Biofeedback and Neurofeedback Are Complementary
Learning self-regulation through technology is the aim of both biofeedback and neurofeedback that affect peripheral and central nervous systems, and muscle activity. Changing voluntary and involuntary functions, and their interactions, in the service of health and performance are the aims of these self-regulation methods. Tosti and her Italian and Brazilian colleagues (2024) reviewed studies using biofeedback (BFB) and neurofeedback (NFB) together to address nicotine addiction, sports performance, attention deficit hyperactivity disorder (ADHD), and autism spectrum disorder (ASD).
Although the number of studies and participants did not allow a systematic review or meta-analysis, they showed where BFB/NFB integration shows promise, whether BFB and NFB are conducted concurrently or in sequence. Their premise was that since the physiology underlying movement, thinking, and emotion are intimately intertwined, integrated BFB/NFB training should have a synergistic effect. Integrated training promotes personalized health care and performance enhancement.
Applications in Addiction Recovery
Consider the case of nicotine addiction, where both brain reward circuitry and visceral stress responses play crucial roles in maintaining dependency and triggering relapse. Relapse following cessation is usually associated with emotional distress with their visceral components. NFB effectively changes the former, and BFB the latter. A 2023 study by Pandria and colleagues illustrated BFB/NFB integration, which significantly reduced oxidative stress, improved executive function, and enhanced brain network performance. This multi-system approach addressed the complex physiological reality of addiction more completely.
Enhancing Athletic Performance Through Dual Training
The applications in sports performance further illustrate this principle. While experimental studies examining integrated approaches remain limited, the work with Canadian Olympic athletes before the 2010 Vancouver games suggests that combined training contributed to their exceptional performance. Dupee and colleagues (2016) provided BFB+ NFB to Canadian Olympic athletes who performed unusually strongly at the 2010 Vancouver Games. Shokri and Nosratabadi (2021) compared BFB/NFB to BFB alone in novice basketball players. The integrated approach resulted in significant improvement in more skill areas. This makes intuitive sense—athletic excellence requires both mental focus and physical control, which these complementary approaches target in concert.
A Comprehensive Approach to ADHD
The integrated approach acknowledges the condition's heterogeneity and complex physiological presentation when applied to attention deficit hyperactivity disorder. Children with ADHD typically display abnormalities in both brain wave patterns and autonomic regulation. Thompson and Thompson's framework incorporates neurofeedback, heart rate variability training, and concepts from polyvagal theory to address these multiple dimensions simultaneously.
The authors noted the importance of determining individual frequency bands before NFB. For example, whether a subject’s alpha band is lower than the usual 8-10 Hz. Because excessive frontal surface EMG (SEMG) activity may impede NFB training, BFB to regulate muscle activity may enhance NFB outcome.
Bakhshayesh et al. (2011) found theta/beta NFB and frontal SEMG BFB produced similar positive outcomes with ADHD children, suggesting that integrated BFB/NFB might prove more effective.
Personalization and sequential integration are important in treating ADHD. Bazanova et al. (2018) contrasted standard theta/beta NFB, NFB with individually tailored frequency bands, individually tailored NFB plus EMG BFB, and sham NFB with ADHD children. Individualized NFB led to better effects than standard NFB, and adding BFB led to better maintenance of improvement. Standard and sham NFB showed weaker outcomes. This suggests that generic, one-size-fits-all protocols may miss the mark for many individuals, whose physiological baseline patterns vary considerably.
Addressing the Complexity of Autism Spectrum Disorder
The research on autism spectrum disorder further reinforces the value of integrated approaches. Given the complex neurophysiological presentation of autism, including potential polyvagal system dysfunction that may underlie social avoidance behaviors, addressing multiple systems makes theoretical sense. Goodman et al. (2018) compared HRV BFB (12 hours) with HRV (6 hours) plus mu rhythm NFB (6 hours). Both groups showed positive changes but in different measures (HRV: emotional regulation and social behavior; HRB+NFB: emotional negativity/lability and autistic symptoms). This pattern suggests that different physiological training targets may address different aspects of the condition, highlighting the potential value of comprehensive approaches.
Toward a More Nuanced Understanding of Self-Regulation
What emerges from this body of research is a more nuanced understanding of physiological self-regulation. Our central and peripheral systems influence each other bidirectionally, standard protocols may be less effective than individually tailored approaches, and different physiological systems may affect different aspects of functioning. In some cases, peripheral regulation, such as muscle relaxation, may even be needed for effective central nervous system training.
Future Directions and Personalized Interventions
While Tosti and colleagues acknowledged that the current research remains too limited for systematic review or meta-analysis, these preliminary findings show the potential of integrated approaches to create more holistic, personalized, and effective interventions. By recognizing and working with the interconnected nature of our physiological systems, practitioners may develop more comprehensive approaches to complex conditions that manifest across multiple dimensions of human functioning.
This research represents an encouraging step toward more personalized health care and performance enhancement that considers how human physiological systems interact in concert rather than isolation. As we develop a deeper understanding of these interactions, we may discover even more effective ways to support individuals in gaining greater conscious control over their own physiology, serving both health and performance goals.
Key Takeaways
Integrating biofeedback and neurofeedback creates synergistic effects by simultaneously addressing both central and peripheral nervous systems, potentially yielding more comprehensive improvements than either approach alone.
