Combining biofeedback with stress

management interventions: a systematic

review of physiological and psychological
effects
Nele A.J. De Witte a, Inez Buyck a, b, & Tom Van Daele a

a Expertise Unit Psychology, Technology & Society, Thomas More University of

Applied Sciences, Antwerp, Belgium
b LUCAS, Centre for Care Research and Consultancy, KU Leuven

Published: De Witte, N. A. J., Buyck, I., & Van Daele, T. (2019). Combining
biofeedback with stress management interventions: a systematic review of
physiological and psychological effects. Applied Psychophysiology and Biofeedback,
44(2), 71-82. [Link]

Corresponding author
Nele AJ De Witte
Thomas More University of Applied Sciences
Molenstraat 8
2018 Antwerpen
E-mail: [Link]@[Link]
Tel. + 32 (0)3 432 18 91

ORCID ID
Nele De Witte: 0000-0001-6313-7256
Inez Buyck: 0000-0002-3711-5165
Tom Van Daele: 0000-0001-9237-9297

Acknowledgements

This work was written within the Carewear project, funded by a VLAIO TETRA
grant

(grants IWT.150614 and HBC.2016.0099).

 Biofeedback for stress management

Abstract

Current mental healthcare systems experience difficulties meeting the

challenges of a growing population with elevated stress symptoms. Outpatient stress

management interventions have already proven to be effective in routine care and

recent technological advances now allow to expand such interventions, for example by

adding a physiological component like biofeedback. Adding biofeedback to stress

management interventions appears promising, but there is a lack of insight into the

general conceptualization and evaluation of the resulting interventions, both in relation

to psychological and physiological stress indicators. A comprehensive literature search

was performed to investigate stress management interventions with a biofeedback

component. This systematic review provides an overview of these interventions and

explores to what extent they can improve both physiological and psychological

indicators of stress. Fourteen RCTs were included. A large diversity was observed in

intervention design and effectiveness. Nevertheless, there is preliminary evidence that

the use of biofeedback can improve both physiological and psychological indicators of

stress. Biofeedback could provide an accessible and low-cost addition to stress

interventions. Further research into the effectiveness of different components of

biofeedback interventions is needed.

Keywords: Biofeedback, stress reduction, mHealth, effectiveness, heart rate

variability

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 Biofeedback for stress management

Introduction

Stress-related problems are becoming increasingly common and are associated

with large health risks (Van Daele, Hermans, Van Audenhove, & Van den Bergh,

2012). There is a need for interventions that can capture and improve the complex

interplay between physiological and psychological stress processes in daily life.

Technological advances allow existing psychophysiological laboratory designs for

stress management to be modified for use outside of the lab, where mHealth

applications could provide immediate feedback in a way that has not yet been possible

in traditional mental healthcare (Williams, 2016). mHealth refers to the use of mobile

information and communication technology, such as mobile computers, medical

sensors, and wearable devices in healthcare (Istepanian, Jovanov, & Zhang, 2004).

However, prior to making the translation from experimental to clinical applications,

research into the underlying mechanisms providing effectiveness, both on a

psychological and a physiological level, is needed to establish which interventions

have the largest potential for broad application.

Stress is a complex phenomenon that is triggered by a psychological or physical

threat to homeostasis and consists of a variety of psychological, behavioral, and

physiological responses (Bali & Jaggi, 2015). There are many different potential

sources of stress, such as work-related stress, stress due to family conditions or stress

associated with medical or physical illness (such as chronic pain). Experiencing mild

stress is not maladaptive or unhealthy in itself, but experiencing high levels of stress

without sufficient recovery is a substantial health risk. Elevated and prolonged

experience of stress is a common problem, which has a negative impact on both

mental and physical health, and is associated with large economic costs (American

Psychiatric Association, 2016; Cooper & Dewe, 2008). Current mental healthcare

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 Biofeedback for stress management

systems have difficulties meeting the challenges of a growing population of individuals

with elevated stress. A recent survey showed that 75% of Americans had experienced

at least one symptom of stress (e.g., feeling nervous, being irritable or experiencing

fatigue) in the past month (American Psychological Association, 2017). This is a 4%

increase as compared to the previous measurement in 2016.

Stressful situations can evoke changes in heart rate, heart rate variability (HRV),

blood pressure, electrodermal activity (EDA), and breathing rate (Chrousos & Gold,

1992; Jarczok et al., 2013; Lin, Lin, Lin, & Huang, 2011). Such physiological

parameters can be a useful addition to self-report data, since these do not suffer from

reporting or social desirability biases. An example of an intervention strategy strongly

based on physiological processes is biofeedback. Biofeedback works to help clients

improve their performance and health by gaining voluntary control over real-time

physiological processes, such as HRV or EDA (Dillon, Kelly, Robertson, & Robertson,

2016). Formerly, a large disadvantage of interventions based on physiology was the

need for large and expensive devices, which reduced mobility and therefore

generalizability outside of the lab. However, the advance of mHealth can reduce the

cost and increase the impact of psychophysiological interventions. Wearables have

the potential to non-invasively collect behavioral and physiological data and thereby

provide additional information that can guide treatment.

The review of Schoenberg and David (2014) shows that biofeedback can be a

successful intervention to treat psychiatric symptoms. Biofeedback appears especially

relevant when maladaptive physiological mechanisms (such as heightened autonomic

nervous system activity) are at play, which is the case in stress experiences. The

mechanisms of change in psychophysiological interventions are still largely unknown.

Wheat and Larkin (2010) show that HRV biofeedback can induce significant changes

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 Biofeedback for stress management

in physiological parameters in different medical and psychiatric disorders. However,

very little research directly assesses the relationship between physiological and

psychological outcomes of biofeedback. It remains unclear whether physiological

changes are a prerequisite to psychological effects of such psychophysiological

interventions.

As highlighted in the previous paragraphs, psychophysiological parameters

could be relevant indicators for mental health, with the required technology to measure

these parameters becoming increasingly low-cost and less invasive. As such

technology now allows to (pro)actively monitor or intervene outside of highly controlled

lab settings, the question arises to what extent there is already evidence available on

the use and added value of psychophysiological interventions in mental healthcare.

The current systematic review focuses on the question whether there is any evidence

for using biofeedback in the context of stress management interventions. Additionally,

the association between physiological and psychological outcomes of these

interventions is explored.

