Biofeedback-Assisted Relaxation Therapy on Women with Breast Cancer after Mastectomy: Effects of EMG-HRV Biofeedback on Psychological Symptoms

Document Type : Original Article


1 Department of Clinical Psychology, Faculty of Psychology and Educational Sciences, Semnan University, Semnan, Iran

2 Department of Clinical Psychology, Faculty of Psychology and Educational Sciences, Semnan University, Semnan, Iran.



Introduction: Breast cancer patients usually react to mastectomy surgery by increased levels of stress, anxiety and depression which requires effective interventions.  The aim of present research was to investigate the effects of an Electromyography (EMG) and heart rate variability (HRV) biofeedback-assisted relaxation training to alleviate the psychological symptoms of mastectomy breast cancer women.
Method: In a randomized controlled trial design about 14 mastectomy women were randomly chosen and divided into two groups and measures of Depression Anxiety Stress Scale were gathered for them. The experimental group received biofeedback-assisted relaxation training, whereas no intervention administered on the control group. All subjects again completed the DASS scales afterwards. Indices of smooth artifact free surface Electromyography (sEMG) and HRV biofeedback recorded using a Biofeedback 2000 x-pert system Version 4. Data were analyzed by a General Linear Model: Multivariate Analysis of Variance statistical analysis.
Results: Depression, anxiety, and stress average scores showed a significant difference after biofeedback intervention. Significant differences were observed in the sEMG and Heart Rate Variability-Index (HRV-Index) measures of the two groups with better results for the experimental subjects as well.
Conclusion: The biofeedback-assisted relaxation training could effectively decrease negative psychological symptoms of the mastectomy breast cancer patients due to sEMG and HRV positive changes and is then recommended for these patients in the course of their treatment.


