Hostname: page-component-6bf8c574d5-vmclg Total loading time: 0 Render date: 2025-02-28T20:53:40.367Z Has data issue: false hasContentIssue false
  • English
  • Français

The effect of heart rate variability biofeedback training on stress and anxiety: a meta-analysis

Published online by Cambridge University Press:  08 May 2017

V. C. Goessl ,
J. E. Curtiss  and
S. G. Hofmann
V. C. Goessl
Affiliation:
Department of Psychological and Brain Sciences, Boston University, Boston, MA, USA
J. E. Curtiss
Affiliation:
Department of Psychological and Brain Sciences, Boston University, Boston, MA, USA
S. G. Hofmann*
Affiliation:
Department of Psychological and Brain Sciences, Boston University, Boston, MA, USA
*
*Address for correspondence: S. G. Hofmann, Ph.D., Department of Psychological and Brain Sciences, Boston University, 648 Beacon St., 6th floor, Boston, MA 02215, USA. (Email: shofmann@bu.edu)
Get access Rights & Permissions [Opens in a new window]

Abstract

Background

Some evidence suggests that heart rate variability (HRV) biofeedback might be an effective way to treat anxiety and stress symptoms. To examine the effect of HRV biofeedback on symptoms of anxiety and stress, we conducted a meta-analysis of studies extracted from PubMed, PsycINFO and the Cochrane Library.

Methods

The search identified 24 studies totaling 484 participants who received HRV biofeedback training for stress and anxiety. We conducted a random-effects meta-analysis.

Results

The pre-post within-group effect size (Hedges' g) was 0.81. The between-groups analysis comparing biofeedback to a control condition yielded Hedges' g = 0.83. Moderator analyses revealed that treatment efficacy was not moderated by study year, risk of study bias, percentage of females, number of sessions, or presence of an anxiety disorder.

Conclusions

HRV biofeedback training is associated with a large reduction in self-reported stress and anxiety. Although more well-controlled studies are needed, this intervention offers a promising approach for treating stress and anxiety with wearable devices.

Keywords

AnxietybiofeedbackHRVmeta-analysisstress
Type
Review Article
Information
Psychological Medicine , Volume 47 , Issue 15 , November 2017 , pp. 2578 - 2586
Copyright
Copyright © Cambridge University Press 2017 

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

Footnotes

†

Both authors claim first-authorship as they have both contributed equally to the current project.

