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 Table of Contents  
Year : 2021  |  Volume : 5  |  Issue : 3  |  Page : 90-94

Case study: Monitoring the effectiveness of aromatherapeutic breathing with heart rate variability biofeedback

1 Hong Kong Association of Psychology, Hong Kong, China
2 Chinese University of Hong Kong, Hong Kong, China

Date of Submission16-Mar-2021
Date of Acceptance07-Jul-2021
Date of Web Publication29-Sep-2021

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_22_21

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Heart rate variability (HRV) can be used as an objective measure of mental health and workplace stress. 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 to biologically monitor the effectiveness of aromatherapeutic breathing intervention for his client, a manager who works in an educational center in Hong Kong. The researcher presents a review of each of the four sessions he has conducted with his client. Both aromatherapeutic breathing with “earth” (ABwE) and HRVB were used during the sessions, and the client was able to shift her physiology profoundly. Results were promising, and the researcher recommends using ABwE as an important intervention and agent for change for stressful clients.

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

How to cite this article:
Low A, Chan S. Case study: Monitoring the effectiveness of aromatherapeutic breathing with heart rate variability biofeedback. Heart Mind 2021;5:90-4

How to cite this URL:
Low A, Chan S. Case study: Monitoring the effectiveness of aromatherapeutic breathing with heart rate variability biofeedback. Heart Mind [serial online] 2021 [cited 2023 Mar 27];5:90-4. Available from: http://www.heartmindjournal.org/text.asp?2021/5/3/90/326961

  Introduction Top

Heart rate variability (HRV) can be used as an objective measure of mental health and workplace stress.[1] Workplace stress is an emerging global problem. Moreover, workplace stress triggers employee reactions as in physical ailments, psychological effects, and unhealthy coping habits. Conjointly, organizational productivity drops as absenteeism, presenteeism, turnover, and sick leave increase.[2]

Heart rate variability

HRV refers to the beat-to-beat alterations in heart rate calculated by quantifying the amount of R-R intervals (duration between two consecutive R-waves of the electrocardiogram [ECG]) changes as generated from ECG data.[3] The R-R interval can be influenced by physical and psychological variables such as hypertension medications, antihypertension medications, and antidepressants.

The importance of heart rate variability in assessing workplace stress

The demand–control model of workplace stress suggests that, when demands are high and the control is low, low social support will cause workplace employees to be stressed. It causes an imbalance between the job demand and the person's ability to meet those demands.[4] An increased HRV decreases performance anxiety[5] and increases resilience,[6] whereas a decreased HRV is associated with the inability to respond by physiological variability and complexity. A meta-analysis[7] found that a low HRV is associated with a 32%–45% increased risk of first cardiovascular disease.

The emWave Pro Plus

The emWave Pro Plus is designed by the Institute of HeartMath.[8] It collects pulse data by placing a pulse sensor on the participant's earlobe or fingertip, and data can be plugged into a computer [see [Figure 1]. It translates data of heart rhythms and allows real-time assessment of how thoughts and emotions affect the participant's heart rhythms. It uses photoplethysmography technology which is a reliable and valid method of capturing and quantifying real-time HRV data[9] and is used in the following case.
Figure 1: Emwave Pro Plus computer hardware and heart rate variability monitor reading

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For this case study, HRV was measured by various parameters: SDNN, RMSSD, mean heart rate range (MHRR), and normalized coherence. SDNN is the standard deviation of all mean normal-to-normal intervals measured in milliseconds. The measure reflects the ebb and the flow of all the factors that contribute to HRV and the heart's ability to respond to hormonal changes.[10] The RMSSD is the root mean square of successive differences between the normal heartbeats reflecting the short-term variance in heart rate; this value provides an estimate of the parasympathetic regulation of the heart.[10] MHRR is the difference between the maximum and the minimum heart rate during each breathing cycle. The result is then expressed in beats per min, as the mean of these heart rate differences for each measured cycle.[10] Finally, normalized coherence is a frequency domain measure of coherence where power in the coherence peak of the power spectral density is divided by total power. This measure represents the ratio of coherence relative to total power and ranges from 0 to 100.[11] Moreover, a coherent heart rhythm is visualized as a harmonic sine wave-like signal with a narrow, high-amplitude peak in the LF (0.04–0.26 Hz) region of the HRV spectrum. Coherence is evaluated by detecting the maximum (coherence) peak in the 0.04–0.26 Hz range, calculating the integral in a window 0.030 Hz wide, centered on the highest peak in that region, and then calculating the total power of the entire spectrum.[3]

