An Overview

What biofeedback devices are and what they do: Biofeedback devices (including devices for sub-specialties such as neurofeedback (brainwave / EEG feedback), muscle tension feedback, etc. are actually a combination of highly sophisticated (a) physiological recording equipment and (b) audio and visual teaching display systems. It can be difficult to understand how to use the equipment appropriately to insure that valid recordings are made and optimal displays for learning are produced.

You need some skills in biofeedback techniques, physiology, and biofeedback instrumentation before you can use biofeedback equipment effectively let alone even begin to decide which equipment to purchase. You can learn these skills by taking our general biofeedback and or EEG biofeedback courses and then get some hands-on experience with the equipment and mentoring through your first few clients.

If you aren’t familiar will biofeedback, go HERE to get an idea of the variety of tasks biofeedback devices are used for.

Two important points –

• Biofeedback is learning: Biofeedback devices all record well recognized physiological signals such as muscle tension, heart rate, and brain waves. The information recorded is shown IN REAL TIME to the person being recorded and any coach / therapist who may be present so the person can learn to recognize the level at which the physiological system is functioning and its responses to stress, etc. The person being recorded can use this information to learn to control abnormal responses and reset abnormal levels of the physiological system. This is learning. Nothing goes from the device to the person which controls any physiological system.
• Biofeedback is a tool not a profession or treatment: Biofeedback is a learning tool which professionals such as coaches, teachers, and clinicians use in combination with other techniques to evaluate and treat clients. It is not a treatment on its own as it only provides information about how physiological systems are functioning. A professional needs to incorporate this information into an overall treatment. No amount of training in biofeedback techniques can provide the education needed to be a professional clinician or educator.

Regulation of Biofeedback Devices: Biofeedback devices are regulated by the US Government’s Food and Drug Administration (FDA). You should not use any biofeedback device not labeled as safe and effective by the FDA or, if you are outside the US, by your own government unless you are using it for approved research. Each device accepted by the FDA has a label which states what it has been shown to be effective for.

If you use the device off label, you must inform your clients in writing that you are doing so. For a fuller discussion of FDA issues including who can prescribe the use of biofeedback devices, please see the discussion at www.aapb.org.

Aligning your needs with a device – how to know what you need in a device: When you know enough about biofeedback recording and teaching techniques to know what you wish to accomplish and have an idea of the types of disorders you are interested in treating, it is time to begin making decisions about what kind of device you need. The major questions you need to answer in order to choose a device are covered below in the discussion entitled “How do I choose which biofeedback device to purchase?”

How do I choose which biofeedback device to purchase?

Some years ago, B.Robert Crago Ph.D. (Director of Neurobehavioral Health Services in Tucson, Arizona) developed an “equipment buying guide” which was posted on AAPB’s web site. When I wrote the current discussion for AAPB, I incorporated much of the material from that guide and appreciate its continued availability. For questions about the current material, please contact Dr. Rich Sherman at rsherman@nwinet.com

Choosing which biofeedback device is right for you is very difficult. It is not a decision to make quickly or based on the first device you happen to see and / or use.

One of the most expensive investments in starting to do biofeedback is the equipment. Getting a device up and working can be overwhelming. Figuring out what your practice needs and knowing you are getting just what you need can be overwhelming. You learn what hardware, software, and sensors you need during your basic coursework. Until you’ve had had appropriate training, you should wait.

While considering your equipment needs, if possible attend a conference where the most common biofeedback devices are being demonstrated in one place at one time. This gives you the golden opportunity to see them and try them for yourself. In spite of many similar descriptions, you will find they differ in ease of use, displays, sensors, hardware, software and cost. You will also get to meet the people who will be your most crucial resource – Tech Support. The AAPB and ISNR annual meetings have the widest display of biofeedback devices.

Here are the most important questions you need to answer before you buy a biofeedback device.

* Aligning types of interventions and clients to be seen with type of equipment:

The device you get needs to fit your needs. For example, if you are only going to perform pelvic floor biofeedback with women having urinary incontinence, you don’t need a multichannel system capable of recording EEG. You don’t need to pay for complex hardware or software capable of recording anything other than two channels SEMG. Another example would be if you only see clients with one major class of disorders – such as stress related breathing problems – and you only want to use a few biofeedback techniques – such as heart rate variability and respiration, then you only need a two channels and those channels only need to pick up heart rate and respiration. You don’t need to pay for software or hardware with other capabilities. However, you need to be certain that this is all you will do as two channels are not sufficient to perform a stress profile or do many other types of biofeedback.

* Number of channels of which signals needed for which interventions:

As I said above, there is no need to purchase a very expensive device capable of recording many more channels than you will ever use – as long as you are certain you won’t expand your use of biofeedback techniques and types of patients. In general, if quality of hardware and software is kept equal, the more channels, the greater the cost so you can easily build from a device costing less than a thousand dollars to one costing over ten thousand but get nothing immediately useful for your money.