Personalized protocols significantly outperform standardized approaches, emphasizing the importance of tailoring interventions to individual physiological patterns rather than using generic protocols.
Different physiological systems influence different aspects of functioning, suggesting that targeting multiple systems may be necessary to address complex conditions like autism and ADHD fully.
Sequential integration enhances effectiveness, with peripheral regulation (muscle relaxation) sometimes serving as a necessary prerequisite for successful central nervous system training.
While preliminary evidence across addiction, sports, ADHD, and autism shows promise, more rigorous research is needed before definitive conclusions about integrated approaches can be drawn.
Glossary
addiction: a chronic condition involving compulsive substance use or behavior despite adverse consequences, often associated with neurobiological and physiological changes.
ADHD (attention deficit hyperactivity disorder): a neurodevelopmental disorder characterized by inattention, impulsivity, and hyperactivity, often linked to atypical brain wave patterns and autonomic dysregulation.
athletic performance: the execution of physical and mental skills in sports, influenced by factors such as focus, coordination, and physiological regulation.
autism spectrum disorder (ASD): a neurodevelopmental condition characterized by challenges in social interaction, communication, and repetitive behaviors, often associated with atypical sensory and autonomic regulation.
biofeedback: a technique that enables individuals to gain voluntary control over physiological processes such as heart rate, muscle tension, and respiratory rate by using real-time monitoring and feedback.
brain network functioning: the coordinated activity of interconnected neural regions that support cognitive, emotional, and behavioral processes.
central nervous system (CNS): the part of the nervous system consisting of the brain and spinal cord, responsible for processing and transmitting information.
cognitive performance: the ability to execute mental processes such as attention, memory, problem-solving, and reasoning.
heart rate variability (HRV): a measure of the variation in time intervals between heartbeats, often used as an indicator of autonomic nervous system balance and stress regulation.
mu rhythm: a type of brain wave associated with sensorimotor processing, which is often studied in the context of neurofeedback and autism spectrum disorder.
neurofeedback: a biofeedback technique that enables individuals to regulate brain activity by receiving real-time feedback on neural oscillations.
oxidative stress: a physiological condition characterized by an imbalance between free radicals and antioxidants, often linked to cellular damage and various diseases.
peripheral nervous system (PNS): the part of the nervous system outside the brain and spinal cord that controls bodily functions and transmits sensory and motor signals.
personalized intervention: a tailored therapeutic approach that accounts for an individual’s unique physiological and psychological characteristics.
physiological self-regulation: the process of consciously or unconsciously controlling bodily functions such as heart rate, breathing, and muscle tension.
polyvagal theory: a framework that describes the role of the autonomic nervous system, particularly the vagus nerve, in regulating emotional and social behaviors.
sequential integration: the process of structuring interventions in a specific order to maximize their effectiveness, often by addressing peripheral regulation before central nervous system training.
synergistic effects: the enhanced outcomes that arise when multiple interventions interact to produce a greater effect than the sum of their individual impacts.
visceral stress responses: physiological reactions to stress that involve autonomic and endocrine activity, such as changes in heart rate, respiration, and digestion.
References
Bakhshayesh, A. R., et al. (2011). Neurofeedback in ADHD: A single-blind randomized controlled trial. European Child and Adolescent Psychiatry, 20, 481–491. https://doi.org/10.1007/s00787-011-0208-y
Bazanova, O. M., et al. (2018). On the efficiency of individualized theta/beta ratio neurofeedback combined with forehead EMG training in ADHD children. Frontiers in Human Neuroscience. 12, 3. https://doi.org10.3389/fnhum.2018.00003
Dupee, M., et al. (2016). Perceived outcomes of a biofeedback and neurofeedback training intervention for optimal performance: Learning to enhance self-awareness and self-regulation with Olympic athletes. Sports Psychology, 30, 339-349. https://doi.org/10.1123/tsp.2016-0028
Goodman, M. S., et al. (2018). A neurovisceral approach to autism: targeting self-regulation and core symptoms using neurofeedback and biofeedback. NeuroRegulation, 5, 9–29. https://doi.org10.15540/nr.5.1.9
Pandria, N., et al. (2023). Does combined training of biofeedback and neurofeedback affect smoking status, behavior, and longitudinal plasticity? Frontiers in Behavioral Neuroscience, 17, 1096122. https://doi.org10.3389fnbeh.2023.1096122
Porges, S. W. (2003). The polyvagal theory: Phylogenetic contributions to social behavior. Physiology and Behavior, 79, 503–513. https://doi.org/10.1016/S0031-9384(03)00156-2
Shokri, A., & Nosratabadi, M. (2021). Comparison of biofeedback and combined interventions on athletic performance. Applied Psychophysiology and Biofeedback, 46, 227-234. https://doi.org/ 10.1007/s10484-020-09498-5
Thompson, L., and Thompson, M. (2023). Effective intervention for attention deficit/hyperactivity disorder using quantitative electroencephalography and neurofeedback. In D. R. Chartier, M. B. Dellinger, J. R. Evans, and H. K. Budzynski (Eds.). Introduction to quantitative EEG and neurofeedback (pp. 375-396). Academic Press.
Tosti, B., et al., (2024). Integrated use of biofeedback and neurofeedback techniques in treating pathological conditions and improving performance: A narrative review. Frontiers in Neuroscience, 18, 1358481. https://doi.org10.3389/fnins.2024.1358481
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