Scientific Background


HeartRateVariability is a non-invasive treatment in which patients are assumed to selfregulate a physiological dysregalated vagal nerve. HRVbiofeedback is promising.
6 Randomized Controlled Trials have shown that 8 weeks treatment with HRV biofeedback combined with CBT results in 77% reduction on the Beck Depression Scale while the controlgroup ( CBTtreatment  or CBT with relaxation training) only showed 37% reduction on the BDI-scale. Also with PostTraumatic StressDisorder HRVbiofeedback plus CBT shows 53% reduction compared with 24% reduction in the control group (CBT and medicine).

Anxiety, trauma, ADHD, burnout and depression all immediately have effect on our physiology, especially dysregulation of the Autonomic Nervous System (ANS). As well as stress, peakperformance and performing anxiety. In a normal state sympathetic and parasympathetic activity alternate permanently: brake and accelerator of our nervous system. With severe dysregulation of ANS-balance the Sympathetic Nervous System is hyperactive (and in later stage fully dysregulated and shutting down) and Vagal Nerve is deactivated. Effects: no ability te feel quiet, sleeping problems and constantly puzzling, depressive mood.

After 8 weeks training HRV-biofeedback (breathing rhythm in resonance with heartrhytm) this dysregulation can be recovered and balanced, which will optimize treatment of stressrelated disorders (combined with cognitive behaviour therapy, psychotherapy, medication).
Effective treatment needs selfregulation by yourself, balancing ANS, which creates more resilience. 
HeartRate Variability biofeedback makes visible balance and dysbalance of our neurophysiology. The screen shows the HRV pattern and the analysis of Action (sympathetic/ hyperactivity), Balance (autonomic balance and resilience) or Calm-sleepy (dominance of parasympathetic system).


Orange: Action (sympathetic nerve activity)
Violet:   Balance 
Green:  Calm, pacifying(vagal nerve activity)

A short review of development of HeartRateVariability research

1. First publications

Akselrod S,Gordon D et al (1981) Power spectrum analysis of heart rate fluctuation: A quantitive probe of beat-to-beat cardiovascular control. Science 1981; 213:220-222.

Sinnreich R,Friedlander Y, Sapoznikov D (1988) Five minute recordings of heart rate variability for population studies:repeatability and age-sex characteristics. Heart 1988; 80 156-162.

Fuller (1992) The effects of stress-anxiety and coping styles on heart rate variability. International Journal of Psychophysiology 12(1): 81-6.

Porges (1995) Cardiac vagal tone: a physiological index of stress. In: Neuroscience Biobehav 19(2): 225-233.

Tsuji H, Larson MG,Levy D, et al (1996) Impact of reduced heart rate variability on risk for cardiac events. The Framingham Heart Study. Circulation,1996.

Berntson GG, Bigger JT, Eckberg DL, Grossman P.Origins (1997), methods and interpretive caveats. J Psychophys 1997;34: 623-48.

Paul Lehrer, Stephen Porges et al(1997) Respiratory Sinus Arrhythmia versus Neck Trapezia EMG and incentive inspirometry biofeedback for asthma. In: Appl Psychophysiol and Biofeedback Vol 22, no 2. 


2. Foundation and Standards of HRV-biofeedback

Taskforce of the European Society of Cardiology and the North American Society of pacing and Electrophysiology (1996) Heart Rate Variability: Standards of measurement, physiological interpretations, and clinical use in: European Heart Journal (1996) 17, 354-381  download

Nolan J, Batin P et al (1998) Prospective study of heart rate variability and mortality in chronic heart failure: Results of the United Kingdom Heart Failure Evaluation and Assessment of Risk Trial (UK-Heart).Circulation 1998 98: 1510-1516.

Gevirtz (2000) Physiology of stress. In: Stress and Health, research and clinical applications, Sydney, Harwood Academic Publishers.

Lehrer P, Vasschillo E, Vasschilo B

Sahar T, Porges, SW (2001) Vagal modulation of responses to mental challenge in posttraumatic stress disorder, Biol.Psychiatry, 2001;49.637-643. download

Vasschillo, Lehrer (2002) Heart Rate Variability biofeedback as a method assessing baroreflex function: a preliminary study of resonance in the cardiovascular system. In: Applied Psychophysiology and Biofeedback Vol 27, No1.

Porges,S (2003) Social Engagement and attachement a phylogenetic perspective. Ann N.Y.Academy of Sciences 10.1196/annals1301.004.

Vasschillo, Lehrer (2006) Characteristics of resonance in HRV stimulated by biofeedback, J of Appl Psychophys & Biofeedback  download

Lehrer, Woodfolk &Sime (2007) Principles and practice of stressmanagement, 3d edition New York: Guilford.

Gevirtz R (2009) Autonomous Nervous system markers for Psychophysiological Anxiety and Physical Disorders, in: Integrated Neuroscience and Personalized Medicine.

Porges S (2011) The Polyvagal Theory: neuropsychological foundations of emotions, attachement, communication and selfregulation. New York.

​Lehrer P.Gevirtz R (2014) Heart Rate Variability biofeedback: how and why does it work? Frony Psychol, 2014;5:756.


3. Clinical research in different areas after first results of HRV biofeedback with asthma. Positive effects have been measured in: fibromyalgia, depression, panic disorders, stress and anxiety, ADHD, PTSD, COPD, abdominal pain, cardiac rehabilitation, Coronary Artery Disease and high blood pressure and with different  groups: youth, elderly people, sport, police, army, hospitals and clinical situations.

