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Evidence-Based Practice Preview: Part 3

Updated: Jan 18

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 Epilepsy, Irritable Bowel Syndrome, Panic Disorder, Post-Traumatic Stress Disorder, and Preeclampsia.

Soldier with PTSD

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Evidence-Based Practice Efficacy Criteria

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

Task Force Criteria


Level 4

SMR-based and SCP-based NFB for seizures

Level 3

SMR-based NFB for non-seizure manifestations

Level 1

Connectivity-based NFB for seizures

Epilepsy is a family of neurological disorders featuring short, periodic motor, sensory, or cognitive malfunction attacks. Epileptic seizures have been divided into (1) partial or focal seizures, (2) primary generalized seizures, (3) status epilepticus, and (4) recurrence patterns.

child with electrodes

Petit mal seizures feature loss of consciousness without abnormal movement (the patient appears to be daydreaming). The patient, typically a child, may suffer hundreds of these seizures daily for periods lasting up to 30 seconds.

Tonic-clonic seizures (grand mal seizures) are primary generalized seizures featuring a peculiar cry, loss of consciousness, fall, tonic-clonic convulsions of all extremities, incontinence, and amnesia for the episode. These seizures are diagnosed in fewer than 20% of adult epileptics.

epilepsy symptoms

About 2% of adults in the United States experience a seizure, and two-thirds of these patients do not have additional episodes. Those who experience two or more seizures are diagnosed with epilepsy, which is frequently idiopathic (no identified cause) or symptomatic (identified cause like a brain tumor). The age of seizure onset provides a guide to its likely cause (Adamolekun, 2013).

The main therapeutic objectives for individuals with epilepsy are to achieve the cessation of seizures and eliminate the impacts of any comorbid conditions related to epilepsy. Aiming for a complete stop of seizures is crucial as persistent, uncontrolled seizures over time are linked to a higher prevalence of mental health issues like depression and anxiety and a greater risk of death (Fisher et al., 2000).

Lauren Frey rated SMR-based and SCP-based NFB as efficacious for seizures, SMR-based NFB as probably efficacious for non-seizure manifestations of epilepsy, and connectivity-based NFB as not empirically supported for seizures. In a meta-analysis, SMR- and SCP-based treatments were associated with fewer seizures and improved quality of life in a RCT.

Irritable Bowel Syndrome

Level 4

Irritable bowel syndrome (IBS) is a functional gastrointestinal disorder. IBS patients respond to stressors with alternating diarrhea and constipation associated with abdominal pain, cramping, excessive mucus in the feces, flatulence, loss of appetite, and nausea.


IBS symptoms

Worldwide, approximately 10-20% of adults are impacted by IBS. It's more commonly observed in females and individuals under the age of 50 (AlButaysh et al., 2020).

Based on five RCTs, Donald Moss and Mark Watkins rated rectosigmoid and temperature biofeedback with Progressive Relaxation for IBS as efficacious. Participants reduced GI and IBS symptoms and CPSR global index scores.

Panic Disorder

level 5

Panic Disorder (PD) involves recurring instances of severe fear that arise suddenly and unexpectedly.

panic attack

These episodes are associated with physical symptoms such as chest pain, heart palpitations, difficulty breathing, dizziness, or stomach discomfort. They manifest spontaneously, not in response to a recognizable fear or stress-inducing situation.

Panic attack symptoms

The National Comorbidity Survey Replication (NCS-R) reported PD prevalence in the previous year among U.S. adults aged 18 and above:

  1. About 2.7% of U.S. adults experienced PD in the last year.

  2. PD was more prevalent in women (3.8%) than men (1.6%).

  3. 4.7% of U.S. adults will face PD at some point in their lifetime.

Based on five RCTs, Donald Moss and Matthew Watkins rated BFB for PD as efficacious and specific.

The BFB interventions included end-tidal CO2 increase, HRV increase, and SEMG decrease. Participants reduced agoraphobic avoidance, anger, panic-related cognitions, PD frequency and severity, and state and trait anxiety. They increased end-tidal CO2 and sleep time.

Post-Traumatic Stress Disorder

Level 4

Post-Traumatic Stress Disorder (PTSD) can manifest in individuals who have undergone a terrifying, distressing, or hazardous event. Typically, PTSD symptoms manifest within 3 months following the traumatic incident, although in some cases, they may surface later.

Soldier with PTSD

To qualify for a PTSD diagnosis, an individual must exhibit these symptoms for more than a month, and these symptoms must be sufficiently intense to disrupt daily life activities, like relationships or work. These symptoms must not be due to medication, substance abuse, or other health conditions.

PTSD causes

The National Comorbidity Survey Replication (NCS-R) reported PTSD prevalence in the previous year among U.S. adults aged 18 and above:

  1. About 3.6% of U.S. adults experienced PSTD in the last year.

  2. PTSD was more prevalent in women (5.2%) than men (1.8%).

  3. 6.8% of U.S. adults will face PTSD at some point in their lifetime.

Donald Moss, Fred Shaffer, and Matthew Watkins rated BFB and NFB for PTSD as efficacious based on four RCTs.

