Matter Over Mind: A Randomised-Controlled Trial of Single-Session Biofeedback Training on Performance Anxiety and Heart Rate Variability in Musicians

Studie fra 2012. Viser hvordan sakte pust (6 pust/min) gir like gode resultater på prestasjonsangst hos musikere både med og uten biofeedback. Men denne studien gjorde pusteteknikken kun i 30 min, en gang. Andre studier viser at biofeedback gir en tydeligere respons i nervesystemet. Denne studien viste ingen generell reduksjon i angst, men den viste tydelig at de med høyest angst før studien hadde størst reduksjon i angst etter pusteteknikken.


Musical performance is a skilled activity performed under intense pressure, thus is often a profound source of anxiety. In other contexts, anxiety and its concomitant symptoms of sympathetic nervous system arousal have been successfully ameliorated with HRV biofeedback (HRV BF), a technique involving slow breathing which augments autonomic and emotional regulatory capacity. Objective: This randomised-controlled study explored the impact of a single 30-minute session of HRV BF on anxiety in response to a highly stressful music performance.


A total of 46 trained musicians participated in this study and were randomly allocated to a slow breathing with or without biofeedback or no-treatment control group. A 3 Group×2 Time mixed experimental design was employed to compare the effect of group before and after intervention on performance anxiety (STAI-S) and frequency domain measures of HRV.


Slow breathing groups (n = 30) showed significantly greater improvements in high frequency (HF) and LF/HF ratio measures of HRV relative to control (n = 15) during 5 minute recordings of performance anticipation following the intervention (effect size: η2 = 0.122 and η2 = 0.116, respectively). The addition of biofeedback to a slow breathing protocol did not produce differential results. While intervention groups did not exhibit an overall reduction in self-reported anxiety, participants with high baseline anxiety who received the intervention (n = 15) displayed greater reductions in self-reported state anxiety relative to those in the control condition (n = 7) (r = 0.379).


These findings indicate that a single session of slow breathing, regardless of biofeedback, is sufficient for controlling physiological arousal in anticipation of psychosocial stress associated with music performance and that slow breathing is particularly helpful for musicians with high levels of anxiety. Future research is needed to further examine the effects of HRV BF as a low-cost, non-pharmacological treatment for music performance anxiety.

Heart rate variability biofeedback (HRV BF) is an intervention involving slow breathing (6 breathes per minute), which dampens physiological arousal in stressful situations[17]. It has been associated with reductions in anxiety symptoms [18][19] and improved cognitive performance [20]. Heart Rate Variability (HRV) is an index of beat to beat changes in heart rate and is a psychophysiological marker for physical and mental health [21][23]. Low HRV is associated with mood and anxiety disorders[24][27]. High HRV has a protective effect and is associated with good health [28] and well-being [29].

High frequency (HF) HRV reflects the magnitude of PNS influence on HR associated with breathing – respiratory sinus arrhythmia (RSA) [30] – which is carried to the heart via the tenth cranial (vagus) nerve. Power spectral analysis partitions the observed variability into components of high (HF), low (LF) and very low frequency (VLF) using spectral decomposition, most commonly a Fast Fourier Transformation [30]. PNS, sympathetic nervous system (SNS) and blood pressure mechanisms operate on different time scales, so each of these components is thought to be associated with different sources of variability [31]. The HF component (between 0.15–0.4 Hz) is known to be PNS mediated [32][34], while the LF component (0.04–0.15 Hz) reflects a combination of PNS and SNS activity [35] via baroreflex function [31]. As a consequence, the LF/HF ratio is thought to provide information about the relationship of vagal input to the other sources of variability [36].

Higher levels of resting state HF HRV may indicate increased ability to inhibit SNS-mediated arousal [37], leading to increased behavioural flexibility [38] in the face of stress and reduced anxiety, as argued by Thayer and colleagues [39][41]. Maladaptive emotion regulation strategies, such as worry, lead to acute reductions in HRV [25]whereas social approach behaviors are associated with increased parasympathetic activity, which is facilitated by an increase in vagal tone [42].

The aim of HRV BF is to slow the breathing (normally ~15 breaths per minute) to coincide with HRV changes due to the baroreflex (~6 cycles per minute, or 0.1 hz) resulting in what is known as resonant frequency [55], resulting in a large multiplicative increase in the amplitude of HR oscillations and HRV power. Each individual has a resonant frequency [49] usually achieved at around 6 breaths per minute [51]. HRV BF involves training in abdominal breathing techniques, establishment of resonant frequency and monitoring over 10 weeks with home practice [55]. It has been linked to improvements in PTSD symptoms [18][19], depression [56][59], state anxiety [56],[60], cardiovascular disease 17,61,62 and HRV levels [17][19][56][60].

Participants who received slow breathing exhibited greater increases in HF and decreases in LF/HF ratio than controls after intervention, indicating increased levels of parasympathetic influence on HR while under stress. This increased level of PNS inhibition may allow participants to better regulate physiological arousal prior to music performance and to perform more competently. Amongst highly anxious individuals, the intervention also led to greater reductions in self-reported anxiety than controls, indicating that slow breathing may have clinically-relevant effects for performing musicians who suffer from anxiety.

LF/HF ratio indicates the amount of HRV that is due to a combination of SNS, PNS and blood pressure mechanisms (LF) relative to vagal input (HF) under normal conditions. It should be noted that LF levels are also inflated by slow breathing, especially when breathing at a rate of 0.1 Hz, which is in the LF range. Breathing at this rate creates a resonant effect whereby oscillations of vagal outflow are timed to coincide with those in baroreflex action, producing large increases in the amplitude of HR changes [55]

In summary, the results of the present study indicate that diaphragmatic breathing instruction and a single session of slow breathing are sufficient to produce HRV increases and state anxiety reductions among musicians with high state anxiety, and that biofeedback is not necessary for these changes to occur. This suggests that integration of slow breathing with more comprehensive psychotherapy strategies may have clinical utility in the treatment of individuals with MPA. Slow breathing may be a viable alternative to beta-blockers for inhibition of SNS activity during performance.

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