Method

A search of the literature was performed using broad keywords such as

“physiolog*” and “psychophysiolog*” combined with “intervention” and “stress”. This

resulted in a striking amount of articles, but it became evident that controlled research

into psychophysiological interventions for stress was mostly confined to biofeedback.

A closer inspection of these manuscripts also revealed that a substantial subgroup of

results focused on stress in the context of posttraumatic stress disorder (PTSD) or

urinary stress incontinence. The current review is focused on the management of

ongoing psychological stressors (e.g., demanding occupations or chronic pain) and,

therefore, PTSD and urinary stress incontinence are out of scope. Consequently, the
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 Biofeedback for stress management

focus of the literature search was narrowed by use of the PICO-TS model to improve

the relevance of the results and maximize comparability between studies. The current

review aims to investigate the general population (P) with potential stress complaints.

The intervention (I) is the main focus of the review and consists of biofeedback, either

stand-alone or in addition to other stress management interventions. There was a

special interest in mobile health interventions (using wearable devices) when they were

available. There were no requirements pertaining to the control condition (C), but the

reported outcomes (O) did need to consist of both physiological and psychological

indices. No timings (T) were specified and with regard to study design (S), only

randomized controlled trials were included.

A literature search of studies published until September 2017 was set up

through search engines PubMed (MEDLINE), Web of Science, PsycINFO, and

Cochrane Library database. The systematic search implemented the following string

of keywords: (biofeedback OR wearable) AND stress NOT ("urinary" or posttraumatic

or PTSD) AND (interven* OR treat* OR ther* OR manag*). Articles were selected for

review based on three inclusion criteria: (1) studies implemented psychophysiological

indices in a stress management intervention; (2) study designs were randomized

controlled trials with a valid psychological as well as physiological measure of stress

before and after the intervention; (3) articles needed to be published in an international,

peer-reviewed journal and written in English. Studies were excluded when

psychophysiological indices were used for diagnostic purposes only.

In a first step, two authors (IB and TVD) independently evaluated titles and

abstracts for eligibility criteria. After resolving disagreements through discussion, the

same authors were involved in full text evaluation. Subsequently, reference sections

of the included studies were manually inspected for additional articles, yet no

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 Biofeedback for stress management

supplemental studies could be included. The studies that were found showed large

diversity in the design and outcome variables, thereby eliminating the possibility of

performing a meta-analysis. Relevant data on the samples, interventions and

outcomes variables was extracted from the articles and summarized in tables.

Additionally, a Fisher’s Exact test was performed to investigate the association

between the occurrence of physiological and psychological outcomes.

A risk of bias analysis was conducted using the Cochrane Risk of Bias Tool

(Higgins et al., 2011). The included studies were screened for selection bias,

performance bias, detection bias, attrition bias and reporting bias. Studies were

considered to be highly susceptible for selection bias if violations were detected in the

random assignment of participants to intervention or control groups. Selection bias was

regarded low if adequate procedures regarding random group assignment were

conducted, resulting in comparable groups to be investigated. Performance bias was

considered to be high when there was no blinding (or masking) of study participants

and personnel. Although difficult to set up in biofeedback studies, such a procedure

reduces the risk that mere knowledge of the offered intervention affects outcome.

When successful blinding was undertaken, this bias was considered low. Detection

bias was considered to be high when researchers analyzing the data were aware of

the intervention allocated to participants. Contrary, if the blinding of these outcome

assessors was assured, risk of bias was considered to be low. A high risk for attrition

bias was considered to be present in case of incomplete outcome data from the

analyses, usually due to drop-out of participants. Studies were regarded to be low in

risk for attrition bias if the data of each outcome measure were complete. Selective

outcome reporting, i.e., not reporting the results of one of the outcome measures, was

considered an indication of reporting bias. Studies were evaluated low in reporting bias

7
 Biofeedback for stress management

if the results of all outcome measures were reported, in comparison to published study

protocols. In all risk of bias analyses, insufficient details on the respective aspect of the

study methodology resulted in a statement of unclear risk of bias.

Results

Study selection

The search generated 2056 potentially relevant articles (Figure 1), which were

reduced to 1718 articles after removal of duplications. A total of 1605 articles were

eliminated following title and abstract screening. Finally, after reading the full text

another 85 articles were excluded because they did not fulfil inclusion criteria. In all,

this resulted in the inclusion of 14 articles for review.

- enter Figure 1 about here -

Risk of bias evaluation

All studies randomized participants across study conditions, resulting in

satisfactory conditions in terms of selection bias (Table 1). Performance bias was often

considered to be present, as clear-cut control conditions were frequently used, with

only a single study opting for a double blind design. Furthermore, it was difficult to

assess whether any detection bias occurred, as most studies failed to provide input on

whether or not outcome assessors were blinded. Attrition bias did seem to be present

in several studies. This is typically due to drop-out of participants during the

intervention or assessment, resulting in incomplete compilation of data. Drop-out rate

itself was, however, well documented in most studies. Finally, no study protocols

appeared to have been pre-published, which is however, only a fairly recent practice.

Most articles did make use of a non-published protocol, or provided a comprehensive

overview of their study results. It was therefore concluded that overall there seemed to

be little evidence of reporting bias.

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 Biofeedback for stress management

- enter Table 1 about here -

Study focus and sample

As Table 2 illustrates, the majority of included studies focused specifically on

stress management or stress reduction, although one study was aimed at general self-

control (Mackay et al., 2015). The stress interventions were implemented in a healthy

population (Dillon et al., 2016; Kotozaki et al., 2014; Murphy, 1984; Whited, Larkin, &

Whited, 2014), a population with demanding job characteristics (Allen & Blanchard,

1980; Lemaire, Wallace, Lewin, de Grood, & Schaefer, 2011; McCraty, Atkinson,

Lipsenthal, & Arguelles, 2009; Sutarto, Wahab, & Zin, 2012), or in a medical context,

targeting patients with chronic pain (Berry et al., 2014; Hallman, Olsson, von Schéele,

Melin, & Lyskov, 2011), multiple sclerosis (Mackay et al., 2015), heart disease (Nolan

et al., 2005), obesity (Teufel et al., 2013), and pregnant women at risk for preterm labor

(Siepmann et al., 2014). In total, the included studies comprised 488 participants, of

which 51% was female (n = 250). Participants were between 18 and 60 years old

(pooled M = 39.72, pooled SD = 7.61; Allen and Blanchard (1980) were not included

in the pooled statistics since they only reported age range).

