Description
Biofeedback is a therapeutic technique that helps individuals learn to control physiological functions that are typically involuntary, such as heart rate, muscle tension, and blood pressure.
By employing electronic monitoring devices, biofeedback provides instant feedback on these bodily functions. This feedback supports individuals in making conscious adjustments to improve their health and well-being
Efficacy
Intestinal/anorectal function: There is some evidence from a meta-analysis, two good-sized randomized controlled trials (RCTs) and a cohort study that biofeedback may improve intestinal/anorectal function for rectal cancer patients, but the evidence is subject to risk of bias.
Port needle insertion: There is some evidence from one good-quality RCT (n=62) that a respiratory biofeedback-based virtual reality game may reduce pain, fear and anxiety for paediatric oncology patients having port needle insertion.
Other outcomes: There is currently inconclusive evidence from a small number of studies per outcome, all with methodological limitations, for the effects of biofeedback on continence in prostate cancer (one RCT, one cohort), anxiety (two RCTs), cognitive impairments (one SR, one RCT), quality of life (one SR, one RCT), pain (one SR, one RCT), nausea (one RCT), and sleep/fatigue (one SR, two RCTs).
Safety
Biofeedback is generally considered safe with only mild and transient adverse events.
Description and definition
Biofeedback is a process that enables an individual to learn how to modify physiological activity for the purposes of improving health and performance (Association for Applied Psychophysiology and Biofeedback USA, 2020). A variety of different biofeedback techniques are available. The two most commonly used techniques by people with cancer are electromyography (EMG), which measures the electric activity in muscles, and skin temperature (ST) biofeedback. These instruments rapidly and accurately 'feed back' information to the user. The presentation of this information, often in conjunction with changes in thinking, emotions, and behaviour, supports desired physiological changes. Over time, these changes can endure without continued use of an instrument.
Alleged indications
Biofeedback is aimed at facilitating the monitoring and regulation of specific physiological responses that an individual may be unaware of otherwise. Using biosensors, information related to specific physiological activities is presented back to the user, to improve self-awareness of internal states and learn self-regulation skills (Yu 2018).
In the context of cancer, biofeedback is commonly used to reduce stress and anxiety, improve pain and rehabilitation (Crevenna 2022). Adverse effects, including gastro-intestinal upsets such as nausea and vomiting that are caused by high levels of anxiety also appear to be reduced through this muscle relaxation mechanism.
Mechanism of action
Biofeedback allows the brain to learn and relearn self-regulation skills, changing the electroencephalogram (EEG) patterns, leading to symptomatic changes (Hetkamp 2019). It aims to improve the conscious control of the individual’s involuntary physiological activity (e.g. nausea and vomiting, peripheral blood flow or anorectal function) and acts as a distractor (Burish 1992; Li 2022). It has been suggested that the 'relaxation response' may help break the pain-anxiety-muscle-tension cycle (Tsai 2007). It has been proposed that learning biofeedback and relaxation skills can contribute to improved feelings of self-efficacy, by helping people with cancer feel more in control of any side-effects including chronic pain (Tsai 2007).
Application and dosage
Biofeedback is often taught by health care professionals including clinical psychologists and nurses, as well as hypnotherapists and complementary practitioners. Training is either conducted in groups or one-on-one sessions, lasting twenty to thirty minutes. Interactive computer programs or mobile devices can also be used, with or without therapist input (Yu 2018). There is, however, inconsistency in the ‘dosage’ e.g. for heart rate variability feedback total duration, minutes of breathing, number of sessions and location varied widely (Lalanza 2023). The ‘dosage’ depends on the training goal, and guidelines are lacking (Yu 2018)
The focus is on training rather than treatment, as biofeedback is an active intervention (Frank 2010), with detailed explanations given to participants, including suggestions about how to influence physiological responses and any symptoms they are experiencing. For example, EMG-biofeedback users are told they may find it helpful to imagine relaxing and letting go of any muscle tension and see how this alters the biofeedback reading and tone. ST-biofeedback users are told they may find it helpful to imagine that their fingers and hands are warm and comfortable. A small band indicates changes in finger temperature.
Legal issues
The Biofeedback Certification International Alliance (BCIA) certifies individuals who meet education and training standards in biofeedback and neurofeedback, and progressively recertifies those satisfying continuing education requirements.