References

Beckham, AJ, Greene, TB, Meltzer-Brody, S (2013). A pilot study of heart rate variability biofeedback therapy in the treatment of perinatal depression on a specialized perinatal psychiatry inpatient unit. Archives of Women's Mental Health 16, 59–65.CrossRefGoogle ScholarPubMed
Berntson, GG, Bigger, JT, Eckberg, DL, Grossman, P, Kaufmann, PG, Malik, M, Nagaraja, HN, Porgeas, SW, Saul, JP, Stone, JP, Stone, MW, van der Molen, MW (1997). Heart rate variability: origins, methods, and interpretive caveats. Psychophysiology 34, 623–648.CrossRefGoogle ScholarPubMed
Borenstein, M, Rothstein, H (2014). Comprehensive Meta-Analysis: a Computer Program for Research Synthesis. Biostat: Englewood, NJ.Google Scholar
Browne, TG (2001). EEG Theta Enhancement and Heart Rate Variability Biofeedback on Interactional Stress in a Clinical Population . Ph.D., California Institute of Integral Studies: San Francisco, CA (http://search.ebscohost.com/login.aspx?direct=true&db=psyh&AN=2001-95012-281&site=ehost-live&scope=site&scope=cite).Google Scholar
Camm, AJ, Malik, M, Bigger, JT (1996). Heart rate variability. Standards of measurement, physiological interpretation, and clinical use. Circulation 93, 1043–1065.Google Scholar
Cohen, J (1988). Statistical Power Analysis for the Behavioral Sciences. Erlbaum: Hillsdale.Google Scholar
Cuijpers, P, Li, J, Hofmann, SG, Andersson, G (2010). Self-reported versus clinician-rated symptoms of depression as outcome measures in psychotherapy research on depression: a meta-analysis. Clinical Psychology Review 30, 768–778.Google Scholar
Duval, S, Tweedie, R (2000). Trim and fill: a simple funnel-plot-based method of testing and adjusting for publication bias in meta-analysis. Biometrics 56, 455–463.CrossRefGoogle ScholarPubMed
Friedman, BH (2007). An autonomic flexibility neurovisceral integration model of anxiety and cardiac vagal tone. Biological Psychology 74, 185–199.CrossRefGoogle ScholarPubMed
Futterman, AD, Shapiro, D (1986). A review of biofeedback for mental disorders. Hospital & Community Psychiatry 37, 27–33.Google ScholarPubMed
Gatchel, RJ, Proctor, JD (1976). Effectiveness of voluntary heart rate control in reducing speech anxiety. Journal of Consulting and Clinical Psychology 44, 381–389.Google Scholar
Gevirtz, R (2013). The promise of heart rate variability biofeedback: evidence-based application. Biofeedback 41, 110–120.Google Scholar
Giardino, ND, Chan, L, Borson, S (2004). Combined heart rate variability and pulse oximetry biofeedback for chronic obstructive pulmonary disease: preliminary findings. Applied Psychophysiology and Biofeedback 29, 121–133.CrossRefGoogle ScholarPubMed
Gross, JJ (2002). Emotion regulation: affective, cognitive, and social consequences. Psychophysiology 39, 281–291.Google Scholar
Hedges, LV, Olkin, I (1985). Statistical Methods for Meta-Analysis. Academic Press: Orlando.Google Scholar
Henriques, G, Keffer, S, Abrahamson, C, Jeanne Horst, S (2011). Exploring the effectiveness of a computer-based heart rate variability biofeedback program in reducing anxiety in college students. Applied Psychophysiology and Biofeedback 36, 101–112.Google Scholar
Higgins, JP, Altman, DG, Gotzsche, PC, Juni, P, Moher, D, Oxman, AD, Savovic, J, Schulz, KF, Weeks, L, Sterne, JA (2011). The Cochrane Collaboration's tool for assessing risk of bias in randomised trials. British Medical Journal 343, d5928.Google Scholar
Hofmann, SG (2014). Interpersonal emotion regulation model of mood and anxiety disorders. Cognitive Therapy and Research 38, 483–492.Google Scholar
Hofmann, SG, Moscovitch, DA, Litz, BT, Kim, HJ, Davis, L, Pizzagalli, DA (2005). The worried mind: autonomic and prefrontal activation during worrying. Emotion 5, 464–475.CrossRefGoogle ScholarPubMed
Keeney, JE (2009). Effects of Heart Rate Variability Biofeedback-Assisted Stress Management Training on Pregnant Women and Fetal Heart Rate Measures . Ph.D., University of North Texas: Denton, TX (https://www.heartmath.org/research/research-library/dissertations/effects-of-hrv-biofeedback-assisted-stress-management-training-on-pregnant-women-and-fetal-heart-rate-measures/).Google Scholar
Kemp, AH, Quintana, DS, Felmingham, KL, Matthews, S, Jelinek, HF (2012). Depression, comorbid anxiety disorders, and heart rate variability in physically healthy, unmedicated patients: implications for cardiovascular risk. PLoS ONE 7, 1–8.CrossRefGoogle ScholarPubMed
Kessler, RC, Soukup, J, Davis, RB, Foster, DF, Wilkey, SA, Van Rompay, MI, Eisenberg, DM (2001). The use of complementary and alternative therapies to treat anxiety and depression in the United States. American Journal of Psychiatry 158, 289–294.Google Scholar
Khazan, IZ (2013). The Clinical Handbook of Biofeedback: a Step-by-Step Guide for Training and Practice with Mindfulness. Wiley-Blackwell: West Sussex, UK.Google Scholar
Khodik, K (2013). Self-Regulation and Heart Rate Variability Biofeedback: Promoting Emotional and Spiritual Fitness in Alcohol Addiction Treatment . Ph.D., Widener University: Chester, PA (https://www.heartmath.org/research/research-library/dissertations/self-regulation-and-hrv-biofeedback-emotional-spiritual-fitness-in-alcohol-addiction-treatment/).Google Scholar