- enter Table 2 about here -

Biofeedback intervention

Nine studies implemented stress interventions that relied on variations of

biofeedback on heart rate (Kotozaki et al., 2014) and heart rate coherence or HRV

(Berry et al., 2014; Hallman et al., 2011; Lemaire et al., 2011; McCraty et al., 2009;

Nolan et al., 2005; Siepmann et al., 2014; Sutarto et al., 2012; Whited et al., 2014;

Table 3). Two recent studies used EDA as the leading physiological parameter for

biofeedback (Dillon et al., 2016; Teufel et al., 2013), while in two older studies,

9
 Biofeedback for stress management

feedback was provided on electromyographic (EMG) activity (Allen & Blanchard, 1980;

Murphy, 1984). One final study applied breathing rate and muscle tension biofeedback

(Mackay et al., 2015).

The duration of the biofeedback interventions ranged from one single session

(Dillon et al., 2016) to an intervention that was spread out over the course of 12 weeks

(McCraty et al., 2009), with most interventions being implemented for approximately

four weeks (Berry et al., 2014; Kotozaki et al., 2014; Lemaire et al., 2011; Murphy,

1984; Nolan et al., 2005). The length and number of sessions showed large variability

as well. Most studies encouraged daily practice of the learned skills (Allen & Blanchard,

1980; Hallman et al., 2011; Kotozaki et al., 2014; Lemaire et al., 2011; Mackay et al.,

2015; McCraty et al., 2009; Murphy, 1984; Sutarto et al., 2012; Teufel et al., 2013;

Whited et al., 2014).

The studies offered biofeedback as a stand-alone intervention (Dillon et al.,

2016; Hallman et al., 2011; Kotozaki et al., 2014; Murphy, 1984; Siepmann et al., 2014;

Sutarto et al., 2012; Teufel et al., 2013) or as part of a broader intervention program

for stress management (Allen & Blanchard, 1980; Berry et al., 2014; Lemaire et al.,

2011; Mackay et al., 2015; McCraty et al., 2009; Nolan et al., 2005; Whited et al., 2014).

The training was offered in a controlled laboratory setting (Berry et al., 2014; Dillon et

al., 2016; Hallman et al., 2011; Mackay et al., 2015; Nolan et al., 2005; Teufel et al.,

2013; Whited et al., 2014), at work (Allen & Blanchard, 1980; Murphy, 1984; Sutarto et

al., 2012), at home (Kotozaki et al., 2014), or outside of the lab without further

specifications (Lemaire et al., 2011; McCraty et al., 2009). Siepmann et al. (2014) did

not specify the location of the intervention.

- enter Table 3 about here -

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 Biofeedback for stress management

Control condition

The implemented control conditions were also characterized by high levels of

diversity. Six studies included passive control groups, specifically a waiting list control

group (Allen & Blanchard, 1980; McCraty et al., 2009; Murphy, 1984; Teufel et al.,

2013) or no intervention (Kotozaki et al., 2014; Whited et al., 2014). However, Allen

and Blanchard (1980) and Murphy (1984) additionally included a second active control

condition. Active control conditions consisted of standard care for stress management

(Berry et al., 2014; Nolan et al., 2005), individual and group discussions on stress

(Allen & Blanchard, 1980), a breathing protocol (Hallman et al., 2011), educational

information (Lemaire et al., 2011), muscle relaxation (Murphy, 1984), or a combination

of relaxation, mindfulness, social support and education (Mackay et al., 2015). Finally,

three studies designed a control condition with corresponding features to the

biofeedback intervention, such as playing a game (Dillon et al., 2016), presenting the

visuals of the experimental intervention at the same frequency and duration, but

without instruction (Siepmann et al., 2014), or physiological monitoring without

providing biofeedback (Sutarto et al., 2012).

Outcome measures

Most studies evaluated physiological treatment effects through the measure that

was implemented in the biofeedback condition, specifically frontal EMG (Allen &

Blanchard, 1980; Murphy, 1984), EDA (Teufel et al., 2013), muscle tension and

breathing rate (Mackay et al., 2015), and HRV (coherence) in a resting state, in

response to stress, or in a relaxation condition (Berry et al., 2014; Hallman et al., 2011;

Nolan et al., 2005; Siepmann et al., 2014; Sutarto et al., 2012; Whited et al., 2014).

However, four studies also used different physiological modalities in the outcome

measures as compared to the biofeedback intervention, such as Dillon et al. (2016)

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 Biofeedback for stress management

who assessed the effect of EDA biofeedback on heart rate, Kotozaki et al. (2014) who

used salivary cortisol and grey matter volumes as outcome measures for heart rate

and cerebral blood flow biofeedback, and Lemaire et al. (2011) and McCraty et al.

(2009) who implemented HRV coherence biofeedback and measured heart rate, blood

pressure and several molecules (such as cortisol). The included studies measured

HRV in both the frequency and time domain, with most studies implementing multiple

HRV indices. With regard to the measurement of psychological treatment effects, there

is not a golden standard for the measurement of stress. The Perceived Stress Scale

(PSS; Cohen, Kamarck, & Mermelstein, 1983) was used three times (Berry et al., 2014;

Nolan et al., 2005; Whited et al., 2014) and the Depression Anxiety Stress Scales

(DASS; Lovibond & Lovibond, 1995) was included twice (Mackay et al., 2015; Sutarto

et al., 2012), all of the other studies implemented different assessments.

Effects of the intervention

Berry et al. (2014), Dillon et al. (2016), and Kotozaki et al. (2014) observed

beneficial effects of biofeedback for stress management as compared to the control

condition in both the physiological and psychological domain. Five additional studies

observed a significant physiological effect of the intervention, as compared to the

control condition (Hallman et al., 2011; Murphy, 1984; Nolan et al., 2005; Sutarto et al.,

2012; Whited et al., 2014). Finally, one study observed improved psychological

outcomes in the biofeedback intervention, as compared the control condition (Lemaire

et al., 2011). HRV was the most commonly affected physiological outcome variable,

specifically HRV in recovery from stress (Hallman et al., 2011; Nolan et al., 2005;

Sutarto et al., 2012; Whited et al., 2014) or at rest (Hallman et al., 2011).