In Europe, the Biofeedback Federation of Europe (BFE) and the European Association for Biofeedback and Applied Psychophysiology (EABP) are aimed at setting standards, providing certification, and fostering a community of professionals dedicated to the advancement of biofeedback techniques. In the US, the Association for Applied Psychophysiology and Biofeedback USA (AAPB) is a key professional organization in the field, which collaborates with BCIA to ensure standards and ongoing research in biofeedback.
In cancer care, different types of biofeedback have been used in a wide variety of health care and rehabilitation settings.
Two systematic reviews (SRs) have been published. One on biofeedback for patients with bowel dysfunction following rectal cancer surgery in 12 studies with a total of 561 patients: two randomized controlled trials (RCTs), two nonrandomised studies, and 8 case series (Li 2022). The other systematic review of neurofeedback (NF) or electroencephalogram (EEG)-biofeedback in cancer patients included six studies: three RCTs (n=71, 71 and 82, respectively), one observational study (n=22) and two case reports (Hetkamp 2019).
In addition, eight RCTs reported in nine papers (Burish 1992; Cho 2021; de Lira 2019; Fink 2023; Hasuo 2023; Kye 2016; Liu 2019; Savaş 2024b; Tsai 2007), and two controlled cohort studies (Liang 2016; Yoshida 2018) have assessed the benefits of biofeedback for cancer patients (but were not included in the two reviews). There are few trials per treatment outcome and most trials have small sample sizes and other methodological limitations. The trials are presented in Table 1.
We also identified 14 small feasibility or pilot studies (Burch 2020; Chen 2022; Chepeha 2024; Dreneva 2020; Fournié 2022; Girod-Roux 2020; Gruber 1993; Rolbiecki 2023; Şahin 2016; Savaş 2024a; Schmidt 2023; Schwenk 2016; Sideroff 2023; Yamauchi 2021) which we have not included here given the volume of definitive RCTs.
Description of studies
Intestinal/anorectal function
A well conducted SR with meta-analysis included 12 studies on biofeedback in patients with bowel dysfunction following rectal cancer surgery (Li 2022). Their meta-analysis found significant improvements in bowel function (Wexner score: t=7, MD=3.33; 95% CI 2.48, 4.18; Vaizey score: t=3, MD=2.46; 95% CI 1.98, 2.93). However, the majority of the studies were case series or non-randomised studies, most were small and at high risk of bias.
A well conducted RCT (n=126) of EMG biofeedback for patients with middle and low rectal cancer found significant improvements in intestinal function compared to both pelvic floor muscle training and standard care (Liu 2019). The study was relatively large, but it is unclear how sample size was calculated, there were no objective outcome measures and compliance with the intervention was not assessed.
Another well-conducted RCT (n=56) (Cho 2021) and interim analysis (Kye 2016) of biofeedback for rectal cancer patients with sphincter-saving surgery found no difference in the primary outcome of incontinence, but did find a significant difference between biofeedback and control group in liquid stool incontinence , mean resting pressure stability and maximal sensory threshold at 12 months and in change of mean resting pressures at 6 months. Both study groups also received recommendation to do self-rehabilitation e.g. Kegel exercises. The sample size was powered and the study is well reported, although there is little information on the biofeedback intervention.
A nonrandomised retrospective cohort study (n=61) ) also studied biofeedback for rectal cancer patients and found significant differences for maximum resting pressure, maximum squeeze pressure and rectal capacity compared to healthy volunteers (Liang 2016. Although well conducted, as a cohort study it cannot control for time, attention, therapist interaction, or other treatments.
Continence
A well-conducted RCT (n=31) of pelvic floor muscle training including EMG biofeedback for men undergoing radical prostatectomy for prostate cancer found no significant differences for incontinence compared to usual care (de Lira 2019). Although there was no loss to follow up the sample size was just under the number needed and objective outcome measures were not used.
A prospective cohort study (n=116) found biofeedback using ultrasound with pelvic floor training significantly reduced the mean time to continence recovery for men (n=116) undergoing radical prostatectomy compared to pelvic floor training only, although the sample size was not powered and group allocation included an element of preference (Yoshida 2018).
Mental health and cognitive outcomes
One SR of six studies and three additional RCTs included mental health or cognitive outcomes.
