Since my private practice has moved to being all virtual, people who are interested in biofeedback and heart rate variability, or HRV, training have wondered how this process works remotely, so I decided to make this video to define and describe biofeedback and heart rate variability, as well as share how I work with people from the comfort and privacy of their own home thanks to the internet.
What follows is an edited transcript of the video. If you want to see examples of programs and data, please watch the video.
My work is contemplative care, which aims at guiding you towards greater insight as to how you engage with yourself, with the world around you, with life. Biofeedback is but one of a myriad of mind-body approaches that can help you cultivate greater insight and awareness.
So let me define biofeedback.
Biofeedback is the process of detecting, monitoring and measuring biological, or physiological, signals and presenting the data being measured back to the individual in real time, in order to build awareness in order to make adjustments and changes in mentally and physically.
Biofeedback can help us “see” how the brain and body respond, often on an unconscious level. You can think of biofeedback as a way of making our unconscious processes conscious, our physiological and mental reactions of which we are unaware aware, making what is often unseen seen.
Anything, therefore, that allows you to monitor and detect changes in your body as it is happening can be considered a biofeedback device. It doesn’t have to involve expensive electrodes, sensors, and device. Take a mirror, for example. Looking at my reflection I get clear “data” about my posture. I see when my shoulders are contracted and up by my ears, yet the mirror cannot tell the exact amount of tension in my muscles, or if one muscle group is more tense than the other. That would require more sensitive equipment.
Another example could posture and weight distribution. I can place a scale under each foot and track the weight registered on each scale. Under my right foot might be 75 pounds while the left reads 65. Then, in real time, I can then shift my posture and balance to train myself to evenly distribute my weight. Scales, in this case, offer a bit more sophistication in the data they provide.
These examples demonstrate the stages of biofeedback training. First, we build awareness. You might, for example, become aware that every time you talk about your boss or your trip home for the holidays, you hold your breath, or your shoulders raise up to your ears. You already know that you carry tension in your body, because at the end of the day you’re exhausted, your neck hurts and you have a headache. But what you are not aware of is when you actually begin to contract your muscles or hold your breath.
With awareness, you move to the next stage – self-regulation. Now you use the data fed back to you about your breath or muscle tension to practice responding and orienting to your stressors (your boss and family) in a new way. You train yourself to keep the breath flowing and the muscles soft while talking about work and family.
The hope is that with all this training, all this practice, all this awareness and self-regulation, the effects will spill out into your daily life and not just while sitting in front of a screen or device, that you can carry these skills into other settings, and perhaps they can become your new normal - something called generalization. Eventually when in the actual presence of your boss you will find yourself calmer and more at ease. You may even find yourself less reactive to other triggers since relaxed muscles and effortless breathing might become your default state.
So what type of biological signals do biofeedback therapists commonly measure? In no order of importance, we have:
Sweat, or skin conductance, also known as electrodermal activity or galvanic skin response – typically measured on the palms of the hands or the sole of the feet, although in all my years of practice I have never once measured this on anyone’s feet. Sweat in these specific areas is regulated by our sympathetic nervous system, so whenever we are activated, mobilized, agitated or energized, whether we call that anxiety or excitement, the eccrine glands in our hands and feet secrete sweat. This is the reason some people’s hands get clammy when stressed.
Carl Jung, the great psychotherapist would use skin conductance in his word association tests. He would place sensors on your hands and invite the subject to sit and relax. Then he would say a word and wait a period of time, say 30 to 60 seconds, and observe the automatic physiological reaction, in this case, sweat. After a baseline period, he would say words like, puppy, wait for a moment, taxes, wait, wildfires, wait, ocean, mother-in-law, etc. He saw this as a way of connecting to your unconscious since many people either wouldn’t admit to having any mental, emotional or physical reactions to those words or concepts, or they completely were unaware that their body was responding.
Temperature or thermal biofeedback– and like skin conductance, it is commonly measured on the fingers of the hands, but depending on the goal for training or your health condition, can be measured anywhere on the body. As with sweat, the sympathetic nervous system, when activated, signals the blood vessels in our distal extremities, fingers and toes, to constrict and as a result of the decrease in blood flow causes the temperature to go down. When we are calmer and more relaxed, the blood vessels open, the blood flows, and our temperature goes up. So stress can result in cold and clammy hands.
