How to Increase the Impact of HRV Biofeedback Training Part 1. Fred Shaffer, PhD, BCB. Credit. Credit

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1 How to Increase the Impact of HRV Biofeedback Training Part 1 Fred Shaffer, PhD, BCB Truman State University Center for Applied Psychophysiology fredricshaffer@gmail.com Credit I want to recognize the contributions of several amazing colleagues: Dick Gevirtz, PhD, BCB, Paul Lehrer, PhD, BCB, Donald Moss, PhD, BCB, BCN, and Erik Peper, PhD. Credit Inna Khazan, PhD, BCB, David Hagedorn, PhD, BCN, and Rollin McCraty, PhD. 1

2 Credit Thanks to Inna Khazan, the Institute of HeartMath, J & J Engineering, Mind Media, and Thought Technology Ltd., for graphics and adapted figures used in this presentation. Credit Thanks to the undergraduates who staff Truman State University s Center for Applied Psychophysiology. Credit Finally, thanks to Lab Managers Christopher Zerr ( ) and Zachary Meehan (2015). 2

3 Learning Objectives 1. Attendees will be able to explain how to assess breathing. 2. Attendees will be able to explain how to measure a client s resonance frequency. 3. Attendees will be able to describe how to structure training sessions to increase heart rate variability. Learning Objectives 4. Attendees will be able to describe effective home practice assignments that will help clients generalize self regulation skills. Disclaimer I have no financial conflicts of interest to declare. Neither I nor AAPB endorse biofeedback hardware or software products. 3

4 Unit 1: The main function of breathing is gas exchange. The respiratory system exchanges oxygen for carbon dioxide (CO2). Breathing assessment is critical because respiration is an important regulator of heart rate variability, which consists of the beat to beat changes in the heart rhythm. 4

5 Unless corrected, dysfunctional breathing can interfere with HRV biofeedback training, as well as with electrodermal biofeedback, neurofeedback, and temperature biofeedback training. Effortless breathing is Erik Peper s term for healthy abdominal or diaphragmatic breathing. When breathing is effortless, a client experiences her body breathing itself. Subjectively this feels like 70% effort as your client utilizes passive volition, which is allowing rather than forcing (Peper et al., 2008). 5

6 Effortless Breathing 70% of maximum effort (passive volition) attention just below the abdomen abdominal expansion and lower rib/back widening during inhalation 5 7 breaths per minute tidal volume over 1000 ml smooth airflow and respirometer waveform Effortless Breathing Effortless Breathing Passive Volition Clothing, Posture, Ergonomics Healthy breathing maintains an optimal level of CO2 in the blood, releases oxygen to body tissues for gas exchange, and promotes nitric oxide (NO) release to blood vessels for vasodilation. 6

7 blood CO2 and ph hemoglobin release of oxygen and NO oxygen and glucose to tissues; and vasodilation Khazan (2013) considers overbreathing to be the most common dysfunctional breathing pattern. 7

8 Clients overbreathe when they exhale so much CO2 that blood CO2 declines. This is indexed by end tidal CO2 in pressure units (mmhg or torr) using a capnometer. When end tidal CO2 declines, blood ph (alkalinity) increases, and hemoglobin releases insufficient oxygen to tissues and less NO to blood vessels, which causes vasoconstriction. 8

9 Overbreathing lowers CO2 in the blood more subtly than hyperventilation through behaviors like gasping, sighing, and yawning. Moderate overbreathing can reduce oxygen delivery to the brain by 30% 40%, while severe overbreathing can reduce it by 60%. End tidal CO2 Levels Healthy breathing mmhg Overbreathing Mild to moderate mmhg Moderate to severe mmhg Severe < 25 mmhg 9

10 Reduced blood CO2 levels (pco2) may contribute to asthma, panic, phobia, and pain disorders like chronic low back pain (Khazan, 2013). pain phobia low pco2 panic asthma The Waiting Room 1. The waiting room is an ideal place to observe breathing behaviors without reactivity. 10

11 2. Your staff should covertly observe respiration rate, shoulder movement, gasping, sighing, yawning, and apnea (breath holding). The Clinic 1. Look for restrictive clothing that could interfere with abdominal movement. 11

12 2.Look for posture that could interfere with abdominal movement. 3. Check for reverse breathing, where the abdomen contracts during inhalation. Reverse Breathing This pattern often accompanies thoracic breathing and results in incomplete ventilation of the lungs. 12

13 Reverse Breathing 4. Check for clavicular breathing. Clavicular Breathing In clavicular breathing, the shoulders rise and fall during breathing. Clavicular breathing may accompany thoracic breathing. Patients breathe through their mouths to increase air intake. This pattern provides minimal pulmonary ventilation. 13

14 Clavicular Breathing The accessory muscles (sternocleidomastoid, pectoralis minor, scalene, and trapezius) use more oxygen than clavicular breathing provides (deficit spending) over time. Clavicular Breathing 5. Check whether breathing is primarily thoracic or abdominal using covert observation and a respirometer. 14

