Can We Evaluate Neurofeedback’s real-life impact?

Neurofeedback (NF) is a special kind of biofeedback during which clients learn to intentionally regulate their brain activity and thereby gain control over processes usually not available for conscious regulation (Holtmann et al., 2014). The principle is that by changing brain activity improvements in cognitive function and emotional regulation will improve, leading to positive behavioural change.

Use of Neurofeedback Therapy has increased significantly in the past decade both due to a combination of increasing research validation of its application, greater knowledge/education of its application to practitioners, and newer & more user-friendly NF technologies like the Muse headbands that allow for wider usage of EEG-based Neurofeedback, either for self-education and regulation, or from the practitioner’s side of providing better NF therapy.

One point to bear in mind (pun intended!) is that neurofeedback does not offer a quick fix to all problems. Triggering neuroplasticity and changing the brain through conditioning and gaining control over one’s psychophysiology requires time and dedication; thus attending sessions regularly is vital for long-term change. Similar to strength training in the gym for athletes, where multiple regular workouts are required to achieve the desired changes physical performance changes, consistent regular brain workouts are necessary to change the deeply entrenched patterns of thought and behaviour.

Sticking with the gym and athlete analogy, ultimately the goal of the athlete is to transfer the gym training and performance into “real life”; real-life in this case being the sport they perform in. A boxer who spends their time in the weights room and boxing gym does so for the purpose of it all transferring into actual boxing competition, a means to an end.
Similarly, the purpose of all biofeedback therapy is to elicit cognitive, behavioural and emotional-regulatory changes that transfer into a clients real life; real-life in this case being….well, real life. Unlike sports where the rules are clearly defined, in life, there are no rules. stressors can come in all shape and sizes and at any given moment, for any given duration and as many times as possible. Which is why it is important to assess the learnings and transferral of neuropsychological training into the context of real life.

Session Outcomes v “Functional Outcomes”

One of key risks of any therapy session as the single evaluation of progress is the difference between session outcomes and treatment/functional outcomes. Essentially, learning outcomes (i.e., the ability to learn self-regulation) is sometimes not necessarily linked to treatment success (i.e., treatment/functional outcome) and vice versa Alkoby et al. (2018). In effect, a client may become better at the given treatments and tests themselves, but may not necessarily transfer the newly learned skills into real-life behavioural and emotional changes. Sticking to the sports and fitness analogy again, its akin the gym goer becoming stronger in the gym, but not being able to lift a heavy box or couch without injuring their back. All treatment must translate to real-life context.

A potential factor contributing to above mentioned problems may be the application of standardised NF protocols that are usually not tailored to individual needs.
One such example; a study demonstrated that ADHD patients who received theta/beta NF based on individual differences in alpha activity were more successful and showed stronger symptom improvements than those who received standard, individualised NF (Bazanova et al., 2018). However, while individualised NF trainings are becoming more common (e.g., Karch et al., 2019), they are far from the norm. But even with an individualised approach, it still leaves us with the key question; how do we assess the transfer of improved self-regulation into daily setting?

What is “HRV Biofeedback Training”?

HRV is the fluctuation of the length of heartbeat intervals, and represents the ability of the Autonomous Nervous System (ANS) to respond to a variety of physiological, psychological, and environmental stimuli via the Sympathetic and Parasympathetic branches within the ANS. There are many ways to assess ANS activity, but one simple way can be measuring the time between the initiations of succeeding heart beats, called the R-R interval , because contrary to popular belief every heart beat rhythm isn’t quite the same.

The use of HRV is often associated with real-time therapeutic feedback. In biofeedback, an individual’s psychophysiological state is measured via different pathways or parameters (e.g., heart rate, electrodermal activity, brain activity, etc.) and fed back in real time. The immediate feedback loop helps the individual gain voluntary control over the respective physiological process and induce favourable changes.
Heart Rate Variability biofeedback specifically aims at increasing individual cardiac vagal tone, usually via the physiological link between breathing and the heart, via the effect of respiratory sinus arrhythmia (RSA) during breathing. In this use-case of HRV that’s based on breathing regulation, trainees/clients of therapists learn to utilize slow breathing to improve HRV in real-time, with the parameters of changes fed back to the users or therapist, and increasing one’s ability to self-regulate their emotions.

