• Users Online: 377
  • Home
  • Print this page
  • Email this page
Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 

 Table of Contents  
Year : 2021  |  Volume : 8  |  Issue : 1  |  Page : 65-68

Biofeedback in oral cancer pain: A review

Department of Oral Pathology and Microbiology, Dr. D. Y. Patil Dental College and Hospital, Dr. D. Y. Patil Vidyapeeths Pune, Maharashtra, India

Date of Submission25-Aug-2020
Date of Decision14-Sep-2020
Date of Acceptance17-Sep-2021
Date of Web Publication25-Feb-2021

Correspondence Address:
Roopa Yadahalli
Department of Oral Pathology and Microbiology, Dr. D. Y. Patil Vidyapeeth's, Dr. D. Y. Patil Dental College and Hospital, Pimpri, Pune - 411 018, Maharashtra
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jdrr.jdrr_112_20

Rights and Permissions

Pain is one of the initial symptoms in oral cancer, and is a prevalent condition in patients who are waiting for the treatment and in those undergoing treatment. Literature reviews very little data on the management of oral cancer pain nonpharmacologically. Successful management of pain control needs to be tackled by a multimodal approach. There is no confirmation of the effectiveness of nonpharmacological ways as relaxation, imagery, hypnosis, distraction, and biofeedback for the treatment of oral cancer pain. Recently, biofeedback and relaxation therapy are known to be a potential treatment for an extensive range of conditions. This biofeedback therapy can be applied to oral cancer pain management through the muscle relaxation technique is being covered in the present review.

Keywords: Biofeedback, cancer, oral cancer, pain management

How to cite this article:
Yadahalli R, Sarode GS, Sarode SC. Biofeedback in oral cancer pain: A review. J Dent Res Rev 2021;8:65-8

How to cite this URL:
Yadahalli R, Sarode GS, Sarode SC. Biofeedback in oral cancer pain: A review. J Dent Res Rev [serial online] 2021 [cited 2023 Feb 5];8:65-8. Available from: https://www.jdrr.org/text.asp?2021/8/1/65/310188

  Introduction Top

One of the unpleasant sequels of cancer is pain, mostly creating major psychological agony to the patient. This particular issue is aimed at one of the significant problems faced by society.[1] The cancer pain is uttered to be “second only to the fear of death.”[2] From the clinicians' point of view, pain seems to be the toughest entity regarding diagnosis and remedial aspects in oncology. Proper management of cancer pain is required and which requires multidisciplinary means. Cancer pain can be most sensibly dealt with generally by the blending of pharmacological, psychological, behavioral, anesthetic, stimulatory, and rehabilitative methods. Cognitive and behavioral therapy, being relaxation, imagery, hypnosis, distraction, and biofeedback, are persuasive as an element of nonpharmacological access.[3] These complemental modes which could benefit physically and even psychologically are suggested to be incorporated along with conventional way of treatment as almost sufferers of cancer were not fulfilled by the standard protocol in curing these problems.[4]

The survivors of cancer also go for nonpharmacological and alternative medicine therapies, usually to cope up with symptoms such as pain, anxiety, depression, and insomnia.[5] In the present era, mind-body therapies are seeking attention in regulating symptoms and developing good life quality and comfort in cancer and cancer survivors.[6],[7] Even the National Comprehensive Cancer Network advocated accepting nonpharmacological therapies when pain score is noted at 4 or more on a 10-point scale by re-evaluating of pharmacological treatment for adult cancer pain.[8] In general, patients are unwilling for narcotic analgesics due to the stigma attached, or only used at times during severe pain.[9] Recently, biofeedback and relaxation therapy, a nonpharmacological approach is known to be a potential remedy for a wide range of conditions.[10] This paper reviews the concept and importance of biofeedback therapy in managing pain dealt with cancer pain with its future implications.