15 Thoracic Breathing In thoracic breathing, the external intercostals lift the rib cage up and out. Upward and outward movement of the ribs enlarges the thoracic cavity producing a partial vacuum. Negative pressure expands the lungs, but is too weak to ventilate their lower lobes. Thoracic Breathing Thoracic Breathing This reduces oxygen delivery since the lower lobes receive a disproportionate share of the blood supply due to gravity. Thoracic breathing, with or without reverse breathing, expends excessive energy and incompletely ventilates the lungs. 15

16 Thoracic Breathing 6. Check for apnea, which is suspension of breathing, often for 30 seconds or longer. Apnea Don t confuse apnea with a post expiratory pause. 16

17 Apnea While awake, a patient may present with this symptom when engaged in ordinary activities like opening a jar, speaking, or writing a check. Episodes of apnea decrease ventilation and may increase blood pressure. Apnea 7. Check respiration rate (breaths per minute) and amplitude (amount of abdominal respirometer movement). Thoracic breathing at rates at or above 16 bpm may be associated with hyperventilation syndrome (HVS). 17

18 Common symptoms of hyperventilation include feelings of anxiety, breathlessness, dizziness, lightheadedness, rapid heartbeat, and tingling (Lehrer et al., 2013). 8. Check breathing effort by monitoring the abdominal tracing for loss of a smooth sinusoidal pattern. Effortful Breathing 18

19 Effortful Breathing 9. Also check breathing effort by monitoring accessory (trapezius and scalene) and frontal SEMG. Effortful Breathing 10. Check oxygen saturation (PO2) using a pulse oximeter. A range of 95% 98% is ideal. Hyperventilation may increase it to 100% Values outside of this range signal reduced oxygen delivery to tissues (Gilbert, 2012). 19

20 11. Check end tidal CO2 using a capnometer. A value of 36 torr (5%) is normal, while values below 33 torr are seen in HVS. A healthy range is torr. Breathing Assessment Protocol ECG or PPG sensor (HRV) Respirometer (excursion, RR) SEMG sensor (accessory muscle activity) optional Capnometer (end tidal CO2) Oximeter (PO2) Breathing Assessment Protocol Check for reverse breathing 1 min Resting baseline 3 min Serial 7s stressor 3 min Recovery 1 3 min Visualization stressor 3 min Recovery 2 3 min 20

21 Breathing Assessment Protocol Mild hyperventilation 1 min Recovery 3 3 min Hyperventilation challenge is contraindicated for clients diagnosed with epilepsy, heart disease, kidney disease, and panic disorder. Breathing Assessment Protocol Nijmegen questionnaire (nī ˌmā gәn) The Nijmegen questionnaire lists neurological symptoms produced by constriction of cerebral blood vessels during hyperventilation. 21

22 Evaluation Checklist Apnea Abdominal excursion Breathing pattern Effort (breathing rhythmicity and SEMG) Phase synchrony (HR and respiration) Respiratory sinus arrhythmia (RSA) 22

23 You could structure a breathing evaluation protocol as follows: 1. Check for reverse breathing: "Take a normal breath, hold it, and then exhale." Wait 30 seconds. "Take another normal breath and then exhale." (1 minute, no feedback) Watch the screen for evidence of reverse breathing and accessory muscle use. 2. Resting baseline: Breathe normally for the next three minutes." (3 minutes, no feedback) Watch the screen for abdominal excursion, apnea, breathing effort, and respiration rate. Watch your client for gasps, sighs, and yawns. 23

24 3. Serial 7s stressor: "Mentally, count backward from 1000 by 7s until I stop you and ask for your current number. (3 minutes, no feedback) Watch the screen for abdominal excursion, apnea, breathing effort, and respiration rate. Watch your client for gasps, sighs, and yawns. 24

25 4. Recovery 1: "Stop subtracting and breathe normally for the next 3 minutes." (3 minutes, no feedback) Watch the screen for abdominal excursion, apnea, breathing effort, and respiration rate. Watch your client for gasps, sighs, and yawns. 5. Visualize a mildly upsetting experience: "Use all your senses to vividly recreate a mildly upsetting experience. Raise a finger when you are re experiencing the event and continue for the next 3 minutes." (3 minutes, no feedback) Watch the screen for abdominal excursion, apnea, breathing effort, and respiration rate. 25

26 6. Recovery 2: "Stop your visualization and breathe normally for the next 3 minutes." (3 minutes, no feedback) Watch the screen for abdominal excursion, apnea, breathing effort, and respiration rate. Watch your client for gasps, sighs, and yawns. 26

27 7. Hyperventilation challenge: Breathe rapidly for the next minute or until you are uncomfortable. (1 minute, no feedback) Stop immediately if your client experiences dizziness, pain, or panic. Watch for respiration rate, end tidal CO2, and oxygen saturation. 8. Recovery 3: "Stop breathing rapidly and breathe normally for the next 3 minutes." (3 minutes, no feedback) Watch the screen for abdominal excursion, apnea, breathing effort, and respiration rate. Watch your client for gasps, sighs, and yawns. Condition Breaths/Min Torr Baseline Hyperventilation Recovery Data from a 53 year old married woman, diagnosed with panic disorder and agoraphobia courtesy of Donald Moss, PhD, BCB, BCN. 27