How Biofeedback Can Help Defeat Chronic Pain

Weaning patients off opioids and ending pain management visits thanks to cardiorespiratory training.

“The longer you have pain, the better your spinal cord gets at producing danger messages to the brain, even if there is no danger in the tissue”: Dr. Lorimer Moseley, a pain scientist at the University of South Australia, outlines how our brain and nervous system “learn” to keep producing pain. This statement offers hope – because we can also teach them to stop doing so.

Chronic pain is one of the most common reasons why adults seek medical care. Linked to numerous physical and mental conditions, it contributes to high healthcare costs and a decrease in productivity. Studies estimate that the prevalence of chronic pain in the U.S., as an example, ranges from 11 to 40% of the population. In 2016, an estimated 20.4% of U.S. adults had chronic pain; and 8% of U.S. adults suffered from high-impact chronic pain, defined as lasting three months or longer and accompanied by at least one major activity restriction. Authors of a recent case report propose that biofeedback can modulate heart rate variability (HRV) whole-health biomarkers by inducing cardiorespiratory efficiency. This helps to reduce unremitting hyperarousal as a cause for chronic pain, assess for opioid risk behavior, as well as improve overall outcomes.

Measuring pain 

The Pain Catastrophizing Scale (PCS), developed by Chaves and Brown in 1978, consists of 13 items rated on a 5-point scale. Participants are instructed to indicate the degree to which they have specific thoughts and feelings when experiencing pain. PCS assesses the extent of catastrophic thinking due to low back pain according to the key factors of rumination, magnification, and helplessness. Out of these, rumination is most highly correlated with pain outcomes. In this context, a recent case review demonstrates a bidirectional relationship between hyperarousal and pain linked to intrusive thoughts and catastrophizing.

In order to minimize catastrophic thinking, clinicians may work with patients to disengage attention toward pain symptoms. Persistent and inflexible sympathetic dominance appears to play a key role in relieving chronic pain; it can be measured by the variation in time between each heartbeat (HRV). Greater variability indicates greater ability of the autonomic nervous system to regulate itself. 

The case report by Raouf Gharbo et al., referred to above, looks to untangle the relationship between chronic pain and hyperarousal. By disengaging fear ruminations using heart rate variability biofeedback (HRVB), this framework has the potential to reverse the negative effects of helplessness as measured by PCS. This case presents an elderly female with a complex medical history who had suffered from daily axial low back pain for over five years, worsened by physical activity but temporarily ameliorated by opioids. The patient accepted the offer for a program centered on physiological grounding of fear ruminations with regular HRVB practice – a non-invasive therapy training aiming at increasing heart rate oscillations through real-time feedback and slow breathing training. 

The benefits of HRVB

HRVB training has been shown to improve HRV coherence (HRV-c), restore autonomic health, and reduce the severity of symptoms. With cyclical diaphragmatic breathing, HRV-c is achieved when cardiac beat-to-beat intervals increase and decrease in synchrony with respiration, and shift into a smooth sinusoidal rhythm. High HRV-c has been associated with improved mood, cognition, and executive functions. Raouf Gharbo et al., who also run a randomized controlled trial studying HRVB for chronic pain in veterans, describe the positive effects of HRVB training on their patient. Her skills of inducing and maintaining cardiorespiratory synchronization improved and persisted, she was weaned off opioids, and did not require any more pain management visits. These results underline that HRVB can enhance quality of life and reduce healthcare costs.

Today, patients can use their smartphones for managing chronic pain (e.g. Caspar Health, Kaia Health). Smartphones also enable HRV measurement, supporting patients who opt for breathing exercises to provide a simple and cost-effective way to take control of their body functions. The fight against chronic pain can be won, as Dr. Moseley suggested.