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 Table of Contents  
Year : 2018  |  Volume : 2  |  Issue : 2  |  Page : 51-56

Case study: Adopting heart rate variability biofeedback to decrease workplace stress

1 Hong Kong Association of Psychology, Hong Kong, China
2 Master of Psychology Student, University of Liverpool, United Kingdom

Date of Web Publication22-Aug-2019

Correspondence Address:
Dr. Adrian Low
Room 906, 9/F, Office Tower 2, Grand Plaza, 625 Nathan Road, Mongkok, Kowloon
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/hm.hm_16_18

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Stress is associated with negative outcomes and we all make effort to avoid it. Workplace stress is associated with poor performance, and organizations desire optimal performance from employees. In this case study, the researcher utilizes a heart rate variability biofeedback (HRVB) tool as a workplace stress intervention for his participant, a senior manager who works in a big company in Hong Kong. The researcher presents a review of each of the four sessions he has conducted with his participant. The participant was able to see directly how stressful thoughts and emotions can adversely affect his body. He was motivated to change from the visuals flaring up that he saw on the biofeedback. Stress reduction exercises (SREs) were used during the sessions, and the participant was able to profoundly shift his physiology. The present case demonstrated that emWave Pro Plus HeartMath tool can be used as an important HRVB and SRE tool in the future.

Keywords: biofeedback, heart rate variability, heart rate variability biofeedback, workplace stress

How to cite this article:
Low A, Wong I. Case study: Adopting heart rate variability biofeedback to decrease workplace stress. Heart Mind 2018;2:51-6

How to cite this URL:
Low A, Wong I. Case study: Adopting heart rate variability biofeedback to decrease workplace stress. Heart Mind [serial online] 2018 [cited 2023 Apr 1];2:51-6. Available from: http://www.heartmindjournal.org/text.asp?2018/2/2/51/265159

  Introduction Top

Workplace stress is an emerging global problem in countries such as Canada, the United Kingdom, the Unites States, and Hong Kong. In facing a stressful environment, negative attitude toward work is indicated, resulting in a consequent drop in motivation, performance, and efficiency. Moreover, workplace stress triggers employee reactions as in physical ailments, psychological effects, and unhealthy coping habits. On the same side of the coin, organizational productivity drops as absenteeism, presenteeism, turnover, and sick leave increase.[1]

What is heart rate variability?

Heart rate variability (HRV) refers to the beat-to-beat alterations in heart rate calculated by quantifying the amount of R–R interval (duration between two consecutive R-waves of the electrocardiogram [ECG]) changes as generated from an ECG data.[2] The R–R interval can be influenced by both physical and psychological variables.

The clinical significance of heart rate variability and its relationship with stress

The demand-control model of workplace stress suggests that when demands are high and the control is low with low social support will cause workplace employees to be stressful. It causes an imbalance between the job demand and the person's ability to meet those demands.[3] An increased HRV decreases performance anxiety[4] and increases resilience,[5] while a decreased HRV is associated with inability to respond by physiological variability and complexity. A meta-analysis[6] found that a low HRV is associated with a 32%–45% increased risk of a first cardiovascular disease.

How to evaluate heart rate variability in clinical practice?

The researcher uses the emWave Pro Plus (Quantum Intech Inc., Boulder Creek, CA, USA) to collect and analyze data.

emWave Pro Plus

The emWave Pro Plus is designed by the Institute of HeartMath.[7] It collects pulse data through a pulse sensor, placed on the participant's earlobe or fingertip, and data can be plugged to a computer [Figure 1]. It translates data of heart rhythms and allows real-time assess on how thoughts and emotions are affecting the participant's heart rhythms. It uses photoplethysmography technology which is a reliable and valid method of capturing and quantifying real-time HRV data[8] and is used in the following case.
Figure 1: emWave Pro Plus computer hardware and heart rate variability monitor reading[7]

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  Case Presentation: Analyses and Evaluations Top

This case is presented with Andy (fictitious name), 36-year-old Chinese man, a professional working as a senior manager in Hong Kong.

Andy expressed stressors about the overwhelming workload at the workplace, recent stressors of the recent new-born and not much time with his family due to the extended working hours. He suffered from an anterior cruciate ligament tear 2 years ago and recently had meniscus torn and had undergone surgery. He agreed to participate and expressed interest in participating in the HRV biofeedback (HRVB) experience and the stress reduction exercises (SRE) with the hope of reducing the stress he experienced at his workplace. Andy agreed with a waiver and informed consent was obtained before the sessions.

Sessions summary

Andy attended four sessions with an analysis of the emWave Pro Plus data and therapeutic exercise.

