Biofeedback for CRPS: Why Haven't I Tried That?
By Kenneth R. Lofland, PhD

CRPS is a painful disorder that continues to challenge the medical community. The cause, course, treatment, and outcomes are highly variable and remain a source of vigorous debate among the brightest professionals specializing in chronic pain.

Biofeedback is a non-drug intervention that is used to treat patients with a variety of medical conditions. Taken simply, biofeedback can be defined by breaking down the word as "bio," referring to the body, and "feedback," receiving information about the body, that one would ordinarily not be aware of. A simple example of how biofeedback can work is the case of a patient with poor circulation to the extremities, often referred to as Raynaud's disease. When this disorder is severe, coldness, pain, and poor healing results in the extremities due to decreased blood flow. It can increase the risk of frostbite and minor cuts to fingers or toes becoming infected, not healing properly, and even requiring amputation. Improving blood flow to the extremities through thermal biofeedback is one of the most effective treatments for this condition.

How does biofeedback work?
Although it sounds amazing that anyone can learn to alter blood flow, it is actually quite easy to learn. We all have a "flight or flight response." If I am to give a presentation in front of 500 people, I will notice my hands get cold and clammy. When physical or psychological stress occurs, our bodies instantly secrete adrenaline, our breathing rate changes, our blood pressure increases, our heart rate increases, and our blood flows away from the periphery toward the core of our body, thus the cold, clammy hands. When the stressor is over, our bodies relax and these physiological responses reverse. Learning deep relaxation techniques, in combination with receiving feedback from machines measuring small changes in temperature, can advance this process and allow the blood vessels to dilate (open up) even more, allowing more blood to flow out to the periphery. So in the case of the Raynaud's sufferer, learning deep relaxation techniques and biofeedback allows for increased blood flow to his or her hands. This improved circulation increases hand temperature to normal levels, decreases pain, and improves the body's ability to heal any cuts or injuries naturally.

How can biofeedback help my CRPS?
Changes in blood flow often accompany CRPS. Learning deep relaxation techniques can be paired with a biofeedback device which measures skin temperature in order to help a CRPS sufferer learn to relax deeply, increase blood flow to a part of the body with a restriction in blood flow, increase the temperature of that part of the body, and decrease the pain.

What does the science say?
Biofeedback has not been subjected to the same level of scientific scrutiny as many medications. More, larger scale, and better controlled research studies are needed in this area, as is funding to support this type of research. Several studies have been done evaluating biofeedback for pain and found positive effects. For example, Grunert et al (1990), found that 20 patients with documented CRPS for 18 to 60 months and who failed to respond to a variety of treatments underwent thermal biofeedback with relaxation training as a part of counseling treatment. The results found that patients were able to significantly increase their blood flow and significantly decrease their pain levels (p<.0001). This pain reduction was maintained at 1-year follow-up assessment and 14 of the 20 patients had returned to work. The conclusion was that this intervention was effective to reduce pain in CRPS/RSD for the long term, even in patients who had failed prior treatments. Multiple other case studies exist but I reiterate that additional well-controlled treatment outcome studies are needed with larger sample sizes.

As a clinician I am very enthusiastic about the use of thermal biofeedback for the treatment of CRPS. Specific sources for this enthusiasm include:

1. The number of case reports indicating successful outcomes, even in cases where other treatments have not helped the CRPS patient (see above)

2. The common sense aspect that at least one hallmark symptom of CRPS, namely decreased blood flow and temperature in the affected area of the body, can be reversed with thermal biofeedback

3. My own clinical experiences, which have demonstrated positive results using thermal biofeedback with CRPS sufferers

4. It is one of the few treatments in medicine that has essentially no known negative side effects. There are very few other treatments available to chronic pain sufferers with no negative side effects.

How do I find a biofeedback provider?
First, some caution must be taken when identifying a biofeedback provider. While being a licensed clinical psychologist requires a specific doctoral degree and a license, and being a licensed physician requires a specific medical degree and a license, being a biofeedback therapist does not require a specific degree or license. Therefore, practitioners at much different levels of training and experience may be presenting themselves as biofeedback therapists. It is always best to ask a prospective provider to tell you about his or her training in general, specific training in biofeedback, and what conditions he or she specializes in when treating with biofeedback. Knowing the individual's level of training, specialization, office practices, etc., can make you a more informed client.

Several states have biofeedback societies with web sites, such as the one in Illinois www.biofeedbacksocietyil.org. These sites generally have a list of practitioners that are members of the state biofeedback society. Membership in these organizations does not indicate any level of training or expertise. However, health care professionals with an interest in biofeedback can be found there.

Also, a national organization exists, the Biofeedback Certification Institute of America (BCIA) that certifies some individuals who chose to learn biofeedback through this particular organization. Being a member of this organization does indicate a certain basic level of biofeedback training, but it does not guarantee the degree to which a provider has specialized or the amount of experience a provider has had. Further, not being certified by this organization does not indicate a lack of training or experience of those who may have gotten trained via other routes, such as in graduate school.

1. Grunert, BK, Devine, CA, Sanger, JR, Matloub, HS, Green, D. (1990). Thermal self-regulation for pain control in reflex sympathetic dystrophy syndrome. Journal of Hand Surgery. 1990; July 15(4): 615-618.

Dr. Lofland is the Director of Pain Studies and the Director of Psychological Services at the Pain and Rehabilitation Clinic of Chicago. He is past President of the Biofeedback Society of Illinois and the current President of the Midwest Pain Society. He is both a dedicated clinician, treating individuals with pain syndromes such as CRPS, and an active scientist, researching the most effective treatments for many chronic pain syndromes. He can be reached for follow-up questions at lofland1@aol.com.