory: Three year outcome
of alpha/theta neurofeedback training in the treatment of problem drinking among Dine' (Navajo)
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LaVaque, T. J., Hammond, D. C., Trudeau, D., Monastra, V. J., Perry, J., & Lehrer, P. (2002). Template
for developing guidelines for the evaluation of the clinical efficacy of psychophysiological
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Lowe, F. (1999). How essential is the EEG component of the Peniston and Kulkosky protocol? Applied
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Moore, J. P., & Trudeau, D. L. (2000). Comparison of alpha-theta, alpha and EMG neurofeedback in the
production of alpha-theta crossover and the occurrence of visualizations. Journal of Neurotherapy,
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Newton, T. F., Cook, I. A., Kalechstein, A. D., Duran, S., Monroy, F., Ling, W., & Leuchter, A. F.
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Peniston, E.G., & Kulkosky, P.J. (1989). Alpha-Theta brainwave training and beta endorphin levels in
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Peniston, E. G., Kulkosky, P. J. (1990). Alcoholic personality and alpha-theta brainwave training.
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Peniston, E. G., & Kulkosky, P. G. (1991). Alpha-theta brain wave neurofeedback for Vietnam veterans
with combat related post traumatic stress disorder. Medical Psychotherapy, 4, 1–14.
Peniston, E. G. (1998). Comments by Peniston. Applied Psychophysiology and Biofeedback, 23, 273–275.
Peniston, E. G., Marriman, D. A., Deming, W. A., & Kulkosky, P. G. (1993). EEG alpha-theta brain wave
synchronization in Vietnam theater veterans with combat related post traumatic stress disorder and
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Saxby, E., & Peniston, E. G. (1995). Alpha-theta brainwave neurofeedback training: An effective
treatment for male and female alcoholics with depressive symptoms. Journal of Clinical Psychology,
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Scott, W., & Kaiser, D. (1998). Augmenting chemical dependency treatment with neurofeedback training.
Journal of Neurotherapy, 3(1), 66.
Scott, W. C., Brod, T. M., Sideroff, S., Kaiser, D., & Sagan, M. (2002). Type-specific EEG biofeedback
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Annual Meeting, 2002.
Scott, W. C., Kaiser, D., Othmer, S., & Sideroff, S. I. (2005). Effects of an EEG biofeedback protocol on
a mixed substance abusing population. American Journal of Drug Alcohol Abuse, 31(3), 455–469.
Sharp, C., Hurford, D. P., Allison, J., Sparks, R., & Cameron, B. P. (1997). Facilitation of internal locus
of control in adolescent alcoholics through a brief biofeedback-assisted autogenic relaxation training
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Taub, E., Steiner, S. S., Weingarten, E., & Walton, K. G. (1994). Effectiveness of broad spectrum
approaches to relapse prevention in severe alcoholism: A long term, randomized controlled trial of
transcendental meditation, EMG biofeedback, and electronic neurotherapy. Alcoholism Treatment
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Trudeau, D. L., Thuras, P., & Stockley, H. (1999). Quantitative EEG findings associated with chronic
stimulant and cannabis abuse and ADHD in an adult male substance use disorder population. Clinical
Electroencephalography, 30(4), 165–174.
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suggestions for future research. Clinical Electroencephalography, 31(1), 13–26.
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Chapter 8 – Anxiety and Anxiety Disorders

Agnihotry, H., Paul, M., & Sandhu, J. S. (2007). Biofeedback approach in the treatment of generalized
anxiety disorder. Iranian Journal of Psychiatry, 2, 90-95.
Barlow, D. (2002). Anxiety and its disorders: The nature and treatment of anxiety and panic (2nd ed.).
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Therapy, 15(5), 431–449.
Beckham, J., Greene, T. B., & Meltzer-Brody, S. (2013). A pilot study of heart rate variability
biofeedback therapy in the treatment of perinatal depression on a specialized perinatal psychiatry
inpatient unit. Archives of Women’s Mental Health, 16(1), 59–65.
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population. Biofeedback and Self-Regulation, 15(3), 273–284.
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Meuret, A. E., Wilhelm, F. H., & Roth, T. W. (2001). Respiratory biofeedback-assisted therapy in panic
disorders. Behavior Modification, 25(4), 584–605.
Meuret, A. E., Wilhelm, F. H., & Roth, T. W. (2004). Respiratory feedback for treating panic disorder.
Journal of Clinical Psychology, 60(2), 197–207.
Mikosch, P., Hadrawa, T., Laubreiter, K., Brandl, J., Pilz, J., Stettner, H., & Grimm, G. (2010).
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Chapter 9 – Arthritis
Baird, C. L., Muraski, M. M., & Wu, J. (2010). Efficacy of guided imagery with relaxation for
osteoarthritis symptoms and medication intake. Pain Management Nursing, 11(1), 56–65.
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& Wilk, K. G. (2010). A randomized trial of three psychosocial treatments for the symptoms of
rheumatoid Arthritis. Seminars in Arthritis and Rheumatism, 40(3), 222–232.
doi:10.1016/j.semarthrit.2010.04.001
Boczkowski, J. A. (1983). Biofeedback training for the treatment of chronic pain in an elderly arthritic
female. Clinical Gerontologist, 2(3), 39–46. doi:10.1300/J018v02n03_05
Dissanayake, R. K., & Bertouch, J. V. (2010). Psychosocial interventions as adjunct therapy for patients
with rheumatoid arthritis: A systematic review. International Journal of Rheumatic Diseases, 13(4),
324–334. doi:10.1111/j.1756–185X.2010.01563.x
Giggins, O. M., Persson, U. M., & Caulfield, B. (2013), Biofeedback in rehabilitation. Journal of
Neuroengineering, 18(10), 60. doi:10.1186/1743-0003-10-60
Morone, N. E., & Greco, C. M. (2007). Mind-body interventions for chronic pain in older adults: A
structured review. Pain Medicine, 8(4), 359–375.
Tamhane, A., McGwin, G., Redden, D. T., Hughes, L. B., Brown, E. E., Westfall, A. O&. Callahan, L. F.
(2014). Complementary and alternative medicine use in African Americans with rheumatoid arthritis.
Arthritis Care Research, 66, 180–189. doi:10.1002/acr.22148
Wasielewski, N. J., Parker, T. M., & Kotsko, K. M. (2011). Evaluation of electromyographic
biofeedback for the quadriceps femoris: A systematic review. Journal of Athletic Training, 46(5),
543–554.
Yilmaz, O. Senocak, O., Sahin, E., Baydar, M., Gulbahar, S., Bircan, C., & Alper, S. (2010). Efficacy of
EMG-biofeedback in knee osteoarthritis. Rheumatology International, 30(7), 887–892.
doi:10.1007/s00296-009-1070-9
Zijlstra, A., Mancini, M., Chiari, L., & Zijlstra, W. (2010). Biofeedback for training balance and mobility
tasks in older populations: A systemic review. Journal of NeuroEngineering and Rehabilitation, 7,
58. doi:10.1186/1743-0003-7-58

