Applied Psychophysiology and Biofeedback

, Volume 32, Issue 1, pp 1–10 | Cite as

A Pilot Study of the Efficacy of Heart Rate Variability (HRV) Biofeedback in Patients with Fibromyalgia

  • Afton L. HassettEmail author
  • Diane C. Radvanski
  • Evgeny G. Vaschillo
  • Bronya Vaschillo
  • Leonard H. Sigal
  • Maria Katsamanis Karavidas
  • Steven Buyske
  • Paul M. Lehrer
Original Paper


Fibromyalgia (FM) is a non-inflammatory rheumatologic disorder characterized by musculoskeletal pain, fatigue, depression, cognitive dysfunction and sleep disturbance. Research suggests that autonomic dysfunction may account for some of the symptomatology of FM. An open label trial of biofeedback training was conducted to manipulate suboptimal heart rate variability (HRV), a key marker of autonomic dysfunction. Methods: Twelve women ages 18–60 with FM completed 10 weekly sessions of HRV biofeedback. They were taught to breathe at their resonant frequency (RF) and asked to practice twice daily. At sessions 1, 10 and 3-month follow-up, physiological and questionnaire data were collected. Results: There were clinically significant decreases in depression and pain and improvement in functioning from Session 1 to a 3-month follow-up. For depression, the improvement occurred by Session 10. HRV and blood pressure variability (BPV) increased during biofeedback tasks. HRV increased from Sessions 1–10, while BPV decreased from Session 1 to the 3 month follow-up. Conclusions: These data suggest that HRV biofeedback may be a useful treatment for FM, perhaps mediated by autonomic changes. While HRV effects were immediate, blood pressure, baroreflex, and therapeutic effects were delayed. This is consistent with data on the relationship among stress, HPA axis activity, and brain function.


Heart rate variability Biofeedback Fibromyalgia Depression Pain Breathing 



We thank the patients with FM from the Rheumatology clinic at Robert Wood Johnson Medical School for their willingness to assist us with our research. We also remain grateful to the Arthritis Foundation, especially the New Jersey Chapter, for their ongoing support of this and other HRV biofeedback research for patients with FM. Finally, we would like to thank the anonymous reviewers for their helpful contributions to the text of this paper.


