How do I choose which biofeedback device to purchase?

Some years ago, B. Robert Crago PhD (Director of Neurobehavioral Health Services in Tucson, Arizona) developed an “equipment buying guide” which was posted on AAPB’s web site. The current discussion incorporates much of the material from that guide and we appreciate its continued availability. For questions about the current material, please contact Dr. Rich Sherman at rsherman@nwinet.com.

Choosing which biofeedback device is right for you is very difficult. It is not a decision to make quickly and should not be based on the first device you happen to see and / or use.

The most expensive investment in starting to do biofeedback is the equipment. The costs can dwarf the price of all the training and mentoring you need to buy. The time commitment needed to actually get a device working can be overwhelming. Too many people never enter the field because they see the incredible cost of multichannel equipment with tons of whistles and bells and then realize that its use is simply incomprehensible. You need to learn to evaluate what equipment is appropriate for your intended use. In addition, you must determine if you can actually understand and use it within a reasonable amount of time. You learn what hardware, software, and sensors you need during your basic biofeedback training. Having appropriate training will help you make appropriately informed equipment purchase decisions.

If at all possible, attend a national professional organization meeting (such as AAPB or ISNR) where most common biofeedback devices are being demonstrated in one place and at one time. This gives you the golden opportunity to see and try the equipment and compare pieces “head to head”. In spite of many similar descriptions on paper, you will find they are incredibly different in ease of use, displays, sensors, hardware, and software. You will also get to meet the people who will be your most crucial resource – the technical support folk. If you can’t understand them at the meeting, you probably won’t understand them during a call either. AAPB’s annual meeting probably has the widest display of biofeedback devices.

Here are the most crucial questions you need to answer before you buy a biofeedback device.

(a) Aligning types of interventions and clients to be seen with type of equipment

The device you get should fit your needs. For example, if you are only going to perform pelvic floor biofeedback with women for urinary incontinence issues, you don’t need a multichannel system capable of recording EEG. You don’t need to pay for complex hardware or software capable of recording anything other than two channels SEMG. Another example would be if you only see clients with one major class of disorders such as stress related breathing problems, and you only want to use a few biofeedback techniques, such as heart rate variability and respiration, then you only need a two channels and those channels only need to pick up heart rate and respiration. You don’t need to pay for software or hardware with other capabilities. However, you need to be certain that this is all you will do as two channels are not sufficient to perform a stress profile (recording made while a person is relatively relaxed and psychologically or physically stressed) or do many other types of biofeedback. You will learn which physiological systems you need to record to treat various disorders and improve the functioning of healthy clients when you take an appropriate biofeedback course.

(b) Number of channels of which signals needed for which interventions

As previously stated, there is no need to purchase a very expensive device capable of recording many more channels than you will ever use – as long as you are certain you won’t expand your use of biofeedback techniques and types of patients. In general, if quality of hardware and software is kept equal, the more channels, the greater the cost so you can easily go from a device costing less than a thousand dollars to one costing over ten thousand but get nothing immediately useful for your money.

Be absolutely certain that the device you choose can actually record and display the signals you want to see simultaneously. Many units can record the signals you want but not together at one time on one screen. Thus, if you purchase sufficient sensors to record what you need to know, the device may only be able to display or record a few of them at once. This means you can’t do a stress profile or other activities requiring simultaneous views of changes in several signals.

(c) Allowing for expansion from current to future needs vs. saving money now

The device needs to be right for your current needs. However, you also need to keep an eye out for future expansion of your client base or you may wind up with a device which can’t grow with you. This is the trade off I just discussed between a low enough price to get going contrasted with a more hefty investment which could save you buying an entirely new system in the near future. Be sure to ask the vendor to explain their policies about adding capabilities or upgrading equipment.

(d) Understanding which sensors are needed and the costs involved

Sensors are the leads and signal transformers which connect to the client and are typically specialized for only a few types of signals. They can increase the cost of a device by many hundreds of dollars – perhaps thousands. You should have learned exactly which sensors you need for the tasks you want to accomplish during your basic training in biofeedback. So, only get the sensors you need and be sure that the device’s software can actually support the ones you want. For example, if you want to record respiration patterns from the chest and abdomen simultaneously for breathing assessments relative to stress, don’t get a device which has the software capability or hardware capability for recording and then displaying only one at a time. This is sadly common. The same goes for multiple channels of muscle tension. If you are working with musculoskeletal pain patients, you need to be able to see at least four channels of SEMG simultaneously – not two now and two later. On the other hand, if all you are going to do is EEG biofeedback (neurofeedback), you don’t need to pay for lots of other types of sensors (other than one channel of SEMG) – regardless of what the “standard package” may be. So, know what you want to record and stick to your guns when you are making the purchase. You can always buy more sensors later as long as the hardware and software support them.

