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Evidence-Based Practice Preview: Part 1

Updated: Jul 5, 2023

AAPB will release Evidence-Based Practice in Biofeedback and Neurofeedback (4th ed.) in late Summer 2023. This series highlights several of its findings to encourage you to purchase EBP4 and recommend it to your colleagues.

This installment covers Adult Headache, Alcohol and Drug Dependence, ADHD, Asthma, and Concussion.

EBP4 cover

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AAPB-ISNR Task Force

An Association for Applied Psychophysiology and Biofeedback (AAPB) and the International Society for Neuroregulation & Research (ISNR) Task Force established efficacy guidelines (LaVaque et al., 2002). Dr. Don Moss and Jay Gunkelman, as AAPB and ISNR Presidents, formed this Task Force to evaluate treatment efficacy scientifically.

Don Moss

Jay Gunkelman

The editorial team of Drs. Inna Khazan, Fred Shaffer, Don Moss, Randy Lyle, Saul Rosenthal, and Leslie Shivers produced EBP4.

Evidence-Based Practice Efficacy Criteria

EBP4 assigned efficacy ratings from Level 1 (not empirically supported) to Level 5 (efficacious and specific).

Task Force Criteria

Since efficacy evaluation depends on available peer-reviewed studies, ratings can improve across editions. For example, biofeedback and neurofeedback treatment for depression increased from level 4 (efficacious) to level 5 (efficacious and specific) in the fourth edition due to independent randomized controlled trials. Lower ratings do not preclude assigning higher levels in future editions.

Interpreting EBP4 Ratings

Most of the RCTs reviewed in EBP4 combined BFB or NFB with components like CBT, guided imagery, and relaxation training. When clinicians combine biofeedback with relaxation procedures, it is called Biofeedback-Assisted Relaxation Training (BART).

The EBP4 Review Process

The EBP4 editorial team invited experts who contributed to EBP3 and recruited new reviewers. For the first time, we asked reviewers to provide tables summarizing the study design and outcomes.

Two editors copyedited each review, followed by Leslie Shivers and Fred Shaffer. We required unanimous editor agreement when authors proposed raising efficacy ratings from the third edition. We based these decisions on the Task Force criteria and reviewed studies.

Adult Headache

level 4

Adult headache includes migraine and tension-type headaches.


A migraine with aura (classic migraine) features a prodrome or neurological symptoms that precede a breakthrough headache, hours to days before headache onset. Migraine with aura accounts for up to 31% of all migraine patients (Launer et al., 1999).

The headache is preceded (10-20 minutes) by painless neurological symptoms that are mainly visual (scintillating scotomata and visual field defects) and last from 20-60 minutes. Headache onset may occur at any time and lasts 4-72 hours (Martin & Elkind, 2005).

About 64% of all migraine patients experience migraine without aura, which is also called common migraine (Martin & Elkind, 2005; Launer et al., 1999).

Tension-type headache is characterized by a steady, nonthrobbing pain involving the frontotemporal vertex or occipito-cervical areas with a lateral or bilateral distribution. This headache has a duration of 30 minutes to 7 days.

Tension-type headache is divided into episodic and chronic headache. Episodic tension-type headache is diagnosed when the patient has at least 10 previous headaches, fewer than 15 days per month, and no evidence of a secondary headache disorder.

Chronic tension-type headache is diagnosed when there is an average headache frequency of more than 15 days per month for more than 6 months (Martin & Elkind, 2005).

Based on eight randomized controlled trials (RCTs), Tracy Brown and Patrick Steffen rated biofeedback for adult migraine and tension-type headaches as efficacious. The biofeedback modalities included EMG, HRV, neck pressure, TEMP, and vasoconstriction/vasodilation biofeedback. Biofeedback outcomes included reduced headache frequency and severity, medication, and performance loss.

Alcohol and Substance Use Disorder

level 3

In DSM-5, substance use disorders (SUDs) are seen as behavioral disorders consisting of three elements:

1. Loss of control (e.g., compulsive use)

2. Continued intake despite serious adverse consequences 3. Preoccupation with obtaining, using, and recovering from the substance (Julien et al., 2023)

substance use disorder

From 1999 to 2017, drug overdoses claimed the lives of over 700,000 Americans, significantly impacting the recent decrease in the country's overall life expectancy (McGinty & Barry, 2020). Most of these deaths were among young, healthy males.

Approximately 8-10% of Americans aged 12 and above, around 20-22 million individuals, suffer from addiction to alcohol or other drugs. In 2018, almost 89% out of the estimated 20.2 million Americans who satisfied the DSM-5 criteria for a Substance Use Disorder (SUD) did not receive specialized treatment for their condition.

Of concern, about 90% of these individuals believed they did not require treatment (Volkow et al., 2016).