  1. Aaron, L. A., Burke, M. M., & Buchwald, D. (2000). Overlapping conditions among patients with chronic fatigue sybdrome, fibromyalgia and temporomandibular disorder. Archives of Internal Medicine, 160, 221–227.PubMedCrossRefGoogle Scholar
  2. Agelink, M. W., Majewski, T., Wurthmann, C., Postert, T., Linka, T., & Rotterdam, S. (2001). Autonomic neurocardiac function in patients with major depression and effects of antidepressive treatment with nefazodone. Journal of Affective Disorders, 62, 187–198.PubMedCrossRefGoogle Scholar
  3. Asmundson, G. J., & Stein, M. B. (1994). Vagal attenuation in panic disorder: An assessment of parasympathetic nervous system function and subjective reactivity to respiratory manipulations. Psychosomatic Medicine, 56, 187–193.PubMedGoogle Scholar
  4. Badra, L. J., Cooke, W. H., Hoag, J. B., Crossman, A. A., Kuusela, T. A., Tahvanainen, K. U., & Eckberg, D. L. (2001). Respiratory Modulation of human autonomic rhythms. American Journal of Physiology - Heart & Circulatory Physiology, 280, H2674–H2688.Google Scholar
  5. Beck, A. T., Steer, R. A., & Brown, G. K. (1996). Manual for Beck Depression Inventory-II. San Antonio, TX: Psychological Corporation.Google Scholar
  6. Bennett, R. (2005). Fibromyalgia: present to future. Current Rheumatology Reports, 7(5), 371–376.PubMedGoogle Scholar
  7. Bou-Holaigah, I., Rowe, P. C., Kan, J. S., & Calkins, H. (1995). The relationship between neurally mediated hypotension and the chronic fatigue syndrome. Journal of the American Medical Association, 1274, 961–967.CrossRefGoogle Scholar
  8. Buckelew, S. P., Conway, R., Parker J., Deuser, W. E., Read J., Witty, T. E., et al. (1998). Biofeedback/relaxation training and exercise interventions for fibromyalgia: a prospective trial. Arthritis Care Research, 11(3), 196–209.CrossRefGoogle Scholar
  9. Burckhardt, C. S., Clark, S. R., & Bennett, R. M. (1991). The Fibromyalgia Impact Questionnaire: development and validation. Journal of Rheumatology, 18, 728–733.PubMedGoogle Scholar
  10. Burr, R. L., Heitkemper, M., Jarrett, M., & Cain, K. C. (2000). Comparison of autonomic nervous system indicies based on abdominal pain reports in women with irritable bowel syndrome. Biological Research for Nursing, 2, 97–106.PubMedCrossRefGoogle Scholar
  11. Buysse, D. J., Reynolds, C. F., Monk, T. H., Berman, S. R., & Kupfer, D. J. (1989). The Pittsburgh Sleep Quality Index: a new instrument for psychiatric research and practice. Psychiatry Research, 28, 193–213.PubMedCrossRefGoogle Scholar
  12. Carpenter, J. S., & Andrykowski, M. A. (1998). Psychometric evaluation of the Pittsburgh Sleep Quality Index. Journal of Psychosomatic Research, 45, 5–13.PubMedCrossRefGoogle Scholar
  13. Chernigovskaya, N. V., Vaschillo, E. G., Petrash, V. V., & Rusanovsky, V. V. (1990). Voluntary regulation of the heart rate as a method of functional condition correction in neurotics. Human Physiology, 16, 58–64.Google Scholar
  14. Chernigovskaya, N. V., Vaschillo, E. G., Rusanovsky, V. V., & Kashkarova, O. E. (1990). Instrumental autotraining of mechanisms for cardiovascular function regulation in treatment of neurotics. The SS Korsakov's Journal of Neuropathology and Psychiatry, 90, 24–28.Google Scholar
  15. Clauw, D. J., & Chrousos, G. P. (1997). Chronic pain and fatigue syndromes: overlapping clinical and neuroendocrine features and potential pathogenic mechanisms. Neuroimmunology, 4, 134–153.Google Scholar
  16. Clauw, D. J., Radulovic, D., Antonetti, D., Bagati, R., Baraniuk, J., & Barbey, J. T. (1996). Tilt table testing in fibromyalgia. Arthritis and Rheumatism, 39(9S), S276.Google Scholar
  17. Clauw, D. J., Radulovic, D., Heshmat, Y., & Barbey, J. T. (1996). Heart rate variability as a measure of autonomic dysfunction in patients with fibromyalgia. Arthritis and Rheumatism, 39(9S), S276.Google Scholar
  18. Cohen, H., Benjamin, J., Geve, A., Matar, A., Kaplan, Z., & Kotler, M. (2000). Autonomic dysregulation in panic disorder and in posttraumatic stress disorder: application of power spectral analysis of heart rate variability at rest and in response to recollection of trauma or panic attacks. Psychiatry Research, 6, 1–3.CrossRefGoogle Scholar
  19. Cohen, H., Neumann, L., Alhosshle, A., Kotler, M., Abu-Shakra, M., & Buskila, D. (2001). Abnormal sympathovagal balance in men with fibromyalgia. Journal of Rheumatology, 28, 581–589.PubMedGoogle Scholar