Be absolutely certain that the device you choose can actually record the signals you want to see simultaneously at the same time. Many units can record the signals you want but not together. Thus, if you purchase sufficient sensors to record what you need to know, the device may only be able to display or record a few of them at once. This means you can’t do a stress profile or other activities requiring simultaneous views of changes in several signals.

* Allowing for expansion from current to future needs vs. saving money now:

The device needs to be right for your current needs but you also need to keep an eye out for future uses you may have for biofeedback or you may wind up with a device which can’t grow with you. This is the trade off I just discussed between a low enough price to get going contrasted with a more hefty investment which may save you needed to buy an entirely new system.

* Understanding which sensors are needed and the costs involved:

Sensors are the leads and signal transformers which connect to the client. Each is usually specialized for only a few types of signals. They can increase the cost of a device by many hundreds of dollars – perhaps thousands. You should have learned exactly which sensors you need for the tasks you want to accomplish during your basic training in biofeedback. So, only get the sensors you need and be sure that the device’s software can actually support the ones you want. For example, if you want to record respiration patterns from the chest and abdomen simultaneously for breathing assessments relative to stress, don’t get a device which has the software capability or hardware capability for recording and then displaying only one at a time. This is sadly common. The same goes for multiple channels of muscle tension. If you are working with musculoskeletal pain patients, you need to be able to see at least four channels of SEMG simultaneously – not two now and two latter. On the other hand, if all you are going to do is EEG biofeedback (neurofeedback), you don’t need to pay for lots of other types of sensors (other that a channel of SEMG) – regardless of what the “standard package” may be. So, know what you want to record and stick to your guns when you are making the purchase. You can always buy more sensors later as long as the hardware and software support them.

If you purchase sensors from a company other than the manufacturer, be sure that your device’s software is compatible with the sensors as well as the hardware. If you purchase a device which records a signal not supported by your biofeedback device (capnometers for picking up nasal CO2 are frequently in this position) be sure that your device’s software or computer software can actually display the signal along with the other signals you want to view simultaneously. Be sure to either see it working or get the capability in writing!

* Accessory equipment and supplies:

There are many seemingly small items which are needed for biofeedback including disposable pre-jelled SEMG sensor pads, breathable tape used to attach temperature leads, conductive jell for reducing impedance, and adhesive removal pads. Most of these can be purchased from sources ranging from independent dealers to the corner drug store. So, know what you want and don’t overpay for it. However, remember that you frequently get what you pay for so don’t trade quality for cost savings. High quality pre-jelled SEMG sensors may cost a dollar for three sensors but you will get a consistently high quality signal for the duration of a long ambulatory recording.

* Do you need a special computer to run the device?:

Most modern biofeedback devices will run on any modern windows laptop or desk top. The need for anything fancy such as a second screen so you can see something without the patient seeing it is really problematic. In any case, most modern windows systems can handle two screens. The manufacturers of virtually every quality biofeedback device which needs a computer for some aspect of its functioning provide the exact computer specifications needed to run the device. Some device manufacturers try to sell you a special computer to go with their device. Before you purchase a computer from a manufacturer, be sure you understand exactly why you need to purchase theirs. If their software can’t be easily installed in a modern laptop or their hardware needs something special inside to run the biofeedback device, be sure you know just what you are getting into as far as extra costs and repair support.

* Actual recording and feedback capabilities vs. your need for signal quality (Can the device actually record the portion of the signal you are interested in at the resolution you need):

There is a very real tradeoff between cost of components and the quality of the signal you can record. If you are a typical clinician and all you need is to be able to record a high enough quality signal to reliably detect changes in amplitude and frequency (e.g. changes in beat to beat heart rate, changes in finger tip temperature, SEMG amplitude, EEG frequencies) then you can use virtually any biofeedback device you see at an AAPB meeting or which meets the specifications shown on the web sites of the major biofeedback device manufacturers. If you are giving typical fingertip temperature biofeedback for control of migraines (etc.), there is no need to record thousands of samples of fingertip temperature per second when the useable change you are interested in comes at a rate of a few per second. Similarly, you don’t need to pay for a device which can show you more of each raw wave then you need. However, you do need to see enough of the raw signal – especially for SEMG and EEG to know if the signals are contaminated by noise. You should have learned how much resolution you need for your uses as part of your basic biofeedback training.

* Device portability vs. durability and use in non-clinic situations.

Most people use biofeedback devices in their offices and clinics then occasionally need to take the device to a different clinic or work situation. Thus, nearly all current biofeedback devices can run on modern laptops and most practitioners use their devices with laptops rather than desktops at least part of the time. Any modern laptop can run typical biofeedback programs just as well as a typical desktop. Thus, biofeedback devices can be used anywhere a laptop can. However, many of the sensors are relatively fragile and don’t do well when recording rapidly moving subjects such as runners. If you are going to use your device for active sports applications, be very concerned about how signals are transmitted from the subject to the laptop and biofeedback device. Be concerned about how sturdy the sensors are and how resistant to movement artifact the entire system is. In this case, you may need a system which transmits from the sensor to the biofeedback device and then from the biofeedback device to the computer by a non-wired telemetry system. Be sure you know how much the sensors will cost to replace when they break (stepped on, etc.) and just what the warrantee covers.