Piccirillo G, Bucca D, Cacciafesta M (1998) Power spectre analysis of heart rate in participants over a hundred years old. Int J Cardiology 1998; 63:53-61.

Bernardi (2002) Congestive Heart Failure, Circulation.

Frederic Luskin (2002) A contolled pilot study of stress management training of elderly patients with congestive heart failure. In: Preventive Cardiology fall 2002.

Perkiomaki JS (2002) HeartRate Variability: recent developments.Ann Noninvasive Electrocardiol 2002, 7: 83-85.

Lehrer PM Vasschillo E, Vaschillo B,e.a.(2004) Biofeedback treatment for asthma, Chest,126 (2) 352-361.

Giardino ND e.a.(2004)Combined Heart rate Variability and pulse oximetry biofeedback for Chronic Obstructive Pulmonary Disease: preliminary findings, Appl Psychophys Biofeedback 29(2),121-133.

Tripathi (2004) respiration and Heart rate variability. A review with special reference to its application in aerospace medicine. Indian Journal of Aerospace Medicine, 48(1) 64-75.

Rajendra Acharya U, Luk Yi Ping, Tji Leng Chua (2004) Heart Rate analysis in normal participants varoius age groups. Biomed Eng Online 2004; 3:24.

Nolan RP et al (2005) HRVBiofeedback as a behavioral neurocardic intervention to enhance vagal heart rate control, Am Heart J. 149(6),1137 (about coronary artery disease)

Hassett A, Lehrer, P (2007), A pilot study of the efficacy of HeartRate Variability Biofeedback in patients with fibromyalgia in: Appl Psychophysiol Biofeedback, 2007; 32:1-10.

Maria Karavidas, Paul Lehrer (2007),  Heart Rate Variability Biofeedback for the treatment of major depression. In: Appl Psychophysiol Biofeedback (2007) 32: 19-30.         

Reinke A, Gevirtz R (2007) Effect of HeartRate Variability feedback in reducing blood pressure. Appl. Psychophysiology and Biofeedback,134.

Zucker T, Samuelson, Gevirtz R (2009) The effects of RSA biofeedback in HRV and PostTraumatic Stess Disorder syndroms, Appl Psychophysiology & Biofeedback   download HRV biofeedback with PTSD

Mc Craty R, (2009) New hope for correctional officers: an innovative program for reducing stress and health risks. In: Appl Psychophysiol Biofeedbck (2009) 34;251-272

Siepman M, Aykac V, Unterdorfer J (2008) A pilot study on the effects of heart rate variability biofeedback in patients with depression and in helthy subjects. Appl Psychophys and Biofeedback, 33 (4), 195-201  download HRV biofeedback for depression

Moravec CS (2008) Biofeedback therapy in cardiovascular disease: rationale and research overview Cleve ClinJ Med 75, Suppl2 S35-38.

Brook H et al (2010) Heart Rate Variability in bipolar mania and schozophrenia, in: Journal of Psychiatric  research 44 (2010) 168-176.

Kikuchi M et al (2010) Heart Rate Variability in drug-naive patients with panic disorder and major depressive disorder in: Progress in Neuro Psychopharmacology & Biological Psychiatry 33   download HRVbiofeedback for depression

Sowder E, Gevirtz (2010) Restoration of Vagal Tone: A possible mechanism for functional abdominal pain. Appl Psychophysiol Biofeedback.

Tan G, Dao TK, Gevirtz R(2011) Heart Rate Variability and Posttraumatic Stressdisorder: a pilotstudt, Appl Psychophysiol.Biofeedback (2011) 36:27-35 download HRV and PTSD

Rene R, Gevirtz R et al (2011) The efficacy of a portable HRV Feedback device in conjunction with mental health treatment of clients with major depressive disorder, Alliant International University.

Gregg Henriques (2011) Exploring the effectiveness of a computer based heart Rate Variability biofeedback program in reducing anxiety in college students in: Appl Psychiphysiol Biofeedback (2011) 36 101-112    

Lin G, Xiang O, Wang S e.a.(2012) Heart Rate Variability biofeedback decreases blood pressure in prehypertensive subjects by improving autonomic function and baroreflex. J AlternComplement.Med 18(2) 143-152.

Patron E, Benvenutti GF, Palombo D (2013), Biofeedback assisted control of RSA as a biobehavioral intervention for depressive symptoms in patients after cardiac surgery: a preliminary study. Appl Psychophysiol Biof 2013;38:1-9.

Ebert, C (2013), The use of HRVB for the treatment of FGID in children and adolescents, AAPB, Portland (about abdominal pain).

Chalmer JA ,e.a. (2014) Anxiety disorders are associated with reduced heart rate variability. Front Psychiatry 2014;5:80.


4. Systematic Reviews

The amount of HRV articles is rising very fastly. Since 2005 10 articles are published weekly:
Nunan D, Sandercock G (2010) A quantitive systematic review of normal values for short term Heart Rate Variability in healthy adults PACE,Vol 33, nov 2010.

Gevirtz R. The promise of Heart rate Variability Biofeedback: Evidence-based application. Biofeedback 2013; 41:110-120. 

Schoenberg PL, Divid AS (2014) Biofeedback for psychiatric disorders: a systematic review, Appl.Psychophysiol Biofeedback 2014;39:109-135

Blase KL, A van Dijke, PJM Cluitmans, E Vermetten, (2016) Evidentie voor de effectiviteit van HRV Biofeedback bij behandeling van depressie en PTSS?, Tijdschrift voor Psychiatrie, 2016.

download the systematic review of K.Blase et al (2016)