  20. Cohen, H., Neumann, L., Shore, M., Amir, M., Cassuto, Y., & Buskila, D. (2000). Autonomic dysfunction in patients with fibromyalgia: application of power spectral analysis of heart rate variability. Seminals of Arthritis and Rheumatism, 29, 217–227.CrossRefGoogle Scholar
  21. Creamer, P., Singh, B., Hochberg, M. C., & Berman, B. M. (2000). Sustained improvement produced by nonpharmacolgi cintervention in fibromyalgia: results of a pilot study. Arthritis Care and Research, 13, 198–204.PubMedCrossRefGoogle Scholar
  22. Cooke, W. H., Cox, J. P., Diedrich, A. M., Taylor, J. A., Beightol, L. A., Ames, I. Y., et al. (1998). Controlled breathing protocols probe human cardiovascular rhythms. American Journal of Physiology, 274, H709–H718.PubMedGoogle Scholar
  23. Drexler, A. R., Mur, E. J., & Gunther, V. C. (2002) Efficacy of an EMG-biofeedback therapy in fibromyalgia patients. A Comparative study of patients with and without abnormality in (MMPI) psychological scales. Clinical and Experimental Rheumatology, 20, 667–682.Google Scholar
  24. Elam, M., Johansson, G., & Wallin, B. G. (1992). Do patients with primary fibromyalgia have an altered muscle sympathetic nerve activity? Pain, 48, 371–375.PubMedCrossRefGoogle Scholar
  25. Epstein, S. A., Kay, G., Clauw, D., Heaton, R., Klein, D., Krupp, L., et al. (1999). Psychiatric disorders in patients with fibromyalgia. A multicenter investigation. Psychosomatics, 40, 57–63.Google Scholar
  26. Ferraccioli, G. F., Fontana, S., Scita, F., Chirelli, L., & Nolli, M. (1989). EMG-biofeedback in fibromyalgia syndrome. Journal of Rheumatology, 16(7), 1013–1014.PubMedGoogle Scholar
  27. Ferraccioli, G. F., Ghirelli, L., Scita, F., Nolli, M., Mozzani, M., Fontana, S., et al. (1987). EMG-biofeedback training in fibromyalgia syndrome. Journal of Rheumatology, 14(4), 820–825.Google Scholar
  28. Goldenberg, D. L., Burckhardt, C., & Crofford, L. (2004). Management of fibromyalgia syndrome. Journal of the American Medical Association, 292(19), 2388–2395.PubMedCrossRefGoogle Scholar
  29. Goldenberg, D. L., Kaplan, K. H., Nadeau, M. G., Brodeur, C., Smith, S., & Schmid, C. H. (1994). A controlled study of stress reduction, cognitive-behavioral treatment program in fibromyalgia. Journal of Musculoskeletal Pain, 2, 53–65.CrossRefGoogle Scholar
  30. Hassett, A. L., Cone, J. C., Patella, S. J., & Sigal, L. H. (2000). The role of catastrophizing in the pain and depression of women with fibromyalgia syndrome. Arthritis and Rheumatism, 43, 2493–2500.PubMedCrossRefGoogle Scholar
  31. Henriksson, C., & Liedberg, G. (2000). Factors of importance for work disability in women with fibromyalgia. Journal of Rheumatology, 160, 271–276.Google Scholar
  32. Hochberg, Y. (1988). A sharper Bonferroni procedure for multiple tests of significance. Biometrika, 75, 800–803.CrossRefGoogle Scholar
  33. Hudson, J. I., Mangweth, B., Pope, H. G. Jr., De Col. C., Hausmann, A., Gutweniger S., et al. (2003). Family study of affective spectrum disorder. Archives of General Psychiatry, 60(2), 170–177.PubMedCrossRefGoogle Scholar
  34. Kaplan, K. H., Goldenberg, D. L., & Galvin-Nadeau, M. G. (1993). The impact of a medication-bases stress reduction program on fibromyalgia. General Hospital Psychiatry, 15(5), 284–289.PubMedCrossRefGoogle Scholar
  35. Kelemen, J., Lang, E., Balint, G., Trocsanyi, M., & Muller, W. (1998). Orthostatic sympathetic derangement of baroreflex in patients with fibromyalgia [letter; comment]. Journal of Rheumatology, 25(4), 823–825.PubMedGoogle Scholar
  36. Kuusela, T. A. (2001). WinCPRS. Turku, Finland: Absolute Aliens Ay.Google Scholar
  37. Lacey, B. C., & Lacey, J. I. (1978). Two-way communication between the heart and the brain. Significance of time within the cardiac cycle. American Psychologist, 33, 99–113.PubMedCrossRefGoogle Scholar
  38. Lehrer, P., Carr, R. E., Smetankine, A., Vaschillo, E., Peper, E., Porges, S., et al. (1997). Respiratory sinus arrhythmia versus neck/trapezius EMG and incentive inspirometry biofeedback for asthma: a pilot study. Applied Psychophysiology and Biofeedback, 22(2), 95–109.PubMedCrossRefGoogle Scholar