As already explained one of the popular requirements for “biofeedback” is in its use for real-time response and feedback-loop. This means the psychophysiological response has to be rapid enough to provide the required immediate response-loop. Within the academic biofeedback community, there are still some that question how much of HRV Biofeedback is actually “biofeedback”, due to its much slower response time and needing longer sample time, compared to other biofeedback methods such as EEG, skin conductance, HR, etc.
Ultimately, I feel a lot of these debates comes down to one’s definition of “biofeedback” and whether biofeedback MUST always imply real-time. Sure real-time is the most common use for biofeedback, but I don’t understand why the definition must be limited to real-time. Feedback is a reaction to a stimulus, but a reaction doesn’t HAVE to be immediate. And “bio” stands for biological, so there is nothing in the title that says biofeedback must mean immediate response to stimulus, outside of its original use-case.

Another type of Use Case: Daily Evaluation of regulation ability

With the concept of real-time usage in mind, one of the criticisms of HRV may also be one of its strengths; which is in capturing the body’s “storing” and response to stressors, or delayed response-time. It means rather than using HRV is a real-time biofeedback therapeutic tool to bring about change to clients, HRV can be just as effective (possibly even more so) to capture the body’s ability to respond and cope to daily stress.

Resting-HRV, which would be the readings of the ANS during or soon after a rested state (think morning upon waking up), provides greater insight into one’s general “baseline” regulation & coping capacity, as its during these periods of rest that the body is responding and making adjustments to the stress it is receiving on a daily basis. So for instance, a suppression of HRV readings at rest usually means reduced parasympathetic activity overall and thus a reduced ability to self-regulate on a day-to-day basis. An accumulation of this, naturally is linked with a host of mental health conditions and difficulties. Whereas the opposite is also equally true; an increase in resting/baseline HRV usually indicates improved emotional self-regulation, resiliency and coping-capacity.


It can be argued that Resting-HRV has a more practical use-case than Real-Time HRV Biofeedback, mainly on the basis that the biofeedback value provided by real-time HRV can also be provided by other forms of biofeedback; such as neurofeedback therapy and other forms of biofeedback, as all these methods can be regarded as in-session therapy interventions. Though the low-cost nature and use-of use of HRV Biofeedback still give its great value to in-clinic/session therapy.

But we can also conclude that Resting-HRV provides a low-cost and practical supplement to ALL of the in-session therapies outlined above, as a way of evaluating the biofeedback therapies on a client’s actual day-to-day application of the therapies they’ve learnt. Therapy lies beyond the session and the practice, but its true value can only be found if the changes can carry over into the real world of the individuals receiving therapy.

Weber, L.A., Ethofer, T. and Ehlis, A.-C. (2020). Predictors of neurofeedback training outcome: A systematic review. NeuroImage: Clinical, 27(1), p.102301. doi:10.1016/j.nicl.2020.102301.

S. Karch, M. Paolini, S. Gschwendtner, H. Jeanty, A. Reckenfelderbäumer, O. Yaseen, M. Maywald, C. Fuchs, B.-S. Rauchmann, A. Chrobok, A. Rabenstein, B. Ertl-Wagner, O. Pogarell, D. Keeser, T. Rüther. (2019). Real-time fMRI neurofeedback in patients with tobacco use disorder during smoking cessation: Functional differences and implications of the first training session in regard to future abstinence or relapse. 65–65

Alkoby, O., Abu-Rmileh, A., Shriki, O. and Todder, D. (2018). Can We Predict Who Will Respond to Neurofeedback? A Review of the Inefficacy Problem and Existing Predictors for Successful EEG Neurofeedback Learning. Neuroscience, 378(1), pp.155–164. doi:10.1016/j.neuroscience.2016.12.050.

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Biofeedback monitoring platform for therapists & Counsellors. “Another way to know if they’re okay.”