This article was written by our trainer Maria Vittoria Zulli
Fibromyalgia syndrome (FMS) is a long-term condition characterised by widespread chronic pain associated with fatigue, sleep disturbances, cognitive impairments, memory problems, anxiety, depression, and poor quality of life.
Due to the lack of effective treatments for fibromyalgia, scientists looked at Neurofeedback (NF) as a possible intervention for FMS
Effective treatments for fibromyalgia are lacking. Pharmacological agents such as analgesics and antidepressants (SSRIs) have only moderate efficacy and can cause short and long-term side effects. Other nonpharmacological treatments such as exercise and Cognitive Behavioural Therapy (CBT) are also implemented as therapeutic approaches for treating FMS, but these rarely lead to long-term relief. Despite the available nonpharmacological treatment approaches, the controlled trials supporting and providing evidence of the efficacy of these interventions remain limited (Hassett & Gevirtz, 2009). Due to the lack of effective treatments for fibromyalgia, scientists looked at Neurofeedback (NF) as a possible intervention for FMS.
The problem in the way pain messages are carried and received in the body by the central nervous system in FMS
The exact cause of fibromyalgia and its underlying mechanisms are not understood yet. However, one of the possible causes has to do with a problem in the way pain messages are carried and received in the body by the central nervous system (CNS), which may explain the constant feelings of pain and pain sensitivity.
Since neurofeedback works directly with the CNS, it can be a beneficial therapeutic approach for reducing FMS-related symptoms with no side effects and achieving long-term results compared to pharmacological treatments and other forms of therapies.
An imbalance of connectivity within the pain system in FMS
Imaging studies have demonstrated that patients with FMS show a reduction in pain tolerance as well as enhanced sensory processing (Mountz et al., 1995). Furthermore, FMS individuals also exhibit an imbalance of connectivity within the pain system, with enhanced brain connectivity in areas responsible for pain processing and a decrease in connectivity in areas involved in inhibitory pain mechanisms (Cifre et al., 2012).
Neurofeedback training targets aspects such as network connectivity and thus it can be possible to regulate the sensation of pain and provide relief to individuals with FMS.
Sensory Motor Rhythm (SMR) neurofeedback training can help reorganise the imbalance in pain perception
Sensory Motor Rhythm (SMR) brain waves are associated with an active mind and calm body, often affected by chronic pain and anxiety (Egner et al., 2004). SMR neurofeedback training can help reorganise the imbalance in pain perception (Egner & Gruzelier, 2001). Interestingly, SMR training increases P300 amplitudes in the brain, which are reduced in patients with FMS (Kayiran et al., 2007). The P300 amplitude reflects the activation of inhibitory processes in the CNS. Thus, a lower P300 amplitude in individuals with FMS indicates a decrease in inhibitory mechanisms, which results in the amplification and neuro-sensitization of pain (Ozgocmen et al., 2003). Neuro-sensitization is developed due to progressively enhanced reactivity of central nervous system mechanisms, which is why the symptoms experienced in FMS may appear excessive in duration and severity.
Since SMR neurofeedback training increases P300 amplitudes in the brain, it can potentially facilitate the activation of inhibitory processes and thus, improve pain perception and neuro-sensitization by suppressing the transmission of painful information in individuals with FMS.
The effectiveness of SMR neurofeedback training on individuals with FMS
Several studies looked at the effectiveness of SMR neurofeedback training on individuals with FMS, using self-report measures to evaluate pain levels. A preliminary study showed that 10 sessions of SMR training at C4 improved FMS-related symptoms in 3 female patients (Kayiran et al., 2007).
Their subsequent study showed that after receiving 20 sessions of SMR training in the same region (C4), 18 patients with FMS reported significant improvements in pain intensity, fatigue, depression, anxiety, and quality of life, compared to a control group receiving medication (Kayiran et al., 2010).
Interestingly, they found that the therapeutic efficacy of neurofeedback SMR training began in the 2nd week and reached a maximum effect at week 4, as opposed to the medication group where the maximum effect took longer to achieve (up to 8 weeks).
The efficient and long-lasting reduction of FMS symptoms might be related to the positive effect that neurofeedback training has on CNS inhibitory mechanisms.
A more recent study involving 37 women with FMS showed that after 20 sessions of SMR training at C4, there was an increase in SMR amplitude along with a significant improvement in pain perception and FMS symptoms (Barbosa-Torres & Cubo-Delgado, 2021).
The effect of alpha neurofeedback training has also been investigated in individuals with fibromyalgia
In addition to SMR training, the effect of alpha neurofeedback training has also been investigated in individuals with fibromyalgia. Studies have demonstrated that patients with chronic pain show a decrease in alpha brain waves (Jensen et al., 2013) and that alpha neurofeedback training reduces anxiety and improves cognitive processing and performance (Angelakis et al., 2007; Zoefel et al., 2011). Alpha brainwaves are associated with a state of relaxation.
When training SMR and alpha brain waves at C3, C4 and CZ for 8 weeks, 60 patients with FMS demonstrated a significant improvement in cognitive functions and sleep latency which resulted in reduced pain and symptom severity (compared to patients in a control group).
They concluded that pain is bi-directionally associated with both cognitive function and sleep. Therefore, by targeting both of these aspects, they could see a reduction in FMS-related pain symptoms (Wu et al., 2021)
Besides seeing significant improvements in pain, fatigue, depression and anxiety, further studies demonstrated that SMR neurofeedback training helps reduce attention difficulties in patients with FMS (Caro & Winter, 2011).