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Chapter 10 – Asthma
Bowler, S. D., Green, A., & Mitchell, C. A. (1998). Buteyko breathing techniques in asthma: A blinded
randomised controlled trial. Medical Journal of Australia, 169(11–12), 575–578.
Cowie, R. L., Conley, D. P., Underwood, M. F., & Reader, P. G. (2008). A randomised controlled trial of
the Buteyko technique as an adjunct to conventional management of asthma. Respiratory Medicine,
102(5), 726–732. doi:10.1016/j.rmed.2007.12.012
Holloway, E. A., & West, R. J. (2007). Integrated breathing and relaxation training (the Papworth
method) for adults with asthma in primary care: A randomised controlled trial. Thorax, 62(12), 1039–
1042.
Jackson, A. C., Murphy, M. M., Rassulo, J., Celli, B. R., & Ingram, R. H., Jr. (2004). Deep breath
reversal and exponential return of methacholine-induced obstruction in asthmatic and nonasthmatic
subjects. Journal of Applied Physiology, 96(1), 137–142.
Kligler, B., Homel, P., Blank, A. E., Kenney, J., Levenson, H., & Merrell, W. (2011). Randomized trial of
the effect of an integrative medicine approach to the management of asthma in adults on disease-
related quality of life and pulmonary function. Alternative Therapies in Health and Medicine, 17(1),
10–15.
Lehrer, P., Carr, R. E., Smetankine, A., Vaschillo, E., Peper, E., Porges, S., … Hochron, S. (1997).
Respiratory sinus arrhythmia versus neck/trapezius EMG and incentive inspirometry biofeedback for
asthma: A pilot study. Applied Psychophysiology and Biofeedback, 22(2), 95–109.
Lehrer, P., Smetankin, A., & Potapova, T. (2000). Respiratory sinus arrhythmia biofeedback therapy for
asthma: A report of 20 unmedicated pediatric cases using the Smetankin method. Applied
Psychophysiology and Biofeedback, 25(3), 193–200.
Lehrer, P. M., Hochron, S. M., Mayne, T., Isenberg, S., Carlson, V., Lasoski, A. M., … Rausch, L.
(1994). Relaxation and music therapies for asthma among patients prestabilized on asthma
medication. Journal of Behavioral Medicine, 17(1), 1–24.
Lehrer, P. M., Vaschillo, E., Vaschillo, B., Lu, S.-E., Scardella, A., Siddique, M., & Habib, R. H. (2004).
Biofeedback treatment for asthma. Chest, 126(2), 352–361.
Opat, A. J., Cohen, M. M., Bailey, M. J., & Abramson, M. J. (2000). A clinical trial of the Buteyko
Breathing Technique in asthma as taught by a video. Journal of Asthma, 37(7), 557–564.
Singh, S., Soni, R., Singh, K. P., & Tandon, O. P. (2012). Effect of yoga practices on pulmonary function
tests including transfer factor of lung for carbon monoxide (TLCO) in asthma patients. Indian Journal
of Physiology and Pharmacology, 56(1), 63–68.
Sodhi, C., Singh, S., & Dandona, P. K. (2009). A study of the effect of yoga training on pulmonary
functions in patients with bronchial asthma. Indian Journal of Physiology and Pharmacology, 53(2),
169–174.
Sundblad, B. M., & Larsson, K. (2002). Effect of deep inhalations after a bronchial methacholine
provocation in asthmatic and non-asthmatic subjects. Respiratory Medicine, 96(7), 477–481.
Vazquez, I., & Buceta, J. (1993). Relaxation therapy in the treatment of bronchial asthma: Effects on
basal spirometric values. Psychotherapy and Psychosomatics, 60(2), 106–112.
Vazquez, M. I., & Buceta, J. M. (1993). Psychological treatment of asthma: Effectiveness of a self-
management program with and without relaxation training. Journal of Asthma, 30(3), 171–183.

Chapter 11 – Autism
Coben, R. (2007, September). Autistic spectrum disorder: A controlled study of EEG coherence training
targeting social skill deficits. Presented at the 15th annual conference of the International Society for
Neurofeedback and Research, San Diego, California.
Coben, R. (2009). Efficacy of connectivity guided neurofeedback for Autistic Spectrum Disorder:
Controlled analysis of 75 cases with a 1 to 2 year follow-up. Journal of Neurotherapy, 13(1), 81.
Coben, R., & Hudspeth, W. (2006, September). Mu-like rhythms in Autistic Spectrum Disorder: EEG
analyses and neurofeedback. Presented at the 14th Annual Conference of the International Society for
Neuronal Regulation, Atlanta, Georgia.

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Coben, R., & Padolsky, I. (2007). Assessment-guided neurofeedback for autistic spectrum disorder.
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Jarusiewicz, B. (2002) Efficacy of neurofeedback for children in the autistic spectrum: A pilot study.
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Kouijzer, M. E. J., de Moor J. M. J., Gerrits, B. J. L., Buitelaar, J. K., & van Schie, H. T. (2009) Long-
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Kouijzer, M. E. J., de Moor, J. M. H., Gerrits, B. J. L., Congedo, M., & van Schie, H.T. (2009).
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Neurofeedback treatment in autism. Preliminary findings in behavioral, cognitive, and
neurophysiological functioning. Research in Autism Spectrum Disorders, 4, 386–399.
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Kouijzer, M. E. J., van Schie, H. T., Gerrits, B. J. L., Buitelaar, J. K., & de Moor, J. M. H. (2013) Is EEG-
biofeedback an effective treatment in autism spectrum disorders? A ranzomized controlled trial.
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La Vaque, T. J., & Hammond, D. C. (2002). Template for developing guidelines for the evaluation of the
clinical efficacy of psychophysiological interventions. Applied Psychophysiology and Biofeedback,
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Oberman, L. M., Hubbard, E. M., McCleery, J. P., Altschuler, E. L., Ramachandran, V. S., & Pineda, J.
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Othmer, S. (1997). Assessment. EEG spectrum biofeedback training manual. Encino, CA: EEG
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Pineda, J. A., Brang, D., Hecht, E., Edwards, L., Carey, S., Bacon, M., Futagaki, C., Suk, D., Tom, J.,
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Chapter 12 – Cerebral Palsy

Bolek, J. E. (2003). A preliminary study of modification of gait in real-time using surface
electromyography. Applied Psychophysiology and Biofeedback, 28(2), 129–138.
Bolek, J. E. (2006). Use of multiple-site performance-contingent SEMG reward programming in pediatric
rehabilitation: A retrospective review. Applied Psychophysiology and Biofeedback, 31(3), 263–272.
Bloom, R., Przekop, D., & Sanger, T. (2010). Prolonged electrogram biofeedback improves upper
extremity function in children with cerebral palsy. Journal of Child Neurology, 25(2), 1480–1484.
doi:10.1177/0883073810369704
Cincinnati Children’s Hospital Medical Center (2010). Best evidence (BESt). Biofeedback intervention
for children with hemiplegic cerebral palsy. Agency for Healthcare Research and Quality.
Dodd, K., Taylor, N., & Graham, H. (2003). A randomized clinical trial of strength training in young
people with cerebral palsy. Developmental Medicine and Child Neurology, 37, 652–657.
Dursun, E., Dursun, N., & Alican, D. (2004). Effects of biofeedback treatment on gait in children with
cerebral palsy. Disability and Rehabilitation, 26(2), 116–120.
James, R. (1992). Biofeedback treatment for cerebral palsy in children and adolescents: A review.
Pediatric Exercise Science, 4, 198–212.
Koheil, R., Sochaniwskyj, A., Bablich, K., Kenny, D., & Milner, M. (1987). Biofeedback techniques and
behavior modification in the conservative remediation of drooling by children with cerebral palsy.
Developmental Medicine and Child Neurology, 29, 19–26.
Maher, C., Sherrington, C., Herbert, R., Moseley, A., & Elkins, M. (2003). Reliability of PEDro scale for
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Malhotra, S., Pandyan, A., Day, C. Jones, P., & Hermens, H. (2009). Spasticity, an impairment that is
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Moreland, J., Thomson, M., & Fuoco, A. (1998). Electromyographic biofeedback to improve lower
extremity function after stroke: A meta-analysis. Archives of Physical Medicine and Rehabilitation,
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Van Dijk, H., Jannink, M., & Hermens, H. (2005). Effect of augmented feedback on motor function of the
affected upper extremity in rehabilitation patients: A systematic review of randomized controlled
trials. Journal of Rehabilitation Medicine, 37(4), 202–211.
Wolf, S., & Binder-MacLeod, S. (1983). Electromyographic biofeedback applications to the hemiplegic
patient: Changes in upper extremity neuromuscular and functional status. Physical Therapy, 63,1404–
1413.

Chapter 13 – Chemobrain
Alvarez, J., Meyer, F. L., Granoff, D. L., & Lundy, A. (2013). The effect of EEG biofeedback on
reducing postcancer cognitive impairment. Integrative Cancer Therapies, 12(6), 475–487.
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Becerra, J., Fernández, T., Roca-Stappung, M., Díaz-Comas, L., Galán, L., Bosch, J., … Harmony, T.
(2012). Neurofeedback in healthy elderly human subjects with electroencephalographic risk for
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doi:10.1016/j.neuroimage.2010.08.078

Chapter 14 – Chronic Pain

Arns, M., Gunkelman, J., Breteler, M., & Spronk, D. (2008). EEG phenotypes predict treatment outcome
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Bennett, R. M. (1999, April). Emerging concepts in the neurobiology of chronic pain: Evidence of
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Chiarioni, G., & Whitehead, W. E. (2008). The role of biofeedback in the treatment of gastrointestinal
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temporomandibular disorders. Applied Psychophysiology and Biofeedback, 30, 333–345.
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variability in patients with known coronary artery disease. American Heart Journal, 147, E11.
Donaldson, C., Nelson, D., Skubick, D., & Clasby, R. (1998). Potential contributions of neck muscle
dysfunctions to initiation and maintenance of carpal tunnel syndrome. Applied Psychophysiology and
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Durmus, D., Alayli, G., & Canturk, F. (2005). Effects of biofeedback-assisted isometric exercise and
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cognitive-behavioral therapy, and conservative medical interventions in the treatment of chronic
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Hamblen, E., Sherman, R., & Powell, J. B. (1996, December). The effect of premenstrual syndrome and
primary dysmenorrhea on women's cognitive functioning and job performance before and after
biofeedback treatment. Biofeedback and Self-Regulation, 21(24), 357.
Harden, R., Houle, T., Green, S., Remble, T., Weinland, S., Colio, & Kuiken, T. (2005). Biofeedback in
the treatment of phantom limb pain: A time-series analysis. Applied Psychophysiology and
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Hawkins, R. S., & Hart, A. D. (2003). The use of thermal biofeedback in the treatment of pain associated
with endometriosis: Preliminary findings. Applied Psychophysiology and Biofeedback, 28(4), 279–
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Hetrick, D., Glazer, H., Liu, Y., Turner, J., Frest, M., & Berger, R. (2006). Pelvic floor electromyography
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Chapter 15 – Constipation
Bassotti, G., Chistolini, F., Sietchiping-Nzepa, F., de Roberto, G., Morelli, A., & Chiarioni, G. (2004).
Biofeedback for pelvic floor dysfunction in constipation. BMJ, 328(7436), 393–396.

