Practice in Clinical & Health Psychology
Cardiovascular Disorders
HRV Biofeedback Training


 Biofeedback Training for a Healthy Heart 
Healthy breathing is effortless, continuous, and slow. You mainly move air by expanding your stomach as you inhale and contracting it as you exhale. This allows the dome-shaped diaphragm muscle in your chest cavity to fully inflate your lungs, maintain an optimal level of carbon dioxide (CO2) in your blood, deliver needed oxygen to your body’s tissues, and increase the healthy variability of your heart.
What is respiratory biofeedback therapy?
Respiratory biofeedback therapy uses biofeedback instruments to enhance your awareness and control of rapidly-changing physiological responses. A therapist’s biofeedback instructions are guided by feedback provided by biofeedback devices. Respiratory biofeedback can help you learn to breathe effortlessly.
How does respiratory biofeedback measure your breathing?
In respiratory biofeedback, strain gauge sensors placed around your chest and stomach detect outward movement as you inhale and inward movement as you exhale. Biofeedback equipment can measure breathing depth and respiration rate.
Breathing depth or excursion is the difference between a stomach strain gauge’s outward and inward movement during each breathing cycle. In healthy breathing, the stomach effortlessly expands and contracts to more completely ventilate your lungs.
Respiration rate is the number breathing cycles that you complete each minute. In healthy breathing, you learn to slow your breathing down to 5-7 breaths per minute to increase the healthy variability in your heart rhythm and ensure sufficient CO2 in your blood.
Personal respiratory biofeedback training can teach you to increase your awareness of your breathing, to fill your lungs more completely, and to breathe slowly and continuously during everyday activities.
Which breathing problems can respiratory biofeedback correct?
Apnea, or breath-holding, is a common breathing behavior. Patients who exhibit apnea suspend their breathing during routine activities like talking or writing a check. Apnea disrupts the delivery of oxygen to your tissues, can make you feel starved for air, and can raise your blood pressure. A strain gauge can show stomach movement “flat-lines” during an apnea episode instead of showing regular waves of stomach expansion and contraction.
Biofeedback providers also use respiratory biofeedback to correct three problem breathing patterns:
In thoracic breathing, your chest muscles expand and contract your ribs to move air. This inefficient pattern causes shallow rapid breathing, reduced ventilation of your lungs, less oxygen delivery to your tissues, minimal variability in your heart rhythm, and wasted energy.
In clavicular breathing, your accessory muscles raise and lower your chest and collarbones to move air. This pattern is often combined with chest breathing and exaggerates its problems.
In reverse breathing, your chest and stomach contract when you inhale and expand when you exhale. This pattern is also seen with chest breathing and also magnifies its negative effects.
What is effortless breathing?
Breathing is effortless when your body seems to breathe itself. Since effortless breathing feels like you are only using about 70% of maximum effort to fill your lungs, you may forget that you are breathing.
What are some effortless breathing tips for beginners?
You can quickly master effortless breathing if you:
  • sit upright so that your stomach can relax
  • wear clothing that allows your stomach to move freely
  • breathe 5-7 breaths per minute
  • exhale twice as long as you inhale
How does breathing affect your heart rhythm?
The autonomic nervous system controls your heart rhythm through its sympathetic and parasympathetic branches. The sympathetic branch accelerates your heart rate to prepare you for emergencies like fighting or fleeing snarling saber-toothed tigers. Think of the sympathetic branch as your heart’s gas pedal. In contrast, the parasympathetic branch slows your heart rate when you eat a meal. Think of the parasympathetic branch as your heart’s brake.
When you inhale, you take your foot off the parasympathetic brake and your heart rate accelerates. When you exhale, you press down hard on the parasympathetic brake and your heart rate slows. This rhythmic change in your heart rate is called heart rate variability (HRV).  A simple measure of HRV is the difference between your fastest and slowest heart rate.
What else influences heart rate variability (HRV)?
Aerobic exercise and positive emotion can increase HRV. Aging, heart disease, physical inactivity, and negative emotion can reduce HRV. Chronic stress has a very strong negative effect on HRV.
How can you increase your heart’s healthy variability?
You can maximize heart rate variability (HRV) when you breathe from 4-7 breaths per minute because this combines the effects of your autonomic nervous system, blood pressure control system, and respiratory system on the variability of your heart rhythm. Researchers also believe that experiencing heartfelt emotions, like a parent’s love for a child, increases HRV.
How do biofeedback therapists monitor heart rate variability?
