Biofeedback of Heart Rate Variability and Related Physiology: A Critical Review

Abstract

Low heart rate variability (HRV) characterizes several medical and psychological diseases. HRV biofeedback is a newly developed approach that may have some use for treating the array of disorders in which HRV is relatively low. This review critically appraises evidence for the effectiveness of HRV and related biofeedback across 14 studies in improving (1) HRV and baroreflex outcomes and (2) clinical outcomes. Results revealed that HRV biofeedback consistently effectuates acute improvements during biofeedback practice, whereas the presence of short-term and long-term carry-over effects is less clear. Some evidence suggests HRV biofeedback may result in long-term carry-over effects on baroreflex gain, which is an area most promising for future investigations. On the other hand, concerning clinical outcomes, there is ample evidence attesting to efficacy of HRV biofeedback. However, because clinical and physiological outcomes do not improve concurrently in all cases, the mechanism by which HRV biofeedback results in salutary effects in unclear. Considerations for the field in addressing shortcomings of the reviewed studies and advancing understanding of the way in which HRV biofeedback may improve physiological and clinical outcomes are offered in light of the reviewed evidence.

This is a preview of subscription content, access via your institution.

References

  1. Agelink, M., Boz, C., Ullrich, H., & Andrich, J. (2002). Relationship between major depression and heart rate variability: Clinical consequences and implications for antidepressive treatment. Psychiatry Research, 113, 139–149.

    Article  PubMed  Google Scholar 

  2. Bigger, J., Fleiss, J., Rolnitzky, L., & Steinman, R. (1993). The ability of several short-term measures of RR variability to predict mortality after myocardial infarction. Circulation, 88, 927–934.

    PubMed  Google Scholar 

  3. Boysen, A., Lewin, M., Hecker, W., Leichter, H., & Uhlemann, F. (2007). Autonomic function testing in children and adolescents with diabetes mellitus. Pediatric Diabetes, 8, 261–264.

    Article  PubMed  Google Scholar 

  4. Cohen, H., Benjamin, J., Geva, A., Matar, M., Kaplan, Z., & Kotler, M. (2000). Autonomic dysregulation in panic disorder and in post-traumatic stress disorder: Application of power spectrum analysis of heart rate variability at rest and in response to recollection of trauma or panic attacks. Psychiatry Research, 96, 1–13.

    Article  PubMed  Google Scholar 

  5. Cohen, H., Kotler, M., Matar, M., & Kaplan, Z. (1997). Power spectral analysis of heart rate variability in posttraumatic stress disorder patients. Biological Psychiatry, 41, 627–629.

    Article  PubMed  Google Scholar 

  6. Cowan, M., Pike, K., & Budzynski, H. (2001). Psychosocial nursing therapy following sudden cardiac arrest: Impact on two-year survival. Nursing Research, 50, 68–76.

    Article  PubMed  Google Scholar 

  7. Del Pozo, J., Gevirtz, R., Scher, B., & Guarneri, E. (2004). Biofeedback treatment increases heart rate variability in patients with known coronary artery disease. American Heart Journal, 147, G1–G6.

    Article  Google Scholar 

  8. Eckberg, D. L. (2003). The human respiratory gate. The Journal of Physiology, 548, 339–352.

    PubMed  Google Scholar 

  9. Elliot, W., Izzo, J., White, W., Rosing, D., Snyder, C., Alter, A., et al. (2004). Graded blood pressure reduction in hypertensive outpatients associated with use of a device to assist with slow breathing. Journal of Clinical Hypertension, 6, 553–559.

    Article  PubMed  Google Scholar 

  10. Giardino, N., Chan, L., & Borson, S. (2004). Combined heart rate variability and pulse oximetry biofeedback for chronic obstructive pulmonary disease: Preliminary findings. Applied Psychophysiology & Biofeedback, 29, 121–133.

    Article  Google Scholar 

  11. Hassett, A., Radvanski, D., Vaschillo, E., Vaschillo, B., Sigal, L., Karavidas, M., et al. (2007). A pilot study of the efficacy of heart rate variability (HRV) biofeedback in patients with fibromyalgia. Applied Psychophysiology & Biofeedback, 32, 1–10.