Muscle tension, aka surface electromyography or EMG – electrodes can be placed almost anywhere on the surface of body to measure the degree of muscle activity. Technically we are measuring the action potential along a muscle fiber, but this correlates to the degree of tension or relaxation of a muscle. EMG biofeedback can help train people to relax in general, by truly practicing letting go of muscle tension. It can be used to train people to efficiently perform a task, like learning to play a sport or musical instrument, without extra and unnecessary muscular effort. I once worked with a violinist who was suffering from shoulder and neck pain. Her violin teacher told her she was using unnecessary muscles and raising her shoulders while bowing. Through biofeedback, she could see how much she was engaging these muscles and she would practice playing the violin while keeping those muscles softer.
Breathing or Respiration Rate – a strain gauge can be place anywhere on the torso where you wish to measure movement connected with the breath – so that could be around the chest or abdomen. Registering each time the torso expands and contracts gives you the breath rate - the number of breaths per minute. You can also break that data down further to determine the length of the inhale and length of the exhale. With respiration biofeedback, you can see how posture influences your breathing, and how your breathing pattern influences other physiological signals, like the next group:
Heart Rate and Heart Rate Variability (or HRV)– I am going to spend a little bit more time here since most of my remote biofeedback training focuses on breathing and heart rate variability
Heart rate is simply the number of heart beats per minute. You measure the pulse for a full 60 seconds (not 5, 10 or 15 and multiply) and that number is your heart rate.
HRV refers to the changes in the time intervals between consecutive heart beats. With HRV, we are measuring the time between each heart beat, or what we call the R-R interval. Unless you have a pacemaker, your heart does not beat at consistent, steady interval. It speeds up and slows down. Just as a reference, if your heart rate was 60 beats per minute and the each heartbeat was exactly the same, the time between each beat, each RR interval, would be a 1000 ms.
You might be able to feel this when taking your pulse. If you can, right now, place your index and middle finger on the thumb side of your wrist, or on the side of your neck, a few inches from the Adam’s apple. Now as you take a big breath in and hold it for a few seconds, pay close attention to the space, or time, between heartbeats. Now slowly exhale and notice what happens now to the time between heart beats. You might observe that as you inhale, the heart rate speeds up, the space between heartbeats gets smaller, and as you exhale the time between beats gets longer, the heart rate slows down. This phenomenon, by the way, is called Respiratory Sinus Arrhythmia or RSA and it is a normal physiological arrhythmia and something we train during HRV biofeedback. The heart rate rhythm isn’t always, and shouldn’t always, be sinusoidal. Breath pacing simply strengthens this pattern. We use breath pacing to increase this pattern since it relates to the function and power of the parasympathetic system, which I discuss in exhaustive detail during individual on-on-one sessions.
This is a great example of why equipment is beneficial if not necessary. Our fingers are just not sensitive enough to calculate the time between subsequent heart beats down to the millisecond and then display it in a way that makes sense to us.
I want to add something about wearables and apps for a moment. Since biofeedback training involves seeing data as it is happening, devices, app, or programs that measures biological signals, like heart rate variability, that do not allow you to see the changes in real time are not technically biofeedback devices. Wearables like the Oura Ring and Whoop do track your HRV, yet they don’t show the moment-to-moment changes in your heart rate as it is occurring. They measure your HRV, but they calculate a score or number once the measuring process is complete. While useful for other reasons, these wearables aren’t used in biofeedback training.
While I am a tech geek, my goal is to help people tune in and listen to themselves with compassion and care. I have worked with many who religiously track their HRV on wearables and apps and allow their data to overshadow any self-awareness. On more than one occasion, people tracking their HRV have reported becoming more agitated, anxious, and stressed about their health the longer they self-monitored. A person will tell me that they aren’t feeling well or had a poor night’s sleep, and when I ask them to elaborate, they talk about the value from their app, and NOT their own internal experience, and that is counter to the intention of my work. If biofeedback monitoring and training does not lead to greater personal insight about how you are experiencing the world, I believe a significant piece of the process is missing.
While I can go on about HRV, I still have one more biological signal to mention and that is:
Brain waves, also known as electroencephalography, EEG, or neurofeedback – this type of biofeedback is a specialty unto itself, and since I do not practice this, and I won’t be mentioning any more about it here.