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Battaglia, E., Serra, A. M., Buonafede, G., Dughera, L., Chistolini, F., Morelli, A., … Bassotti, G. (2004).
Long-term study on the effects of visual biofeedback and muscle training as a therapeutic modality in
pelvic floor dyssynergia and slow-transit constipation. Diseases of the Colon and Rectum, 47(1), 90-
95.
Bleijenberg, G., & Kuijpers, H. C. (1994). Biofeedback treatment of constipation: A comparison of two
methods. The American Journal of Gastroenterology, 89(7), 1021–1026.
Chang, H. S., Myung, S. J., Yang, S. K., Jung, H. Y., Kim, T. H., Yoon, I. J., … Min, Y. I. (2003). Effect
of electrical stimulation in constipated patients with impaired rectal sensation. International Journal
of Colorectal Disease, 18(5), 433–438.
Chiarioni, G., Salandini, L., & Whitehead, W. E. (2005). Biofeedback benefits only patients with outlet
dysfunction, not patients with isolated slow transit constipation. Gastroenterology, 129(1), 86–97.
Chiarioni, G., Whitehead, W. E., Pezza, V., Morelli, A., & Bassotti, G. (2006). Biofeedback is superior to
laxatives for normal transit constipation due to pelvic floor dyssynergia. Gastroenterology, 130(3),
657–664.
Enck, P., Van der Voort, I. R., & Klosterhalfen, S. (2009). Biofeedback therapy in fecal incontinence and
constipation. Neurogastroenterology and Motility, 21(11), 1133–1141. doi:10.1111/j.1365-
2982.2009.01345.x
Farid, M., El Monem, H. A., Omar, W., El Nakeeb, A., Fikry, A., Youssef, T., … El Lithy, R. (2009).
Comparative study between biofeedback retraining and botulinum neurotoxin in the treatment of
anismus patients. International Journal of Colorectal Disease, 24(1), 115–120. doi:10.1007/s00384-
008-0567-0
Faried, M., El Nakeeb, A., Youssef, M., Omar, W., & El Monem, H. A. (2010). Comparative study
between surgical and non-surgical treatment of anismus in patients with symptoms of obstructed
defecation: A prospective randomized study. Journal of Gastrointestinal Surgery, 14(8), 1235–1243.
doi:10.1007/s11605-010-1229-4
Gilliland, R., Heymen, S., Altomare, D. F., Park, U. C., Vickers, D., & Wexner, S. D. (1997). Outcome
and predictors of success of biofeedback for constipation. British Journal of Surgery, 84(8), 1123–
1126.
Glia, A., Gylin, M., Gullberg, K., & Lindberg, G. (1997). Biofeedback retraining in patients with
functional constipation and paradoxical puborectalis contraction. Diseases of the Colon and
Rectum, 40(8), 889–895.
Hart, S. L., Lee, J. W., Berian, J., Patterson, T. R., Del Rosario, A., & Varma, M. G. (2012). A
randomized controlled trial of anorectal biofeedback for constipation. International Journal of
Colorectal Disease, 27(4), 459–466. doi:10.1007/s00384-011-1355-9
Heymen, S., Jones, K. R., Scarlett, Y., & Whitehead, W. E. (2003). Biofeedback treatment of
constipation: A critical review. Diseases of the Colon and Rectum, 46(9), 1208–1217.
Heymen, S., Scarlett, Y., Jones, K., Ringel, Y., Drossman, D., & Whitehead, W. E. (2007). Randomized,
controlled trial shows biofeedback to be superior to alternative treatments for patients with pelvic
floor dyssynergia-type constipation. Diseases of the Colon and Rectum, 50(4), 428–441.
Heymen, S., Wexner, S. D., Vickers, D., Nogueras, J. J., Weiss, E. G., & Pikarsky, A. J. (1999).
Prospective, randomized trial comparing four biofeedback techniques for patients with constipation.
Diseases of the Colon and Rectum, 42(11), 1388–1393.
Koutsomanis, D., Lennard-Jones, J. E., Roy, A. J., & Kamm, M. A. (1995). Controlled randomised trial
of visual biofeedback versus muscle training without a visual display for intractable constipation. Gut,
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Lehur, P. A., Stuto, A., Fantoli, M., Villani, R. D., Queralto, M., Lazorthes, F., … Villet, R. (2008).
Outcomes of stapled transanal rectal resection vs. biofeedback for the treatment of outlet obstruction
associated with rectal intussusception and rectocele: A multicenter, randomized, controlled trial.
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Palsson, O. S., Heymen, S., & Whitehead, W. E. (2004). Biofeedback treatment for functional anorectal
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Randomized controlled trial of biofeedback, sham feedback, and standard therapy for dyssynergic
defecation. Clinical Gastroenterology and Hepatology, 5(3), 331–338.
Rao, S. S. (2008). Dyssynergic defecation and biofeedback therapy. Gastroenterology Clinics of North
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Chapter 16 – Chronic Obstructive Pulmonary Disease (COPD)

Esteve, F., Blanc-Gras, N., Gallego, J., & Benchetrit, G. (1996). The effects of breathing-pattern training
on ventilatory function in patients with COPD. Biofeedback and Self-Regulation, 21(4), 311–321.
Giardino, N. D., Chan, L., & Borson, S. (2004). Combined heart rate variability and pulse oximetry
biofeedback for chronic obstructive pulmonary disease: Preliminary findings. Applied
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van Gestel, A. J., Kohler, M., Steier, J., Teschler, S., Russi, E. W., & Teschler, H. (2012). The effects of
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Chapter 17 – Coronary Artery Disease

Cowan, M. J., Kogan, H., Burr, R., Hendershot, S., & Buchanan, L. (1990). Power spectral analysis of heart
rate variability after biofeedback training. Journal of Electrocardiology, 23 (Supplement), 85–94.
Cowan, M. J., Pike, K. C., & Budzynski, H. K. (2001). Psychosocial nursing therapy following sudden
cardiac arrest: Impact on two-year survival. Nursing Research, 50(2), 68–76.
Del Pozo, J. M., Gevirtz, R. N., Scher, B., & Guarneri, E. (2004). Biofeedback treatment increases heart
rate variability in patients with known coronary artery disease. American Heart Journal, 147(3), 545.
Johnston, D. W., & Lo, C. R. (1983). The effects of cardiovascular feedback and relaxation on angina
pectoris. Behavioural Psychotherapy, 11, 257–264. doi:0.1017/S0141347300009071
Mikosch, P., Hadrawa, T., Laubreiter, K., Brandl, J., Pilz, J., Stettner, H., & Grimm, G. (2010).
Effectiveness of respiratory-sinus arrhythmia biofeedback on state-anxiety in patients undergoing
coronary angiography. Journal of Advanced Nursing, 66(5), 1101–1110. doi:10.1111/j.1365-
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Nolan, R. P., Kamath, M. V., Floras, J. S., Stanley, J., Pang, C., Picton, P., & Young, Q. R. (2005). Heart
rate variability biofeedback as a behavioral neurocardiac intervention to enhance vagal heart rate
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biobehavioral and exercise therapies on heart rate variability in coronary artery disease: A systematic
review. European Journal of Cardiovascular Prevention and Rehabilitation, 15, 386–396.
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myocardial infarction. Journal of Psychosomatic Research, 26, 469–473.