Estate M. Sokhadze and David Trudeau rated NFB for SUD as probably efficacious based on an RCT (N = 121) using the Scott–Kaiser NFB protocol. The five other RCTs incorporated alpha and high beta regulation, alpha/theta with TEMP and guided imagery, SMR and beta upregulation with 1-13 Hz and high beta (18-22 Hz) suppression, SMR/theta followed by alpha-theta, and the Scott–Kaiser NFB protocol.

The Scott-Kaiser protocol, which starts with NF ADHD training and then progresses to the Peniston protocol, has improved retention and abstinence in these hard-to-treat populations. Participants increased abstinence, quality of life, self-efficacy, time in the program, and TOVA (continuous attention), and reduced addiction severity and craving.

The Scott-Kaiser modification of the Peniston Protocol can be classified as probably efficacious with residential or office-based rehabilitation and opioid replacement for alcohol, opioid, mixed-substance, and stimulant abusers. Alpha-theta NF received a level-2 rating of possibly efficacious.

Attention Deficit Hyperactivity Disorder (ADHD)

Attention Deficit Hyperactivity Disorder (ADHD) is one of the most frequently diagnosed disorders in children, often persisting through their teenage years and even into adulthood. ADHD is characterized by symptoms such as struggling with maintaining focus and attention, challenges in managing behavior, and exhibiting over-activity, also known as hyperactivity.


The National Comorbidity Survey Replication (NCS-R; Kessler et al., 2006) estimates the prevalence of adult ADHD (18 to 44 years) as 4.4%, higher for men (5.4%) than women (3.2%).

Based on six RCTs, Stefanie Enriquez-Geppert and colleagues rated NFB for ADHD as efficacious and specific. NFB interventions included training to decrease the theta/beta ratio and increase sensorimotor rhythm (SMR) activity or slow cortical potential (SCP) activity.

NFB training resulted in post-treatment gains in ADHD symptoms, including the Attention Deficit Disorders Evaluation Scale (ADDES). Participants also improved on intelligence, TOVA measures of attentiveness, impulse control, and response variability, and Wide Range Achievement Test scores.


The Global Initiative for Asthma (2018) defined asthma as a "... heterogeneous disease, usually characterized by chronic airway inflammation. It is defined by the history of respiratory symptoms, such as wheeze, shortness of breath, chest tightness, and cough that vary over time and in intensity, together with variable expiratory limitation.“

Chronic inflammation produces bronchiole hypersensitivity to stimuli (e.g., allergens, cold air, exercise, and viral infection), airway constriction, and reversible airflow restriction.

pathology of asthma

Asthma affects 8.3% of the population in the United States. This percentage represents 26.5 million individuals, out of which 20.4 million are adults and 6.1 million are children. Asthma prevalence is more pronounced in children, affecting 9.4% of youth, compared to 7.7% in adults. Similarly, it is more common in females, with a prevalence of 9.2%, compared to 7.0% in males (CDC, 2023).

Based on five RCTs, Paul Lehrer, Gali Moritz, and Naomi Greenfield rated HRV BFB for asthma as efficacious and specific. Participants improved in asthma severity and symptoms, pulmonary function, and medication use. The impact of HRVB on airway inflammation is uncertain.


level 3

Traumatic brain injury (TBI) results when an external force produces intracranial injury due to acceleration or direct impact. A concussion is considered a mild TBI. Measurable cognitive deficits following mTBI are rare after several months and are probably attributable to non-cerebral causes (Belanger et al., 2018).

More than 90% of individuals with more than 5 mTBI episodes had a neurologic deficit, while less than 20% of those with a single episode had such a deficit.

Anne Ward Stevens and Kori Trotter rated NFB for concussion as probably efficacious based on three RCTs.

HRV was the only BFB modality. NFB training involved operant conditioning utilizing real-time normative database comparisons (z-score training) and training several measures concurrently (e.g., inhibiting 4-7 Hz and rewarding 15-18 Hz activity). EEG tomography through Low-Resolution Electromagnetic Tomography Analysis (LORETA) offered greater training specificity and TBI treatment customization.

Participants reduced medication, the number of symptoms, symptom severity, and anxiety. They improved on attention, cognitive function, memory, and tandem gait time (walking in a straight line by placing one foot directly in front of the other, heel-to-toe).


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Alpha-theta protocol: a protocol to slow the EEG to the 6-9 Hz crossover region while maintaining alertness. Asthma: a chronic respiratory condition where the bronchial tubes become inflamed and constrict, leading to episodes of wheezing, coughing, and shortness of breath. Attention Deficit Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder characterized by persistent inattention, hyperactivity, and impulsivity patterns.

Biofeedback-assisted relaxation training (BART): biofeedback combined with relaxation procedures.

Heart rate variability (HRV): a measure of the variation in time between each heartbeat, used as an index of autonomic nervous system function.