  Biofeedback Therapy Top


Biofeedback therapy is the commonly followed mind-body therapies aiming at the insight of disease and treatment. It has different types of training most common being–electromyography (EMG), skin temperature (ST) biofeedback, and neurofeedback methods.[10] Neurofeedback is a type of biofeedback, which relay on self-control of brain functions to subjects by evaluating brain waves and furnishing a feedback signal.[11] EMG is a competent method in providing individuals to breach the tension cycle of pain-anxiety-muscle by gaining the acquired relaxation reaction. It runs by the concept of electronic monitoring were subjects are attached to sensors with surface EMG electrodes, and externally a probe to record ST. Then, “feedback” is given by these sensors as a visual or auditory way to assist a person in gaining attention and control upon a range of conditions on their physiology. The gradual learning is acquired by patients' involuntary control on that function [Flow Chart 1].[12],[13] This methodology is assisted by a trained person who is qualified by a certified biofeedback therapist. The patient is trained to gain this response by taking breaths by the diaphragm which is slow, deep, and steady, with the movement of the chest being very less. The accuracy of breathing is monitored by the Procomp + biofeedback device. Subsequently on gaining accurate training on diaphragmatic breathing, then individuals are trained for 6 sittings on guided biofeedback. The most followed method in EMG biofeedback is placing the electrodes over the frontal area. As per protocol during the first 2 training sessions, subjects was instructed for deep and slow breathing up to 4–7 times per min keeping under the observation of visual display of their EMG signals. Then, in the subsequent 4 sessions, it was followed by the inhibition of auditory signals. The favorable result of required diaphragmatic breathing was showed by displaying fall in frontal is EMG levels after practices.[14]

Neurofeedback therapy mainly focuses on the alpha, beta, delta, theta, and gamma treatment or a combination protocols as alpha/theta ratio, beta/theta ratio.[15],[16] Neurofeedback methodology follows by self-regulation training protocol, by which patient can reduce or even eliminate pain sensations. Studies revealed the changes in the functional organization of the brain at the point of the somatosensory cortex in patients with chronic pain. Biofeedback protocols are plotted regarding the peripheral correlation of arousal, such as temperature, heart rate variability, and muscle tension while neurofeedback direct effect on the processing of pain perception.[17]

  Pain-related to Oral Cancer Top

The foremost sign of oral cancer can be a pain and is a usual problem of patients waiting for therapy, in those undergoing treatment and even those who underwent the treatment.[18] This oral malignancy being particular in that it causes intense pain at the primary site and remarkably hinders speaking, deglutition, and masticatory activities.[19] The reasons for cancer-associated pain may be of tumor progression, invasive procedures regarding diagnostic or therapeutic aspects, chemo, and radiotherapy-induced toxicity, infection, or muscle pain by limitation of physical movement.[20] Many consequences make difficult in managing head- and neck-related malignancy pain due to: the evasiveness of tumors due to location; the high vascular supply of the region; the sudden pain aroused by constant functions as mastication, speaking, and the neural pain caused by chemotherapeutics and radiotherapeutics.[21]

Sixty percent is the expected 5-year survival rate for oral cancer patients. With this better rate of survival, a load of pain bared by these patients will also increase. Accordingly, the management of it needs care by palliative therapy to overcome the symptoms associated with cancer. Productive palliative care remains by proper identification of symptoms, which needs meticulous investigation of the applicable aspect of studies. At present, only a few studies related to quality-of-life are done which analyze cancer-related symptoms of oral cancer subjects. Oral cancer is seen in the buccal mucosa, the tongue was the muscle mass is significant and the biofeedback acts on the concept of a break-in pain-muscle-anxiety cycle which can be applied and studied appropriately. By summing up the result of all related studies suggest that accept of survival, pain comes in the foremost list of worry for oral cancer patients, while quality-of-life studies disclose serious stages of pain, debilitation, and anxiety in oral cancer subjects, present clinical trials, and therapy protocol do not adequately direct these problems.[22],[23]