A follow-up measurement was included in five studies. Teufel et al. (2013)

observed that both psychological and physiological effects remained or even improved
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 Biofeedback for stress management

until 3 months follow-up. Lemaire et al. (2011) observed maintained psychological

effects at 28 days follow-up and Murphy (1984) detected maintained physiological

effects at three months follow-up. Siepmann et al. (2014) did not measure stress

immediately after the intervention but did find a reduction in stress at four weeks follow-

up. Finally, Allen and Blanchard (1980) did not find an effect of biofeedback on self-

reported stress immediately after the intervention or at six weeks follow-up (these

authors did not include a physiological follow-up measurement).

Association between physiological and psychological effects

Table 4 provides an overview of the occurrence of significant psychological and

physiological outcomes, as compared to the control condition, in the fourteen included

studies. The results showed that 38% of studies observing beneficial physiological

outcomes also observed reduced stress levels and 75% of studies with reduced stress

levels also observed improved physiological outcomes, a difference that was not

significant (p = .580, two tailed Fisher’s Exact test).

- enter Table 4 about here -

Effectiveness related to different components of the biofeedback intervention

and sample

The included studies showed large diversity in the characteristics of the

implemented biofeedback intervention. Different physiological systems were targeted,

interventions were offered for varying durations of time, were applied both in a lab and

real-life context, used different control conditions, and were operationalized as a stand-

alone intervention or embedded in a broader intervention program. However, when

plotting the occurrence of certain characteristics (such as duration) of a study against

positive outcomes, visual inspection of the data did not reveal clear indications for

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 Biofeedback for stress management

better performance based on differences in this characteristic. Outcomes did not

appear to improve when additional interventions were included, a real-life context was

used or the duration was longer than four weeks.

Additionally, there were differences in the characteristics of the samples. The

current review included both healthy subjects and individuals with health problems.

There was no clear tendency for improved effectiveness of biofeedback in either group.

It is difficult to compare the levels of stress between individuals and participant groups,

since stress is a highly subjective experience and different assessment tools were used

to measure stress. Dillon et al. (2016) induced stress in healthy participants prior to

biofeedback and McCraty et al. (2009) reported that 21% of the sample showed high

cortisol levels at baseline. However, the other studies did not induce stress or report

whether their samples displayed elevated stress at baseline. Individuals with severe

stress-related problems might show more room for improvement on the outcome

variables (e.g., HRV) as compared to participants with less severe problems. However,

the current data do not allow assessing whether stress levels at baseline influenced

the outcome of biofeedback.

Discussion
Elevated stress is a common negative psychological state that is associated

with physiological changes. Therefore, stress management programs might benefit

from the addition of a psychophysiological component. The purpose of this review was

to investigate whether stress management interventions with a biofeedback

component could improve both physiological and psychological indicators of stress.

The results show that there is large diversity in the characteristics and effectiveness of

the included interventions. No association between the occurrence of physiological and

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 Biofeedback for stress management

psychological effects could be observed. There is a need for further research

assessing which components of biofeedback can improve stress outcomes.

Three studies observed significant improvements in both physiological and

psychological stress indices in the biofeedback condition as compared to the control

condition. Berry et al. (2014) implemented HRV coherence biofeedback in the context

of chronic pain and achieved significantly higher HRV coherence and lower PSS

scores after the intervention as compared to treatment as usual. The stress

management study of Kotozaki et al. (2014) found that heart rate and cerebral blood

flow biofeedback led to significantly decreased cortisol levels, decreased subjective

stress, and neural changes. The mHealth design of Dillon et al. (2016) showed that

EDA biofeedback games significantly decreased heart rate and perceived stress in

comparison to a non-biofeedback game in a healthy population.

In addition to these three studies that observed effects on both outcome

variables, six studies observed significantly stronger improvement in either

physiological or psychological variables. HRV biofeedback significantly improves HRV

in different participant populations, specifically individuals with stress-related chronic

neck pain (Hallman et al., 2011), patients with coronary heart disease (Nolan et al.,

2005), labourers (Sutarto et al., 2012), and students (Whited et al., 2014). Murphy et

al. (1984) showed that EMG biofeedback leads to significantly lower EMG values in a

working class population. Nolan et al. (2005) and Sutarto et al. (2012) additionally

observed reduced PSS and DASS scores after the intervention, but there was no

significant difference with the control group. Lemaire et al. (2011) implemented stress

management with HRV coherence biofeedback and documented lower perceived

stress levels that remained at 28 days follow-up.

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 Biofeedback for stress management

The remaining five studies also observed improvement in some of the outcome

variables, but group differences did not reach significance. Stress was targeted in

white-collar workers by Allen & Blanchard (1980) and McCraty et al. (2009) through

EMG and HRV coherence biofeedback. These studies recorded EMG and HRV

reductions that did not differ from the control condition. No psychological effects were

found. Mackay et al. (2015) and Siepmann et al. (2014) on the other hand observed

non-significant psychological effects, but no effects on breathing rate, muscle tension

and heart rhythm, after implementing breathing rate and muscle tension biofeedback

in multiple sclerosis patients or HRV biofeedback in pregnant women, respectively.

Finally, in the study of Teufel et al. (2013) EDA biofeedback was associated with small

to medium effects on EDA and small to large effects on perceived stress in an obese

population, but no group differences could be found.

Several aspects of the study design could contribute to differences in the

effectiveness of biofeedback. However, outcomes did not appear to vary according to

specific intervention characteristics, such as duration, context or additional

interventions. Sample characteristics could hamper statistical power to detect group

differences. The studies included in the current review suffered from small sample

sizes, sometimes reaching no more than ten participants per condition (Allen &

Blanchard, 1980; Berry et al., 2014; Teufel et al., 2013). Additionally, the majority of

studies did not report whether the included sample showed elevated stress at baseline.

Healthy individuals with few stress-related symptoms may not have a lot of room for

improvement in the outcome measures. Finally, individual differences and preferences

can also influence effectiveness through effects on motivation, engagement, and

compliance (Marcus, Stuart, Wang, Shadish, & Steiner, 2012).