    Article  Google Scholar 

  12. Joseph, C., Porta, C., Casucci, G., Casiraghi, N., Maffeis, M., Rossi, M., et al. (2005). Slow breathing improves arterial baroreflex sensitivity and decreases blood pressure in essential hypertension. Hypertension, 46, 714–718.

    Article  PubMed  Google Scholar 

  13. Karavidas, M., Lehrer, P., Vaschillo, E., Vaschillo, B., Marin, H., Buyske, S., et al. (2007). Preliminary results of an open label study of heart rate variability biofeedback for the treatment of major depression. Applied Psychophysiology & Biofeedback, 32, 19–30.

    Article  Google Scholar 

  14. La Rovere, M., Bigger, J., Jr., Marcus, F., Mortara, A., & Schwartz, P. (1998). Baroreflex sensitivity and heart-rate variability in prediction of total cardiac mortality after myocardial infarction. Lancet, 351, 478–484.

    Article  PubMed  Google Scholar 

  15. La Vaque, T., Hammond, D., Trudeau, D., Monastra, V., Perry, J., Lehrer, P., et al. (2002). Template for developing guidelines for the evaluation of the clinical efficacy of psychophysiological interventions. Applied Psychophysiology & Biofeedback, 27, 273–281.

    Article  Google Scholar 

  16. Lehrer, P. (2007). Biofeedback training to increase heart rate variability. In P. M. Lehrer, R. L. Woolfolk, & W. E. Sime (Eds.), Principles and practice of stress management (3rd ed., pp. 227–248). New York: Guilford.

    Google Scholar 

  17. Lehrer, P., Carr, R., 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 & Biofeedback, 22, 95–109.

    Article  Google Scholar 

  18. Lehrer, P., Vaschillo, E., Lu, S., Eckberg, D., Vaschillo, B., Scardella, A., et al. (2006). Heart rate variability biofeedback: Effects of age on heart rate variability, baroreflex gain, and asthma. Chest, 129, 278–284.

    Article  PubMed  Google Scholar 

  19. Lehrer, P., Vaschillo, E., & Vaschillo, B. (2000). Resonant frequency biofeedback training to increase cardiac variability: Rationale and manual for training. Applied Psychophysiology & Biofeedback, 25, 177–191.

    Article  Google Scholar 

  20. Lehrer, P., Vaschillo, E., Vaschillo, B., Lu, S., Eckberg, D., Edelberg, R., et al. (2003). Heart rate variability biofeedback increases baroreflex gain and peak expiratory flow. Psychosomatic Medicine, 65, 796–805.

    Article  PubMed  Google Scholar 

  21. Lehrer, P., Vaschillo, E., Vaschillo, B., Lu, S., Scardella, A., Siddique, M., et al. (2004). Biofeedback treatment for asthma. Chest, 126, 352–361.

    Article  PubMed  Google Scholar 

  22. Martinez Lavin, M., Hermosillo, A., Rosas, M., & Soto, M. (1998). Circadian studies of autonomic nervous balance in patients with fibromyalgia: A heart rate variability analysis. Arthritis and Rheumatism, 41, 1966–1971.

    Article  PubMed  Google Scholar 

  23. McGrady, A. (2007). Psychophysiological mechanisms of stress: A foundation for the stress management therapies. In P. M. Lehrer, R. L. Woolfolk, & W. E. Sime (Eds.), Principles and practice of stress management (3rd ed., pp. 16–37). New York: Guilford.

    Google Scholar 

  24. Muench, F. (2008). The portable StressEraser heart rate variability biofeedback device: Background and research. Biofeedback, 36, 35–39.

    Google Scholar 

  25. Nolan, R., Kamath, M., Floras, J., Stanley, J., Pang, C., Picton, P., et al. (2005). Heart rate variability biofeedback as a behavioral neurocardiac intervention to enhance vagal heart rate control. American Heart Journal, 149, 1137.e1–1137.e7.

    Article  Google Scholar 

  26. Overhaus, S., Rüddel, H., Curio, I., Mussgay, L., & Scholz, O. (2003). Biofeedback of baroreflex sensitivity in patients with mild essential hypertension. International Journal of Behavioral Medicine, 10, 66–78.

