“The tonic’s not always in a bottle”: a qualitative study investigating a heart rate variability biofeedback coherence intervention for individuals with gastrointestinal disorders

1. Introduction

Gastrointestinal disorders (GID) negatively affect quality of life and psychological health [1]. Furthermore, there are significant economic impacts on health care systems and secondary costs from absenteeism and impaired productivity [2]. GID disorders can be either organic (e.g. Inflammatory bowel disease (IBD), including Crohn's disease and Ulcerative Colitis) or functional (e.g. Irritable Bowel Syndrome (IBS) and constipation). However, presentation is not always clear cut.

Healthcare, as it stands, is principally developed on a reactive disease treatment model and a move towards a proactive health-enhancement model is to be transformational. More recently, there has been a surge of interest in mind-body medicine, not only by clinicians but also by patients [3]. Greater involvement of patients in their own care is critical, and it is vital that individuals understand their chronic disease and how they can reduce symptoms and alleviate distress [4].

During the last few years, there has been a move in the Gastrointestinal field towards a biopsychosocial model. Dysregulation of the brain-gut axis is the aim of treatment for GIDs with the awareness that patients’ symptoms are the consequence of a dynamic between biomedical, gastrointestinal and psychosocial processes [4]. There are a wide range of treatments available, including dietary therapies, behavioural and psychological therapies and drug treatments which have all been well recognised and validated in controlled trials [2]. In a recent review gut-directed hypnotherapy, E-treatment/telemedicine, Cognitive Behavioural Therapy and Biofeedback assisted relaxation training, were all found to be effective in treating GIDs, by supporting adaptive coping, providing symptom relief, and improving quality of life [4]

One area that has become apparent in GIDs is the impact of stress. It has been shown that chronic episodes of stress may negatively impact the Autonomic Nervous System (ANS). This leads to the release of large quantities of stress hormones, such as glucocorticoids (e.g. cortisol) and catecholamines (e.g. norepinephrine and epinephrine) [5]. These hormones have a direct effect on the Enteric Nervous System (ENS) and can cause detrimental changes in visceral sensitivity and gastrointestinal motility [6]. Stressful events typically affect respiration, blood pressure, and immune system functioning; acute and chronic stress increases allostatic load in the body which over time causes mental and/or physical health problems [7]. Therefore, stress management interventions in this population group are critical.

This research focuses on an intervention aimed at improving self-regulation of a key aspect of the stress response, Heart Rate Variability (HRV) biofeedback. HRV is a measure of beat-to-beat variations in heartbeat, often called cardio-vagal tone [7]. The heart produces the strongest electrical signal in the body and, during coherence, the heart rhythm oscillates at a frequency of 0.1 Hz oscillations. Brainwaves can synchronise to 0.1Hz oscillations in areas of the brain such as the prefrontal cortex [8, 9]. The vagus nerve is the tenth, longest cranial nerve ranging from the brainstem to the colon and is the predominant neural substrate of the parasympathetic nervous system [10]. This nerve has both efferent and afferent pathways and has a critical role in gastrointestinal motility, information and pain. The functioning of the nervous system can be enhanced by improving the state of HRV coherence in the body. As this occurs, there is increased activity in the prefrontal cortex and a reduction in stress; consequently, this can enhance ability to self-regulate thoughts, feelings and behaviours [11].

Coherence can be optimised by regulating breathing and by intentionally experiencing positive and pleasant emotions which have been found to benefit physical and mental health and quality of life [12]. Six breaths per minute respiratory rate is an effective way to create coherence within the autonomic nervous system and between heart and brain [8]. HeartMath technology uses biofeedback (BF) principles to teach individuals about their HRV coherence in real-time and facilitate an understanding of the nervous system [13]. It is proposed that the key to management of stress is firstly to become aware of it and, secondly, be able to self-regulate the emotional response.

Studies over recent years have found a 75 % accuracy in determining emotional quality from examining HRV coherence patterns [7]. Negative emotions such as anger and frustration, create jagged and incoherent heart rhythm patterns which send incoherent signals to the brain. On the other hand, positive emotions such as love, care and compassion create coherence as demonstrated by a smooth and sine-like wave pattern [7]. Becoming coherent can be initiated by regulating the breath and increased by intentionally experiencing positive and pleasant emotions which have been found to have profound benefits on physical, mental health and quality of life [12].

Of particular interest in this research are interventions that have used HeartMath Technology to measure HRV coherence. HeartMath technology uses biofeedback principles to teach individuals about their heart rate variability coherence in real-time and facilitate an understanding of the nervous system. It is proposed that the key to management of stress is firstly to become aware of it and, secondly, be able to self-regulate the emotional response.