* Different people are more comfortable with different software:

I can not overemphasize the nightmare that many first time users experience the first time they sit down with a new machine and try to use it. Different people find different software packages easier to use, more intuitive for them, etc. It is really important to get some practice actually using the software for each device you are considering without a sales person working it for you. Some devices need considerable learning to be able to use while others are obvious from the second you turn them on. However, there may be a significant trade off between ease of use and flexibility. Many practitioners want to be able to alter the feedback screens so the views are just the combination they want for assessment and teaching. Some systems don’t have this capability and some have it but require a training class to take advantage of it. Many feedback displays actually make no sense scientifically or to any typical patient. There may be too much information or it is based on some unverified idea. Some of the stand alone devices don’t have the flexibility to permit you to provide feedback displays you may feel to be suitable. Many devices have software with capabilities vanishingly few people will ever use or can learn to use in a reasonable amount of time so make absolutely certain that those elements of the software you need to control the displays you want are useable for you. Audio feedback has become especially difficult to use in some devices. If you can’t find and easily control the controls for the threshold line, sweep speed, offset, bandwidth (especially), and gain while a session is in progress, be very hesitant about purchasing the device.

* The need to get training for each device and training availability without having to go someplace to take a course in using the device:

Biofeedback devices can be harrowing to learn to use properly. You need to commit to taking the time to read the manual and run the tutorials so you do your best to understand how they work. However, most people have great difficulty learning to use a new electronic gizmo such as a microwave or TV by reading the manual. The average person probably muddles through enough of the instructions to get the thing to (at least apparently) do the minimum needed and hopes for the best that it keeps doing it. This is very akin to casting a spell. This technique is neither effective nor appropriate for biofeedback devices. You need to know what the device is actually doing and be able to get it to do just what you need it to. True, most of the major multichannel systems have capabilities that vanishingly few people will ever use but you need to be able to find and understand those you do want. So, how are you going to learn? Is there a really good tutorial with “live” examples built into the software? Is there a free class on the web? Do you have to go halfway across the world to learn to turn it on? Is there adequate technical support when you need it to answer questions you really can’t answer from reading the on-line manual? The bottom line is, don’t buy it if you aren’t going to be able to use it because there is no reasonable way to learn how.

* Timely availability of professional technical support:

What happens when you have read the manual and done the tutorials – perhaps even taken a class – and your device still won’t do something it is advertised to be able to do which you need it to do NOW?? You gave it a reasonable effort but you just can get it to work. Is it broken? Is there something you are simply overlooking in the software? Are you making a dumb mistake which you will be very embarrassed about later (my most common problem)? This is where excellent technical support is crucial. You need to know and have in writing exactly what support you can expect. You need to be able to reach a knowledgeable technician (in the best sense of the word) within an hour or so during normal business times and days. If you can’t get effective (not the same as nice) help very quickly, you are in trouble and could experience many of the stress related symptoms the devices are supposed to help you treat. Don’t accept the vendor’s word that tech support is available. You need specifics and the vendor needs to know that they get to give you a full refund if knowledgeable, understandable tech support is not appropriately available. Remember that this only goes if you have done your part in trying to learn about the device. Tech support isn’t there to teach you the basics.

* Rapid turnaround for warrantee service and repairs:

Biofeedback devices do break. Occasionally sensors or an entire device arrives broken. You should have learned how to check whether a device is recording properly during your basic biofeedback course. If it doesn’t work, you are stuck with (hopefully) a lot of clients who can’t be seen until the device is repaired. You need to know what the warrantee actually covers – especially including turnaround time, availability of loaners (and cost of the loaner), shipping costs, etc. Same for what happens if the device breaks when it is out of warrantee. I know several people who have waited months for a broken device to be repaired.

If the device you are considering purchasing is not labeled by the FDA as being safe and effective, you have no idea whether it is actually safe to use. You certainly don’t know if it can do what it claims to. If you are using the device for anything other than research approved by a federally approved research committee, you must be very hesitant about using any device not labeled by the FDA. Most biofeedback devices now have an FDA label for some use. However, Very few biofeedback devices are labeled by the FDA as being effective for every disorder you may want to use them for. Do not take the word of the vendor about what the device is labeled for or even if it has FDA approval. If you aren’t shown the label, you should strongly consider walking away.

Slideshows with text only (without audio) (smaller file size):

Text 1. Why do you need an anatomy and physiology course?

Text 2. Why do you need a basic and then an advanced biofeedback course?

Text 3. Why do you need to know the principles of research and the placebo efect?

Text 4. Why do you need to know the details of how biofeedback devices work?