Heart Rate Variability Biofeedback Promising in Chronic Pain

Pauline Anderson

October 25, 2017

SAN DIEGO — Heart rate variability biofeedback (HRV-B) is a promising intervention for veterans with chronic pain, new research suggests.

The technique, which uses breathing to control heart rate and reduce stress, is an inexpensive and increasingly accessible approach to manage pain, Jack Ginsberg, PhD, a clinical psychologist and research health scientist, Dorn Veterans Administration (VA) Medical Center, and clinical assistant professor, Department of Pharmacology, Physiology & Neuroscience, University of South Carolina School of Medicine, Columbia, told Medscape Medical News.

Dr Jack Ginsberg

"The VA is becoming increasingly interested in using biofeedback as a treatment intervention both for pain and for post-traumatic stress disorder," he said.

The findings were presented here at the Academy of Integrative Pain Management (AIPM) 28th Annual Meeting.

Stress Response Amplifies Pain

Pain initiates a stress response that increases sympathetic output and autonomic imbalance. Sympathetic overdrive, shown as reduced HRV (the variation in the time interval between heartbeats), is common in chronic pain.

"Pain is amplified by the stress response, so if you have a little bit of pain and you add a big stress response on top of that, now you have elevated or amplified pain," explained Dr Ginsberg. "If you can lower that stress response, which is what this maneuver does, you then reduce the amplified pain down to a much more manageable level."

With biofeedback, pain patients learn to increase HRV and restore autonomic balance, he added.

HRV-B has three components. The first, called "resonant frequency breathing," is achieved at around 6 breaths per minute and can be quantitatively determined by the size and shape of a peak of HRV around 0.1 Hz.

"Heart rate variability is very easily measured nowadays; the technology is simple and relatively inexpensive, and so we can collect data quite easily," said Dr Ginsberg.

Getting HRV to an appropriate target requires mindful attention to breathing, a second component of the HRV-B technique. It's relatively easy to sense when you're breathing at the correct rate for optimal HRV, said Dr Ginsberg.

The biofeedback technique also includes a third, "emotional," component, said Dr Ginsberg. "It creates what veterans call 'being in the zone,' and they can sort of feel when they are in that."

Veterans — and others — can learn the skill "fairly rapidly, within a month, if not less," said Dr Ginsberg. Many who master HRV-B find it "self empowering," he added.

Feasible, Effective

In the new VA research, HRV-B training involved 4 to 6 weekly 45-minute meetings with a biofeedback coach, along with daily 10-minute sessions at home.

Dr Ginsberg discussed three randomized studies of HRV-B in veterans with chronic pain, generally aged 50 to 60 years, each with a matched control group. Two studies used a wait-list control and the third used sham HRV-B training.

The first study, a pilot, found that the group that received HRV-B training had significantly lower outcomes on pain ratings and perceived stress compared with the control group, which received treatment as usual (all P < .05).

Those study authors concluded that HRV-B is feasible and effective.

The second study, which evaluated HRV-B in 34 cancer survivors, provided further evidence of feasibility and effectiveness. Patients who practiced biofeedback had increased HRV and significant decreases in several symptoms compared with controls receiving treatment as usual.

These reductions were seen in pain (as measured on the Brief Pain Inventory), stress (Perceived Stress Scale), depression (Beck Depression Inventory II), fatigue (Multidimensional Fatigue Inventory), and sleep (Insomnia Symptom Questionnaire).

The ongoing third study is comparing HRV-B vs an inactive treatment control over a 6-week period in a larger group of veterans with chronic pain.

Participants assigned to the "sham" HRV-B in this study are scheduled for a weekly clinic meeting that matches the timing and duration of the active HRV-B sessions.

During sham training, participants have their heart rate, respiration, blood pressure, and blood pressure volume recorded during a 15-minute resting period, but no active training or coaching on resonant frequency breathing is provided.

To date, 29 veterans out of a planned enrollment of 80 have completed this study. However, the full analysis has not yet been completed.

Portable, Low Cost

An advantage of this biofeedback technique is that it's portable and just about anyone can practice it, said Dr Ginsberg

"You can do biofeedback while you're sitting on the bus, for example. And once you learn how to do it, you can practice the skill on your own, any time, anywhere."

There's no danger of getting the heart rate down to a dangerously low level using biofeedback, said Dr Ginsberg

However, he cautions against people with significant cognitive impairment or heart disease practicing the technique.

Another "big advantage" of HRV-B is its "very low cost," said Dr Ginsberg. "It requires minimal usage of those precious healthcare dollars and resources."

Many patients with chronic pain use avoidance strategies to lessen their pain, said Dr Ginsberg. While this might work in the short term, it can actually exacerbate the pain in the long term and cause anxiety and negatively affect quality of life.

VA facilities across the country have started using biofeedback. An increasing number of healthcare practitioners, including mental health and primary care clinicians, psychologists, nurses, and others, are training veterans on the technique, said Dr Ginsberg.

As with other nonpharmacologic therapies, HRV-B can reduce the use of opioids, another added benefit.  The high level of opioid prescribing continues to contribute to an epidemic in overdoses, abuse, misuse, and diversion of these drugs.

The VA has been "very active" in bringing integrated models of care to veterans "as part of their emphasis on utilizing fewer opioids" in patients with chronic pain, commented W. Clay Jackson, MD, AIPM president and clinical assistant professor of family medicine and psychiatry, University of Tennessee College of Medicine, Memphis.

"They are finding that these techniques can be highly effective," Dr Jackson told Medscape Medical News. "We should learn from our colleagues in the military in terms of how they're treating their patient population and how that may be generalized to the larger patient population."

Elsewhere, researchers are investigating HRV-B for other disorders, including anxiety, depression, cardiovascular conditions, and chronic fatigue, in addition to chronic pain.   

Dr Ginsberg and Dr Jackson have disclosed no relevant financial relationships.

Academy of Integrative Pain Management (AIPM) 28th Annual Meeting. Abstract 19. Presented October 20, 2017.

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