Quality of Biofeedback and Neurofeedback

The criteria for the assessment of the quality of biofeedback and neurofeedback can basically be divided into 2 categories:

  1. Quality
    1. Quality of the biofeedback/neurofeedback training
      Quality of the basic profession
  2. Quality of the biofeedback/neurofeedback device

.      Devices in line with the medical devices law

  1. End-user devices without certification
  2. Multiple channel devices/single channel devices

The managing board of the German Society of Biofeedback („Deutsche Gesellschaft für Biofeedback e.V.“, „DGBfb“) would like to issue the following statement:

As to 1. a) Quality of the practitioner (quality of the biofeedback/neurofeedback training)

Due to our long-standing experience with trainees, queries made by patients and our experiences during oral exams we recommend training that at least corresponds to DGBfb requirements (for a biofeedback/neurofeedback therapist we recommend a minimum training of approx.1.5 - 2 years comprising the substantive criteria (approx.110 - 145 hours of theory and practical work, device and system knowledge, legal requirements, practical work with patients (a minimum of 60 hours) guided and supervised (10 - 15 hours) (For details see https://www.dgbfb.de/index.php/en/training-guidelines)

In case of a shorter training duration or less intense training insufficient professional competence must be assumed or at best, a professional competence that does not comprise all clinical fields of applications of biofeedback (limited competence of certain diagnoses only).

Therefore, the DGBFB urgently recommends to question and to evaluate the quality of the certificates – in case of doubt we are happy to assist!

As to 1. b) Quality of the practitioner (quality basic profession)

For biofeedback, no state education curriculum does exist (missing legal regulations for biofeedback).

However, there are in fact corresponding continuing education offers for basic professions.

The DGBFB allows the following basic professions to enter the curriculum to become a biofeedback and/or neurofeedback therapist:

licensed medical doctors

licensed psychological psychotherapists

certified psychologist with clinical focus (upon application)

Within these basic professions, the basic therapeutic competence has been already trained and practiced during the pursuit of these original professions. Moreover, complex knowledge about differential diagnoses (that is diagnoses that cannot be cured by biofeedback, for example, and the ability to recognize and to differentiate these diagnoses) has been practiced during a five- to six- year study period and training of the original profession.

Additionally, people with different (mostly non-academic) degrees in the health care sector may become biofeedback trainers (this training tries to compensate for possible shortcomings concerning competence by prolonged and specific training).

As to 2.a): Quality of the device: devices in line the with medical devices law

For therapeutic treatment (that is for curative treatment or the alleviation of an illness) a device that is in line with the medical devices law is an absolute prerequisite. Physicians and psychological psychotherapists are bound to these regulations.

This entails two aspects:

1.: Patients’ safety (as, for example, electrical insulation, setting up of the device, operating safety)

2.: Does the device really measure what it is supposed to measure?

Devices (in line with the medical devices law) have to pass a strict inspection in addition to the CE label, which is quite expensive. Thus, they are safe to be used. All the common well known multiple channel devices the DGBfb uses for training purposes are certified according to those standards.

Moreover, clear accessible inspection records are required. These protocols should contain the inspection process (what was inspected and how was it inspected?).

As to 2.b): Quality of the device: End-user devices without certification

Mostly, devices are officially offered to end-users bearing an indication such as: „not to be used for therapeutic treatment” or “not for clinical purposes”.

However, people being challenged by certain deficits or diagnoses tend to buy those devices.

Often, it remains unclear which part of the device was inspected and if it was inspected at all. Usually, there is no documentation or no obligation for documentation.

This hinders device evaluation in terms of safety and measurement precision.

In general, this does not necessarily imply that these devices do not measure what they are supposed to measure or that a safety violation must exist. However, even professionals sometimes have difficulties to understand which device provides useful data and which does not.

Often, non-certified devices are singe channel devices that measure only one parameter.

As to 2.c): Quality of the device: Single channel / multiple channel devices

Strictly speaking, the distinction between single channel and multiple channel devices is no quality feature. There are certified devices (in line with the medical devices law) for single channel measurement as well for multiple channel measurement.

(However, there are more single channel devices that have not been certified – end-user devices).

For a complex biofeedback procedure which is mainly used for the purpose of therapeutic treatment, we do, however, recommend that the therapist owns a multiple channel device which he or she can handle accordingly. Multi-channel devices come with the advantage of artefacts (that is artificially caused measurement errors) being recognized earlier (in case of peripheral biofeedback, for example, the increase of a skin conductance response curve might be caused by a movement - which then can be observed in the recording of the muscle).

 *For simplification, the text only mentions biofeedback, however, it does refer to biofeedback as well as to neurofeedback.

*The same applies for the quality of the devices for therapeutic treatment by means of biofeedback/neurofeedback.