Biofeedback: a valuable technique in chronic pain?

18 Nov 2014  |  Print

Biofeedback: a valuable technique in chronic pain?

‘Biofeedback’ is a catchy buzzword, but what does it really mean? What techniques does it encompass? And should we be using it with our chronic pain patients? These are important questions for everyday clinical practice. We examine them below.


Biofeedback – real-time physiological analysis

Biofeedback includes a variety of methods in which patients get real-time feedback on various physiological parameters. The goal is to develop awareness of and control over these bodily processes.[1]

At a practical level, targets can include heart rate, electromyography (EMG) of skeletal muscle, and skin temperature.[1] In the context of chronic pain, these targets are typically processes associated with pain exacerbations or with stress responses that exacerbate pain.[1]

For example, a patient might learn to slow their heart rate or ease muscle tension, with instant feedback from a heart rate monitor or electromyogram. The idea is that eventually they will learn to control these functions alone, without the biofeedback equipment.[2]

Effectiveness of biofeedback therapy in chronic pain

The efficacy of biofeedback has been demonstrated in a number of pain conditions. For example, in a study of 40 patients with knee osteoarthritis, those receiving 3 weeks of EMG-biofeedback in addition to an exercise program experienced significant improvements in energy and sleep scores relative to those receiving the exercise program alone.[3] Physical mobility and pain scores were significantly improved in both groups.

In a study of patients with cancer-related pain, those randomized to EMG-biofeedback experienced greater reductions in pain that those receiving conventional therapy.[4]

Meanwhile, in fibromyalgia, biofeedback training conducted to manipulate suboptimal heart rate variability was found to have a number of benefits – including clinically significant decreases in pain and depression, as well as improvements in functioning.[5]

Positive effects are not limited to isolated trials; they have also been documented in systematic reviews across multiple studies. For example, a Cochrane review examined the results from 17 trials of various psychosocial interventions in the management of chronic orofacial pain.[6] It revealed that biofeedback in combination with cognitive behavioral therapy improved long-term pain intensity, activity interference and depression.

Similarly, a review of the efficacy of biofeedback methods used to treat headache across 94 studies found reductions in muscle tension, perceived self-efficacy, symptoms of anxiety and depression, and medication consumption.[7]

EEG-biofeedback – the next frontier?


Analysis of electrical activity in the brain – through electroencephalography (EEG) – offers a novel concept in biofeedback therapy for chronic pain.

In EEG-biofeedback, the amplitudes of various resting EEG frequency bands are represented visually. Patients attempt to increase or decrease the power or amplitude of particular frequency bands.[1] These include theta (associated with early-stage sleep), alpha (associated with a relaxed attention state) and beta bands (associated with higher-order cognition).

This technique has already shown promise in fibromyalgia. In a pilot study of 15 patients receiving EEG-biofeedback, visual attention improved significantly, and measures of pain, tenderness and fatigue were also improved.[8] Similarly, in a randomized trial, patients receiving EEG-biofeedback for 4 weeks showed significant improvements in pain, psychological symptoms and quality of life compared with controls.[9] EEG-biofeedback has also shown potential in a small study of patients with spinal cord injury.[10]

Further studies of this technique as a tool for chronic pain management are warranted.

Biofeedback – a role in your patients?

Biofeedback for chronic pain

The ultimate question is whether biofeedback has a role in daily clinical practice with chronic pain patients. The evidence certainly suggests that it can be efficacious. It also has support in a number of international guidelines.

For example, the American Society of Anesthesiologists’ guidelines on managing chronic pain note that psychological treatments like biofeedback: “may be used as part of a multimodal strategy for low back pain and for other chronic pain conditions”.[11]

The Institute for Clinical Systems Improvements’ guidelines on the assessment and management of chronic pain suggest that an interdisciplinary team approach is desirable, with a cognitive-behavioral component that may include biofeedback.[12]

The elderly offer a potentially important target group, because the use of medical therapies is often limited by comorbidities.[13] The British Geriatric Society’s guidance on the management of pain in older people states that biofeedback appears to be as efficacious in older patients as in younger subjects.[14] Hence, it could be an important part of multidisciplinary pain management in these patients.

Moving forward with biofeedback, important challenges remain. For example, further work is needed to better understand which physiological parameters to provide feedback on among pain patients.[1] Additional research may help to elucidate the parameters that subjects are most able to modulate, and those that are most closely related to pain.[1]

In the meantime, current biofeedback techniques can offer important benefits to patients. They should be considered as part of a multidisciplinary approach to chronic pain.


1. Jensen KB, Berna C, Loggia ML, et al. The use of functional neuroimaging to evaluate psychological and other non-pharmacological treatments for clinical pain. Neurosci Lett 2012;520(2):156-164.

2. WebMD. Overview of Biofeedback. 2014. Available at: 13 October 2014.

3. Yilmaz OO, Senocak O, Sahin E, et al. Efficacy of EMG-biofeedback in knee osteoarthritis. Rheumatol Int 2010;30:887-892.

4. Tsai PS, Chen PL, Lai YL, Lee MB, Lin CC. Effects of electromyography biofeedback-assisted relaxation on pain in patients with advanced cancer in a palliative care unit. Cancer Nurs 2007;30:347-353.

5. Hassett AL, Radvanski DC, Vaschillo EG, et al. A pilot study of the efficacy of heart rate variability (HRV) biofeedback in patients with fibromyalgia. Appl Psychophysiol Biofeedback 2007;32:1-10.

6. Aggarwal VR, Lovell K, Peters S, et al. Psychosocial interventions for the management of chronic orofacial pain. Cochrane Database Syst Rev 2011;11:CD008456.

7. Nestoriuc Y, Martin A, Rief W, Andrasik F. Biofeedback treatment for headache disorders: a comprehensive efficacy review. Appl Psychophysiol Biofeedback 2008;33:125-140.

8. Caro XJ, Winter EF. EEG biofeedback treatment improves certain attention and somatic symptoms in fibromyalgia: a pilot study. Appl Psychophysiol Biofeedback 2011;36:193-200.

9. Kayiran S, Dursun E, Dursun N, Ermutlu N, Karamürsel S. Neurofeedback intervention in fibromyalgia syndrome; a randomized, controlled, rater blind clinical trial. Appl Psychophysiol Biofeedback 2010;35:293-302.

10. Jensen MP, Gertz KJ, Kupper AE, et al. Steps toward developing an EEG biofeedback treatment for chronic pain. Appl Psychophysiol Biofeedback 2013;38:101-108.

11. American Society of Anesthesiologists Task Force on Chronic Pain Management; American Society of Regional Anesthesia and Pain Medicine. Practice guidelines for chronic pain management: an updated report by the American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine. Anesthesiology 2010;112:810-833.

12. Hooten WM, Timming R, Belgrade M, et al. Institute for Clinical Systems Improvement. Assessment and Management of Chronic Pain. Updated November 2013. Available at: Accessed 13 October 2014.

13. Marcus DA. Chronic Pain: A Primary Care Guide to Practical Management. 2nded. Totowa, NJ: Humana Press; 2009.

14. Abdulla A, Adams N, Bone M, et al. Guidance on the management of pain in older people. Age Ageing 2013;42(Suppl 1):i1-i57.