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 Biofeedback for stress management

Biofeedback is based on the concept that increased control over physiological

processes can improve performance and well-being. The current review assessed

changes in both the physiological and psychological domain to better understand how

improvements in these domains are related to one another. While Nolan et al. (2005)

did find an inverse association between subjective stress and HRV modulation (the

physiological outcome measure of the study) that was limited to the biofeedback

condition, the current review did not observe a significant association between

physiological and psychological outcomes variables. The mechanisms of change in

biofeedback remain unclear. Berry et al. (2014) propose that biofeedback combined

with self-regulation techniques can increase awareness of internal psychophysiological

processes and hereby improve coping techniques (for pain). Biofeedback can not only

increase awareness but also promote conscious control. Dillon et al. (2016) state that

stress can be caused by a perceived lack of control and that perceived control can be

improved by teaching individuals how to master physiological processes through

biofeedback.

The majority of included studies encouraged participants to practice the skills

individually between sessions and two studies reported that over 90 percent of

participants indeed performed (daily) exercises at home (Mackay et al., 2015; Whited

et al., 2014). This finding is relevant for the development of mHealth applications using

biofeedback since it suggests that participants are both able and motivated to apply

biofeedback exercises individually and in different contexts. Benefits of an mHealth

approach are that participants can use the intervention flexibly and at low cost, which

can facilitate widespread adoption. A promising mHealth application for biofeedback is

wearable technology, in which mobile sensory devices (e.g., wristbands) are used to

non-invasively collect physiological data. Wearable devices can measure EDA

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 Biofeedback for stress management

(Villarejo, Zapirain, & Zorrilla, 2012), breathing patterns, and heart rhythm (and

accordingly allow for the calculation of HRV) (Cropley et al., 2017). There is also a

growing interest in using wearables to collect blood pressure and breathing rate as a

guide for stress recovery training at home (through biofeedback), but further research

is needed (e.g., Uddin et al., 2016). Ideally, however, a wide range of different

physiological parameters could be collected by wearables, their data integrated and

subsequently used as an additional source of information to guide preventive or

therapeutic interventions (De Witte, Bonroy, Debard, Sels, & Van Daele, 2018). There

are some important practical barriers for implementation of mHealth, such as

commercial availability of affordable and reliable physiological measurement tools,

potential problems with data security, and diverse needs (for interfaces and tools) in

different populations (Munos et al., 2016).

The current review was able to include one mHealth and game-based

biofeedback intervention. Dillon et al. (2016) induced stress in their participants and

subsequently offered EDA biofeedback through two mobile games. This approach has

several potential advantages. It maximizes opportunities for generalization since

participants learn to use biofeedback when they are stressed and the medium (a

smartphone) makes it flexible to use in different contexts. Additionally, gamification

elements could increase engagement and motivation. However, the effect sizes of

Dillon et al. (2016) were modest and no follow-up measures were included. Other

mobile biofeedback applications have been developed (e.g., Gaggioli et al., 2014;

Munster-Segev, Fuerst, Kaplan, & Cahn, 2017), however, these applications still need

to undergo rigorous testing and often lack gamification elements. Despite potential

benefits, gamification is currently rarely included in stress management applications

for adults (Hoffmann, Christmann, & Bleser, 2017). Biofeedback video games have

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 Biofeedback for stress management

been developed for children and adolescents, such as Dojo and MindLight

(Schoneveld, Lichtwarck-Aschoff, & Granic, 2017).

Some limitations of the current review require discussion. Although the goal was

to include all stress interventions using psychophysiological components, an

exploratory literature search showed that this field of research was mostly limited to

biofeedback interventions and the scope was consequently limited to increase

comparability. A likely explanation for the lack of other interventions using

psychophysiological measures is that, until recently, practical limitations (related to

hardware or big data) impeded the possibilities for postponed feedback or report of

psychophysiological data. As opposed to other interventions, biofeedback does not

require large amounts of storage or computing power. Secondly, it is important to

consider both the psychological and physiological outcome domains when

investigating the effectiveness of psychophysiological interventions. Studies often did

not investigate both outcome domains and could therefore not be included in the

current review. The current review was only able to assess the association between

these two outcome domains using dichotomous variables. Future research needs to

investigate the association between physiological and psychological outcomes further

by using analyses with more power, such as correlations. The included studies had

very diverse samples. Comorbid conditions (such as obesity or chronic pain) could

influence the effects of biofeedback. The large variability in the implemented control

conditions and psychological measurement instruments did not allow to directly

compare different studies and perform a meta-analysis. More high-quality standardized

effectiveness studies of biofeedback interventions for stress are needed.

Taken together, the studies included in the current review suggest that

biofeedback can be a promising intervention for stress management. It is feasible to

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 Biofeedback for stress management

explore the implementation of biofeedback in different contexts and in samples with

stress associated to various conditions. One third of the included studies, however, did

not observe any incremental effectiveness of biofeedback. Small sample sizes and

large differences between study designs also impede generalization. Additional

research needs to determine which components of biofeedback are effective and

establish whether psychophysiological measurements are an appropriate component

of stress management programs. It is feasible to offer biofeedback as a gamified

mHealth application and one included study supports that this is associated with

positive short-term outcomes in both physiological and self-report indicators of stress.

Conflict of interest

The authors declare that they have no conflict of interest.

20
 Biofeedback for stress management

References

Allen, J. K., & Blanchard, E. B. (1980). Biofeedback-based stress management training

with a population of business managers. Biofeedback and Self-Regulation, 5(4),

427-438.

American Psychiatric Association. (2016). Stress in America: the impact of

discrimination. Stress in America™ Survey.

American Psychological Association. (2017). Stress in America: The State of Our

Nation. Stress in America™ Survey.

Bali, A., & Jaggi, A. S. (2015). Clinical experimental stress studies: methods and

assessment. Reviews in the Neurosciences, 26(5), 555-579.

[Link]

Berry, M. E., Chapple, I. T., Ginsberg, J. P., Gleichauf, K. J., Meyer, J. A., & Nagpal,

M. L. (2014). Non-pharmacological Intervention for Chronic Pain in Veterans: A

Pilot Study of Heart Rate Variability Biofeedback. Global Advances in Health

and Medicine, 3(2), 28-33. [Link]

Chrousos, G. P., & Gold, P. W. (1992). The concepts of stress and stress system

disorders. Overview of physical and behavioral homeostasis. JAMA, 267(9),

1244-1252.