In heart rate variability biofeedback, special instruments are used to detect your heart’s rhythmic contraction and relaxation. Clinicians use two biofeedback devices to monitor the heart. An electrocardiogram (EKG) uses sensors placed on your wrists and torso to detect the electrical signal generated by the heart. Alternatively, a photoplethysmograph (PPG) uses sensors placed on your earlobe or fingers to detect the pulse waves created by your heart’s pumping action.
HRV biofeedback can display both your breathing pattern and heart rhythm back to you to teach you to increase your heart’s healthy variability. You can learn to increase the difference between your fastest and slowest heart rate many times more than the average 3-5 beats-per-minute difference seen in adults.
How does increasing heart rate variability protect your health?
Some researchers believe that HRV biofeedback instructions increase the balance between the two branches of the autonomic nervous system and that this can reduce your risk of dying from a heart attack.
How effective is HRV biofeedback therapy?
Biofeedback clinical trials have shown that HRV biofeedback techniques can help you control problems like anxiety, asthma, depression, high blood pressure, panic attacks, unexplained abdominal pain, and stress. HRV training is a promising form of stress management biofeedback for both children and adults.
Who should provide HRV training?
Biofeedback practitioners who are experienced in HRV biofeedback and certified by the Biofeedback Certification International Alliance (BCIA) are qualified to provide this training.
Is there insurance coverage for biofeedback?
Biofeedback reimbursement depends upon your insurance provider. Psychologists may code biofeedback services as psychotherapy to increase your chance of reimbursement.
Autonomic Tone as a Cardio Risk Factor:
The Dangers of Chronic Fight or Flight
Brian M. Curtis, MD & James H. O’Keefe, Jr., MD
Chronic imbalance of the autonomic nervous system is a prevalent and potent risk factor for adverse cardio-vascular events, including mortality. Although not widely recognized by clinicians, this risk factor is easily assessed by measures such as resting and peak exercise heart rate, heart rate recovery after exercise, and heart rate variability. Any factor that leads to inappropriate activation of the sympathetic nervous system can be expected to have an adverse effect on these measures and thus on patient outcomes, while any factor that augments vagal tone tends to improve outcomes. Insulin resistance, sympathomime-tic medications, and negative psychosocial factors all have the potential to affect autonomic function adversely and thus cardio-vascular prognosis. Congestive heart failure and hypertension also provide important lessons about the adverse effects of sympathetic predominance, as well as illustrate the benefits of beta-blockers and angiotension-converting enzyme inhibitors, two classes of drugs that reduce adrenergic tone. Other interventions, such as exercise, stress management, meditation, and biofeedback training, improve cardiovascular outcomes partially by increasing vagal activity and attenuating sympathetic hyperactivity.
Heart Rate Variability Biofeedback as a Behavioral Neurocardiac Intervention to Enhance Vagal Heart Rate Control
Nolan, R.P., Kamath, M.V., Floras, J.S., Stanley, J., Pang, C., Picton, P., Young, Q.R.
Patients with coronary heart disease (CHD) who experience depressed mood or psychological stress exhibit decreased vagal control of heart rate (HR), as assessed by spectral analysis of HR variability (HRV). Myocardial infarction and sudden cardiac death are independently associated with depression and stress, as well as impaired vagal HR control.
This study examined whether a behavioral neurocardiac intervention to reduce stress or depression can augment cardiovagal modulation in CHD patients. We hypothesized that (1) cognitive-behavioral training with heart rate variability (HRV) biofeedback would augment vagal recovery from acute stress, and (2) vagal regulation of HR would be inversely associated with stress and depression after treatment.
METHODS: This randomized controlled trial enrolled 46 CHD patients from 3 clinics of CHD risk reduction in Toronto and Vancouver, Canada. Subjects were randomized to five 1.5-hour sessions of HRV biofeedback or an active control condition. Outcome was assessed by absolute and normalized high-frequency spectral components (0.15-0.50 Hz) of HRV, and by Perceived Stress Scale (PSS) and Centre for Epidemiologic Studies in Depression Scale (CESDS).
RESULTS: Both groups reduced symptoms on the PSS (P = .001) and CESDS (P = .004). However, hierarchial linear regression determined that improved psychological adjustment was significantly associated with the high frequency index of vagal HR modulation only in the HRV biofeedback group. Adjusted R 2 was as follows: HRV biofeedback group, 0.86 for stress (P = .02) and 0.81 for depression (P = .03); versus the active control group, 0.04 (P = .57) and 0.13 (P = .95), respectively.
CONCLUSION: A novel behavioral neurocardiac intervention, heartrate variability biofeedback, can augment vagal HR regulation while facilitating psychological adjustment to CHD.