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Chapter 18 – Depressive Disorders

Baehr, E., Rosenfeld, J. P., & Baehr, R. (2001). Clinical use of an alpha asymmetry neurofeedback
protocol in the treatment of mood disorders: Follow-up study one to five years post therapy. Journal
of Neurotherapy, 4(4), 11–18.
Beidel, D. C., Bulik, C. M., & Stanley, M. A. (2014). Abnormal psychology. Upper Saddle River, NJ:
Pearson Education, Inc.
Choi, S. W., Chi, S. E., Chung, S. Y., Kim, J. W., Ahn, C. Y., & Kim, H. T. (2011). Is alpha wave
neurofeedback effective with randomized clinical trials in depression? A pilot study.
Neuropsychobiology, 63(1), 43–51. doi:10.1159/000322290
Corrado, P., & Gottlieb, H. (1999). The effect of biofeedback and relaxation training on depression in
chronic pain patients. American Journal of Alternative Medicine, 9, 18–21.
Durmus, D., Alayli, G., & Canturk, F. (2005). Effects of biofeedback-assisted isometric exercise and
electrical stimulation on pain, anxiety, and depression scores in knee osteoarthritis. Fizik Tedavi
Rehabilitasyon Dergisi, 51(4), 142–145.
Escolano, C., Navarro-Gil, M., Garcia-Campayo, J., & Minguez, J. (2013). EEG-based upper-alpha
neurofeedback for cognitive enhancement in major depressive disorder: A preliminary, uncontrolled
study. Conf Proc IEEE Eng Med Biol Soc. doi:10.1109/EMBC.2013.6610992
Hassett, A. L., Radvanski, D. C., Vaschillo, E. G., Vaschillo, B., Sigal, L. H., Karavidas, M. K., …
Lehrer, P. M. (2007). A pilot study of the efficacy of HRV biofeedback in patients with fibromyalgia.
Applied Psychophysiology and Biofeedback, 32, 1- 10. doi:10.1007/s10484-006-9028-0
Karavidas, M. K., Lehrer, P. M., Vaschillo, E., Vaschillo, B., Marin, H., Buyske, S.,… Hassett, A. (2007).
Preliminary results of an open label study of heart rate variability biofeedback for the treatment of
major depression. Applied Psychophysiology and Biofeedback, 32(1), 19–30.
Kumano, H., Horie, H., Shidara, T., Kuboki, T., Suematsu, H., & Yasushi, M. (1996). Treatment of a
depressive disorder patient with EEG-driven photic stimulation. Biofeedback and Self-Regulation,
21(4), 323–334.
Linden, D. E. J., Habes, I., Johnston, S. J., Linden, S. Tatineni, R., Subramanian, L., Sorger, B., & Healy,
D. (2012). Real-time self-regulation of emotion networks in patients with depression. PLoS One, 7(6),
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Patron, E., Messerotti Benvenuti, S., Favretto, G., Valfre, C., Bonfa, C., Gasparotto, R., & Palomba, D.
(2013). Biofeedback assisted control of respiratory sinus arrhythmia as a biobehavioral intervention
for depressive symptoms in patients after cardiac surgery: A preliminary study. Applied
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Peeters, F., Oehlen, M., Ronner, J., van Os, J., & Lousberg, R. (2014). Neurofeedback as a treatment for
major depressive disorder – A pilot study. PLoS One, 9(3), e91837. doi:
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Raymond, J., Varney, C., Parkinson, L. A., & Gruzelier, J. H. (2005). The effects of alpha/theta
neurofeedback on personality and mood. Brain Research. Cognitive Brain Research, 23(2–3), 287–
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Rosenfeld, J. P. (2000). An EEG biofeedback protocol for affective disorders. Clinical
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Siepmann, M., Aykac, V., Unterdorfer, J., Petrowski, K., & Mueck-Weymann, M. (2008). A pilot study
on the effects of heart rate variability biofeedback in patients with depression and in healthy subjects.
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Young, K. D., Zotev, V., Phillips, R., Misaki, M., Yuan, H., Drevets, W. C., & Bodurka, J. (2014). Real-
time fMRI neurofeedback training of amygdala activity in patients with Major Depressive Disorder.
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Zucker, T. L., Samuelson, K. W., Muench, F., Greenberg, M. A., & Gevirtz, R. N. (2009). The effects of
respiratory sinus arrhythmia biofeedback on heart rate variability and posttraumatic stress disorder
symptoms: A pilot study. Applied Psychophysiology and Biofeedback, 34(2), 135–143.
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Chapter 19 – Diabetes Mellitus

Aikens, J. E. (1999). Thermal biofeedback for claudication in diabetes: A literature review and case study.
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McGrady, A., Bailey, B. K., & Good, M. P. (1991). Controlled study of biofeedback-assisted relaxation
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Miley, W. M. (1989). Reduction in blood glucose levels in chronically ill Type 2 diabetics by brief
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Rice, B., Kalker, A. J., Schindler, J. V., & Dixon, R. M. (2001). Effect of biofeedback-assisted relaxation
training on foot ulcer healing. Journal of the American Podiatric Medical Association, 91(3), 132–
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Rice, B. I., & Schindler, J. V. (1992). Effect of thermal biofeedback-assisted relaxation training on blood
circulation in the lower extremities of a population with diabetes. Diabetes Care, 15(7), 853–858.
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and Self-Regulation, 7(3), 301–304.

Chapter 20 – Epilepsy
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cortex and behavior. Physiological Reviews, 70(1), 1–41.
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(1991). Self-regulation of slow cortical potentials and its role in epileptogenesis. In J. Carlson & R.
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Chapter 21 – Erectile Dysfunction

Burnett, A. L., Aus, G., Canby-Hagino, E. D., Cookson, M. S., D’Amico, A. V., Dmochowski, R. R., …
Thompson, I. (2007). Erectile function outcome reporting after clinically localized prostate cancer
treatment. J Urol, 178(2), 597–601.
Dorey, G., Speakman, M., Feneley, R., Swinkels, A., Dunn, C., & Ewings, P. (2004). Pelvic floor
exercises for treating post-micturition dribble in men with erectile dysfunction: A randomized
controlled trial. Urol Nurs, 24(6), 490-497, 512.
Dorey, G., Speakman, M. J., Feneley, R. C., Swinkels, A., & Dunn, C. D. (2005). Pelvic floor exercises
for erectile dysfunction. NJU Int, 96(4), 595–597.
Dubbleman, Y. D., Dohle, G. R., & Schröder, F. H. (2006). Sexual function before and after radical
retropubic prostatectomy: A systematic review of prognostic indicators for a successful outcome. Eur
Urol, 50(4), 711–718.

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Prota, C., Gomes, C. M., Ribeiro, L. H., de Bessa Jr, J., Nakano, E., Dall’Oglio, M., … Srougi, M.
(2012). Early postoperative pelvic-floor biofeedback improves erectile function in men undergoing
radical prostatectomy: A prospective, randomized, controlled trial. International Journal of
Impotence Research, 24(5), 174–178. doi:10.1038/ijir.2012.11
Sighinolfi, M. C., Rivalta, M., Mofferdin, A., Micali, S., De Stefani, S., & Bianchi, G. (2009). Potential
effectiveness of pelvic floor rehabilitation treatment for post radical prostatectomy incontinence,
climacturia, and erectile dysfunction: A case series. J Sex Med, 6(12), 3496–3499. doi:
10.1111/j.1743-6109.2009.01493
Van Kampen, M., De Weerdt, W., Claes, H., Feys, H., De Maeyer, M., & Van Poppel, H. (2003).
Treatment of erectile dysfunction by perineal exercise, electromyographic biofeedback, and electrical
stimulation. Phys Ther, 83(6), 536–543.
Walsh, P. C., Epstein, J. I., & Lowe, F. C. (1987). Potency following radical prostatectomy with wide
unilateral excision of the neurovascular bundle. J Urol, 138(4), 823–827.

Chapter 22 – Facial Palsy

Azuma, T., Nakamura, K., Takahashi, M., Ohyama, S., Toda, N., Iwasaki, H., Kalubi, B., & Takeda, N.
(2011). Mirror biofeedback rehabilitation after administration of single-dose botulinum toxin for
treatment of facial synkinesis. Otolaryngology–Head and Neck Surgery, 146(1), 40–45.
doi:10.1177/0194599811424125
Balliet, R., Shinn, J. B., & Bach-Y-Rita, P. (1982). Facial paralysis rehabilitation: Retraining selective
muscle control. Int. Rehab. Med, 4(2), 67–74.
Brown, D. M., Nahai, F., Wolf, S., & Basmajian, J. V. (1978). Electromyographic biofeedback in the
reeducation of facial palsy. American Journal of Physical Medicine, 57, 183–190.
Cardoso, J. R., Teixeira, E. C., Moreira, M. D., Fàvero, F. M., Fontes, S. V., & Bulle de Oliveira, A. S.
(2008). Effects of exercises on Bell’s palsy: Systematic review of randomized controlled trials. Otol
Neurotol, 29, 557–560. doi:10.1097/MAO.0b013e31816c7bf1
Dalla Toffola, E., Bossi, D., Buonocore, M., Montomoli, C., Petrucci, L., & Alfonsi, E. (2005).
Usefulness of BFB/EMG in facial palsy rehabilitation. Disability and Rehabilitation, 27(14), 809–
815.
Dalla Toffola, E., Tinelli, C., Lozza, A., Bejor, M., Pavese, C., Degli Agosti, I., & Petrucci, L. (2012).
Choosing the best rehabilitation treatment for Bell’s palsy. Eur J Phys Rehabil Med, 48(4), 635–642.
Nakamura, K., Toda, N., Sakamaki, K., Kashima, K., & Takeda, N. (2003). Biofeedback rehabilitation for
prevention of synkinesis after facial palsy. Otolaryngology–Head and Neck Surgery, 128, 539–543.
Pereira, L. M., Obara, K., Dias, J. M., Menacho, M. O., Lavado, E. L., & Cardoso, J. R. (2011). Facial
exercises therapy for facial palsy: Systematic review and meta-analysis. Clinical Rehabilitation,
25(7), 649–658. doi:10.1177/0269215510395634
Pourmomeny, A. A., Zadmehre, H., Mirshamsi, M., & Mahmodi, Z. (2013). Prevention of synkinesis by
biofeedback therapy: A randomized clinical trial. Otology and Neurology, 35(4), 739–742.
doi:10.1097/mao.0000000000000217
Ross, B., Nedzelski, J. M., & McLean, J. A. (1991). Efficacy of feedback training in long-standing facial
nerve paresis. Laryngoscope, 101, 744–750.