  39. Lehrer, P., Smetankin, A., & Potapova, T. (2000). Respiratory sinus arrhythmia biofeedback therapy for asthma report of 20 unmedicated pediatric cases using the Smetankin method. Applied Psychophysiology and Biofeedback, 25, 193–200.PubMedCrossRefGoogle Scholar
  40. Lehrer, P., Vaschillo, E., & Vaschillo, B. (2000). Resonant frequency biofeedback training to increase cardiac variability: rationale and manual for training. Applied Psychophysiology and Biofeedback, 25, 177–191.PubMedCrossRefGoogle Scholar
  41. Lehrer, P. M., Vaschillo, E., Vaschillo, B., Lu, S. E., Eckberg, D. L., Edelberg, R., et al. (2003). Heart rate variability biofeedback increases baroreflex gain and peak expiratory flow. Psychosomatic Medicine, 65(5), 796–805.Google Scholar
  42. Lehrer, P., Vaschillo, E., Vaschillo, B., Lu, S., Scardella, A., Siddique, M., & Habib, R. (2004). Biofeedback Treatment for Asthma. Chest, 126, 352–361.PubMedCrossRefGoogle Scholar
  43. Leventhal, L. J. (1999). Management of fibromyalgia. Annals of Internal Medicine, 131, 850–858.PubMedGoogle Scholar
  44. Martinez, J. E., Ferraz, M. B., Fontana, A. M., & Atra, E. (1995). Psychological aspects of Brazilian women with fibromyalgia. Journal of Psychosomatic Research, 39(2), 167–174.PubMedCrossRefGoogle Scholar
  45. Martinez-Lavin, M. (2004). Fibromyalgia as a sympathetically maintained pain syndrome. Current Pain Headache Reports, 8(5), 385–389.Google Scholar
  46. Martinez-Lavin, M., Hermosillo, A. G., Mendoza, C., Ortiz, R., Cajigas, J. C., & Pineda, C. (1997). Orthostatic sympathetic derangement in subjects with fibromyalgia. Journal of Rheumatology, 24, 714–718.PubMedGoogle Scholar
  47. Martinez-Lavin, M., Hermosillo, A. G., Rosas, M., & Soto, M. E. (1998). Circadian studies of autonomic nervous balance in patients with fibromyalgia: a heart rate variability analysis. Arthritis and Rheumatism, 41, 1966–1971.PubMedCrossRefGoogle Scholar
  48. Mayberg, H. S. (2003). Modulating dysfunctional limbic-cortical circuits in depression: towards development of brain-based algorithms for diagnosis and optimized treatment. British Medical Bulletin, 65, 193–207.PubMedCrossRefGoogle Scholar
  49. McCraty, R., Atkinson, M., & Tomasino, D. (2003). Impact of a workplace stress reduction program on blood pressure and emotional health in hypertensive employees. Journal of Alternative and Complementary Medicine, 9, 355–369.CrossRefGoogle Scholar
  50. McEwen, B. S., & Olie, J. P. (2005). Neurobiology of mood, anxiety and emotions as revealed by studies of a unique antidepressant: tianeptine. Molecular Psychiatry, 10, 525–537.PubMedCrossRefGoogle Scholar
  51. Melzack, R. (1975). The McGill Questionnaire: major properties and scoring methods. Pain, 1, 277–299.PubMedCrossRefGoogle Scholar
  52. Mini, A., Rau, H., Montoya, P., Palomba, D., & Birbaumer, N. (1995). Baroreceptor cortical effects, emotions and pain. International Journal of Psychophysiology, 19, 67–77.PubMedCrossRefGoogle Scholar
  53. Moldofsky, H. K. (2001). Disordered sleep in fibromyalgia and related myofascial facial pain conditions. Dental Clinics of North America, 45(4), 701–713.PubMedGoogle Scholar
  54. Mur, E., Drexler, A., Gruber, J., Hartig, F., & Gunther V. (1999). Electromyography biofeedback therapy in fibromyalgia. Wiener Medizinische Wochenschrift, 149(19–20), 561–563.PubMedGoogle Scholar
  55. Naschitz, J. E., Rosner, I., Rozenbaum, M., Gaitini, L., Bistritzki, I., & Zuckerman, E. (2000). The capnography head-up tilt test for evaluation of chronic fatigue syndrome. Seminals of Arthritis and Rheumatism, 30, 79–86.CrossRefGoogle Scholar
  56. Qiao, Z. G., Vaeroy, H., & Morkrid, L. (1991). Electrodermal and microcirculatory activity in patients with fibromyalgia during baseline, acoustic stimulation and cold pressor tests. Journal of Rheumatology, 18, 1383–1389.PubMedGoogle Scholar
  57. R Development Core Team (2005). R: A language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria. ISBN 3-900051-07-0, URL Scholar
  58. Raj, S., Brouillard, D., Simpson, C. S., Hopman, W. M., & Abdollah, H. (2000). Dysautonomia among patients with fibromyalgia: a noninvasive assessment. Journal of Rheumatology, 27, 2660–2665.PubMedGoogle Scholar
  59. Raphael, K. G., Janal, M. N., Nayak, S., Schwartz, J. E., & Gallagher, R. M. (2004). Familial aggregation of depression in fibromyalgia: a community-based test of alternate hypotheses. Pain, 110(1–2), 449–460.PubMedCrossRefGoogle Scholar