Published in: American Heart Journal 2005 Jun; 149(6):1137. PMID: 15976804 [PubMed – indexed for MEDLINE]
Biofeedback Treatment Increases Heart Rate Variability in Patients With Known Coronary Artery Disease
American Heart Journal, 147(3): E11, 2004.
Del Pozo, Gervitz and colleagues at the California School of Professional Psychology at Alliant International University, San Diego, have found that biofeedback increases the variability of heart rates in patients with coronary heart disease.
Diminished heart rate variability has been associated with increased morbidity and mortality in coronary heart disease. Evidence suggests that various lifestyle changes and pharmacological therapies can improve the heart rate variability. The aim of this study was to determine if biofeedback can do the same.
Sixty-three patients with established coronary artery disease were randomly allocated to either conventional therapy or to 6 sessions of “Heart Rate Variability” (HRV) biofeedback training consisting of abdominal breath training, heart and respiratory physiological feedback, and daily breathing practice. This form of biofeedback focuses on teaching patients to breathe from the diaphragm at a specific rate that will synchronize with the change in heart rate called the respiratory sinus arrhythmia (RSA). Each patient was taught to breath slowly and smoothly at a rate that would specifically resonate with their RSA (4.6 to 6.8 bpm) and result in a maximization of HRV. Heart rate variability was measured pre-treatment, post-treatment, and at follow-up 12 weeks post treatment.
The biofeedback group was taught to breath correctly during training sessions and encouraged to continue practicing this breathing technique for a minimum of 5-minutes twice a day after training had ceased.
The heart rate variability in control and treatment groups did not differ significantly pre- or immediately post-treatment, but at 12 weeks post-treatment the biofeedback group showed a significant increase in heart rate variability (p = 0.003).
Biofeedback increases heart rate variability in patients with coronary artery disease and may be an efficient tool for improving cardiac morbidity and mortality.
Heart Rate Variability and Heart Rate Coherence
A healthy heart has a natural variation, from minute to minute, beat to beat – even when you are sitting at rest. A change equivalent to 30 beats per minute over just a few seconds is not uncommon. This phenomenon is known as Heart Rate Variability (HRV). It’s a sign of good health – in fact the greater the beat-to-beat variability the better.
Heart rate (HR) is intimately tied to stress and the bodily expression of emotions. You can probably think of times when your heart raced with excitement, or "missed a beat" following a shock, or responded negatively to ongoing stress.
However, patterns within the heart’s beat-to-beat variabilty are much more significant than the simple rate. In states of stress, anxiety, anger and sadness the beat-to-beat variation tends to be disordered and chaotic. In positive emotional states such as love and gratitude, the beat-to-beat variation tends to be ordered and rhythmic. This state of rhythmic variation is known as Heart Rate Coherence, and is a highly efficient and healthy mode of operating.
The screen shots above show Heart Rate Variability graphs for two contrasting states of mind. The horizontal time scale is 4 minutes on each graph.
Biology of Heart Rate Coherence
The brain has a number of channels of communication with the heart, notably the Autonomic Nervous System (ANS) and the hormone system. The ANS has two branches, the sympathetic and the parasympathetic, which work on the heart like an accelerator and brake respectively. When the heart is in a state of coherence, heart rate variability synchronizes with the breath – a phenomenon known as Respiratory Sinus Arrhythmia (RSA). Heart Rate Coherence is much more than a state of relaxation. It represents a dynamic balance within the ANS. On the in-breath, the sympathetic branch (accelerator) is active, and heart rate increases, while on the out-breath, the parasympathetic branch (brake) is active, and the heart slows. Strong negative emotions and stress disturb this autonomic balance and lead to arousal of both systems simultaneously.
It is less well known that heart-brain communication is actually two-way. The heart has its own "brain" – a group of at least 40,000 neurons, some of which project back to the brain. The heart can drive many other oscillatory systems within the body, including brainwaves (EEG), craniosacral rhythms and blood pressure rhythms – hence the use of the term ‘coherence’. Heart Rate Coherence is a highly efficient mode of functioning with many beneficial effects:
  • faster reaction time
  • improved hormone balancee.g. levels of the "stress hormone" cortisol decrease, while levels of DHEA (the "youth hormone") increase
  • improved cardiac health
  • improved immune system activity
  • emotional balance: as mentioned, the heart is able to send signals back to the brain. Healthy heart rhythms have a beneficial effect on the emotional brain. Thus Heart Rate Coherence facilitates positive emotion and weakens negative emotion
  • improved thinking: cognitive performance can be faster and more accurate. Research subjects report thinking more clearly.