Aromatherapeutic breathing with “earth”

Research has shown that aromatherapy has proven to have significant positive results with HRV[12] such as the effect of lavender aromatherapy on HRV[13] and Juniper essential oil on HRV.[14] In this case study, the researcher introduces aromatherapeutic breathing with “earth” (ABwE), inhaling with an electrical aromatherapeutic device. The product “earth–sweet dream and passion” contains the following ingredients: rose geranium, bergamot, neroli, petitgrain, and vetiver is known to calm the central nervous system [see [Figure 2].
Figure 2: Aromatherapeutic breathing with earth

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  Case Report Top

This case is presented with S. E. (fictitious initials), a 34-year-old Chinese professional woman working as a manager in Hong Kong.

S. E. expressed stressors about the overwhelming workload at the workplace, isolation, and high anticipation from her family. She suffered from neurocardiogenic syncope (also known as “simple fainting”), insomnia, easily feeling tired, frustrated, and anxious. She agreed to participate and expressed interest in participating in heart rate variability biofeedback (HRVB) and ABwE with the hope of reducing the stress she experienced with her family and workplace.

Sessions summary

S. E. attended four sessions with an analysis of the emWave Pro Plus data and the ABwE.

Session 1

In session 1, breathing and HRV data were collected as the baseline by just focusing on the breathing. S. E. was tracked with around 11 breaths per min with 3 sudden intake of breath with coherence score at 40% low coherence (LC), 24% moderate coherence (MC), and 36% high coherence (HC). In a 1 min HRV assessment, S. E.'s MHRR was 17.2 beats per min (reference range: 8.9–38.4), her SDNN was 89.5 milliseconds (reference range: 35.8–144.9), RMSSD was 63.7 msonds (reference range: 19.7–137.9), and her normalized coherence score was 77.9% (reference range: 50–100). In the same session, S. E. recalled a stressful familial event and “seeing images of her father and images of being trapped” with coherence scores (LC = 91%; MC = 0%; and HC = 9%). Uneven breathing pattern and high arousal patterns were noticed and discussed. After that, S. E. practiced ABwE with the researcher and noticed more consistent and sine-like waves (more coherent). Overall coherence levels: LC = 12%; MC = 12%; and HC = 76%. S. E. was invited to practice the ABwE as homework. The visuals related to this session are presented in [Figure 3], [Figure 4], [Figure 5].
Figure 3: The gathering of baseline data in session 1

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Figure 4: The recall of a stressor in session 1

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Figure 5: Overall coherence levels in session 1 with aromatherapeutic breathing with “earth”

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Session 2

After reviewing the assigned homework, the researcher and S. E. were adopting the ABwE intending to help S. E. to recharge her energy and help her feel calmer, relaxed, and activating a regenerative feeling. S. E.'s HRV and the pattern generated more consistent and sine-like waves (more coherent). The average heart rate was lowered from 75 BPM to 61 BPM. Overall coherence levels: LC = 4%; MC = 10%; and HC = 86%, with the main peak heading nearer toward 0.1 in the power spectrum, which suggested the balance between her sympathetic and parasympathetic branches of her autonomic nervous system upon the utilization of the ABwE. S. E. was invited to practice the ABwE as homework. The visuals related to this session are presented in [Figure 6].
Figure 6: Overall coherence and the spectrum average in session 2 with aromatherapeutic breathing with “earth”