  Pain Therapy in Cancer Top

Proper management of pain in oral cancer needs a multimodal plan of action in which it will range from chemotherapy to surgery and pharmacological management established by the World Health Organization, i.e., the analgesic ladder persists to show crucial role.[24] Opioids remain the choice of selection for moderate-to-severe cancer pain other than an analgesic.[25] In case of uncontrollable or refractory pain, the invading techniques such as anesthetic and the neurosurgical procedure are employed.[26] Side effects, particularly gastritis, renal toxicity, and more prone to bleeding, are seen with chronic use of analgesics. In case of frequent use of opioids only a limited volume is recommended but the side effects being induration and irritation at the site of infusion may be encountered along with infection and fatal complications such as obstruction of intravenous lines may also be noticed.[27] There are no confirmations regarding the effectiveness of nonpharmacological practice such as acupuncture, biofeedback, and hypnosis in managing the pain related to oral cancer. Even the outcomes have not been quantified of surgical, radiation, and chemotherapeutic modes which are been suggested as a critical part of pain management.[26]

The relaxation method of pain management is most useful clinically in combination with another form of distraction or pleasant imagery. Using this type of distracting or focusing creates command on the point of attention. The efficacy of biofeedback for overcoming the side effects habituated for chemotherapy has been proved.[9] To date, there are very few studies on cancer management using biofeedback, research on advanced cancer cases concerning pain assessed the significance of electromyography (EMG) biofeedback-assisted relaxation. Their study conveyed that six sessions were well to do for decreasing cancer-related pain when correlated to a normal care control group. Fotopoulos et al. noticed remarkable relief of pain in a class of cancer cases who made to follow electromyographic and electroencephalographic biofeedback-assisted relaxation.[28] The depletion in EMG parameters appears to recommend the alleged efficacy of relaxation by muscular relaxation and further, reducing restlessness and physiological arousal.[14] Individuals to manage more effectively with chronic pain, practicing biofeedback, and relaxation skills will probably intensify an ability to control and self-efficacy.[14]