    Article  PubMed  Google Scholar 

  27. Porges, S. W. (2007). The polyvagal perspective. Biological Psychology, 74, 116–143.

    Article  PubMed  Google Scholar 

  28. Raghuraj, P., & Telles, S. (2008). Immediate effect of specific nostril manipulating yoga breathing practices on autonomic and respiratory variables. Applied Psychophysiology & Biofeedback, 33, 65–75.

    Article  Google Scholar 

  29. Reyes del Paso, G., & González, M. (2004). Modification of baroreceptor cardiac reflex function by biofeedback. Applied Psychophysiology & Biofeedback, 29, 197–211.

    Article  Google Scholar 

  30. Schroeder, E., Liao, D., Chambless, L., Prineas, R., Evans, G., & Heiss, G. (2003). Hypertension, blood pressure, and heart rate variability: The Atherosclerosis Risk in Communities (ARIC) study. Hypertension, 42, 1106–1111.

    Article  PubMed  Google Scholar 

  31. Swanson, K. S., Gevirtz, R. N., Brown, M., Spira, J., Guarneri, E., & Stoletniy, L. (2009). The effect of biofeedback on function in patients with heart failure. Applied Psychophysiology & Biofeedback, 34, 71–91.

    Article  Google Scholar 

  32. Task Force of the European Society of Cardiology and the North American Society of Pacing and Electrophysiology. (1996). Heart rate variability: Standards of measurement, physiological interpretation and clinical use. Circulation, 93, 1043–1065.

    Google Scholar 

  33. Taylor, J. A., Myers, C. W., Halliwill, J. R., Seidel, H., & Eckberg, D. L. (2001). Sympathetic restraint of respiratory sinus arrhythmia: Implications for vagal cardiac tone assessment in humans. American Journal of Physiology: Heart and Circulatory Physiology, 49, H2804–H2814.

    Google Scholar 

  34. Thayer, J., Friedman, B., & Borkovec, T. (1996). Autonomic characteristics of generalized anxiety disorder and worry. Biological Psychiatry, 39, 255–266.

    Article  PubMed  Google Scholar 

  35. Vaschillo, E. G., Vaschillo, B., & Lehrer, P. M. (2006). Characteristics of resonance in heart rate variability stimulated by biofeedback. Applied Psychophysiology & Biofeedback, 31, 129–142.

    Article  Google Scholar 

  36. Wang, T., Wu, X., & Huang, Z. (2007). Analysis of the heart rate variability of normal young men in the process of EMG biofeedback. Chinese Mental Health Journal, 21, 212–215.

    Google Scholar 

  37. Watkins, L., Blumenthal, J., & Carney, R. (2002). Association of anxiety with reduced baroreflex cardiac control in patients after acute myocardial infarction. American Heart Journal, 143, 460–466.

    Article  PubMed  Google Scholar 

  38. Xu, X., Gao, J., Ling, D., & Wang, T. (2007). Biofeedback treatment of prehypertension: Analyses of efficacy, heart rate variability and EEG approximate entropy. Journal of Human Hypertension, 21, 973–975.

    Article  PubMed  Google Scholar 

  39. Yeragani, V., Rao, K., Smitha, M., Pohl, R., Balon, R., & Srinivasan, K. (2002). Diminished chaos of heart rate time series in patients with major depression. Biological Psychiatry, 51, 733–749.

    Article  PubMed  Google Scholar 

  40. Zucker, T. L., Samuelson, K. W., Muench, F., Greenberg, M. A., & Gevirtz, R. N. (2009). The effects of respiratory sinus arrhythmia biofeedback on heart rate variability and posttraumatic stress disorder symptoms: A pilot study. Applied Psychophysiology & Biofeedback, 34, 135–143.

    Article  Google Scholar 

Download references

Author information

Affiliations

Authors

Corresponding author

Correspondence to Amanda L. Wheat.

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Wheat, A.L., Larkin, K.T. Biofeedback of Heart Rate Variability and Related Physiology: A Critical Review. Appl Psychophysiol Biofeedback 35, 229–242 (2010). https://doi.org/10.1007/s10484-010-9133-y

Download citation

Keywords

  • Heart rate variability
  • Biofeedback
  • Baroreflex
  • Respiratory sinus arrhythmia