Chapter 23 – Fecal Incontinence

Bols, E., Berghmans, B., de Bie, R., Govaert, B., van Wunnik, B., Heymans, M., … Baeten, C. (2012).
Rectal balloon training as add‐on therapy to pelvic floor muscle training in adults with fecal
incontinence: A randomized controlled trial. Neurourology and Urodynamics, 31(1), 132–138.
doi:10.1002/nau.21218
Davis, K. J., Kumar, D., & Poloniecki, J. (2004). Adjuvant biofeedback following anal sphincter repair: A
randomized study. Alimentary Pharmacology and Therapeutics, 20(5), 539–549.

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Enck, P., Van der Voort, I. R., & Klosterhalfen, S. (2009). Biofeedback therapy in fecal incontinence and
constipation. Neurogastroenterology and Motility, 21(11), 1133–1141. doi:10.1111/j.1365–
2982.2009.01345.x
Fynes, M. M., Marshall, K., Cassidy, M., Behan, M., Walsh, D., O'Connell, P. R., & O'Herlihy, C.
(1999). A prospective, randomized study comparing the effect of augmented biofeedback with
sensory biofeedback alone on fecal incontinence after obstetric trauma. Diseases of the Colon and
Rectum, 42(6), 753–758.
Heymen, S., Pikarsky, A. J., Weiss, E. G., Vickers, D., Nogueras, J. J., & Wexner, S. D. (2000). A
prospective randomized trial comparing four biofeedback techniques for patients with faecal
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controlled trial shows biofeedback to be superior to pelvic floor exercises for fecal incontinence.
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intervention alone vs education and biofeedback in the management of faecal incontinence in women.
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Randomized clinical trial of intra-anal electromyographic biofeedback physiotherapy with intra-anal
electromyographic biofeedback augmented with electrical stimulation of the anal sphincter in the
early treatment of postpartum fecal incontinence. American Journal of Obstetrics and Gynecology,
191(3), 885–890. doi:10.1016/j.ajog.2004.07.006
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treatment of fecal incontinence. Digestive diseases and sciences, 35(10), 1291–1298.
Naimy, N., Lindam, A. T., Bakka, A., Færden, A. E., Wiik, P., Carlsen, E., & Nesheim, B. I. (2007).
Biofeedback vs. electrostimulation in the treatment of postdelivery anal incontinence: A randomized,
clinical trial. Diseases of the Colon and Rectum, 50(12), 2040-2046.
Norton, C., Chelvanayagam, S., Wilson-Barnett, J., Redfern, S., & Kamm, M. A. (2003). Randomized
controlled trial of biofeedback for fecal incontinence. Gastroenterology, 125(5), 1320–1329.
Norton, C., & Cody, J. D. (2012). Biofeedback and/or sphincter exercises for the treatment of faecal
incontinence in adults. Cochrane Database Syst Rev, 7. doi:10.1002/14651858.CD002111.pub3
Rao, S. S. (2004). Pathophysiology of adult fecal incontinence. Gastroenterology, 126, S14–S22.
Schwandner, T., König, I. R., Heimerl, T., Kierer, W., Roblick, M., Bouchard, R., … Kolbert, G. (2010).
Triple target treatment (3T) is more effective than biofeedback alone for anal incontinence: The 3T-
AI study. Diseases of the Colon and Rectum, 53(7), 1007–1016.
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Schwandner, T., Hemmelmann, C., Heimerl, T., Kierer, W., Kolbert, G., Vonthein, R., … Padberg, W.
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randomized, controlled trial. Deutsches Ärzteblatt International, 108(39), 653.
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Solomon, M. J., Pager, C. K., Rex, J., Roberts, R., & Manning, J. (2003). Randomized, controlled trial of
biofeedback with anal manometry, transanal ultrasound, or pelvic floor retraining with digital
guidance alone in the treatment of mild to moderate fecal incontinence. Diseases of the Colon and
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Chapter 24 – Fibromyalgia
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335–340. doi:10.1016/j.maturitas.2013.05.004
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Babu, A. S., Mathew, E., Danda, D., & Prakash, H. (2007). Management of patients with fibromyalgia
using biofeedback: A randomized control trial. Indian Journal of Medical Sciences, 61(8), 455.
Buckelew, S. P., Conway, R., Parker, J., Deuser, W. E., Read, J., Witty, T. E., … Kay, D. R. (1998).
Biofeedback/relaxation training and exercise interventions for fibromyalgia: A prospective trial.
Arthritis and Rheumatism, 11(3), 196–209.
Caro, X. J., & Winter, E. F. (2011). EEG biofeedback treatment improves certain attention and somatic
symptoms in fibromyalgia: A pilot study. Applied Psychophysiology and Biofeedback, 36(3), 193–
200. doi:10.1007/s10484-011-9159-9
Clauw, D. J., Arnold, L. M., & McCarberg, B. H. (2011). The science of fibromyalgia. Mayo Clinic
Proceedings, 86(9), 907–911. doi:10.4065/mcp.2011.0206
Drexler, A. R., Mur, E. J., & Guenther, V. C. (2001). Efficacy of an EMG-biofeedback therapy in
fibromyalgia patients. A comparative study of patients with and without abnormality in (MMPI)
psychological scales. Clinical and Experimental Rheumatology, 20(5), 677–682.
Ferraccioli, G., Ghirelli, L., Scita, F., Nolli, M., Mozzani, M., Fontana, S., … De Risio, C. (1987). EMG-
biofeedback training in fibromyalgia syndrome. The Journal of Rheumatology, 14(4), 820-825.
Glombiewski, J. A., Bernardy, K., & Häuser, W. (2013). Efficacy of EMG-and EEG-biofeedback in
fibromyalgia syndrome: A meta-analysis and a systematic review of randomized controlled trials.
Evidence-Based Complementary and Alternative Medicine, 2013. doi:10.1155/2013/962741
Holdcraft, L. C., Assefi, N., & Buchwald, D. (2003). Complementary and alternative medicine in
fibromyalgia and related syndromes. Best Practice and Research Clinical Rheumatology, 17(4), 667–
683.
Kayiran, S., Dursun, E., Ermutlu, N., Dursun, N., & Karamürsel, S. (2007). Neurofeedback in
fibromyalgia syndrome. Agri: The journal of the Turkish Society of Algology, 19(3), 47–53.
Meeus, M., Goubert, D., De Backer, F., Struyf, F., Hermans, L., Coppieters, I., … Calders, P. (2013).
Heart rate variability in patients with fibromyalgia and patients with chronic fatigue syndrome: A
systematic review. In Seminars in Arthritis and Rheumatism, 43(2), 279–287.
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Mueller, H. H., Donaldson, C. C., Nelson, D. V., & Layman, M. (2001). Treatment of fibromyalgia
incorporating EEG‐driven stimulation: A clinical outcomes study. Journal of Clinical Psychology,
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Nelson, D. V., Bennett, R. M., Barkhuizen, A., Sexton, G. J., Jones, K. D., Esty, M. L., … Donaldson, C.
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van Santen, M., Bolwijn, P., Verstappen, F., Bakker, C., Hidding, A., Houben, H., … van der Linden, S.
(2002). A randomized clinical trial comparing fitness and biofeedback training versus basic treatment
in patients with fibromyalgia. The Journal of Rheumatology, 29(3), 575–581.
Wolfe, F., Clauw, D. J., Fitzcharles, M. A., Goldenberg, D. L., Katz, R. S., Mease, P., … Yunus, M. B.
(2010). The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and
measurement of symptom severity. Arthritis Care and Research, 62(5), 600–610.
doi:10.1002/acr.20140