Here is a summary of some of the publications in the field of Neurofeedback therapy for Fibromyalgia. Click on the image to view as full screen:
Overall, the studies mentioned above demonstrate the efficacy of neurofeedback training in helping with fibromyalgia. Using protocols such as SMR and Alpha training can help improve the regulation of the CNS and reduce fibromyalgia-related symptoms with no side effects while providing long-term relief.
Angelakis, E., Stathopoulou, S., Frymiare, J. L., Green, D. L., Lubar, J. F., & Kounios, J. (2007). EEG neurofeedback: a brief overview and an example of peak alpha frequency training for cognitive enhancement in the elderly. The Clinical neuropsychologist, 21(1), 110–129. https://doi.org/10.1080/13854040600744839
Barbosa-Torres, C., & Cubo-Delgado, S. (2021). Clinical Findings in SMR Neurofeedback Protocol Training in Women with Fibromyalgia Syndrome. Brain sciences, 11(8), 1069. https://doi.org/10.3390/brainsci11081069
Caro, X. J., & Winter, E. F. (2011). EEG biofeedback treatment improves certain attention and somatic symptoms in fibromyalgia: a pilot study. Applied psychophysiology and biofeedback, 36(3), 193–200. https://doi.org/10.1007/s10484-011-9159-9
Cifre, I., Sitges, C., Fraiman, D., Muñoz, M. Á., Balenzuela, P., González-Roldán, A., Martínez-Jauand, M., Birbaumer, N., Chialvo, D. R., & Montoya, P. (2012). Disrupted functional connectivity of the pain network in fibromyalgia. Psychosomatic medicine, 74(1), 55–62. https://doi.org/10.1097/PSY.0b013e3182408f04
Egner, T., & Gruzelier, J. H. (2001). Learned self-regulation of EEG frequency components affects attention and event-related brain potentials in humans. Neuroreport, 12(18), 4155–4159. https://doi.org/10.1097/00001756-200112210-00058
Egner, T., Zech, T. F., & Gruzelier, J. H. (2004). The effects of neurofeedback training on the spectral topography of the electroencephalogram. Clinical neurophysiology : official journal of the International Federation of Clinical Neurophysiology, 115(11), 2452–2460. https://doi.org/10.1016/j.clinph.2004.05.033
Hassett, A. L., & Gevirtz, R. N. (2009). Nonpharmacologic treatment for fibromyalgia: patient education, cognitive-behavioral therapy, relaxation techniques, and complementary and alternative medicine. Rheumatic diseases clinics of North America, 35(2), 393–407. https://doi.org/10.1016/j.rdc.2009.05.003
Jensen, M. P., Sherlin, L. H., Gertz, K. J., Braden, A. L., Kupper, A. E., Gianas, A., Howe, J. D., & Hakimian, S. (2013). Brain EEG activity correlates of chronic pain in persons with spinal cord injury: clinical implications. Spinal cord, 51(1), 55–58. https://doi.org/10.1038/sc.2012.84
Kayiran, S., Dursun, E., Ermutlu, N., Dursun, N., & Karamürsel, S. (2007). Neurofeedback in fibromyalgia syndrome. Agri : Agri (Algoloji) Dernegi'nin Yayin organidir = The journal of the Turkish Society of Algology, 19(3), 47–53.
Kayiran, S., Dursun, E., Dursun, N., Ermutlu, N., & Karamürsel, S. (2010). Neurofeedback intervention in fibromyalgia syndrome; a randomized, controlled, rater blind clinical trial. Applied psychophysiology and biofeedback, 35(4), 293–302. https://doi.org/10.1007/s10484-010-9135-9
Mountz, J. M., Bradley, L. A., Model, J. G., Alexander, R. W., Triana-Alexander, M., Aaron, L. A., et al. (1995). Fibromyalgia in women. Abnormalities of regional cerebral blood flow in the thalamus and the caudate nucleus are associated with low pain threshold levels. Arthritis and Rheumatism, 38, 926–938.
Ozgocmen, S., Yoldas, T., Kamanli, A., Yildizhan, H., Yigiter, R., & Ardicoglu, O. (2003). Auditory P300 event related potentials and serotonin reuptake inhibitor treatment in patients with fibromyalgia. Annals of the rheumatic diseases, 62(6), 551–555. https://doi.org/10.1136/ard.62.6.551
Sterman M. B. (1996). Physiological origins and functional correlates of EEG rhythmic activities: implications for self-regulation. Biofeedback and self-regulation, 21(1), 3–33. https://doi.org/10.1007/BF02214147
Wu, Y. L., Fang, S. C., Chen, S. C., Tai, C. J., & Tsai, P. S. (2021). Effects of Neurofeedback on Fibromyalgia: A Randomized Controlled Trial. Pain management nursing : official journal of the American Society of Pain Management Nurses, 22(6), 755–763. https://doi.org/10.1016/j.pmn.2021.01.004
Zoefel, B., Huster, R. J., & Herrmann, C. S. (2011). Neurofeedback training of the upper alpha frequency band in EEG improves cognitive performance. NeuroImage, 54(2), 1427–1431. https://doi.org/10.1016/j.neuroimage.2010.08.078