Session 1

In session 1, breathing and HRV data were collected as the baseline by practicing the neutral tool as an exercise in just focusing on the breathing. Andy was tracked around 11 breaths/min with three sudden intake of breath with coherence score at 26% low coherence (LC); 50% moderate coherence (MC); 24% high coherence (HC). In a 1-min HRV assessment, Andy's mean heart rate range (MHRR) was 19.8 beats/min (reference range 8.6–37.2), his standard deviation of the normalized N–N interval (SDNN) was 126.4 msonds (reference range 35–141.8), root mean square of the successive differences (RMSSD) was 109.9 msonds (reference range 19.1–133.2), and his normalized coherence score was 69.7% (reference range 50–100). In the same session, Andy recalled recall a stressful work event and to “rushing to meet project deadlines.” Uneven breathing pattern and high arousal patterns were noticed and discussed. Thereafter, Andy practiced the neutral tool with the researcher and noticed more consistent and sine-like waves (more coherent). Overall coherence levels: LC = 14%; MC = 3; HC = 83%. Andy was invited to practice the neutral tool as homework. The visuals related to this session are presented in [Figure 2], [Figure 3], [Figure 4].
Figure 2: The recall of a stressor in session 1

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Figure 3: The gathering of baseline data in session 1

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Figure 4: Overall coherence levels in session 1

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Session 2

After reviewing the assigned homework, the researcher and Andy were introduced with the heart lock-in technique that could help Andy to recharge his energy system by focusing attention in the area of the heart, imaging breath is flowing in and out of the heart area, and activating a regenerative feeling. The neutral tool exercise was practiced again in measuring Andy's HRV and the pattern generated more consistent and sine-like waves (more coherent). Overall coherence levels: LC = 3%; MC = 11%; HC = 86%. Andy was invited to practice the neutral tool as homework. The visuals related to this session are presented in [Figure 5], [Figure 6], [Figure 7].
Figure 5: Specific experiences and their effects with heart rate variability in session 2

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Figure 6: Overall coherence in session 2

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Figure 7: The spectrum average in session 2

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Session 3

After reviewing the assigned homework with Andy on his practice of the neutral tool, Andy explored another HeartMath tool known as “attitude breathing” with the researcher. The tool could help him to replace draining, negative attitudes with healthier positive ones by recognizing a feeling or attitude with a replacement attitude, and focusing the attention in the chest area along with slower and deeper breathing. On the emWave Pro Plus, it showed Andy's heart beats per minute further decelerated to an average of 59, where the peaks and valleys of each beat look more consistent after 30 s. Andy was also able to reach coherence levels of 30 (medium) and 70 (high). The visuals related to this session are presented in [Figure 8] and [Figure 9].
Figure 8: The garden game on heart rate variability biofeedback in session 3

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Figure 9: The garden game on the power spectrum in session 3

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Session 4

As the concluding session, Andy was able to reach the highest peak closer to 0.1 and having overall coherence levels of 86% (HC), 6% (MC), and 8% (LC) by controlling his breathing. Andy was encouraged to continue practicing neutral tool in his everyday life. Andy's breathing continued to be low and at around 5–6 breaths/min. Peaks and valleys were ranging from 13 to 20 between peaks, very similar to previous sessions. As a concluding remark, Andy was encouraged to continue practicing neutral tool in his everyday life. The visuals related to this session are presented in [Figure 10].
Figure 10: The quick coherence technique on the heart rate variability biofeedback and the power spectrum in session 4

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  Conclusion Top

Andy was able to see directly how stressful thoughts and emotions could adversely affect the body. It was observed that his stressors contributed to his autonomic nervous system arousal. It was uplifting to see that Andy was motivated to change from the visuals that he saw flaring up on the emWave Pro Plus. Andy appreciated the neutral tool that it was easy to practice which by doing that he was able to profoundly shift his physiology and generated more coherent HRV. The present case demonstrated that emWave Pro Plus HeartMath tool can be used as an important HRVB and SRE tool in the future.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Low A, McCraty R. Emerging dynamics of workplace stress of employees in a large organization in Hong Kong. Public Adm Policy 2018;21:134-51.  Back to cited text no. 1
Shaffer F, McCraty R, Zerr CL. A healthy heart is not a metronome: An integrative review of the heart's anatomy and heart rate variability. Front Psychol 2014;5:1040.  Back to cited text no. 2
Muchinsky PM, Culbertson SS. Psychology Applied to Work: An Introduction to Industrial and Organizational Psychology. 11th ed. Summerfield, NC: Hypergraphic Press, Inc.: 2016.  Back to cited text no. 3
Shaw L, Wilson V, Nihon S. Getting off the bench: EEG and HRV differences between starters and nonstarters. Biofeedback 2012;40:34-8.  Back to cited text no. 4
McCraty R, Shaffer F. Heart rate variability: New perspectives on physiological mechanisms, assessment of self-regulatory capacity, and health risk. Glob Adv Health Med 2015;4:46-61.  Back to cited text no. 5
Hillebrand S, Gast KB, de Mutsert R, Swenne CA, Jukema JW, Middeldorp S, et al. Heart rate variability and first cardiovascular event in populations without known cardiovascular disease: Meta-analysis and dose-response meta-regression. Europace 2013;15:742-9.  Back to cited text no. 6
Institute of HeartMath. EmWave Pro Tour User Manual. Institute of HeartMath; 2016. Available from: https://www.heartmath.com/support/knowledgebase/?article=kA180000000CsvqCAC and t=emWave+Pro+Tour+User+Manual. [Last retrieved on 2017 Jan 23].  Back to cited text no. 7
Russoniello CV, Zhirnov YN, Pougatchev VI, Gribkov EN. Heart rate variability and biological age: Implications for health and gaming. Cyberpsychol Behav Soc Netw 2013;16:302-8.  Back to cited text no. 8


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]

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