Effects of relaxing breathing paired with cardiac biofeedback on performance and relaxation during critical simulated situations: a prospective randomized controlled trial

Does it need an app? - Differences between app-guided breathing and natural relaxation in adolescents after acute stress

A key component of stress management and biofeedback training is the use of relaxation exercises, such as slow/deep breathing (6 breaths/minute) in heart coherence exercises (HCEs). Breathing exercises are also increasingly being integrated into smartphones as part of health apps, though their effectiveness in adolescents after acute stress has rarely been validated scientifically. The aim of the current study was to investigate the effectiveness of an app-guided HCE (n = 36) after an acute stress situation (Trier Social Stress Test) compared with natural relaxation (n = 37), among healthy adolescents (aged 11-17 years). Endocrine, autonomic, and psychological stress parameters (cortisol, alpha-amylase, heart rate, heart rate variability, mood) were examined in 73 adolescents (46 female, 27 male; Mage = 13.86, SDage = 1.87). Significant group differences were found in heart rate variability, with higher values in the low frequency band and low-to-high frequency ratio for the HCE condition, possibly indicating improved physiological functions through the stimulation of vagal tone and baroreflex. The use of a general breathing technique (natural and app-guided) also resulted in stronger relaxation reactions in cortisol when controlling for the previous stronger stress reactivity. On the other hand, app-guided slow breathing without a long training may be experienced as more uncomfortable during relaxation. The integration of breathing exercises in health apps for adolescents appears to be useful, offering a helpful and low-threshold coping/relaxation strategy during acute stress situations. Further studies should examine the benefits of app-guided breathing exercises in both psychiatric samples and the general population across a wide age range.

Unraveling the temporal interplay of slow-paced breathing and prefrontal transcranial direct current stimulation on cardiac indices of autonomic activity

The neurovisceral integration model proposes that information flows bidirectionally between the brain and the heart via the vagus nerve, indexed by vagally mediated heart rate variability (vmHRV). Voluntary reduction in breathing rate (slow-paced breathing, SPB, 5.5 Breathing Per Minute (BPM)) can enhance vmHRV. Additionally, prefrontal transcranial direct current stimulation (tDCS) can modulate the excitability of the prefrontal region and influence the vagus nerve. However, research on the combination of SPB and prefrontal tDCS to increase vmHRV and other cardiac (heart rate (HR) and blood pressure) and peripheral (skin conductance) indices is scarce. We hypothesized that the combination of 20 min of SPB and prefrontal tDCS would have a greater effect than each intervention in isolation. Hence, 200 participants were divided into four groups: active tDCS with SPB, active tDCS with 15 BPM breathing, sham tDCS with SPB, and sham tDCS with 15 BPM breathing. Regardless of the tDCS condition, the 5.5 BPM group showed a significant increase in vmHRV over 20 minutes and significant decreases in HR at the first and second 5-min epochs of the intervention. Regardless of breathing condition, the active tDCS group exhibited higher HR at the fourth 5-min epoch of the intervention than the sham tDCS group. No other effects were observed. Overall, SPB is a robust technique for increasing vmHRV, whereas prefrontal tDCS may produce effects that counteract those of SPB. More research is necessary to test whether and how SPB and neuromodulation approaches can be combined to improve cardiac vagal tone.

Association of Personality Traits With the Efficacy of Stress Management Interventions for Medical Students Taking Objective Structured Clinical Examinations

PURPOSE

Personality traits are associated with psychophysiological stress, but few studies focus on medical students. This study aimed to better understand the association of personality traits with the efficacy of stress management interventions for medical students.

METHOD

A randomized controlled trial was conducted with fourth-year students who took the objective structured clinical examination at Bernard University Lyon 1 in December 2021. Students were randomized in cardiac biofeedback, mindfulness, and control groups. Each intervention was implemented for 6 minutes before the examination. Physiological stress levels were collected during the intervention. Psychological stress levels were rated by students at baseline and after the intervention. Personality traits were assessed via the Big-Five Inventory. Interactions between personality traits and the efficacy of the interventions were analyzed using multivariable linear regression models.

RESULTS

Four hundred eighty-one students participated. Higher baseline psychological stress levels were associated with higher neuroticism and agreeableness ( β = 10.27 [95% confidence interval {CI}, 7.40-13.13; P < .001] and β = 3.42 [95% CI, 0.98-5.85; P = .006], respectively) and lower openness ( β = -4.95; 95% CI, -7.40 to -2.49; P < .001). As compared with the control intervention, both stress management interventions led to lower levels of psychological ( P < .001 for both) and physiological stress levels (biofeedback: P < .001 and mindfulness: P = .009). Biofeedback efficacy varied by extraversion score for psychological ( β = -5.66; 95% CI, -10.83 to -0.50; P = .03) and physiological stress reduction ( β = -0.002; 95% CI, -0.003 to -0.00004; P = .045). Mindfulness efficacy varied by agreeableness score for psychological stress reduction ( β = -7.87; 95% CI, -13.05 to -2.68; P = .003).

CONCLUSIONS

Students with a high score in extraversion may benefit more from biofeedback interventions, while students with high scores in agreeableness may benefit more from mindfulness interventions.