Cohen, S., Kamarck, T., & Mermelstein, R. (1983). A global measure of perceived

stress. Journal of Health and Social Behavior, 24(4), 385-396.

Cooper, C., & Dewe, P. (2008). Well-being – absenteeism, presenteeism, costs and

challenges. Occupational Medicine, 58(8), 522-524.

[Link]

Cropley, M., Plans, D., Morelli, D., Sütterlin, S., Inceoglu, I., Thomas, G., & Chu, C.

(2017). The Association between Work-Related Rumination and Heart Rate

21
 Biofeedback for stress management

Variability: A Field Study. Frontiers in Human Neuroscience, 11, 27.

[Link]

De Witte, N. A. J., Bonroy, B., Debard, G., Sels, R., & Van Daele, T. (2018). Carewear:

an internet-based platform to implement wearable technology in mental health

care. Paper presented at the conferene of the European Society for Research

on Internet Interventions, Dublin.

Dillon, A., Kelly, M., Robertson, I. H., & Robertson, D. A. (2016). Smartphone

Applications Utilizing Biofeedback Can Aid Stress Reduction. Frontiers in

Psychology, 7, 832. [Link]

Gaggioli, A., Cipresso, P., Serino, S., Campanaro, D. M., Pallavicini, F., Wiederhold,

B. K., & Riva, G. (2014). Positive technology: a free mobile platform for the self-

management of psychological stress. Studies in Health Technology and

Informatics, 199, 25-29.

Hallman, D. M., Olsson, E. M., von Schéele, B., Melin, L., & Lyskov, E. (2011). Effects

of heart rate variability biofeedback in subjects with stress-related chronic neck

pain: a pilot study. Applied Psychophysiology and Biofeedback, 36(2), 71-80.

[Link]

Higgins, J. P., Altman, D. G., Gøtzsche, P. C., Jüni, P., Moher, D., Oxman, A. D., …

Group, C. S. M. (2011). The Cochrane Collaboration's tool for assessing risk of

bias in randomised trials. BMJ, 343, d5928. [Link]

Hoffmann, A., Christmann, C. A., & Bleser, G. (2017). Gamification in Stress

Management Apps: A Critical App Review. JMIR Serious Games, 5(2), e13.

[Link]

Istepanian, R., Jovanov, E., & Zhang, Y. T. (2004). Introduction to the special section

on M-Health: beyond seamless mobility and global wireless health-care

22
 Biofeedback for stress management

connectivity. IEEE Transactions on Information Technology in Biomedicine,

8(4), 405-414.

Jarczok, M., Jarczok, M., Mauss, D., Koenig, J., Li, J., Herr, R., & Thayer, J. (2013).

Autonomic nervous system activity and workplace stressors-A systematic

review. Neuroscience and Biobehavioral Reviews, 37(8), 1810-1823.

[Link]

Kotozaki, Y., Takeuchi, H., Sekiguchi, A., Yamamoto, Y., Shinada, T., Araki, T., …

Kawashima, R. (2014). Biofeedback-based training for stress management in

daily hassles: an intervention study. Brain and Behavior, 4(4), 566-579.

[Link]

Lemaire, J. B., Wallace, J. E., Lewin, A. M., de Grood, J., & Schaefer, J. P. (2011). The

effect of a biofeedback-based stress management tool on physician stress: a

randomized controlled clinical trial. Open Medicine, 5(4), e154-163.

Lin, H., Lin, H., Lin, W., & Huang, A. (2011). Effects of Stress, Depression, and Their

Interaction on Heart Rate, Skin Conductance, Finger Temperature, and

Respiratory Rate: Sympathetic-Parasympathetic Hypothesis of Stress and

Depression. Journal of Clinical Psychology, 67(10), 1080-1091.

[Link]

Lovibond, S.H., & Lovibond, P.F. (1995). Manual for the Depression Anxiety Stress

Scales. (2nd. Ed.). Sydney: Psychology Foundation.

Mackay, A. M., Buckingham, R., Schwartz, R. S., Hodgkinson, S., Beran, R. G., &

Cordato, D. J. (2015). The Effect of Biofeedback as a Psychological Intervention in

Multiple Sclerosis: A Randomized Controlled Study. International Journal of MS Care,

17(3), 101-108. [Link]

23
 Biofeedback for stress management

Marcus, S. M., Stuart, E. A., Wang, P., Shadish, W. R., & Steiner, P. M. (2012).

Estimating the Causal Effect of Randomization Versus Treatment Preference in

a Doubly Randomized Preference Trial. Psychological Methods, 17(2), 244–

254. [Link]

McCraty, R., Atkinson, M., Lipsenthal, L., & Arguelles, L. (2009). New hope for

correctional officers: an innovative program for reducing stress and health risks.

Applied Psychophysiology and Biofeedback, 34(4), 251-272.

[Link]

Munos, B., Baker, P. C., Bot, B. M., Crouthamel, M., de Vries, G., Ferguson, I., ...

Wang, P. (2016). Mobile health: the power of wearables, sensors, and apps to

transform clinical trials. Annals of the New York Academy of Sciences, 1375(1),

3-18. [Link]

Munster-Segev, M., Fuerst, O., Kaplan, S. A., & Cahn, A. (2017). Incorporation of a

Stress Reducing Mobile App in the Care of Patients With Type 2 Diabetes: A

Prospective Study. JMIR Mhealth Uhealth, 5(5), e75.

[Link]

Murphy, L. R. (1984). Stress management in highway maintenance workers. Journal

of Occupational Medicine, 26(6), 436-442.

Nolan, R. P., Kamath, M. V., Floras, J. S., Stanley, J., Pang, C., Picton, P., & Young,

Q. R. (2005). Heart rate variability biofeedback as a behavioral neurocardiac

intervention to enhance vagal heart rate control. American Heart Journal,

149(6), 1137. [Link]

Schoenberg, P. L., & David, A. S. (2014). Biofeedback for psychiatric disorders: a

systematic review. Applied Psychophysiology and Biofeedback, 39(2), 109-135.

