Effects of neurofeedback in the management of chronic pain: A systematic review and meta‐analysis of clinical trials

Background and Objective Neurofeedback provides real‐time feedback about neurophysiological signals to patients, thereby encouraging modulation of pain‐associated brain activity. This review aims to evaluate the effectiveness and safety of neurofeedback in alleviating pain and pain‐associated symptoms in chronic pain patients. Methods MEDLINE, PUBMED, Web of Science and PsycINFO databases were searched using the strategy: (“Neurofeedback” OR “EEG Biofeedback” OR “fMRI Biofeedback”) AND (“Pain” or “Chronic Pain”). Clinical trials reporting changes in pain following electroencephalogram (EEG) or functional magnetic resonance imaging (fMRI) neurofeedback in chronic pain patients were included. Only Randomised‐controlled trials (RCT), non‐randomised controlled trials (NRCT) and case series were included. Effect size was pooled for all RCTs in a meta‐analysis. Results Twenty‐one studies were included. Reduction in pain following neurofeedback was reported by one high‐quality RCT, five of six NRCT or low‐quality RCT and thirteen of fourteen case‐series. Pain reduction reported by studies ranged from 6% to 82%, with ten studies reporting a clinically significant reduction in pain of >30%. The overall effect size was ‐0.76 (95% Confidence Interval ‐1.31 to ‐0.20). Studies were highly heterogenous [Q(df=5)=18.46, p<0.002, I2=73%]. Improvements in depression, anxiety, fatigue and sleep were also seen in some studies. Common side‐effects included headache, nausea and drowsiness. These generally did not lead to withdrawal of therapy except in one study. Conclusions Neurofeedback is a novel therapy with promising but largely low‐quality evidence supporting its use in chronic pain. Further high‐quality trials comparing different protocols is warranted to determine the most efficacious way to deliver neurofeedback.