If you purchase sensors from a company other than the manufacturer, be sure that your device’s software is compatible with the sensors as well as the hardware. If you purchase a device which records a signal not supported by your biofeedback device (capnometers for picking up nasal CO2 are frequently in this position), be sure that your device’s software or computer software can actually display the signal along with the other signals you want to view simultaneously. Be sure to either see it working first or get the capability in writing!

(e) Accessory equipment and supplies

There are many seemingly small items which are needed for biofeedback including disposable pre-jelled SEMG sensor pads, breathable tape used to attach temperature leads, conductive jell for reducing impedance, and adhesive removal pads. Most of these can be purchased from sources ranging from independent dealers to the corner drug store. So, know what you want and don’t overpay for it. However, be aware of trading quality for cost savings. High quality pre-jelled SEMG sensors may cost a dollar for three sensors but you will get a consistently high quality signal for the duration of a long ambulatory recording.

(f) Do you need a special computer to run the device?

Most modern biofeedback devices will run on any modern windows laptop or desk top. The need for anything fancy such as a second screen so you can see something without the patient seeing it is really problematic. In any case, most modern windows systems can handle two screens. The manufacturers of virtually every quality biofeedback device which needs a computer for some aspect of its functioning provide the exact computer specifications needed to run the device. Some device manufacturers try to sell you a special computer to go with their device. Before you purchase a computer from a manufacturer, be sure you understand exactly why you need to purchase theirs. If their software can’t be easily installed in a modern laptop or their hardware needs something special inside to run the biofeedback device, be sure you know just what you are getting into as far as extra costs and repair support.

(g) Actual recording and feedback capabilities vs. your need for signal quality
(Can the device really record the portion of the signal you are interested in at the resolution you need?)

There is a very real tradeoff between cost of components and the quality of the signal you can record. If you are a typical clinician and all you need is to be able to record a high enough quality signal to reliably detect changes in amplitude and frequency (e.g. changes in beat to beat heart rate, changes in finger tip temperature, SEMG amplitude, EEG frequencies), then you can use virtually any biofeedback device you see at an AAPB or ISNR meeting or which meets the specifications shown on the web sites of the major biofeedback device manufacturers. If you are giving typical fingertip temperature biofeedback for control of migraines, etc., there is no need to record thousands of samples of fingertip temperature per second when the useable change you are interested in comes at a rate of a few per second. Similarly, you don’t need to pay for a device which can show you more of each raw wave then you need. However, you do need to see enough of the raw signal – especially for SEMG and EEG to know if the signals are contaminated by noise. You should have learned how much resolution you need for your uses as part of your basic biofeedback training.

(h) Device portability vs. durability and use in non-clinic situations

Most people use biofeedback devices in their offices and clinics and occasionally need to take the device to a different clinic or work situation. Thus, nearly all current biofeedback devices can run on modern laptops and most practitioners use their devices with laptops rather than desktops, at least part of the time. Any modern laptop can run typical biofeedback programs just as well as a typical desktop. Thus, biofeedback devices can be used anywhere a laptop can. However, many of the sensors are relatively fragile and don’t do well when recording rapidly moving subjects such as runners. If you are going to use your device for active sports applications, for example, be very concerned about how signals are transmitted from the subject to the laptop and biofeedback device. Be concerned about how sturdy the sensors are and how resistant to movement artifact the entire system is. In this case, you may need a system which transmits from the sensor to the biofeedback device and then from the biofeedback device to the computer by a non-wired telemetry system. Be sure you know how much the sensors will cost to replace when they break (stepped on, etc.) and just what the warrantee covers.