Heart Rate Coherence and Biofeedback Training
Heart Rate Coherence is very much a natural state of functioning. That doesn’t mean it should be present all the time, but ideally a few quiet periods of Heart rate Coherence at various "breaks" in the day will be restorative and balancing.
The ability to consciously engender the state of coherence at will is desirable because it creates a sense of control.
In biofeedback training, computer analysis of heart rate information generates a measure of the level of coherence. This information is fed back to the trainee on an on-going basis, so that the trainee can learn how his/her efforts are affecting coherence. A period of regular practice with biofeedback information can make self-regulation a reality within a relatively short time.
HRC biofeedback training can form a useful component of therapy for: Anxiety, Depression, Autonomic Imbalance Syndromes, and Stress-related symptoms including: insomnia, fatigue, aches and pains, high blood pressure, and pre-menstrual symptoms.
In addition Heart Rate Coherence biofeedback training can help with several organic conditions including: asthma, diabetes, cardiac arrhythmias, fibromyalgia, and chronic fatigue.
Example Case History— John
(Printed here with permission)
In 2003 John had become hypertensive, and anomalies had shown up on his routine annual ECG. After further testing by a specialist, John was diagnosed with ventricular tachycardia and was placed on an initial medication regime of a beta blocker with aspirin. After a few months, however, his systolic blood pressure began to spike up again. So, an angiotensin converting enzyme (ACE) inhibitor was added. But John experienced a lot of problems with this combination of medications. The beta blocker worsened his chronic fatigue and depression, which probably exacerbated the problems in his marriage. John soon developed multiple gastric ulcers, and had to stop taking the aspirin. The ACE inhibitor dose was raised several times, because his systolic BP would start spiking up again after a few weeks and John developed an annoying, persistent dry cough, which is often a side effect of ACE inhibitors.
In mid-2004, John consulted Dr. Mueller, a registered psychologist, for help with his depression, increasing stress, and related health concerns. As part of John’s therapy for depression and stress reduction, Dr. Mueller introduced John to Heart Rate Coherence (HRC) biofeedback training.
John was astonished and initially horrified by what he saw occurring on the biofeedback system computer screen. He could see all the ugly arrhythmia in his heart pulse waves – missed beats, double beats and very irregular changes in beat-to-beat variability.
The left-hand figure shows John’s first HRV biofeedback training session. Note the extreme incoherence of the beat-to-beat variability in his heart rate. The right-hand figure shows John’s HRV after 6 in-clinic training sessions and 3 weeks of in-home practice. Note the dramatic increase in the coherence of his heart rate.
After several sessions with Dr. Mueller, and some home practicing of the regulated diaphragmic breathing he was taught in the clinic, John noticed that the arrhythmia became reduced and the heart rate variability pulse waves became smoother. Out of curiosity, John began to check his blood pressure before and after about 10 to 15 minutes of regulated diaphragmic breathing at home. His systolic BP would drop as much as 20 points, or even more if it had spiked up into the 150s or 160s. John started to do 10 to 15 minutes of regulated breathing twice a day at home, and found the control of his BP to be highly persistent. In consultation his physician, John was now able to discontinue the beta-blocker and to reduce his dose of ACE inhibitor down to a minimal level and still maintain his systolic BP below the 130 level that his physician required. The dry cough did not abate, however. So, John’s physician eventually switched his medication to a minimal dose of a combination angiotensin II receptor blocker and thiazide diuretic – half a tablet per day of Atacand Plus®.
Now, 10 minutes of a heart rate coherence breathing exercise once a day is more than enough to sustain control of John’s BP with the half tablet of Atacand Plus®. His BP now averages 120 over 65. If he does not do his Heart Rate Coherence breathing exercises for more than a couple of days, his BP shows signs of rising again despite continuing his current AT-II medication.
Even more encouraging for John has been the finding on a recent ECG that his heart arrhythmias have disappeared and his heart rhythms are now normal again.
John is now hoping to completely eliminate the need for medication by doing a little more work on his daily heart coherence exercises and reducing his weight somewhat.
Dr. Horst Mueller is a registered psychologist with a private practice in clinical and health psychology. He has special interest and expertise in the application of cognitive-behavioural psychotherapy and applied psychophysiology and biofeedback to the assessment and treatment of children and adults with chronic health problems. He expert in Heart Rate Variability biofeedback training.
Dr. Mueller is listed with the Canadian Register of Health Service Providers in Psychology (CRHSPP) and is Fellow of the Biofeedback International Alliance (BCIA). He is also a member of the Association for Applied Psychophysiology and Biofeedback (AAPB) and the International Society for Neurofeedback and Research (ISNR).