Kim, S, Rath, JF, McCraty, R, Zemon, V, Cavallo, MM, Foley, FW (2015). Heart rate variability biofeedback, self-regulation, and severe brain injury. Biofeedback 43, 6–14.Google Scholar
Lee, J, Kim, JK, Wachholtz, A (2015). The benefit of heart rate variability biofeedback and relaxation training in reducing trait anxiety. Korean Journal of Health Psychology 20, 391–408.Google ScholarPubMed
Lehrer, PM, Gevirtz, R (2014). Heart rate variability biofeedback: how and why does it work? Psychology for Clinical Settings 5, 1–9.Google ScholarPubMed
Mikosch, P, Hadrawa, T, Laubreiter, K, Brandl, J, Pilz, J, Stettner, H, Grimm, G (2010). Effectiveness of respiratory-sinus-arrhythmia biofeedback on state-anxiety in patients undergoing coronary angiography. Journal of Advanced Nursing 66, 1101–1110.Google Scholar
Munafò, M, Patron, E, Palomba, D (2016). Improving managers’ psychophysical well-being: effectiveness of respiratory sinus arrhythmia biofeedback. Applied Psychophysiology and Biofeedback 41, 129–139.Google Scholar
Nance, JA (2015). An Exploration of Heart Rate Variability Biofeedback as an Ancillary Treatment for Patients Diagnosed with Borderline Personality Disorder, an Initial Feasibility Study . Ph.D., Alliant International University: San Diego, CA.Google Scholar
Patron, E, Benvenuti, SM, Favretto, G, Valfrè, C, Bonfà, C, Gasparotto, R, Palomba, D (2013). Biofeedback assisted control of respiratory sinus arrhythmia as a biobehavioral intervention for depressive symptoms in patients after cardiac surgery: a preliminary study. Applied Psychophysiology and Biofeedback 38, 1–9.CrossRefGoogle ScholarPubMed
Paul, M, Garg, K (2012). The effect of heart rate variability biofeedback on performance psychology of basketball players. Applied Psychophysiology and Biofeedback 37, 131–144.Google Scholar
Porges, SW (2007). The polyvagal perspective. Biological Psychology 74, 116–143.Google Scholar
Prinsloo, GE, Derman, WE, Lambert, MI, Rauch, HGL (2013). The effect of a single episode of short duration heart rate variability biofeedback on measures of anxiety and relaxation states. International Journal of Stress Management 20, 391–411.CrossRefGoogle Scholar
Prinsloo, GE, Rauch, HGL, Lambert, MI, Muench, F, Noakes, TD, Derman, WE (2011). The effect of short duration heart rate variability (HRV) biofeedback on cognitive performance during laboratory induced cognitive stress. Applied Cognitive Psychology 25, 792–801.Google Scholar
Ratanasiripong, P, Ratanasiripong, N, Kathalae, D (2012). Biofeedback intervention for stress and anxiety among nursing students: a randomized controlled trial. ISRN Nursing 2012, 1–5.Google Scholar
Reiner, R (2008). Integrating a portable biofeedback device into clinical practice for patients with anxiety disorders: results of a pilot study. Applied Psychophysiology and Biofeedback 33, 55–61.Google Scholar
Rosenthal, R (1991). Meta-Analytic Procedures for Social Science Research. Sage: Newbury Park, CA.Google Scholar
Segerstrom, SC, Nes, LS (2007). Heart rate variability reflects self-regulatory strength, effort, and fatigue. Psychological Science 18, 275–281.Google Scholar
Sherlin, L, Gevirtz, R, Wyckoff, S, Muench, F (2009). Effects of respiratory sinus arrhythmia biofeedback versus passive biofeedback control. International Journal of Stress Management 16, 233–248.CrossRefGoogle Scholar
Sutarto, AP, Wahab, MNA, Zin, NM (2012). Resonant breathing biofeedback training for stress reduction among manufacturing operators. International Journal of Occupational Safety and Ergonomics 18, 549–561.CrossRefGoogle ScholarPubMed
Tabachnick, L (2015). Biofeedback and anxiety disorders: a critical review of EMG, EEG, and HRV feedback. Concept 38, 1–26.Google Scholar
Tan, G, Dao, TK, Farmer, L, Sutherland, RJ, Gevirtz, R (2011). Heart rate variability (HRV) and posttraumatic stress disorder (PTSD): a pilot study. Applied Psychophysiology and Biofeedback 36, 27–35.Google Scholar
Thurber, MR (2007). Effects of Heart-rate Variability Biofeedback Training and Emotional Regulation on Music Performance Anxiety in University Students . Ph.D., University of North Texas: Denton, TX.Google Scholar
Vago, DR, Silbersweig, DA (2012). Self-awareness, self-regulation, and self-transcendence (S-ART): a framework for understanding the neurobiological mechanisms of mindfulness. Frontiers in Human Neuroscience 6, 1–30.Google Scholar
van der Zwan, JE, de Vente, W, Huizink, AC, Bögels, SM, de Bruin, EI (2015). Physical activity, mindfulness meditation, or heart rate variability biofeedback for stress reduction: a randomized controlled trial. Applied Psychophysiology and Biofeedback 40, 257–268.CrossRefGoogle ScholarPubMed
Wells, R, Outhred, T, Heathers, JAJ, Quintana, DS, Kemp, AH (2012). Matter over mind: a randomised-controlled trial of single-session biofeedback training on performance anxiety and heart rate variability in musicians. PLoS ONE 7, 1–11.Google Scholar
White, B (2008). The Effects of Heart Rate Variability Biofeedback as an Adjunct to Therapy on Trauma Symptoms . Ph.D., Alliant International University: San Diego, CA.Google Scholar
Zucker, TL, Samuelson, KW, Muench, F, Greenberg, MA, Gevirtz, RN (2009). The effects of respiratory sinus arrhythmia biofeedback on heart rate variability and posttraumatic stress disorder symptoms: a pilot study. Applied Psychophysiology and Biofeedback 34, 135–143.Google Scholar