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Faidra Papanikolaou, November 26 2021

Biofeedback - Better health just by breathing and listening.

What is biofeedback?

Biofeedback is a process that enables an individual to affect their physiological activity using “feedback” from their internal, physiological signals. To obtain this feedback practitioners use accurate instruments that measure live heart rate, breathing, muscle activity, skin temperature and more (Khazan, 2019). This information is presented and used to support physiological changes that will happen during training but eventually the user can achieve those changes without external feedback. There are several modalities that can be used in practice including heart rate, skin conductance, temperature. In this post I will focus on heart rate variability biofeedback training with breathing, as the most discussed and applied, simple to perform and understand.

Biofeedback and emotion regulation

Biofeedback practice taps on an important skill, emotion regulation. Emotion regulation or self-regulation entails recruiting psychological and physiological processes to detect and react to events that are perceived as a threat to the individual (Taylor, 2006). This process is fundamental for the treatment of mental health disorders since many maladaptive behaviours are linked with self-regulation deficiencies (Harmsel et al., 2021). 

 What biofeedback does is that it illustrates connections between emotions and physiology (Harmsel et al., 2021). It can boost self-regulation and self-efficacy skills (Jafarova et al., 2020; Khazan, 2019; Lehrer et al., 2020) and deliver just in time interventions, especially when instructed with ecological, technological solutions. 

Recent evidence shows that biofeedback practice can be used for alleviating symptoms of specific disorders. It is suggested as efficacious for patients with anxiety, depressive symptoms, irritable bowel syndrome asthma, diabetic ulcers, insomnia, PTSD, traumatic brain injury, tinnitus, fibromyalgia, headaches, migraines, IBS and more (Fournié et al., 2021). Thus it could be a great non-pharmaceutical supplementary or alternative treatment. Moreover, there is evidence that it can help with enhancing performance by improving working memory and attention (Gevirtz, 2013; Tinello et al., 2021).

The myth of tonic heart rate

Until the 1960’s heart rate variability (HRV) was... a nuisance. 

Psychophysiologists were interested in heart rate changes after exposure in different stimuli, but it seemed as if there was no “tonic heart rate”, it kept varying constantly (Lehrer, 2013). Later it became evident that this variation was the signal itself. The heart is a muscle that needs to adapt quickly in response to external circumstances (Schwerdtfeger et al., 2020). Our bodies are healthier and more resilient when our heart does not beat at a steady pace like a metronome, but when the time between heartbeats is constantly changing. The greater this change, the greater the heart rate variability (HRV) (Rajendra Acharya et al., 2006). Several studies find higher HRV related to better overall health, performance, emotional health, (Dinas et al., 2013; Heiss et al., 2021) while low HRV is associated with chronic pain, anxiety, depression, IBS, asthma and other disorders (Dell’Acqua et al., 2020; Heiss et al., 2021).

“HRV can thus be considered as a measure of neurocardiac function that reflects interactions between heart, brain and autonomic nervous system dynamics (Shaffer et al., 2014).”

The practice

One immediate way of affecting HRV is using breathing. Breathing is the only fundamental physiological rhythm that we can have conscious control on (Homma & Masaoka, 2008). Inhalation goes in hand with increasing heart rate, and the opposite for exhalation. There is a particular slow breathing frequency that may enhance the effects of HRV biofeedback training: the resonance breathing rate. Breathing in your resonance rate results in increasing the amplitude of oscillations between breath and heart rate, leading to higher levels of HRV during practice (Lehrer et al., 2020; Shaffer & Meehan, 2020). Heart rate and breathing become synchronised when breathing approximately from 4.5 to 6.5 breaths per minute (Lehrer et al., 2020; Steffen et al., 2017).

Studies suggest that HRV training with resonance breathing results better clinical outcomes, compared to simple slow breathing (Lin et al., 2012; Steffen et al., 2017). However it is a question that is currently being investigated (Kohlenberg, 2021; Lehrer et al., 2020). 

Did you know? Here at Sensae, we assess resonance breathing using guidance from haptic vibrations, while monitoring your physiology!

Where to start?

A simple start is to practice slow breathing. Using a simple breathing pacer, adjust the settings to the most comfortable breathing rate. Start with the highest and gradually reduce it, so that you are more likely to reach your resonance rate. You can use this link to a simple breathing pacer:

https://xhalr.com/ or use the one below!

And the following settings:

Focus on a natural and slow exhalation, from your nose.

Alternatively, you can participate in one of our testing sessions here at Sensae where we determine your individual resonance rate.

You can sign up here!

Did you know? At Sensae, we are currently working on technology to monitor the physiological signs of stress and help people acknowledge their internal body processes. Our mission is to aid in finding suitable and healthy ways to increase body awareness as a means to improve resilience and cope with stress. 