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Session 3

After reviewing the assigned homework with S. E. on her practice of the ABwE, S. E. explored another HeartMath tool known as “attitude breathing” with the researcher. Together with ABwE, the tool could help her 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 with slower and deeper breathing. On the emWave Pro, it showed S. E.'s heartbeats per min further decelerated to an average of 68, where the peaks and valleys of each beat look more consistent after 60 s. Overall coherence levels: (LC = 8%; MC = 10%; and HC = 82%). After that, S. E. practiced the ABwE with the garden game and further achieved coherence levels of 100 (HC). The visuals related to this session are presented in [Figure 7] and [Figure 8].
Figure 7: (a) Attitude breathing with aromatherapeutic breathing with “earth” in session 3. (b) Attitude breathing with aromatherapeutic breathing with “earth” in session 3

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Figure 8: The garden game on heart rate variability biofeedback in session 3

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Session 4

As the concluding session, S. E. has overall coherence levels of 5% (HC), 13% (MC), and 82% (LC) with ABwE. After that, without ABwE, she was able to reach the highest peak closer to 0.1 and attain overall coherence levels of 10% (LC), 19% (MC), and 71% (HC). S. E. was encouraged to continue practicing ABwE in her everyday life. S. E.'s breathing appeared to be lower at around 8 breaths per min. As a concluding remark, S. E. was encouraged to continue practicing ABwE in her everyday life. The visuals related to this session are presented in [Figure 9] and [Figure 10].
Figure 9: (a) Overall coherence levels in session 4 with aromatherapeutic breathing with “earth.” (b) Overall coherence levels in session 4 with aromatherapeutic breathing with “earth”

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Figure 10: (a) Overall coherence levels in session 4 without aromatherapeutic breathing with “earth.” (b) Overall coherence levels in session 4 without aromatherapeutic breathing with “earth”

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  Conclusion Top

S. E. was able to see directly how stressful thoughts and emotions could adversely affect the body. It was uplifting to see that S. E. was motivated to change from the visuals she saw flaring up on the emWave Pro Plus. S. E. appreciated the ABwE that it was easy to practice which by doing that she was able to shift her physiology profoundly and generated more coherent HRV. The present case demonstrated that ABwE can be used as important stress reduction protocol and that HRVB can further evaluate other protocols in future. Future research studies could continually use HRV stress measurements to evaluate the effectiveness of stress management such as using ABwE with more experimental subjects. Finally, organizations can objectively identify the most effective intervention types and customize an employee assistance program to reduce workplace stress.

Declaration of patient consent

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

Ethical statement

Ethical statement is not applicable for the article.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Low A, McCraty R. Heart rate variability: New perspectives on assessment of stress and health risk at the workplace. Heart Mind 2018;2:16-27.  Back to cited text no. 1
  [Full text]  
Low A, McCraty R. Emerging dynamics of workplace stress of employees in a large organization in Hong Kong. Public Administration and Policy. Asia-Pacific J 2018;21:134-151.  Back to cited text no. 2
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. 3
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. 4
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. 5
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. 6
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. 7
Institute of HeartMath. EmWave Pro Tour User Manual; 2016. Available from: https://www.heartmath.com/support/knowledgebase/?article=kA180000000CsvqCAC &t=emWave+Pro+Tour+User+Manual. [Last accessed on 2017 Jan 23].  Back to cited text no. 8
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. 9
Task Force of the European Society of Cardiology and the North American Association of Pacing and Electrophysiology. Heart rate variability: Standards of measurement, physiological interpretation, and clinical use. Eur Heart J 1996;17:354-81.  Back to cited text no. 10
McCraty R, Watkins A. Autonomic Assessment Report: A Comprehensive Heart Rate Variability Analysis-Interpretation Guide and Instructions. Boulder Creek, CA: Institute of HeartMath; 1996.  Back to cited text no. 11
Lin PH, Lin YP, Chen KL, Yang SY, Shih YH, Wang PY. Effect of aromatherapy on autonomic nervous system regulation with treadmill exercise-induced stress among adolescents. PLoS One 2021;16:e0249795.  Back to cited text no. 12
Chien LW, Cheng SL, Liu CF. The effect of lavender aromatherapy on autonomic nervous system in midlife women with insomnia. Evid Based Complement Alternat Med 2012;2012:740813.  Back to cited text no. 13
Park JS. Effects of juniper essential oil on the activity of autonomic nervous system. Biomed Sci Lett 2017;23:286-9.  Back to cited text no. 14


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


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