The BFB interventions included HRV and TEMP increase, and respiration rate (RR) decrease. The NFB interventions included left amygdala fMRI decrease; 2-6 Hz and 22-36 Hz decrease, and 10-13 Hz increase; and theta and high-beta decrease and low-beta increase.

Participants reduced anxiety and depression scores and PTSD symptoms.


Level 5

Preeclampsia or pregnancy-induced hypertension (PIH) involves elevated blood pressure and abnormal protein concentration in the urine after the 20th week of gestation.

Preeclampsia mother

Preeclampsia infographic

Preeclampsia is a condition that affects an estimated 5 to 7 percent of all pregnancies worldwide and is a significant contributor to maternal health complications. Each year, it results in over 70,000 maternal and 500,000 fetal fatalities globally. Within the United States, Black women experience a 60 percent higher incidence of preeclampsia than their White counterparts. Furthermore, Black women are more prone to develop this condition and face a greater risk of associated severe consequences, including kidney damage and mortality (Dawson, 2022).

Based on three RCTs, Fred Shaffer rated electrodermal and temperature BART as efficacious and specific for preeclampsia. Participants improved in hospitalization frequency and length,

diastolic blood pressure (DBP), mean arterial pressure (MAP), systolic blood pressure (SBP), methyldopa dosage, and proteinuria.


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Biofeedback-Assisted Relaxation Training (BART): biofeedback combined with relaxation procedures.

Diastolic blood pressure (DBP): the blood pressure when the heart is in its resting phase between beats. It's the bottom number in a blood pressure reading and is usually lower than the systolic blood pressure. Electrodermal biofeedback: galvanic skin response (GSR) or skin conductance level (SCL) biofeedback.

End-tidal CO2: the maximum amount of carbon dioxide (CO2) present at the end of an exhaled breath, often measured using capnography. It's an important indicator of the adequacy of ventilation and the perfusion of the lungs in the circulatory system.

Epilepsy: a neurological disorder characterized by recurring, unprovoked seizures due to abnormal electrical activity in the brain. Heart rate variability biofeedback (HRVB): the display of the changing time intervals between adjacent heartbeats.

Irritable Bowel Syndrome (IBS): a common disorder affecting the large intestine, causing symptoms such as cramping, abdominal pain, bloating, gas, and diarrhea or constipation, or both. Level 1: not empirically supported. Level 4: efficacious.

Level 5: efficacious and specific.

Mean arterial pressure (MAP): the average pressure in a person's arteries during one cardiac cycle. It's considered an important indicator of blood flow to vital organs.

Methyldopa: a medication used to treat high blood pressure. It works by relaxing the blood vessels so blood flows more smoothly.

Panic Disorder (PD): a type of anxiety disorder characterized by recurrent and unexpected panic attacks, which are sudden periods of intense fear and discomfort that may include palpitations, sweating, trembling, shortness of breath, or a feeling of impending doom.

Petit mal seizures (Absence Seizures): a generalized seizure characterized by brief, sudden lapses in attention. They often occur in children and are marked by periods of staring, subtle body movements, and a lack of awareness of surroundings.

Post-Traumatic Stress Disorder (PTSD): a psychological condition triggered by experiencing or witnessing a terrifying event. Symptoms may include flashbacks, nightmares, severe anxiety, and uncontrollable thoughts about the event.

Preeclampsia: a pregnancy complication characterized by high blood pressure and signs of damage to another organ system, often the liver and kidneys. If left untreated, it can lead to serious, even fatal, complications for both mother and baby.

Proteinuria: a condition characterized by an abnormal amount of protein in the urine. It often indicates kidney disease or damage.

Systolic blood pressure (SBP): the blood pressure when the heart is contracting. It's the top number in a blood pressure reading and is generally higher than diastolic blood pressure.

Tonic-Clonic Seizures (Grand Mal Seizures): the most recognizable type of generalized seizure, involving a loss of consciousness and violent muscle contractions.


AlButaysh, O. F., AlQuraini, A. A., Almukhaitah, A. A., Alahmdi, Y. M., & Alharbi, F. S. (2020). Epidemiology of irritable bowel syndrome and its associated factors in Saudi undergraduate students. Saudi Journal of Gastroenterology: Official Journal of the Saudi Gastroenterology Association, 26(2), 89–93. Dawson, E. L. (2022). Preeclampsia, genomics and public health. CDC.

Fisher, R. S., Vickrey, B. G., Gibson, P., Hermann, B., Penovich, P., Scherer, A., & Walker, S.

(2000). The impact of epilepsy from the patient’s perspective I. Descriptions and subjective

perceptions. Epilepsy Research, 41(1), 39–51. 10.1016/s0920-

1211(00)00126-1 Frey, L. C. (2023). Epilepsy. 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.

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.

Moss, D., Shaffer, F., & Watkins, M. (2023). Posttraumatic stress 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.

Moss, D., & Watkins, M. (2023). Anxiety and anxiety disorders. 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.

Moss, D., & Watkins, M. (2023). Irritable bowel syndrome. 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.

Shaffer, F. (2023). Preeclampsia. 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.



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