Chapter 25 – Functional/Recurrent Abdominal Pain

Baber, K., Anderson, J., Puzanovova, M., & Walker, L. (2008). Rome II versus Rome III classification of
functional gastrointestinal disorders in pediatric chronic abdominal pain. Journal of Pediatric
Gastroenterology and Nutrition, 47(3), 299–302. doi:10.1097/mpg.0b013e31816c4372
Drossman, D. (2006). The functional gastrointestinal disorders and the Rome III process.
Gastroenterology, 130(5), 1377–1390.
Grover, M., & Drossman, D. (2010). Functional abdominal pain. Current Gastroenterology Reports,
12(5), 391–398. doi:10.1007/s11894-010-0125-0
Humphreys, P. A., & Gevirtz, R. N. (2000). Treatment of recurrent abdominal pain: Components analysis
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to the biopsychosocial model? Applied Psychophysiology and Biofeedback, 31(2), 155–165.
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Sowder, E., Gevirtz, R., Shapiro, W., & Ebert, C. (2010). Restoration of vagal tone: A possible
mechanism for functional abdominal pain. Applied Psychophysiology and Biofeedback, 35(3), 199–
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Sperber, A., & Drossman, D. (2010). Functional abdominal pain syndrome: Constant or frequently
recurring abdominal pain. American Journal of Gastroenterology, 105(4), 770–774.
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description of research participants. Journal of Developmental and Behavioral Pediatrics, 20(5),
307–313.

Chapter 26 – Hyperhidrosis
Duller, P., & Gentry, W. D. (1980). Use of biofeedback in treating chronic hyperhidrosis: A preliminary
report. British Journal of Dermatology, 103(2), 143.
Rickles, W. (1978). Treatment of a case of hyperhidrosis with vapor pressure feedback. Annual
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Singh, G., & Singh, G. (1993). Biofeedback assisted relaxation (BAR) in management of hyperhidrosis:
A preliminary study. Indian Journal of Dermatology, Venereology, and Leprology, 59(4), 187–189.

Chapter 27 – Hypertension
Chobanian, A., Bakris, G., Black, H., Cushman, W. C., Green, L. A., Izzo, J. L., Jr., … Roccella, E. J.
(2003). The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation,
and Treatment of High Blood Pressure: The JNC VII report. Journal of the American Medical
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(2013). AHA/ACC Guideline on Lifestyle Management to Reduce Cardiovascular Risk: A Report of
the American College of Cardiology/American Heart Association Task Force on Practice Guideines.
Circulation, 129(25 Suppl 2), S76-S99. doi:10.1161/01.cir.0000437740.48606.d1
Frank, D. L., Khorshid, L., Kiffer, J. F., Moravec, C. S., & McKee, M. G. (2010). Biofeedback in
medicine: Who, when, why and how? Mental Health in Family Medicine, 7, 85–91.
Henderson, R. J., Hart, M.G., Lal, S. K., & Hunyor, S. N. (1998). The effect of home training with direct
blood pressure biofeedback of hypertensives: A placebo-controlled study. Journal of Hypertension,
16(6), 771–778.
Lin, G., Xiang, Q., Fu, X., Wang, S., Chen, S., Shao, L., … Wang, T. (2012). Heart rate variability
biofeedback decreases blood pressure in prehypertensive subjects by improving autonomic function
and baroreflex. Journal of Alternative and Complementary Medicine, 18(2), 143–152.
doi:10.1089/acm.2010.0607
Linden, W., & McGrady, A. (2016). Biobehavioral treatment of essential hypertension. In M. Schwartz &
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Linden, W., & Moseley, J. (2006). The efficacy of behavioral treatments for hypertension. Applied
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McCraty, R., Atkinson, M., & Tomasino, D. (2003). Impact of a workplace stress reduction program on
blood pressure and emotional health in hypertensive employees. Journal of Alternative and
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Nakao, M., Nomura, S., Shimosawa, T., Fujita, T., & Kuboki, T. (2000). Blood pressure biofeedback
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Nakao, M., Yano, E., Nomura, S., & Kuboki, T. (2003). Blood pressure-lowering effects of biofeedback
treatment in hypertension: A meta-analysis of randomized controlled trials. Hypertension Research,
26(1), 37–46.
Nolan, R., Floras, J., Harvey, P., Kamath, M., Picton, P., Chessex, C., … Chen, M. H. (2010). Behavioral
neurocardiac training in hypertension: A randomized, controlled trial. Hypertension, 55, 1033–1039.
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Overhaus, S., Ruddel, H., Curio, I., Mussgay, L., & Scholz, O. B. (2003). Biofeedback of baroreflex
sensitivity in patients with mild essential hypertension. International Journal of Behavioral Medicine,
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Reyes del Paso, G. A., Cea, J. I., Gonzalez-Pinto, A., Cabo, O. M., Caso, R., Brazal, J., … Gonzalez, M. I.
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Sharma, M., Frishman, W., & Gandhi, K. (2011). Resperate: Nonpharmacological treatment of
Hypertension. Cardiology in Review, 19(2), 47–51.
Tsai, P., Chang, N., Chang, W., Lee, P., & Wang, M. (2007). Blood pressure biofeedback exerts
intermediate-term effects on blood pressure and pressure reactivity in individuals with mild
hypertension: A randomized, controlled study. Journal of Alternative and Complementary Medicine,
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Wang, S., Li, M., Xu, X., Lin, G., Shao, L., Zhao, Y., & Wang, T. (2010). Effects of slow abdominal
breathing combined with biofeedback on blood pressure and heart rate variability in prehypertenson.
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Weaver, M. T., & McGrady, A. (1995). A provisional model to predict blood pressure response to
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Yucha, C. B. (2002). Problems inherent in assessing biofeedback efficacy studies. Applied
Psychophysiology and Biofeedback, 27(1), 99–106, 113–114.
Yucha, C. B., Clark, L., Smith, M., Uris, P., Lafleur, B., & Duval, S. (2001). The effect of biofeedback in
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Xu, X., Gao, J., Ling, D., & Wang, T. (2007). Biofeedback treatment of prehypertension: Analyses of
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Chapter 28 – Immune Function

Birk, T. J., McGrady, A., MacArthur, R. D., & Khuder, S. (2000). The effects of massage therapy alone
and in combination with other complementary therapies on immune system measures and quality of
life in human immunodeficiency virus. Journal of Alternative and Complementary Medicine, 6(5),
405–414.
Coen, B. L., Conran, P. B., McGrady, A., & Nelson, L. (1996). Effects of biofeedback-assisted relaxation
on asthma severity and immune function. Pediatric Asthma, Allergy and Immunology, 10(2), 71–78.
Kern-Buell, C. L., McGrady, A. V., Conran, P. B., & Nelson, L. A. (2000). Asthma severity,
psychophysiological indicators of arousal, and immune function in asthma patients undergoing
biofeedback-assisted relaxation. Applied Psychophysiology and Biofeedback, 25(2), 79–91.
Lehrer, P., Karavidas, M. K., Lu, S. E., Coyle, S. M., Oikawa, L. O., Macor, … Lowry, S. F. (2010).
Voluntarily produced increases in heart rate variability modulate autonomic effects of endotoxin
induced systemic inflammation: An exploratory study. Applied Psychophysiology and Biofeedback,
35(4), 303–315. doi:10.1007/s10484-010-9139-5
McGrady, A., Conran, P., Dickey, D., Garman, D., Farris, E., Schumann-Brezinski, C. (1992). The effects
of biofeedback-assisted relaxation on cell-mediated immunity, cortisol, and white blood cell count in
healthy adult subjects. Journal of Behavioral Medicine, 15(4), 343–354.