  60. Rechlin, T. (1994). Decreased parameters of heart rate variation in amitriptyline treated patients: lower parameters in melancholic depression than in neurotic depression—a biological marker? Biological Psychiatry, 41, 627–629.Google Scholar
  61. Rechlin, T., Weis, M., Spitzer, A., & Kaschka, W. P. (1994). Are affective disorders associated with alterations of heart rate variability? Journal of Affective Disorders, 32, 271–275.PubMedCrossRefGoogle Scholar
  62. Sarnoch, H., Adler, F., & Scholz, O. B. (1997). Relevance of muscular sensitivity, muscular activity, and cognitive variables for pain reduction associated with EMG biofeedback in fibromyalgia. Perceptual and Motor Skills, 84(3 Pt 1), 1043–1050.PubMedGoogle Scholar
  63. Schurmann, M., Gradl, G., Zaspel, J., Kayser, M., Lohr, P., & Andress, H. J. (2000). Peripheral sympathetic function as a predictor of complex regional pain syndrome type I (CRPS I) in patients with radial fracture. Autonomic Neuroscience, 86, 127–134.PubMedCrossRefGoogle Scholar
  64. Singh, B. B., Berman, B. M., Hadhazy, V. A., & Creamer, P. (1998). A pilot study of cognitive behavioral therapy in fibromyalgia. Alternative Therapies in Health and Medicine, 4, 67–70.PubMedGoogle Scholar
  65. Steer, R. A., & Clark, D. A. (1997). Psychometric characteristics of the Beck Depression Inventory-II with college students. Measurement and Evaluation in Counseling and Development, 30(3), 128– 136.Google Scholar
  66. Thayer, J. F., Friedman, B. H., & Borkovec, T. D. (1996). Autonomic characteristics of generalized anxiety disorder and worry. Biological Psychiatry, 15, 255–266.CrossRefGoogle Scholar
  67. Thayer, J. F., & Brosschot, J. F. (2005). Psychosomatics and psychopathology: looking up and down from the brain. Psychoneuroendocrinology, 30(10), 1050–1058.PubMedCrossRefGoogle Scholar
  68. Thieme, K., Turk, D. C., & Flor, H. (2004). Comorbid depression and anxiety in fibromyalgia syndrome: relationship to somatic and psychosocial variables. Psychosomatic Medicine, 66(6), 837–844.PubMedCrossRefGoogle Scholar
  69. Vaschillo, E., Lehrer, P., Rishe, N., & Konstantinov, M. (2002). Heart rate variability biofeedback as a method for assessing baroreflex function: a preliminary study of resonance in the cardiovascular system. Applied Psychophysiology and Biofeedback, 27(1), 1–27.PubMedCrossRefGoogle Scholar
  70. Vaschillo, E., Vaschillo, B., & Lehrer, P. (2004). Heartbeat synchronizes with respiratory rhythm only under specific circumstances. Chest, 126(4), 1385–1386.PubMedCrossRefGoogle Scholar
  71. Wiklund, U., Olofsson, B. O., Franklin, K., Blom, H., Bjerle, P., & Niklasson, U. (2000). Autonomic cardiovascular regulation in patients with obstructive sleep apnoea: a study based on spectral analysis of heart rate variability. Clinical Physiology, 20, 234–241.PubMedCrossRefGoogle Scholar
  72. Wolfe, F., Ross, K., Anderson, J., et al. (1995). The prevalence and characteristics of fibromyalgia in the general population. Arthritis and Rheumatism, 38, 19–28.PubMedCrossRefGoogle Scholar
  73. Wolfe, F., Smythe, H. A., Yunus, M. B., Bennett, R. M., Bombardier, C., Goldenberg, D. L., et al. (1990). The American College of Rheumatology 1990 criteria for the classification of Fibromyalgia. Report of the multicenter criteria committee. Arthritis and Rheumatism 1990, 33, 160–172.CrossRefGoogle Scholar
  74. Yeragani, V. K., Balon, R., Pohl, R., & Ramesh, C. (1995). Depression and heart rate variability. Biological Psychiatry, 38, 768–770.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2006

Authors and Affiliations

  • Afton L. Hassett
    • 1
    Email author
  • Diane C. Radvanski
    • 1
  • Evgeny G. Vaschillo
    • 2
  • Bronya Vaschillo
    • 2
  • Leonard H. Sigal
    • 1
    • 3
  • Maria Katsamanis Karavidas
    • 4
  • Steven Buyske
    • 5
  • Paul M. Lehrer
    • 4
  1. 1.Department of MedicineDivision of Rheumatology, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School (UMDNJ-RWJMS)New BrunswickUSA
  2. 2.Center of Alcohol StudiesRutgers University PiscatawayPiscatawayUSA
  3. 3.Pharmaceutical Research InstitutePrincetonUSA
  4. 4.Department of PsychiatryUMDNJ-RWJMSPiscatawayUSA
  5. 5.Department of StatisticsRutgers UniversityPiscatawayUSA

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