Dell’Acqua, C., Dal Bò, E., Messerotti Benvenuti, S., & Palomba, D. (2020). Reduced heart rate variability is associated with vulnerability to depression. Journal of Affective Disorders Reports, 1, 100006. https://doi.org/10.1016/j.jadr.2020.100006

Dinas, P. C., Koutedakis, Y., & Flouris, A. D. (2013). Effects of active and passive tobacco cigarette smoking on heart rate variability. International Journal of Cardiology, 163(2), 109–115. https://doi.org/10.1016/j.ijcard.2011.10.140

Fournié, C., Chouchou, F., Dalleau, G., Caderby, T., Cabrera, Q., & Verkindt, C. (2021). Heart rate variability biofeedback in chronic disease management: A systematic review. Complementary Therapies in Medicine, 60, 102750. https://doi.org/10.1016/j.ctim.2021.102750

Gevirtz, R. (2013). The Promise of Heart Rate Variability Biofeedback: Evidence-Based Applications. https://doi.org/10.5298/1081-5937-41.3.01

Harmsel, J. F. ter, Noordzij, M. L., Goudriaan, A. E., Dekker, J. J. M., Swinkels, L. T. A., van der Pol, T. M., & Popma, A. (2021). Biocueing and ambulatory biofeedback to enhance emotion regulation: A review of studies investigating non-psychiatric and psychiatric populations. International Journal of Psychophysiology, 159, 94–106.

Heiss, S., Vaschillo, B., Vaschillo, E. G., Timko, C. A., & Hormes, J. M. (2021). Heart rate variability as a biobehavioral marker of diverse psychopathologies: A review and argument for an “ideal range.” Neuroscience & Biobehavioral Reviews, 121, 144–155. https://doi.org/10.1016/j.neubiorev.2020.12.004

Homma, I., & Masaoka, Y. (2008). Breathing rhythms and emotions. Experimental Physiology, 93(9), 1011–1021. https://doi.org/10.1113/expphysiol.2008.042424

Jafarova, O., Mazhirina, K., Sokhadze, E., & Shtark, M. (2020). Self-regulation Strategies and Heart Rate Biofeedback Training. Applied Psychophysiology and Biofeedback, 45(2), 87–98. https://doi.org/10.1007/s10484-020-09460-5

Khazan, I. (2019). Biofeedback and Mindfulness in Everyday Life: Practical Solutions for Improving Your Health and Performance. W. W. Norton & Company.

Kohlenberg, S. (2021). Resonance Frequency Assessment: The Impact and Implications of Inaccurate Assessment in the Clinical Use of Heart Rate Variability Biofeedback. Biofeedback, 49(2), 38–41. https://doi.org/10.5298/1081-5937-49.2.01

Lehrer, P. (2013). History of Heart Rate Variability Biofeedback Research: A Personal and Scientific Voyage. Biofeedback, 41, 88–97. https://doi.org/10.5298/1081-5937-41.3.03

Lehrer, P., Kaur, K., Sharma, A., Shah, K., Huseby, R., Bhavsar, J., Sgobba, P., & Zhang, Y. (2020). Heart Rate Variability Biofeedback Improves Emotional and Physical Health and Performance: A Systematic Review and Meta Analysis. Applied Psychophysiology and Biofeedback, 45(3), 109–129. https://doi.org/10.1007/s10484-020-09466-z

Lin, G., Xiang, Q., Fu, X., Wang, S., Wang, S., Chen, S., Shao, L., Zhao, Y., & Wang, T. (2012). Heart Rate Variability Biofeedback Decreases Blood Pressure in Prehypertensive Subjects by Improving Autonomic Function and Baroreflex. The Journal of Alternative and Complementary Medicine, 18(2), 143–152. https://doi.org/10.1089/acm.2010.0607

Rajendra Acharya, U., Paul Joseph, K., Kannathal, N., Lim, C. M., & Suri, J. S. (2006). Heart rate variability: A review. Medical and Biological Engineering and Computing, 44(12), 1031–1051. https://doi.org/10.1007/s11517-006-0119-0

Schwerdtfeger, A. R., Schwarz, G., Pfurtscheller, K., Thayer, J. F., Jarczok, M. N., & Pfurtscheller, G. (2020). Heart rate variability (HRV): From brain death to resonance breathing at 6 breaths per minute. Clinical Neurophysiology, 131(3), 676–693. https://doi.org/10.1016/j.clinph.2019.11.013

Shaffer, F., & Meehan, Z. M. (2020). A Practical Guide to Resonance Frequency Assessment for Heart Rate Variability Biofeedback. Frontiers in Neuroscience, 14, 1055. https://doi.org/10.3389/fnins.2020.570400

Steffen, P. R., Austin, T., DeBarros, A., & Brown, T. (2017). The Impact of Resonance Frequency Breathing on Measures of Heart Rate Variability, Blood Pressure, and Mood. Frontiers in Public Health, 5, 222. https://doi.org/10.3389/fpubh.2017.00222

Taylor, S. E. (2006). Tend and Befriend: Biobehavioral Bases of Affiliation Under Stress. Current Directions in Psychological Science, 15(6), 273–277. https://doi.org/10.1111/j.1467-8721.2006.00451.x

Tinello, D., Kliegel, M., & Zuber, S. (2021). Does Heart Rate Variability Biofeedback Enhance Executive Functions Across the Lifespan? A Systematic Review. Journal of Cognitive Enhancement. https://doi.org/10.1007/s41465-021-00218-3

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Faidra Papanikolaou

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