Level 3: probably efficacious.

Level 4: efficacious.

Level 5: efficacious and specific.

Low-Resolution Electromagnetic Tomography Analysis (LORETA): a method for localizing electrical activity in the brain by analyzing scalp-recorded EEG signals.

Mild traumatic brain injury (mTBI): Often synonymous with concussion, it is a form of TBI characterized by a transient change in mental status or consciousness following biomechanical force to the head. Scott-Kaiser modification: a protocol that starts with NF ADHD training and then progresses to the Peniston protocol

Substance use disorders (SUDS): a group of psychiatric disorders characterized by maladaptive patterns of substance use leading to significant impairment or distress.

Theta: 4-8-Hz rhythms generated a cholinergic septohippocampal system that receives input from the ascending reticular formation and a noncholinergic system that originates in the entorhinal cortex, which corresponds to Brodmann areas 28 and 34 at the caudal region of the temporal lobe.

Traumatic brain injury (TBI): an injury to the brain caused by an external force, resulting in temporary or permanent impairments in cognitive, physical, and psychosocial functions.

Z-score training: a neurofeedback technique that uses real-time comparisons to a normative database to guide the neurofeedback process, aiming to move individual EEG patterns toward the norm.


Belanger, H. G., Tate, D. F., & Vanderploog, R. D.(2018). Concussion and mild traumatic brain injury. In J. E. Morgan & J. H. Ricker (Eds.), Textbook of clinical neuropsychology (2nd ed., pp 411-448). Routledge.

Brown, T., & Steffen, P. (2023). Adult headache. In I. Khazan, F. Shaffer, D. Moss, R. Lyle, & S. Rosenthal (Eds). Evidence-based practice in biofeedback and neurofeedback (4th ed.). Association for Applied Psychophysiology and Biofeedback.

Enriquez-Geppert, S., Brown, T., Henrich, H., Arns, M., & Pimenta, M. G. (2023). Attention Deficit Hyperactivity Disorder. In I. Khazan, F. Shaffer, D. Moss, R. Lyle, & S. Rosenthal (Eds). Evidence-based practice in biofeedback and neurofeedback (4th ed.). Association for Applied Psychophysiology and Biofeedback.

Global Initiative for Asthma (2018). Global strategy for asthma management and prevention.

Huether, S. E., & McCance, K. L., and Brashers, V. L. (2020). Understanding pathophysiology (7th ed.). Mosby.

Julien, R. M., Advokat, C. D., & Comaty, J. E. (2023). Julien’s primer of drug action. Worth Publishers.

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.

Kessler, R. C., Adler, L., Barkley, R., Biederman, J., Conners, C. K., Demler, O., Faraone, S. V., Greenhill, L. L., Howes, M. J., Secnik, K., Spencer, T., Ustun, T. B., Walters, E. E., & Zaslavsky, A. M. (2006). The prevalence and correlates of adult ADHD in the United States: Results from the National Comorbidity Survey Replication. The American Journal of Psychiatry, 163(4), 716–723.

Launer, L. J., Terwindt, G. M., & Ferrari, M. D. (1999). The prevalence and characteristics of migraine in a population-based cohort: The GEM study. Neurology, 53, 537-542. Lehrer, P., Moritz, G., & Greenfield, N. (2023). Asthma. In I. Khazan, F. Shaffer, D. Moss, R. Lyle, & S. Rosenthal (Eds). Evidence-based practice in biofeedback and neurofeedback (4th ed.). Association for Applied Psychophysiology and Biofeedback.

Martin, V., & Elkind, A. (2005). Diagnosis and classification of primary headache disorders. Standards of care for headache diagnosis and treatment. National Headache Foundation.

McGinty, E. E., & Barry, C. L. (2020). Stigma reduction to combat the addiction crisis—Developing an evidence base. The New England Journal of Medicine, 382, 1291–1292.

National Survey on Drug Use and Health (NSDUH). Retrieved from Sokhadze, E. M., & Trudeau, D. (2023). Alcohol and drug dependence. In I. Khazan, F. Shaffer, D. Moss, R. Lyle, & S. Rosenthal (Eds). Evidence-based practice in biofeedback and neurofeedback (4th ed.). Association for Applied Psychophysiology and Biofeedback.

Stevens, A. W., & Trotter, K. (2023). Concussion. In I. Khazan, F. Shaffer, D. Moss, R. Lyle, & S. Rosenthal (Eds). Evidence-based practice in biofeedback and neurofeedback (4th ed.). Association for Applied Psychophysiology and Biofeedback.

Volkow, N. D., & McLellan, A. T. (2016). Opioid abuse in chronic pain--Misconceptions and mitigation strategies. The New England Journal of Medicine, 374(13), 1253–1263.



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10 oct 2023
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Great summary!

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