[Link]

24
 Biofeedback for stress management

Schoneveld, E. A., Lichtwarck-Aschoff, A., & Granic, I. (2017). Preventing Childhood

Anxiety Disorders: Is an Applied Game as Effective as a Cognitive Behavioral

Therapy-Based Program? Prevention Science. [Link]

017-0843-8

Siepmann, M., Hennig, U. D., Siepmann, T., Nitzsche, K., Mück-Weymann, M.,

Petrowski, K., & Weidner, K. (2014). The effects of heart rate variability

biofeedback in patients with preterm labour. Applied Psychophysiology and

Biofeedback, 39(1), 27-35. [Link]

Sutarto, A. P., Wahab, M. N., & Zin, N. M. (2012). Resonant breathing biofeedback

training for stress reduction among manufacturing operators. International

Journal of Occupational Safety and Ergonomics, 18(4), 549-561.

[Link]

Teufel, M., Stephan, K., Kowalski, A., Käsberger, S., Enck, P., Zipfel, S., & Giel, K. E.

(2013). Impact of biofeedback on self-efficacy and stress reduction in obesity: a

randomized controlled pilot study. Applied Psychophysiology and Biofeedback,

38(3), 177-184. [Link]

Uddin, A. A., Morita, P. P., Tallevi, K., Armour, K., Li, J., Nolan, R. P., & Cafazzo, J. A.

(2016). Development of a Wearable Cardiac Monitoring System for Behavioral

Neurocardiac Training: A Usability Study. JMIR Mhealth Uhealth, 4(2), e45.

[Link]

Van Daele, T., Hermans, D., Van Audenhove, C., & Van den Bergh, O. (2012). Stress

reduction through psychoeducation: a meta-analytic review. Health Education

& Behavior, 39(4), 474-485. [Link]

25
 Biofeedback for stress management

Villarejo, M. V., Zapirain, B. G., & Zorrilla, A. M. (2012). A stress sensor based on

Galvanic Skin Response (GSR) controlled by ZigBee. Sensors (Basel), 12(5),

6075-6101. [Link]

Wheat, A. L., & Larkin, K. T. (2010). Biofeedback of heart rate variability and related

physiology: a critical review. Applied Psychophysiology and Biofeedback, 35(3),

229-242. [Link]

Whited, A., Larkin, K. T., & Whited, M. (2014). Effectiveness of emWave biofeedback

in improving heart rate variability reactivity to and recovery from stress. Applied

Psychophysiology and Biofeedback, 39(2), 75-88.

[Link]

Williams, A. D. (2016). Harnessing the quantified self-movement for optimal mental

health and wellbeing. Paper presented at the LTA, Amsterdam.

26
Tables & figures

Table 1

Overview of risk of bias, ranging from low (-), over unclear (0) to high (+) risk of bias

Study Selection bias Performance bias Detection bias Attrition bias Reporting bias
1. Allen & Blanchard - + - - -
2. Berry et al. (2014) - + 0 - -
3. Dillon et al. (2016) - 0 0 - -
4. Hallman et al. (2011) - 0 - + -
5. Kotozaki et al. (2013) - - 0 - +
6. Lemaire et al. (2011) - + + + -
7. Mackay et al. (2015) - 0 0 - -
8. McCraty et al. (2009) - + 0 + -
9. Murphy (1982) - + 0 + +
10. Nolan et al. (2005) - + 0 + -
11. Siepmann et al. - + 0 + -
12. Sutarto et al. (2012) - + + + -
13. Teufel et al. (2013) - + 0 + -
14. Whited et al. (2014) - + 0 + -
Table 2

Study design features

Study Study focus Sample Sample Physiological measurements Psychological Follow-

size (# characteristics & measurements up
female) mean age (SD)
1. Allen & Stress management 30 (8) Middle-level Frontal electromyography, finger SSS 6 weeks
Blanchard managers temperature (SSS)
(1980) Age range: 40-60

2. Berry et Pain and stress 14 (1) Veterans with HRV coherence PSS -
al. (2014) management chronic pain
44.63 (6.96)

3. Dillon et Stress reduction 50 (32) Healthy adults Heart rate Visual Analogue -
al. (2016) 26.7 (5.1) Scale for perceived
stress
4. Hallman Autonomic regulation 24 (22) Adults with stress- HRV during rest, during hand Stress Medicine -
et al. (2011) and perceived health, related chronic grip test, during cold pressor Symptom Scale
pain, stress and neck pain test, and during deep breathing
disability 41.43 (7.07) test

5. Kotozaki Stress management 30 (0) Healthy working Salivary cortisol and voxel- Brief Job Stress -
et al. (2014) adults based morphometry Questionnaire
42.30 (7.90)
6. Lemaire Stress management 40 (17) Physicians Heart rate, blood pressure, Scale based on PSS 28 days
et al. (2011) 46.3 (8.35) salivary cortisol and POQA – revised

7. Mackay Self-control 40 (32) Patients with Muscle tension, breathing rate DASS 3
et al. (2015) multiple sclerosis months
45.9 (12.42) (DASS)

8. McCraty Stress and health risk 75 (23) Correctional HRV, blood pressure, blood POQA -
et al. (2009) reduction officers samples, and saliva samples
40.00 (7.88)

9. Murphy Stress management 38 (4) Highway Forehead electromyography Job Stress Scale 3
(1984) maintenance months
workers
42 (SD not given)

10. Nolan et Stress and depression 46 (6) Patients with HRV at baseline, during PSS -
al. (2005) reduction coronary heart physical, emotional, and
disease personal stressor, and during
54.52 (1.26) recovery

11. Reduction of stress 48 (48) Pregnant women Heart rate, HRV Trier Inventory for 4 weeks
Siepmann et and preterm birth prone to preterm the Assessment of
al. (2014) labor Chronic Stress
29 (5)
 12. Sutarto Stress reduction 36 (36) Manufacturing HRV during rest, stressor, and DASS -
et al. (2012) operators recovery
36.30 (10.14)

13. Teufel et Self-efficacy and stress 30 (30) Obese adults Electrodermal activity to food Perceived Stress 3
al. (2013) reduction 48.67 (9.94) stimuli Questionnaire months

14. Whited Stress reduction 27 (23) Students HRV at rest, during stressor and PSS -
et al. (2014) 22.54 (3.82) during recovery