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Chapter 29 – Insomnia
Bootzin, R. R., & Rider, S.P. 1997. Behavioral techniques and biofeedback for insomnia. In Pressman, M.
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Cortoos, A., Verstraeten, E., & Cluydts, R. (2006). Neurophysiological aspects of primary insomnia:
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Cortoos, A., De Valck, E., Arns, M., Breteler, M. H., & Cluydts, R. (2010). An exploratory study on the
effects of tele-neurofeedback and tele-biofeedback on objective and subjective sleep in patients with
primary insomnia. Applied Psychophysiology and Biofeedback, 35(2), 125–134. doi:10.1007/s10484-
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Freedman, R., & Papsdorf, J. D. (1976). Biofeedback and progressive relaxation treatment of sleep-onset
insomnia. Biofeedback and Self-Regulation, 1(3), 253–271.
Hammer, B. U., Colbert, A. P., Brown, K. A., & Ilioi, E. C. (2011). Neurofeedback for insomnia: A pilot
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Chapter 30 – Irritable Bowel Syndrome

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Chapter 31 – Motion Sickness

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Chapter 32 – Performance Enhancement

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Voliantis, S., McConnell, A. K., Koutedakis, Y., McNaughton, L., Backx, K., & Jones, D. A. (2001).
Inspiratory muscle training improves rowing performance. Medicine and Science in Sports and
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Wahab, N., & Sinandurai, S. K. (2012). Using biofeedback in achieving peak performance for students:
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Wells, G. D., Plyley, M., Thomas, S., Goodman, L., & Duffin, J. (2005). Effects of concurrent inspiratory
and expiratory muscle training on respiratory and exercise performance in competitive swimmers.
European Journal of Applied Physiology, 94, 527–540.
Williams, J. S., Wongsathikun, J., Boon, S. M., & Acevedo, E. O. (2002). Inspiratory muscle training
fails to improve endurance capacity in athletes. Medicine and Science in Sports and Exercise, 34,
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Wilson, V. E., Pepper, E., & Moss, D. (2006) “The Mind Room” in Italian soccer training: The use of
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Zaichkowsky, L. D., & Fuchs, C. Z. (1988). Biofeedback applications in exercise and athletic
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Chapter 33 – Preeclampsia
Cullins, S. W., Gevirtz, R. N., Poeltler, D. M., Cousins, L. M., Edward Harpin, R., & Muench, F. (2013).
An exploratory analysis of the utility of adding cardiorespiratory biofeedback in the standard care of
pregnancy-induced hypertension. Applied Psychophysiology and Biofeedback, 38(3), 161–170.
El-Kosery, S. M. A., Abd-El Raoof, N. A., & Farouk, A. (2005). Effects of biofeedback-assisted
relaxation on preeclampsia. Bull Fac Ph Th Cairo Univ, 10(2), 291–300.
El-Kosery, S. M. A., Saleh, A., & Farouk, A. (2005) Biofeedback-assisted relaxation and incidence of
hypertension during pregnancy. Bull Fac Ph Th Cairo Univ, 10(1), 221–230.
Little, B. C., Hayworth, J., Benson, P., Hall, F., Beard, R. W., Dewhurst, J., & Priest, R. G. (1984).
Treatment of hypertension in pregnancy by relaxation and biofeedback. The Lancet, 323(8382), 865–
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MacKay, A. P., Berg, C. J., & Atrash, H. K. (2001). Pregnancy-related mortality from preeclampsia and
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Somers, P. J, Gevirtz, R. N., Jasin, S. E., & Chin, H. G. (1989). The efficacy of biobehavioral and
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Walling, A. D. (2004). Management of gestational hypertension-preeclampsia. American Family
Physician, 69(4), 979–980.

Chapter 34 – Posttraumatic Stress Disorder

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Chapter 35 – Raynaud’s Disease

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Chapter 36 – Repetitive Strain Injury (RSI)

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Chapter 37 – Stroke
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Jørgensen, H., Nakayama, H., Raaschou, H. O., & Olsen, T. S. (1995). Recovery of walking function in
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Chapter 38 – Temporomandibular Muscle and Joint Disorder (TMJD) Pain

Aggarwal, V. R., Lovell, K., Peters, S., Javidi, H., Joughin, A., & Goldthorpe, J. (2011). Psychosocial
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Gardea, M. A., Gatchel, R. J., & Mishra, K. D. (2001). Long-term efficacy of biobehavioral treatment of
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Medlicott, M. S., & Harris, S. R. (2006). A systematic review of the effectiveness of exercise, manual
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Stowell, A. W., Gatchel, R. J., & Wildenstein, L. (2008). Cost-effectiveness of treatments for
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Turk, D. C., Zaki, H. S., & Rudy, T. E. (1993). Effects of intraoral appliance and biofeedback/stress
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Chapter 39 – Tinnitus
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Chapter 40 – Traumatic Brain Injury (TBI) and Post Traumatic Stress

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biofeedback. Neurorehabilitation, 17(1), 69–80.
Thornton, K., & Carmody, D. (2013). The relation between memory improvement and QEEG changes in
three clinical groups as a result of EEG biofeedback treatment. Journal of Neurotherapy, 17(2), 116–
131. doi:10.1080/10874208.2013.785183
Tinius, T. P., & Tinius, K. A. (2000). Changes after EEG biofeedback and cognitive retraining in adults
with mild traumatic brain injury and attention deficit hyperactivity disorder. Journal of Neurotherapy,
4(2), 27–44.
Walker, J. E., Norman, C. A., & Weber, R. K. (2002). Impact of qEEG-guided coherence training for
patients with a mild closed head injury. Journal of Neurotherapy, 6(2), 31–43.
doi:10.1300/J184v06n02_05
Wing, K. (2001). Effect of neurofeedback on motor recovery of a patient with brain injury: A case study
and its implications for stroke rehabilitation. Topics in Stroke Rehabilitation, 8(3) 45–53.
Zorcec, T., Demerdzieva, A., & Pop-Jordanova, N. (2011). QEEG, brain rate, executive functions and
neurofeedback training in patients with traumatic brain injury. Acta Informatica Medica, 9, 23–28.
Zelek, V. (2002). QEEG brainwave amplitude and coherence values as predictors of cognitive
improvement to neurofeedback after moderate-to-severe acquired brain injury. Journal of Head
Trauma and Rehabilitation, 23(5), 343. doi:10.1097/01.HTR.0000336856.67692.17

Chapter 41 – Urinary Incontinence in Children

Bo, K., Berghmans, B., Morkved, S., & Van Kampen, M. (Eds.). (2015). Evidence based physical therapy
for the pelvic floor (2nd ed.), Edinburgh, UK: Elsevier Ltd.
Desantis, D. J., Leonard, M. P., Preston, M. A., Barrowman, N. J, & Guerra, L. A. (2011). Effectiveness
of biofeedback for dysfunctional elimination syndrome in pediatrics: A systematic review. J Pediatr
Urol, 7(3), 342–348. doi:10.1016/j.jpurol.2011.02.019
Kajbafzadeh, A. M., Sharifi-Rad, L., Ghahestani, S. M., Ahmadi, H., Kajbafzadeh, M., & Mahboubi, A.
H. (2011). Animated biofeedback: An ideal treatment for children with dysfunctional elimination
syndrome. J Urol, 186(6), 2379–2384. doi:10.1016/j.juro.2011.07.118

176
 References

Kaye, J. D., & Palmer, L. S. (2008). Animated biofeedback yields more rapid results than nonanimated
biofeedback in the treatment of dysfunctional voiding in girls. J Urol, 180(1), 300–305.
doi:10.1016/j.juro.2008.03.078
Kibar, Y., Ors, O., Demir, E., Kalman, S., Sakallioglu, O., & Dayanc, M. (2007). Results of biofeedback
treatment on reflux resolution rates in children with dysfunctional voiding and vesicoureteral reflux.
Urology, 70(3), 563–566.
Palmer, L. S. (2010). Biofeedback in the management of urinary incontinence in children. Curr Urol Rep,
11(12), 122–127. doi:10.1007/s11934-010-0099-3
Van Gool, J. D., & de Jonge, G. A. (1989). Urge syndrome and urge incontinence. Arch Dis Child, 64,
1629–1634.
Vasconcelos, M., Lima, E., Caiafa, L., Noronha, A., Cangussu, R., Gomes, S., … Magnus, G. (2006).
Voiding dysfunction in children. Pelvic –floor exercises or biofeedback therapy: a randomized study.
Pediatr Nephrol, 21(12), 1858–1864.
Yagci, S., Kibar, Y., Akay, O., Kilic, S., Erdemir, F., Gok, F., & Dayanc, M. (2005). The effect of
biofeedback treatment on voiding and urodynamic parameters in children with voiding dysfunction. J
Urol, 174(5), 1994–1997.