The ability to self-regulate emotions and feelings have a strong and powerful effect on our heart-brain connection and entrain the flow of information throughout the psycho-physiological network [7]. This bottom-up approach, from the heart to the brain, directly alters physiology and produces more coherent systems which improve an individual's ability to self-regulate and consequently improve health and performance [12]. Of key significance for this research is that scientists at the forefront in this field propose that it is the state of our physiological and nervous system that regulates the stability and quality of the emotions we experience [7].

A recent systematic review concluded that HRV is an objective measure and beneficial tool in categorising function of the ANS [14]. A number of studies have found that low HRV patterns are associated with reduced health and morbidity in comparison with high HRV readings which indicate improved mental and physical health [15-17]. A large and growing body of evidence has shown HRV-BF interventions improve levels of HRV for a range of mental and physical health problems [18, 19].

There are a growing number of quantitative research studies around the effects on HRV-BF intervention in individuals with GIDs which are beyond the scope of this review (for more information, please refer to [20, 21]. In more recent years, research has started to examine the qualitative component regarding HRV-BF interventions within the general populations that have found these interventions to be effective in reducing stress, improving mood and developing coherence [22, 23]. A recent study [24] implemented a HeartMath training protocol with Olympic athletes and analysed the data using thematic analysis. They found themes of improved ability to self-regulate both physiological and psychological states and an enhanced sense of personal control following the intervention. A mixed-method study investigated functional gastrointestinal disorders with 27 paediatric individuals who attended between 3-18 HRV-BF sessions [25]. The researchers found improved quantitative measures on clinical outcome measures of IBS and FAP but, what was most interesting for the purpose of this research, was the qualitative report. Participants reported feeling validated in their symptoms and felt “believed” that the condition was not “all in their head”. Participants reported showing an interest in the psychophysiology of their body and reinforced that the intervention was effective for symptom reduction and patient engagement. However, as no specific type of qualitative design was employed, there were no themes identified in the data. Therefore, it was unclear what the exact procedure was; hence the qualitative analysis is limited. There is very little qualitative research implemented in HRV-BF studies with individuals with GID.

There is, however, research that highlights the difficulties individuals with GID face. In a qualitative study researchers explored the lived experiences of individuals with Crohn's disease (CD) and found they worry about symptom management, such as diarrhoea and constant pain and that disrupts leisure activities, social lives and work [26]. This research found that individuals with CD had increased risks of anxiety and depression. Therefore, the literature highlights the importance of dealing with some of these preoccupations to see whether particular interventions improve lived experiences of condition management.

Several studies investigating individuals with IBS have found that they have erratic HRV patterns when compared to a control group, and this has a greater impact in women than men [6]. These findings suggest individuals with GID may have ANS dysregulation; hence enhancements in HRV coherence are anticipated to make advantageous changes in the ENS [20].

2. Rationale

Further qualitative studies are required to understand the individual experiences of using HRV-BF coherence interventions and its effects on perceptions of emotional states [27-29] especially within individuals who have GID. It is proposed that some GID symptoms may be associated with incoherent heart rhythm patterns caused by stress and that by educating individuals to self-regulate their heart rhythm patterns at a frequency of 0.1 oscillations then HRV coherence will be improved. It is theorised that as a result, GI symptoms may be reduced and psychological outcomes improved [30]. This could pave the way to develop effective, evidenced-based HRV-BF interventions that are cost-effective and patient-centred.

3. Methods

4. Results

The analysis of the results revealed four main Superordinate themes: autonomy, self-regulation, acceptance and mind-body-spirit. These are displayed in Table 1.

5. Discussion

The results of this qualitative six-week HRV-BF coherence study showed favourable outcomes for individuals with GID. IPA identified four main Superordinate themes: autonomy, self-regulation, acceptance and mind-body-spirit.

Under the theme Autonomy, participants reported feeling vulnerable and overwhelmed by their health conditions, particularly around the lack of somatic control. Feeling out of control is a reoccurring theme in the GID literature. Individuals with GI symptoms have reported that their daily living felt compromised and they were controlled by their condition, particularly in relation to going to work or social events, due to preoccupation with being close to toilet facilities [26]. Patients with IBD reported inability to control bodily functions as the most distressing part of living with their condition [33]. This study showed HRV-BF coherence improved participants control and understanding over both their mind and body. Individuals became aware of how they could intentionally activate self-regulation techniques and implement them for symptom management relief in real-time.