Note. Pooled means were calculated for age (in years) when no total group means were provided. Allen & Blanchard (1980) and Murphy (1982)

did not report the mean and/or standard deviation of age. DASS = Depression Anxiety Stress Scales, HRV = heart rate variability, POQA =

Personal and Organizational Quality Assessment, PSS = Perceived Stress Scale, SSS = Subjective Stress Scale
Table 3

Overview of the intervention characteristics and results of the included studies

Study Intervention Experimental Control Physiological effects Psychological Conclusion

duration intervention condition(s) effects
1. Allen & 6 weeks EMG BF, (1) WLC Decrease in basal frontal No effects Physiological effects
Blanchard 55 min / progressive (2) 6 weekly EMG and frontal EMG but no superior
(1980) week relaxation, individual and during stress recovery: INT effect of INT
+ daily abdominal group sessions &C
practice breathing, and on stress
stress inoculation
training

2. Berry 4 weeks HRV coherence TAU POST HRV coherence: INT POST perceived Larger physiological
et al. 1 session / BF and TAU >C stress: INT < C and psychological
(2014) week effects in INT than C

3. Dillon 1 session of Two EDA BF Non- POST HR: INT < C POST perceived Larger physiological
et al. 30 min games biofeedback stress: INT < C and psychological
(2016) game effects in INT than C

4. 10 weeks Resonance HRV Breathing POST HRV during rest, No effects Larger physiological
Hallman 1 session / BF protocol in reactivity to stress and effects in INT than C
et al. week week 1 and 10, recovery from stress: INT > (but not in all HRV
(2011) C indices)
 + 15 min no intermittent
daily treatment
practice
5. 4 weeks HR and CBF BF No intervention Decrease in salivary Decrease in Larger physiological
Kotozaki 5 min / day cortisol level: INT > C tension and and psychological
et al. Increase in grey matter stressors of effects in INT than C
(2014) volume of right lateral working
orbitofrontal cortex and environment score:
left subgenual anterior INT > C
cingulate cortex: INT > C

6. 4 weeks HRV coherence Information No effects Decrease in Larger psychological

Lemaire 3 sessions BF, rhythmic brochure & perceived stress: effects in INT than C
et al. of 5 min / breathing, self- biweekly INT > C
(2011) day generated positive contact with Effects INT
emotion, and research maintained at FU
components assistant
control condition (+ BF training
after 4 weeks)

7. Mackay 3 weeks Breathing rate and Relaxation, No effects Decrease in stress: Psychological
et al. 60 min / muscle tension BF mindfulness, INT effects but no
(2015) week and components social support, significant group
+ daily control condition & education differences
practice
8. 2-day HRV coherence WLC Decrease in blood pressure, No effects Physiological effects
McCraty training BF and “Power to HR, and dehydroepiandro- in INT but no
et al. program Change sterone (DHEA) and significant group
(2009) + 3 months Performance” increase in HRV: INT differences
of daily program Decrease in cholesterol and
practice glucose: INT & C

9. Murphy 2 weeks Forehead EMG BF (1) WLC Decrease in EMG: INT > No effects Larger physiological
(1984) 60 min / day (2) MR WLC effects in INT than C
+ practice Percentages of EMG
between reduction at FU: INT > MR >
sessions WLC

10. Nolan 4 weeks Paced breathing TAU POST HRV increase Decrease in Larger physiological
et al. 5 sessions guided by HRV BF during stress recovery: stress: INT & C effects in INT than
(2005) of 90 min and cognitive- INT > C C, no group
behavioral training difference in
psychological
effects, inverse
association between
stress and HRV
modulation limited to
INT
11. 2 weeks Paced breathing Passive viewing No effects FU decrease in Psychological
Siepmann 3 sessions guided by HRV BF condition chronic stress: INT effects in INT at FU
et al. of minimum but no significant
(2014) 25 min / group differences
week

12. 5 weeks Paced breathing 5 sessions of POST increase in HRV Decrease in stress: Physiological and
Sutarto et 30-50 min / guided by HRV BF 20 min during baseline, stress and INT (no direct psychological effects
al. (2012) week physiological recovery: INT > C group comparison in INT but group
+ 20 min monitoring, Decrease in breaths per performed) differences were not
daily without (BF) minute during baseline, always assessed or
practice instructions stress, and recovery: INT significant
without
device

13. Teufel 8 weeks EDA BF WLC POST and FU reduction in POST reduction Physiological and
et al. 21 min / (1) specific INT: EDA: medium effect in in perceived psychological effects
(2013) week food photos specific INT, small effect in stress: small in INT but no
+ daily (2) relaxation INT: relaxation INT effect in specific significant group
practice landscapes INT differences
without FU reduction in
device perceived stress:
large effect in
specific INT,
 small effect in
relaxation INT
14. 4 to 8 weeks HRV coherence No intervention POST HRV during stress No effects Larger physiological
Whited et 32 min / BF with exercises INT > C effect in INT than C
al. (2014) week for attention,
+ daily breathing and
practice inducing positive
emotions
Note. BF = biofeedback, C = control condition, CBF = cerebral blood flow, EDA = electrodermal activity, EMG = electromyography, FU = follow-

up, HR = heart rate, HRV = heart rate variability, INT = intervention, MR = muscle relaxation, TAU = treatment as usual, WLC = waiting list

control
Table 4

Cross-tabulation of physiological and psychological outcomes of the biofeedback intervention

as compared to the control condition.

Stress reduction No reduction in Total

stress

Improvement in physiological 3 5 8

parameters

No improvement in physiological 1 5 6

parameters

Total 4 10 14
General search strategy (N=2056)

Removal of duplicates (N=338)

Title and abstract screening (N=1718)

Excluded articles based on title or abstract (N=1614)

- Not eligible (N=1605)
- No abstract available (N=9)

Full text screening (N=104)

Excluded articles (N=90)

- No experimental study design (N=3)
- No randomised control trial (N=9)
- No specifications of biofeedback intervention (N=1)
- No physiological or psychological measurements of stress (N=68)
- Cannot be found or accessed (N=5)
- Not written in English (N=3)
- No clear use of physiological feedback (N=1)

Studies included in the review (N=14)

Figure 1. Flow chart of the search strategy.