  Conclusion Top

Nonpharmacological and complementary therapies also should be implicated as and when required. The eventual target for cancer pain management should be certainly a good quality of life and re-establishing physical and psychological health up to a possible extent with minimum side effects. To date, the use of relaxation interventions in cancer which are in an advanced stage and oral cancer cases is still not much revealed. Using biofeedback therapy to remove the muscle tension and decreasing the patients' muscle pain must be inculcated in pain and anxiety management of oral cancer patients also.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Bonica JJ. 'Management of cancer pain'. Acta Anaesfhia Scandinavia 1982;26:75-82.  Back to cited text no. 1
Ahle TA, Ruckdeschel JC, Blanchard EB. 'Cancer-related pain-Assessment with visual analogue scale'. J Psrcfiosomaric Res 1984;28:1984.  Back to cited text no. 2
Breitbart W. Psychiatric management of cancer pain. Cancer 1989;63:2336-42.  Back to cited text no. 3
Deng G, Cassileth BR. Integrative oncology: Complementary therapies for pain, anxiety, and mood disturbance. CA Cancer J Clin 2005;55:109-16.  Back to cited text no. 4
Mao JJ, Palmer CS, Healy KE, Desai K, Amsterdam J. Complementary and alternative medicine use among cancer survivors: A population-based study. J Cancer Surviv 2011;5:8-17.  Back to cited text no. 5
Bower JE. Mindfulness interventions for cancer survivors: Moving beyond wait-list control groups. J Clin Oncol 2016;34:3366-8.  Back to cited text no. 6
Deng G, Cassileth B. Complementary or alternative medicine in cancer care-myths and realities. Nat Rev Clin Oncol 2013;10:656-64.  Back to cited text no. 7
National Comprehensive Cancer Network. Adult Cancer Pain (Version 2.2005). NCCN clinical practice guidelines in oncologyVv. 2.2005. Available from: http://www.nccn.org/professionals/physician_gls/PDF/pain.pdf. [Last accessed on 2005 Jul 01]  Back to cited text no. 8
Twycross RG. Ethical and clinical aspects of pain treatment in cancer patients. Acta Anaesthesiol Scand 1982;26:83-90.  Back to cited text no. 9
Redd W, Silberfarb PM, Andersen BL, Andrykowski MA, Bovjberg D, Burish TG, et al. Psychological and physiological functioning in cancer patients. Cancer 1991;67:813-22.  Back to cited text no. 10
Marzbani H, Marateb HR, Mansourian M. Neurofeedback: A comprehensive review on system design, methodology and clinical applications. Basic Clin Neurosci 2016;7:143-58.  Back to cited text no. 11
Brandmeyer T, Delorme A. Meditation and neurofeedback. Front Psychol 2013;4:688.  Back to cited text no. 12
Lazaridou A, Edwards RR. Techniques and biofeedback for cancer pain management. In: Gulati A, Puttanniah V, Bruel B, Rosenberg W, Hung J, editors. Essentials of Interventional Cancer Pain Management. Cham: Springer; 2019.  Back to cited text no. 13
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;30:347-53.  Back to cited text no. 14
Dempster T. An Investigation into the Optimum Training Paradigm for Alpha Electroencephalographic Biofeedback (PhD Thesis). U.K: Canterbury Christ Church University; 2012.  Back to cited text no. 15
Vernon DJ. Can neurofeedback training enhance performance? An evaluation of the evidence with implications for future research. Appl Psychophysiol Biofeedback 2005;30:347-64.  Back to cited text no. 16
Ibric VL, Dragomirescu LG. Neurofeedback in pain management. In: Budzyknski TH Budzynski H K, Evans JR, Abarbanel A, editors. Introduction to Quantitative Eeg and Neurofeedback: Advanced Theory and Applications. 2nd ed. Amsterdam: Elsevier: Academic Press; 2009. p. 417-51.  Back to cited text no. 17
World Health Organization. Cancer Pain Relief and Palliative Care, Technical Report Series 804. Geneva: World Health Organization; 1990. p. 1-75.  Back to cited text no. 18
Lam DK, Schmidt BL. Serine proteases and protease-activated receptor 2-dependent allodynia: A novel cancer pain pathway. Pain 2010;149:263-72.  Back to cited text no. 19
Foley KM. The treatment of cancer pain. N Engl J Med 1985;313:84-95.  Back to cited text no. 20
Datta S, Pai UT. Interventional approaches to management of pain of oral cancer. Oral Maxillofac Surg Clin North Am 2006;18:627-41.  Back to cited text no. 21
Viet CT, Schmidt BL. Biologic mechanisms of oral cancer pain and implications for clinical therapy. J Dent Res 2012;91:447-53.  Back to cited text no. 22
Chen SC, Yu WP, Chu TL, Hung HC, Tsai MC, Liao CT. Prevalence and correlates of supportive care needs in oral cancer patients with and without anxiety during the diagnostic period. Cancer Nurs 2010;33:280-9.  Back to cited text no. 23
World Health Organization. Cancer Pain Relief and Palliative Care, Technical Report Series 804. In: Geneva: World Health Organization; 1990. p. 1-75.  Back to cited text no. 24
Wootton M. Morphine is not the only analgesic in palliative care: Literature review. J Adv Nurs 2004;45:527-32.  Back to cited text no. 25
Kohase H, Miyamoto T, Umino M. A new method of continuous maxillary nerve block with an indwelling catheter. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002;94:162-6.  Back to cited text no. 26
Dios PD, Lestón JS. Oral cancer pain. Oral Oncology 2010;46:448-51.  Back to cited text no. 27
Fotopoulos SS, Graham C, Cook MR. Psychophysiologic control of cancer pain. In: Bonica JJ, Ventafridda V, editors. The International Symposium on Pain in Advanced Cancer: Advances in Pain Research and Therapy. New York: Raven Press; 1979. p. 231-44.  Back to cited text no. 28


Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

  In this article
Biofeedback Therapy
Pain-related to ...
Pain Therapy in ...

 Article Access Statistics
    PDF Downloaded175    
    Comments [Add]    

Recommend this journal