Chapter 42 – Urinary Incontinence in Men

Anderson, C. A., Omar, M. I., Campbell, S. E., Hunter, K. F., Cody, J. D., & Glazener, C. M. A. (2015).
Conservative management for postprostatectomy urinary incontinence. Cochrane Database of
Systematic Reviews, 2015(1). doi:10.1002/14651858.CD001843.pub5
Bo, K., Berghmans, B., Morkved, S., & Van Kampen, M. (Eds.). (2015). Evidence-based physical
therapy for the pelvic floor. Edinburgh, UK: Elsevier Ltd.
Burgio, K. L., Goode, P. S., Urban, D. A., Umlauf, M. G., Locher, J. L., Bueschen, A., & Redden, D. T.
(2006). Preoperative biofeedback assisted behavioral training to decrease post-prostatectomy
incontinence: A randomized, controlled trial. J Urol, 175(1), 196–201.
Florates, D. L., Sonke, G. S., Rapidou, C. A., Alivizatos, G. J., Deliveliotis, C., Constantinides, C. A., &
Theodorou, C. (2002). Biofeedback vs verbal feedback as learning tools for pelvic muscle exercises
in the early management of urinary incontinence after radical prostatectomy, BJU Int, 89(7), 714–
719.
Goode, P. S., Burgio, K. L., Johnson, T. M., Clay, O. J., Roth, D. L., Markland, A. D., … Lloyd, L. K.
(2011). Behavioral therapy with or without biofeedback and pelvic floor electrical stimulation for
persistent postprostatectomy incontinence: A randomized controlled trial. JAMA, 305(2), 151–159.
doi:10.1001/jama.2010.1972
Marchiori, D., Bertaccini, A., Manferrari, F., Ferri, C., & Martorana, G. (2010). Pelvic floor rehabilitation
for continence recovery after radical prostatectomy: Role of a personal training re-educational
program. Anticancer Res, 30(2), 553–556.
Mariotti, G., Sciarra, A., Gentilucci, A., Salciccia, S., Alfarone, A., Di Pierro, G., & Gentile, V. (2009).
Early recovery of urinary continence after radical prostatectomy using early pelvic floor electrical
stimulation and biofeedback associated treatment. J Urol, 181(4), 1788–1793.
doi:10.1016/j.juro.2008.11.104
Mathewson-Chapman, M. (1997). Pelvic floor exercise/biofeedback for urinary incontinence after
prostatectomy: An education program. J Cancer Educ, 12(4), 218–223.
Ribeiro, L. H., Prota, C., Gomes, C. M., de Bessa, J., Jr., Boldarine, M. P., Dall'Oglio, M. F., Bruschini,
H., & Srougi, M. (2010). Long-term effect of early postoperative pelvic floor biofeedback on
continence in men undergoing radical prostatectomy: A prospective, randomized, controlled trial. J
Urol, 184(3), 1034–1039. doi:10.1016/j.juro.2010.05.040
Robinson, J. P., Bradway, C. W., Nuamah, I., Pickett, M., & McCorkle, R. (2008). Systematic pelvic
floor training for the lower urinary tract symptoms post–prostatectomy: A randomized clinical trial.
Int J Urol Nurs, 2(1), 3–13. doi:10.1111/j.1749-771X.2007.00033

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 Evidence-Based Practice in Biofeedback and Neurofeedback

Wille, S., Sobottka, A., Heidenreich, A., & Hofmann, R. (2003). Pelvic floor exercises, electrical
stimulation and biofeedback after radical prostatectomy: Results of a prospective trial. J Urol, 170(2
Pt 1), 490-493.

Chapter 43 – Urinary Incontinence in Women

Berghmans, L. C., Frederiks, C. M., de Bie, R. A., Weil, E. H., Smeets, L. W., van Waalwijk van Doorn,
E. S., & Janknegt, R. A. (1996). Efficacy of biofeedback, when included with pelvic floor muscle
exercise treatment, for genuine stress incontinence. Neurourology and Urodynamics, 15(1), 37–52.
Burgio, K. L., Goode, P. S., Locher, J. L., Umlauf, M. G., Roth, D. L., Richter, H. E., … Lloyd, L. K.
(2002). Behavioral training with and without biofeedback in the treatment of urge incontinence in
older women: A randomized control trial. JAMA, 288(18), 2293–2299.
Burgio, K. L., Goode, P. S., Locher, J. L., Umlauf, M. B., Varner, R. E., Lloyd, L. K., … Wright, K. C.
(2001). The role of biofeedback in the treatment of urge incontinence in older women. Proceedings of
the American Urogynecological Society, 22nd Annual Meeting, Oct 25–27, Chicago, IL.
Burns, P. A., Pranikoff, K., Nochajski, T. H., Hadley, E. C., Levy, K. J., & Ory, M. G. (1993). A
comparison of effectiveness of biofeedback and pelvic muscle exercise treatment of stress
incontinence in older community-dwelling women. Journal of Gerontology, 48(4), M167–M174.
Herderschee, R., Hay-Smith, E. J. C., Herbison, G. P., Roovers, J. P., & Heineman, M. J. (2011).
Feedback or biofeedback to augment pelvic floor muscle training for urinary incontinence in women.
A Cochrane Review from The Cochrane Library, 2011(7). doi:10.1002/14651858.CD009252
Haylen, B. T., de Ridder, D., Freeman, R. M., Swift, S. E., Berghmans, B., Lee, J., Monga, A., Petri, E.,
Rizk, D. E., Sand, P. K., Schaer, G. N., & Urogynecological Association; International Continence
Society (2010). An International Urogynecological Association (IUGA)/International Continence
Society (ICS) joint report on the terminology for female pelvic floor dysfunction. Neurourol Urodyn,
29(1), 4–20. doi:10.1002/nau.20798
Kinchen, K. S., Long, S., Orsini, L., Crown, W., & Swindle, R. (2003). A retrospective claims analysis of
the direct costs of stress urinary incontinence. Int Urogynecol J Pelvic Floor Dysfunct, 14(6), 403–
411.
Laycock, J., Brown, J., Cusack, C., Green, S., Jerwood, D., Mann, K., … Schofield, A. (2001), Pelvic
floor reeducation for stress incontinence: Comparing three methods. British Journal of Community
Nursing, 6(5), 230–237.
McClurg, D., Ashe, R. G., Marshall, K., & Lowe-Strong, A. S. (2006). Comparison of pelvic floor muscle
training, electromyography biofeedback, and neuromuscular electrical stimulation for bladder
dysfunction in people with multiple sclerosis: A randomized pilot study. Neurourology and
Urodynamics, 25(4), 337–348.
MØrkved, S., BØ, K., & FjØrtoft, T. (2002). Effect of adding biofeedback to pelvic floor muscle training
to treat urodynamic stress incontinence. Obstetrics and Gynecology, 100(4), 730–739.
Schmidt, A. P., Sanches, P. R., Silva, D. P., Jr., Ramos, J. G., & Nohama, P. (2009). A new pelvic muscle
trainer for the treatment of urinary incontinence. International Journal of Gynaecology and
Obstetrics, 105(3), 218–222. doi:10.1016/j.ijgo.2009.01.013
Shepherd, A., Montgomery, E., & Anderson, R. S. (1983). A pilot study of pelvic exerciser in women
with stress urinary incontinence. Journal of Obstetrics and Gynaecology, 3(3) 201–202.
Sherman, R. A., Davis, G. D., & Wong M. F. (1997). Behavioral treatment of exercise–induced urinary
incontinence among female soldiers. Military Medicine, 162(10), 690–694.
Smidt, N., te Giffel, M.A., Gerards-Last, T.M., & de Vet, H.C. (1997). Effectiveness of myofeedback for
women with stress incontinence. Nederlands Tijdscrift Fysiotherapie, 107(5), 121–127.
Wallace, S. A., Roe, B., Williams, K., & Palmer, M. (2004). Bladder training for urinary incontinence in
adults. Cochrane Database of Systematic Reviews, 2004(1), CD001308.
Wang A.C., Wang, Y. Y., & Chen, M. C. (2004). Single-blind, randomized trial of pelvic floor muscle
training, biofeedback-assisted pelvic floor muscle training, and electrical stimulation in the
management of overactive bladder. Urology, 63(1), 61–66.

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 References

Wyman, J. F., Fantl, J. A., McClish, D. K., & Bump, R. C. (1998). Comparative efficacy of behavioral
interventions in the management of female urinary incontinence. Continence Program for Women
Research Group. Am J Obstet Gynecol, 179(4), 999–1007.

Chapter 44 – Vasovagal Syncope

McGrady, A. V., Kern-Buell, C., Bush, E., Devonshire, R., Claggett, A. L., & Grubb, B. P. (2003).
Biofeedback-assisted relaxation therapy in neurocardiogenic syncope: A pilot study. Applied
Psychophysiology and Biofeedback, 28(3), 183–192.
McGrady, A. V., Bush, E. G., & Grubb, B. P. (1997). Outcome of biofeedback-assisted relaxation for
neurocardiogenic syncope and headache: A clinical replication series. Applied Psychophysiology and
Biofeedback, 22(1), 63–72.
Parry, S. W., & Kenny, R. A. (1999). The management of vasovagal syndrome. QJM: An International
Journal of Medicine, 92(12), 697–705. doi:10.1093/qjmed/92.12.697
Rhoades, R., & Bell, D. R. (Eds.) (2013). Medical physiology: Principles for clinical medicine (4th ed.).
Baltimore, MD: Lippincott, Williams, & Wilkins.

179
 ISBN 978-0-9842979-6-2
Evidence-Based Practice in Biofeedback and Neurofeedback, Third Edition
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