This paper is in the following e-collection/theme issue:

Letters to the Editor (4) New Methods (1149) Chronic Conditions (458) Digital Pain Assessment and Management (243) Brain-Machine Interfaces (23) Cognitive and Neurorehabilitation (366) Neurotechnology in Clinical Studies (26) Methods and Feasibility Studies (481) Pilot studies (non-ehealth) (113)

Published on in Vol 15 (2026)

Preprints (earlier versions) of this paper are available at https://preprints.jmir.org/preprint/87420, first published .
Bridging Neurofeedback and Structural Connectivity in Chronic Pain

Bridging Neurofeedback and Structural Connectivity in Chronic Pain

Bridging Neurofeedback and Structural Connectivity in Chronic Pain

Authors of this article:

Alaeddin Acar1 Author Orcid Image ;   Diaa Yahya2 Author Orcid Image ;   Eray Tekirdaş3 Author Orcid Image
Article Authors Cited by Tweetations Metrics

    1Department of Neurosurgery, Kulu State Hospital, No 4, 139518 Street, Dinek, Kulu, Konya, Turkey

    2Department of Neurosurgery, Bucak State Hospital, Burdur, Turkey

    3Department of Neurosurgery, Malatya Training and Research Hospital, Malatya, Turkey

    Corresponding Author:

    Alaeddin Acar, MD



    We read with great interest and appreciation the article by Bialostocki et al [1] published in JMIR Research Protocols. The authors present an innovative electroencephalography-based neurofeedback (EEG-NF) protocol targeting abnormal activity in the right insula (RIns) and dorsal anterior cingulate cortex (dACC) [1].

    The authors’ goal of exploring the functional connectivity between these two key regions is particularly noteworthy. This approach aims to modulate the “salience network,” which is involved in processing the emotional-motivational aspects of pain and includes the RIns and dACC as key nodes [2].

    At this point, we would like to offer a constructive contribution by approaching the protocol’s underlying mechanism from a neurosurgical perspective. This functional circuit involving the RIns and dACC is thought to operate, at least in part, on a structural foundation provided by the cingulum bundle [2].

    This connection is important because invasive modulation of this circuit is a long-established neurosurgical procedure. Anterior cingulotomy is used as a “last resort” option for treatment-resistant, intractable chronic pain syndromes, especially when the affective component of pain is dominant [3]. This procedure creates ablative lesions in the cingulum bundle, permanently interrupting the circuit that Bialostocki et al [1] aim to noninvasively “downtrain.” It is well documented that anterior cingulotomy reduces the emotional response to pain and the component of suffering, rather than the pain intensity itself [3], which is a close parallel to the known functions of the RIns and dACC.

    The EEG-NF protocol presented by Bialostocki et al [1] may therefore be viewed, at least conceptually, as a noninvasive counterpart to this invasive surgical approach. Given this parallel, the inclusion of structural imaging methods, such as diffusion tensor imaging (DTI), could add great value to the protocol. The literature, including a systematic review of DTI in migraine, a chronic pain disorder, has shown that the microstructural integrity of key white matter tracts (eg, reduced fractional anisotropy in thalamic radiations, corpus callosum, cingulum, and association fibers) is frequently altered [4].

    This raises two important questions for future studies:

    1. Could the pretreatment structural integrity of the cingulum bundle, as measured by DTI, be used as a biomarker to predict a patient’s response to this EEG-NF therapy?
    2. Can a successful neurofeedback intervention lead to measurable neuroplastic changes in the cingulum bundle, as measured by DTI? Indeed, a strong relationship between functional and structural connectivity has been reported [5].

    In conclusion, we believe that adding structural DTI analysis to the innovative protocol by Bialostocki et al [1] may deepen the understanding of the targeted mechanisms, help bridge the gap between noninvasive neuromodulation and invasive neurosurgery, and aid in optimizing patient selection for larger clinical trials in the future.

    Acknowledgments

    Google Gemini was used for language editing.

    Conflicts of Interest

    None declared.

    1. Bialostocki LS, Adhia DB, Mudiyanselage DR, et al. Neurofeedback training for managing neuropathic pain-like features in chronic musculoskeletal pain: protocol for an open-label pilot feasibility clinical trial. JMIR Res Protoc. Nov 4, 2025;14(1):e78806. [CrossRef] [Medline]
    2. Seeley WW, Menon V, Schatzberg AF, et al. Dissociable intrinsic connectivity networks for salience processing and executive control. J Neurosci. Feb 28, 2007;27(9):2349-2356. [CrossRef] [Medline]
    3. Sharim J, Pouratian N. Anterior cingulotomy for the treatment of chronic intractable pain: a systematic review. Pain Physician. 2016;19(8):537-550. [Medline]
    4. Rahimi R, Dolatshahi M, Abbasi-Feijani F, et al. Microstructural white matter alterations associated with migraine headaches: a systematic review of diffusion tensor imaging studies. Brain Imaging Behav. Oct 2022;16(5):2375-2401. [CrossRef] [Medline]
    5. Greicius MD, Supekar K, Menon V, Dougherty RF. Resting-state functional connectivity reflects structural connectivity in the default mode network. Cereb Cortex. Jan 2009;19(1):72-78. [CrossRef] [Medline]

    ‎
    dACC: dorsal anterior cingulate cortex
    DTI: diffusion tensor imaging
    EEG-NF: electroencephalography neurofeedback
    RIns: right insula

    Edited by Amy Schwartz; This is a non–peer-reviewed article. submitted 08.Nov.2025; accepted 08.Dec.2025; published 28.Jan.2026.

    Copyright

    © Alaeddin Acar, Diaa Yahya, Eray Tekirdaş. Originally published in JMIR Research Protocols (https://www.researchprotocols.org), 28.Jan.2026.

    This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Research Protocols, is properly cited. The complete bibliographic information, a link to the original publication on https://www.researchprotocols.org, as well as this copyright and license information must be included.