(i) Different people are more comfortable with different software

I can not overemphasize the nightmare that many first time users experience the first time they sit down with a new machine and try to use it. Different people find different software packages easier to use, more intuitive for them, etc. It is really important to get some practice actually using the software for each device you are considering without a sales person working it for you. Some devices have a considerably steep learning curve while others are obvious from the second you turn them on. However, there may be a significant trade off between ease of use and flexibility. Many practitioners want to be able to alter the feedback screens so the views are just the combination they want for assessment and teaching. Some systems don’t have this capability and some have it, but require a training class to take advantage of it. Many feedback displays actually make no sense to a typical client and are not scientifically based. Some of the stand alone devices don’t have the flexibility to permit you to provide feedback displays you may feel to be suitable. Other devices have software with capabilities few people will ever need to use or will learn to use in a reasonable timeframe, so make absolutely certain that those elements you need to control the displays you want to use are available for you. Audio feedback has become especially difficult to use in some devices.

The display you and your client need to learn from is software controlled. As people’s physiological levels change throughout a feedback session, you need to be able to quickly and easily adjust key elements of the display to meet the client’s needs. If you can’t find and easily manipulate the controls for the threshold line, sweep speed, offset, bandwidth (especially), and gain while a session is in progress, be very hesitant about purchasing the device.

(j) Types and availability of training for each device

Biofeedback devices can be harrowing to learn to use properly. You need to commit to taking the time to read the manual and run the tutorials so you do your best to understand how your system functions. However, most people have great difficulty learning to use a new electronic gizmo such as a microwave or TV by reading the manual. The average person probably muddles through enough of the instructions to get the thing to do the minimum needed and hopes for the best that it keeps working. This is very akin to casting a spell. This technique is neither effective nor appropriate for biofeedback devices. You need to know what the device is actually doing and be able to get it to do just what you need it to over and over. True, most of the major multichannel systems have capabilities that very few people will ever use but you need to be able to find and understand those you do want. So, how are you going to learn? Is there a really good tutorial with “live” examples built into the software? Is there a free class on the web? Do you have to go halfway across the world to learn to turn it on? Is there adequate technical support when you need it to answer questions you really can’t answer from reading the on-line manual? The bottom line is, carefully evaluate each vendor’s technical support and don’t buy it if you aren’t going to be able to learn use it easily. There may be no reasonable way to learn how after a purchase.

(k) Timely availability of professional technical support

What happens when you have read the manual and done the tutorials – perhaps even taken a class – and your device still won’t do something it is advertised to be able to do which you need it to do NOW?? You gave it a reasonable effort but you just can not get it to work. Is it broken? Is there something you are simply overlooking in the software? Are you making a dumb mistake which you will be very embarrassed about later (one of the most common situations)? This is where excellent technical support is crucial. You need to know and have in writing exactly what support you can expect. You need to be able to reach a knowledgeable technician within an hour or so during your normal business times and days. If you can’t get effective help very quickly, you are in trouble and could experience many of the stress related symptoms the devices are supposed to help you treat. Don’t accept the vendor’s word that tech support is available. You need specifics and the vendor needs to know that they get to give you a full refund if knowledgeable, understandable tech support is not appropriately available. Remember that this only applies if you have done your part in trying to learn about the device. The goal of tech support is not to teach you the basics.

(l) Rapid turnaround for warrantee service and repairs

Occasionally biofeedback devices do malfunction, sensors or an entire device arrives broken. You should have learned how to check whether a device is recording properly during your basic biofeedback course. If it doesn’t work, you may be scheduled with (hopefully) a lot of clients who can’t be seen until the device is repaired. You need to know what the warrantee actually covers – especially including turnaround time, price and availability of loaners, shipping times and costs, etc. This is the same for what happens if the device breaks when it is out of warrantee. I know several people who have waited months for a broken device to be repaired.

(m) FDA label issues

If you are going to use a biofeedback device for clinical work, it is important to verify that the device you are considering purchasing is labeled by the FDA as being safe and effective. You may not know if the device functions according to its claims. If you are using the device clinically for anything other than research approved by a federally approved committee, you must be very hesitant about using any device for clinical purposes which is not labeled by the FDA. Please read the section on this web site about FDA issues before purchasing a device which is not FDA approved.

Most devices now have an FDA label indicating efficacious usage. However, very few biofeedback devices are labeled by the FDA as being effective for every disorder you may wish to treat. Do not take the word of the vendor about what the device is labeled for or even if it has FDA approval. If you aren’t shown the label, you should strongly consider walking away.

If you use the device for clinical purposes not covered by its label, you must notify the client in writing that you are using it “off label”.

End of discussion.

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