An RCT (n=56) compared alpha and theta neurofeedback training to mindfulness-based therapy for any cancer and found that distress, depression and anxiety decreased for biofeedback similarly to mindfulness but found no change for rumination (Fink 2023). There was no non-treatment control, and the study may be underpowered.
An RCT (n=81) assessed the effectiveness of electromyography (EMG) biofeedback, skin-temperature (ST) biofeedback and relaxation training in reducing the aversiveness of cancer chemotherapy for cancer patients with a history of or likely to have anxiety (Burish 1992). They showed that patients who undertook relaxation training, but not biofeedback, experienced a reduction in anxiety and physiological arousal during their chemotherapy, when compared to the no-intervention group. This study was good quality, but due to having 6 intervention groups it is difficult to ascertain the impact of biofeedback alone, and the size of each group is small, and it is unclear if the study was powered.
The SR by Hetkamp evaluated the effects of a specific type of biofeedback, neurofeedback or EEG biofeedback, on people with cancer (Hetkamp 2019). Six studies were included: three RCTs (n=71, 71 and 82, respectively), one observational study (n=223) and two case reports. They conclude that neurofeedback could be helpful in alleviating cognitive impairments. Although Hetkamp’s searches are well performed, meta-analysis was not possible due to study heterogeneity, and even the narrative synthesis is limited.
The above-mentioned RCT by Fink found no changes in cognitive impairment in biofeedback or mindfulness groups (Fink 2023, n=56).
Quality of life
Li’s (2022) SR also concluded that biofeedback resulted in improvements in health-related quality of life for patients with bowel cancer, although meta-analysis does not seem to have been performed for this outcome.
The RCT by Fink showed improvements in quality-of-life following biofeedback, for any cancer, compared to mindfulness, but the study may be underpowered (Fink 2023, n=56, see above under ‘mental health’).
Pain
The SR by Hetkamp concludes that all included studies of adults reported improvements in pain, but no analysis was performed and it is subject to limitations (Hetkamp 2019, see above under ‘mental health').
A small RCT (n=37), of biofeedback-assisted relaxation training for patients with advanced cancer found significant reduction in pain intensity compared to standard care (Tsai (2007). However, this study is limited by a small non-powered sample size and high dropout rate, and unclear method of randomisation.
Chemotherapy-induced nausea and vomiting
The RCT by Burish showed that all three groups using relaxation training experienced a reduction in nausea during their chemotherapy, when compared to groups receiving no relaxation therapy (Burish 1992, see above under ‘mental health’). EMG and ST biofeedback alone both reduced some indices of physiological arousal but did not reduce other measures of aversiveness of chemotherapy.
Sleep/fatigue
The SR by Hetkamp concludes that neurofeedback could be helpful in alleviating and fatigue but is very limited (Hetkamp 2019, see above under 'mental health').
Fink found no change in fatigue for biofeedback for any cancer (Fink 2023, n=56, see above under ‘mental health’).
The RCT by Hasuo (2023, n=50) investigated heart rate variability biofeedback for patients with incurable cancer and sleep disturbance, comparing a session in clinic and home practice to the clinic session only. They found that the home practice group had significantly greater improvement in sleep efficiency and heart rate variability. Their sample size seems adequate although some reporting details are missing.
Port needle insertion
Savas (2024b) compared a respiratory biofeedback-based virtual reality game to standard care, for paediatric oncology patients (age 6-12) having port needle insertion (n=62). They found reduced pain, fear, anxiety and respiratory rates and higher satisfaction. The RCT was well conducted.
Biofeedback is generally considered safe.
Adverse events
Adverse events are generally mild and transient and include headaches, tiredness, or emotional discomfort (NatMed 2020). EEG biofeedback has been linked to reports of decreased or increased seizure threshold (Ernst 2008), NatMed 2020).
One study analysed for this summary assessed safety and did not report any adverse events. (Hasuo 2023).
Contraindications
Some concern has been raised about the use of this intervention in individuals with epilepsy (see above). (Ernst 2008; Nat Med 2020).
Interactions
None known.
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Citation
Ava Lorenc, CAM-Cancer Collaboration. Biofeedback . November 2024.
Document history
Most recent update in October 2024 by Ava Lorenc. Updated in 2020, November 2015, November 2013 and September 2012 by Helen Cooke. Summary first published in August 2011, authored by Helen Cooke.