  1. References

    1. Pearson JL. The effects of an integrated exercise and recreation therapy intervention on breast cancer survivors: The University of North Carolina at Chapel Hill; 2012.
    2. Ives J. A comparison between a combined exercise and recreation therapy intervention and an exercise only intervention in post-treated breast cancer patients: The University of North Carolina at Chapel Hill; 2009.
    3. Kim KS, Lee SW, Choe M, Yi MS, Choi S, Kwon SH. Effects of abdominal breathing training using biofeedback on stress, immune response and quality of life in patients with a mastectomy for breast cancer. J Korean Acad Nurs. 2005;35(7):1295-303.
    4. Cherry DK, Burt CW, Woodwell DA. National ambulatory medical care survey: 2001 summary. Adv Data. 2003(337):1-44.
    5. Fisher B, Costantino JP, Wickerham DL, Cecchini RS, Cronin WM, Robidoux A, et al. Tamoxifen for the prevention of breast cancer: current status of the National Surgical Adjuvant Breast and Bowel Project P-1 study. J Natl Cancer Inst Monogr. 2005;97(22):1652-62.
    6. Stopeck AT, Lipton A, Body J-J, Steger GG, Tonkin K, De Boer RH, et al. Denosumab compared with zoledronic acid for the treatment of bone metastases in patients with advanced breast cancer: a randomized, double-blind study. J Clin Oncol. 2010;28(35):5132-9.
    7. Lam WW, Chan M, Ka HW, Fielding R. Treatment decision difficulties and post‐operative distress predict persistence of psychological morbidity in Chinese women following breast cancer surgery. Psycho‐Oncology: Journal of the Psychological, Social and Behavioral Dimensions of Cancer. 2007;16(10):904-12.
    8. Patel SR. The effects of yoga on mood disturbance and pain in an underserved breast cancer population: Yeshiva University; 2004.
    9. Goldschneider KR, Lucky AW. Pain management in epidermolysis bullosa. Dermatol Clin. 2010;28(2):273-82.
    10. Hosseinian E. Efficacy of group logotherapy on cancer patients' life expectation. International journal of behavioural sciences. 2010; 3(4): 287-292.
    11. Masoudnia E. Illness perception and delay in seeking help in women with breast cancer symptoms: An appraisal of self-regulation model. International journal of behavioural sciences. 2008; 2(3): 271-282.
    12. Vilholm OJ, Cold S, Rasmussen L, Sindrup SH. The postmastectomy pain syndrome: an epidemiological study on the prevalence of chronic pain after surgery for breast cancer. Br J Cancer. 2008;99(4):604.
    13. Andre F, Campone M, O'Regan R, Manlius C, Massacesi C, Tarek S, et al. Phase I study of everolimus plus weekly paclitaxel and trastuzumab in patients with metastatic breast cancer pretreated with trastuzumab. J Clin Oncol. 2010;28(34):5110-5.
    14. Raison CL, Capuron L, Miller AH. Cytokines sing the blues: inflammation and the pathogenesis of depression. Trends Immunol. 2006;27(1):24-31.
    15. Glaser R, Kiecolt-Glaser JK. Stress-induced immune dysfunction: implications for health. Nat Rev Immunol. 2005;5(3):243.
    16. Padgett DA, Glaser R. How stress influences the immune response. Trends Immunol. 2003;24(8):444-8.
    17. Prinsloo GE, Rauch HL, Derman WE. A brief review and clinical application of heart rate variability biofeedback in sports, exercise, and rehabilitation medicine. Phys Sportsmed. 2014;42(2):88-99.
    18. Frank DL, Khorshid L, Kiffer JF, Moravec CS, McKee MG. Biofeedback in medicine: who, when, why and how? Ment Health Fam Med. 2010;7(2):85.
    19. Wood CM, Kipp K. Use of audio biofeedback to reduce tibial impact accelerations during running. J Biomech. 2014;47(7):1739-41.
    20. Mirelman A, Herman T, Nicolai S, Zijlstra A, Zijlstra W, Becker C, et al. Audio-biofeedback training for posture and balance in patients with Parkinson's disease. Journal of neuroengineering and rehabilitation. 2011;8(1):35.
    21. Crowell HP, Milner CE, Hamill J, Davis IS. Reducing impact loading during running with the use of real-time visual feedback. journal of orthopaedic & sports physical therapy. 2010;40(4):206-13.
    22. Giggins OM,  McCarthy Persson U, Caulfield B. Biofeedback in rehabilitation. Journal of Neuroeng Rehabil. 2013; 10.1: 60.
    23. McNevin NH, Shea CH, Wulf G. Increasing the distance of an external focus of attention enhances learning. Psychol Res. 2003;67(1):22-9.
    24. Pascua LA, Wulf G, Lewthwaite R. Additive benefits of external focus and enhanced performance expectancy for motor learning. J Sports Sci. 2015;33(1):58-66.
    25. Burish TG, Jenkins RA. Effectiveness of biofeedback and relaxation training in reducing the side effects of cancer chemotherapy. Health Psychol. 1992;11(1):17.
    26. McGrady A. Psychophysiological mechanisms of stress. Principles and practice of stress management. 2007;3:16-37.
    27. Agelink MW, Boz C, Ullrich H, Andrich J. Relationship between major depression and heart rate variability.: Clinical consequences and implications for antidepressive treatment. Psychiatry Res. 2002;113(1-2):139-49.
    28. Watkins LL, Blumenthal JA, Carney RM. Association of anxiety with reduced baroreflex cardiac control in patients after acute myocardial infarction. Am Heart J. 2002;143(3):460-6.
    29. Wheat AL, Larkin KT. Biofeedback of heart rate variability and related physiology: A critical review. Appl Psychophysiol Biofeedback. 2010;35(3):229-42.
    30. Ratanasiripong P, Ratanasiripong N, Kathalae D. Biofeedback intervention for stress and anxiety among nursing students: a randomized controlled trial. ISRN Nurs. 2012.
    31. Ratanasiripong P, Sverduk K, Hayashino D, Prince J. Setting up the next generation biofeedback program for stress and anxiety management for college students: A simple and cost-effective approach. Coll Stud J. 2010;44(1):97-100.
    32. Peira N, Fredrikson M, Pourtois G. Controlling the emotional heart: Heart rate biofeedback improves cardiac control during emotional reactions. Int J Psychophysiol. 2014;91(3):225-31.
    33. Lin I-M, Fan S-Y, Lu H-C, Lin T-H, Chu C-S, Kuo H-F, et al. Randomized controlled trial of heart rate variability biofeedback in cardiac autonomic and hostility among patients with coronary artery disease. Behav Res Ther. 2015;70:38-46.
    34. Lovibond PF, Lovibond SH. The structure of negative emotional states: Comparison of the Depression Anxiety Stress Scales (DASS) with the Beck Depression and Anxiety Inventories. Behav Res Ther. 1995;33(3):335-43.
    35. Crawford JR, Henry JD. The Depression Anxiety Stress Scales (DASS): Normative data and latent structure in a large non‐clinical sample. Br J Clin Psychol. 2003;42(2):111-31.
    36. Brown TA, Chorpita BF, Korotitsch W, Barlow DH. Psychometric properties of the Depression Anxiety Stress Scales (DASS) in clinical samples. Behav Res Ther. 1997;35(1):79-89.
    37. Afzali A, Delavar A, Borjali A, Mirzamayn M. Psychometric characteristics of DASS-42 test based on a sample of high school students in Kermanshah. J Behav Sci Res. 2007;5(2):81-92.
    38. Jha A, Sen M, editors. sEMG Based Study on the Difference in the Muscle Strength of a Half Paralytic Person due to Stroke. Proc International Conference on Innovations in Engineering and Technology; 2014.
    39. Vaschillo E, Lehrer P, Rishe N, Konstantinov M. Heart rate variability biofeedback as a method for assessing baroreflex function: a preliminary study of resonance in the cardiovascular system. Appl Psychophysiol Biofeedback. 2002;27(1):1-27.
    40. Gruber BL, Hersh SP, Hall NR, Waletzky LR, Kunz JF, Carpenter JK, et al. Immunological responses of breast cancer patients to behavioral interventions. Biofeedback Self Regul. 1993;18(1):1-22.
    41. Masafi S, Rezaei O, Ahadi H. Efficacy of biofeedback associated with relaxation in decreasing anxiety in women with breast cancer during chemotherapy. Procedia-Social and Behavioral Sciences. 2011;30:143-8.
    42. McCraty R, Atkinson M, Tomasino D, Goelitz J, Mayrovitz HN. The impact of an emotional self-management skills course on psychosocial functioning and autonomic recovery to stress in middle school children. Integr Physiol Behav Sci. 1999;34(4):246-68.
    43. Arguelles L, McCraty R, Rees RA. The heart in holistic education. Encounter: Education for meaning and social justice. 2003;16(3):13-21.
    44. Masoudnia E. Illness perception and delay in seeking help in women with breast cancer symptoms: An appraisal of self-regulation model. Journal of Behavioral Sciences.2008; 2(3):271-282.

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