As I have said, my virtual practice focuses primarily on breathwork and heart rate variability, but if you are interested in other modalities, such as temperature and skin conductance, I do these as well, but they are a bit more involved so reach out to me directly.
Remote training does require some investment, in the form of programs and sensors, but the main benefit is that you will have what you need to do training at home on your own in between our sessions.
So what do you need for this process.
First you need a program – whether on your computer or smartphone or tablet – and this program needs to show changes in your physiology in real time. As I have already mentioned, the Oura Ring and Whoop cannot be used for remote biofeedback training since, they do not show the moment to moment fluctuations of the heart rate interval as it is occurring.
Next you need a sensor that pairs with your specific program. Chest straps, like the Polar Heart Strap, pair with many of HRV apps I have come across. Chest straps use ECG technology, while finger and ear sensors are PPGs or photoplethysmographs, which is measuring the blood flow through the blood vessels. Both work and the choice is often dictated by the program you use. Some programs and apps, such as those by HeartMath, require their own sensors, a Bluetooth PPG or wired PPG (both for the app-based system called Inner Balance) and the USB ear sensor for their computer-based program, called emWave Pro.
The final piece of the equation is the most technical - you need to be able to share the program as it is running during our virtual session. If using an app-based program, then you will need to either connect your phone or tablet to your computer to share your data in real time, or if you logging on to our session with your phone, you will have to be able to share that particular app during our session. Don’t worry, With the proper cables and set up, I can walk you this process.
Typically, I use one of three programs for remote training, although I am constantly evaluating new software. These are:
EliteHRV app for smartphone or tablet paired with either a chest strap or finger sensor
The computer-based program, emWave pro, by HeartMath (and on occasion, their phone-based app, called Inner Balance)
The Alive System by Somatic Vision, which is for the computer only (both Mac and PC), and it requires its own USB finger sensor for PC or Mac, but if using a PC, you can pair it with a Polar Heart strap as well.
EliteHRV is one of the simplest, and least expensive ways to do remote HRV biofeedback training, pairing it with either a Polar Heart Strap (which runs about $99) or a finger sensor through Kyto Fitness from Japan (that runs around about $34, excluding shipping).
I recommend trainees log into their virtual session with me using their computer rather than their phone or tablet, since it is then easier to share their screen. Connecting my iPhone to my iMac through a USBc cable, I can easily share my screen during our video session. The QuickTime program allows me to display my phone screen directly on my computer, which I then share during our session. This process can be done with other apps as well. Again, don’t stress, breathe, I can walk you through this set up.
The second system I commonly use with people is by Heartmath
For the computer they offer the emWave Pro and for the smartphone and tablet, the app is called Inner Balance – both systems come with their own specific sensors. The app offers a Bluetooth or cable sensor, while the computer program uses a USB connection. I tend to recommend the computer system for remote training since it is easier to share the screen but also because it has a bit more complexity to it. Some people prefer using the smartphone app since it is portable and can go with you anywhere you take your phone. That said, I still prefer the computer based, emWave pro, program as it offers a few other options for training, such as games, which is a nice addition to training.
The next system I use, in my opinion, is a step up from HeartMath and it is called Alive by Somatic Vision. Alive is for the computer only, they don’t have an app version, but it offer more feedback in forms of graphs, environments and games for training than emWave. Like emWave, you can buy a home version of Alive for your individual use. Along with the program you will have buy either a finger HRV sensor that uses a USB connection, or if you are on a PC, you can pair this with a polar heart strap.
If you don’t want to purchase your own copy, I can provide you a code so that you can download the software which allows us to do an hour long one-on-one session once a week, and then between session you can training for 10 minutes a day. However, you still will need to purchase a sensor, which costs around $99.
You can also invest in another some more hardware, called the BioSignal, which is a USB device to which you attach sensor for respiration, temperature, skin conductance and HRV. You can either buy this directly or rent this from me, and we then can train these other modalities as well.
That is just a brief overview of biofeedback, HRV and how I do remote training. Hopefully the video gave you a better understand of what type of feedback you get during training. Please reach out any time if you have questions or to learn more about contemplative care, mind-body approaches, and biofeedback. Feel free to pass this along to anyone you think might be interested.