Under the theme Self-regulation, a sense of ownership was cultivated through sessions, as an effective way of managing stress. Participants recognised that entering into a state of coherence was not an abstract concept but a reality, and one that all participants were able to cultivate and feel. These experiences are consistently reported in the literature [28, 29].

Under the theme, Acceptance, individuals recognised that cultivating kindness for themselves was not only beneficial for their mind but also for their body and quality of life. At the start of the intervention, participants spoke about guilt and feeling responsible for their health conditions. Acceptance has been identified as important in the IBD literature particularly around adjustment to living with a stoma and a long-term health condition [33]. Self-compassion has been linked to improved gastrointestinal tract motility and immune function [34]. Participants can be taught self-compassion which is beneficial for individuals who feel guilty or blame themselves for their GID [35, 36].

Under the Mind-Body-Spirit theme, some patients reported a reduction in pain. All clients noticed an improvement in their gastrointestinal symptoms following the intervention. One participant described the intervention as “The tonic’s not always in a bottle”, with the recognition that psychological components of healing can help physical aspects. One patient even noticed reduced stoma output and bleeding following HRV-BF coherence practice. One previous case report of HRV-BF after ileostomy formation reported psychological but not stomal improvements [37]. Furthermore, individuals reported feeling more relaxed, calmer, and renewed following the HRV-BF training, in keeping with previous studies [29].

As a whole, the themes provide evidence HRV-BF coherence interventions raise awareness of both the psychological and physiological components of stress, with beneficial effects on mind-body health. The importance of self-control within individuals with GIDs is reiterated throughout the literature [38]. Resilience, self-regulation, and optimism are three individual strengths in the context of psychogastroenterology that have strong associations with symptom experience in other chronic disease groups [39]. Optimism has been linked to healthier autonomic function and increased levels of HRV [40] which are increasingly implicated in the pathophysiology of gastrointestinal disorders [41-43]. Future HRV studies could incorporate measures of optimism and resilience within their study design. It is clear that all participants were able to achieve a state of coherence which was a new health behaviour for them; the mastery of this technique improved self-confidence and perspective taking, which are directly linked to positive health outcomes [44].

This study provides detailed insight into the experiences of patients with functional and organic GIDs and suggests that by empowering individuals to self-regulate their emotions, they are gaining some level of control. Further, this research shows that HRV-BF interventions are amenable to digital delivery. The rise in digital technology and wearable sensors has grown dramatically in recent years, with the general population interested in lifestyle apps for health (e.g. sleep trackers or fitness trackers). This domain is gaining traction and it is proposed that HRV-BF devices, and diaphragmatic breathing apps, could be implemented in the teaching of disease self-management skills as part of a patient’s care and may be administered remotely [45-47].

6. Limitations

Only six participants were included in the study, reducing generalisability. Yet, the results suggest positive effects across genders. Furthermore, this study followed recommendations to ensure strong validity throughout the research process [48]. The researcher demonstrated sensitivity to context by understanding participants’ viewpoints, linguistic perceptions, and the socio-culture within which the research was conducted. These factors were considered salient as they may influence not only how the participant reports, but also what they report and how that is interpreted by the researcher. The themes generated throughout the data were sensitively and carefully derived rather than by imposing pre-determined categories on the data to ensure commitment and transparency of the approach. The present findings support previous qualitative literature in biofeedback studies that have found increased awareness, improved self-regulatory capacity and adaptive behavioural change following a HRV-BF intervention [49]. Collectively, both the present study, and existing literature, highlight that biofeedback interventions, using HeartMath technology, reveal greater self-regulation, enhanced autotomy, enriched acceptance and a better understanding of the Mind-Body-Spirit [28, 29]. They also extend previous findings to show improved benefit for individuals with either a functional or organic GID. Further studies involving psycho-physiological interventions, with mixed-method designs and using larger samples, should be undertaken, that also include a detailed HRV analysis [29]. Future studies will also need to consider what represents optimal dosing of HRV coherence practice.

7. Conclusions

The study findings support an integrative approach to wellness and ill-health that targets mental, emotional, physical, and spiritual aspects of the whole person [50]. It is important that these types of research studies are developed in order to understand not only how best to personalise such methodologies that maximise public health potential, but also are easy for patients to learn, non-invasive and without known side effects [3, 37].

This study has specifically shown the potential for HRV-BF coherence as a self-management tool to improve symptoms in gastrointestinal conditions. Given the widespread availability of apps and devices to monitor heart rate and the lack of evidence for adverse effects, this type of intervention provides a low-cost option for patients to try. It follows that this could also demonstrate to what extent these practices can shift the course of disease and minimise the need for pharmaceuticals and invasive tests and procedures.