A Synthesized Model for Applying Stress Management and Biofeedback Interventions in Research Utilization: A Systematic Review and Meta-analysis

Background

Stress management and biofeedback interventions have been shown to be effective in improving mental and physical health outcomes. However, previous research studies and synthesized models for applying these interventions in research utilization are insufficient.

Objective

This study aimed to synthesize a model for applying stress management and biofeedback interventions in research utilization.

Methods

A systematic review and meta-analysis were conducted according to the PRISMA guidelines.Multiple studies were used to assess the effectiveness of applying stress management and biofeedback interventions published from 2017 to 2023. The process included identifying the research questions, conducting a comprehensive literature search, assessing study quality, extracting data, synthesizing the data, analyzing and interpreting the findings, drawing conclusions, and making recommendations.

Results

The results indicated a significant mean effect size without evidence of publication bias. The effect sizes of the subgroups among the study variables were not significantly different [Q = 4.02, p = .26]. However, there were significant differences regarding the mean effect sizes among the studies [Q = 63.59, p < .001] and also in terms of the test of subgroups among the participants [Q = 8.49, p = .04].

Conclusion

The results emphasize the importance of evidence-based practice and highlight the need for ongoing evaluation and refinement of interventions. The proposed model was supported by related theories and research studies in order to ensure the robustness and reliability to guide practice and future research in the field of biofeedback interventions. By following this model, researchers and practitioners can ensure that stress management and biofeedback interventions are evidence-based and are effective in improving mental and physical health outcomes.

Breathing Practices for Stress and Anxiety Reduction: Conceptual Framework of Implementation Guidelines Based on a Systematic Review of the Published Literature

Anxiety and stress plague populations worldwide. Voluntary regulated breathing practices offer a tool to address this epidemic. We examined peer-reviewed published literature to understand effective approaches to and implementation of these practices. PubMed and ScienceDirect were searched to identify clinical trials evaluating isolated breathing-based interventions with psychometric stress/anxiety outcomes. Two independent reviewers conducted all screening and data extraction. Of 2904 unique articles, 731 abstracts, and 181 full texts screened, 58 met the inclusion criteria. Fifty-four of the studies' 72 interventions were effective. Components of effective and ineffective interventions were evaluated to develop a conceptual framework of factors associated with stress/anxiety reduction effectiveness. Effective breath practices avoided fast-only breath paces and sessions <5 min, while including human-guided training, multiple sessions, and long-term practice. Population, other breath paces, session duration ≥5 min, and group versus individual or at-home practices were not associated with effectiveness. Analysis of interventions that did not fit this framework revealed that extensive standing, interruptions, involuntary diaphragmatic obstruction, and inadequate training for highly technical practices may render otherwise promising interventions ineffective. Following this evidence-based framework can help maximize the stress/anxiety reduction benefits of breathing practices. Future research is warranted to further refine this easily accessible intervention for stress/anxiety relief.

Kindness Isn't Just about Being Nice: The Value Proposition of Kindness as Viewed through the Lens of Incivility in the Healthcare Workplace

The healthcare workplace is a high-stress environment. All stakeholders, including patients and providers, display evidence of that stress. High stress has several effects. Even acutely, stress can negatively affect cognitive function, worsening diagnostic acumen, decision-making, and problem-solving. It decreases helpfulness. As stress increases, it can progress to burnout and more severe mental health consequences, including depression and suicide. One of the consequences (and causes) of stress is incivility. Both patients and staff can manifest these unkind behaviors, which in turn have been shown to cause medical errors. The human cost of errors is enormous, reflected in thousands of lives impacted every year. The economic cost is also enormous, costing at least several billion dollars annually. The warrant for promoting kindness, therefore, is enormous. Kindness creates positive interpersonal connections, which, in turn, buffers stress and fosters resilience. Kindness, therefore, is not just a nice thing to do: it is critically important in the workplace. Ways to promote kindness, including leadership modeling positive behaviors as well as the deterrence of negative behaviors, are essential. A new approach using kindness media is described. It uplifts patients and staff, decreases irritation and stress, and increases happiness, calmness, and feeling connected to others.

Personality traits affect anticipatory stress vulnerability and coping effectiveness in occupational critical care situations

The present study aimed at investigating the influence of personality on both anticipatory stress vulnerability and the effectiveness of coping strategies in an occupational stressful context. Following assessment of individual personality traits (Big Five Inventory), 147 volunteers were exposed to the anticipation of a stressful event. Anxiety and cardiac reactivity were assessed as markers of vulnerability to anticipatory stress. Participants were then randomly assigned to three groups and subjected to a 5-min intervention: relaxation breathing, relaxation breathing combined with cardiac biofeedback, and control. The effectiveness of coping interventions was determined through the cardiac coherence score achieved during the intervention. Higher neuroticism was associated with higher anticipatory stress vulnerability, whereas higher conscientiousness and extraversion were related to lower anticipatory stress vulnerability. Relaxation breathing and biofeedback coping interventions contributed to improve the cardiac coherence in all participants, albeit with greater effectiveness in individuals presenting higher score of openness to experience. The present findings demonstrated that personality traits are related to both anticipatory stress vulnerability and effectiveness of coping interventions. These results bring new insights into practical guidelines for stress prevention by considering personality traits. Specific practical applications for health professionals, who are likely to manage stressful situations daily, are discussed.