Biofeedback-Assisted Resilience Training for Traumatic and Operational Stress: Preliminary Analysis of a Self-Delivered Digital Health Methodology

Abstract

Background: Psychological resilience is critical to minimize the health effects of traumatic events. Trauma may induce a chronic state of hyperarousal, resulting in problems such as anxiety, insomnia, or posttraumatic stress disorder. Mind-body practices, such as relaxation breathing and mindfulness meditation, help to reduce arousal and may reduce the likelihood of such psychological distress. To better understand resilience-building practices, we are conducting the Biofeedback-Assisted Resilience Training (BART) study to evaluate whether the practice of slow, paced breathing with or without heart rate variability biofeedback can be effectively learned via a smartphone app to enhance psychological resilience.

Objective: Our objective was to conduct a limited, interim review of user interactions and study data on use of the BART resilience training app and demonstrate analyses of real-time sensor-streaming data.

Methods: We developed the BART app to provide paced breathing resilience training, with or without heart rate variability biofeedback, via a self-managed 6-week protocol. The app receives streaming data from a Bluetooth-linked heart rate sensor and displays heart rate variability biofeedback to indicate movement between calmer and stressful states. To evaluate the app, a population of military personnel, veterans, and civilian first responders used the app for 6 weeks of resilience training. We analyzed app usage and heart rate variability measures during rest, cognitive stress, and paced breathing. Currently released for the BART research study, the BART app is being used to collect self-reported survey and heart rate sensor data for comparative evaluation of paced breathing relaxation training with and without heart rate variability biofeedback.

Results: To date, we have analyzed the results of 328 participants who began using the BART app for 6 weeks of stress relaxation training via a self-managed protocol. Of these, 207 (63.1%) followed the app-directed procedures and completed the training regimen. Our review of adherence to protocol and app-calculated heart rate variability measures indicated that the BART app acquired high-quality data for evaluating self-managed stress relaxation training programs.

Conclusions: The BART app acquired high-quality data for studying changes in psychophysiological stress according to mind-body activity states, including conditions of rest, cognitive stress, and slow, paced breathing.

Keywords: PHIT; Personal Health Informatics and Intervention Toolkit; biofeedback, psychology; digital health; heart rate variability; mhealth; mindfulness; relaxation therapy; resilience, psychological; respiratory sinus arrhythmia; stress, psychological; well-being.

Figure 1

Overall architecture and major components of the Biofeedback-Assisted Resilience Training (BART) study mobile app. BT: Bluetooth; HRV: heart rate variability.

Figure 2

Biofeedback-Assisted Resilience Training (BART) app home screen activities menu and examples of health assessment survey questions. (a) Activities menu; (b,c) sample survey questions.

Figure 3

(a) Resilience training begins with verification of heart rate (HR) data quality to ensure high-quality heart rate variability (HRV) biofeedback. (b) Once the HR is checked, participants sit at rest for a 3-minute baseline period. (c) Then participants receive paced breathing via an audiovisual graphic animation (top), while the HR signal, HRV trend, and instantaneous HRV meter are displayed in real time (bottom).

Figure 4

The cognitive Training Game stressor exercise is preceded by (a) an instruction screen, followed by (b) 4 minutes of Eriksen flanker stimuli with user response, and completed with (c) 3 minutes of poststress recovery.

Figure 5

Incentive management data flow and processes conducted within the Biofeedback-Assisted Resilience Training (BART) app (left) and in the secure backend data server (right) for monitoring and rewarding participant adherence.

Figure 6

Total number of resilience training sessions across participants by study day.

Figure 7

Compliance with scheduled study activities (listed in Table 1).

Figure 8

Heart rate variability (HRV) at rest and during cognitive stress, recovery, and paced breathing. Error bars represent ±2 SE.