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17 Articles in Volume 19, Issue #7
Analgesics of the Future: Inside the Potential of 3 Drug Delivery Systems
Balancing Pain Care - and Opioids - in the Aging Adult
Book Review: A Useful Guide for New Pain Practitioners
Correspondence: Opioid Tapering & Discontinuation
Effective Interventions for Post-Stroke Shoulder Subluxation and Pain
Family: Their Role and Impact on Pain Management
Introducing the "Phoenix Sign:" Improved Vascular Perfusion of the Dorsalis Pedis Artery after a Subanesthetic Dose of Lidocaine
Medication Management of Chronic Pain in Patients with Comorbid Cardiovascular Disease
Multisite Pain May Be Associated with Fractures in the Elderly
Reconciling the New HHS Opioid Tapering Guideline with CDC and State Policies
Research Insights: Impaired Motor Imagery in Chronic Pain Conditions
Tapentadol: A Real-World Look at Misuse, Abuse, and Diversion
Temporomandibular Disorders in Performance Artists (Part 2)
Thoracic Outlet Syndrome Presenting as an Acute Stroke Mimic
Untangling Chronic Pain and Hyperarousal with Heart Rate Variability: A Case Report
What topicals exist for post-herpetic neuralgia pain?
When to Keep Your License: Older Physicians and Boundary Issues

Untangling Chronic Pain and Hyperarousal with Heart Rate Variability: A Case Report

The authors propose that biofeedback can modulate HRV whole health biomarkers by inducing cardiorespiratory efficiency, thereby reducing unremitting hyperarousal, and helping to assess for opioid risk behavior and improve overall outcomes.
Pages 33-36

A recent cross-lagged systematic review1 demonstrated a bidirectional relationship between hyperarousal and pain that was linked to intrusive thoughts and catastrophizing. As clinicians know, the Pain Catastrophizing Scale (PCS), validated by Sullivan, et al, is a validated biopsychosocial scale incorporating three components: magnification, rumination, and helplessness—with rumination most highly correlated with pain outcomes.2 To minimize catastrophic thinking, clinicians may work with patients to incorporate strategies that disengage (not distract) attention toward pain symptoms.2 Persistent and inflexible sympathetic dominance measured with heart rate variability (HRV), compared to other modalities and controls across the circadian cycle, may play a key role in relieving chronic pain.3

This case report provides a pragmatic clinical framework to help untangle the relationship between chronic pain and hyperarousal. By disengaging fear ruminations using heart rate variability biofeedback (HRV-b), this framework has potential to reverse the disability and costs associated with helplessness as measured by the PCS.2


HRV Coherence and Biofeedback Training

HRV coherence (HRV-c) is an established measure of optimal autonomic and cardiorespiratory function. With cyclical diaphragmatic breathing, HRV-c is achieved when cardiac beat-to-beat intervals increase and decrease in synchrony with respiration and shift into a smooth sinusoidal rhythm.4 High HRV-c has been associated with improved mood, cognition, and executive functions whereas low HRV-c has been associated with early mortality, inflammation, and other adverse intermediary outcomes.5

HRV-b training has been shown to improve HRV-c, restore autonomic health, and reduce the severity of symptoms.5 The authors propose that HRV-b is a safe, nonpharmacologic, inexpensive, and self-maintained option for chronic pain and the management of mood disorders associated with hyperarousal and intrusive thoughts. Further in-depth explanation of the complex physiology and translational nature of HRV is beyond the scope of this paper.5

The authors’ ongoing randomized controlled trial studying HRV-b for chronic pain in veterans has demonstrated symptomatic relief and persistence of the HRV-c skill months later.6 Their clinic (Riverside) works to target fear ruminations among chronic pain patients through HRV-c. Over 4 years, 116 subjects have participated in the trial. We have found that the program leads to sustained skill attainment under duress which has helped to improve healthy decision-making in a range of adults up to 80 years old over a 10-year period. These concepts are simplified for our patient audience in what we call The Stop, Shift & Decide methodology.

The following case report examines how HRV-b methodology can empower patients with chronic pain, improve coping, and reduce healthcare utilization.

Patient Case


A 71-year-old female presented to our spine rehabilitation clinic in May 2016 with the chief complaint, “My back pain is causing me to miss out on everything.” She had suffered from daily axial low back pain for over 5 years, worsened by physical activity but temporarily ameliorated by opioids. A recent workup concluded with diabetic polyneuropathy; radiographs of her remote L3-L5 fusion and T12, L1, and L2 kyphoplasties for compression fractures were unremarkable. Medical history included panic attacks, agoraphobia, osteoporosis, and depression. Months prior, she had declined cognitive behavioral therapy, citing uneasiness with the approach. Pertinent medications included: citalopram 20 mg per day, gabapentin 2400 mg per day, and varying intermittent doses of oxycodone up to twice per day as needed for back pain. Functionally, she ambulated household distances independently with a cane and throughout her community using a rolling walker. The patient had not participated in regular activities, such as grocery shopping, in more than 2 years.

On physical examination, the patient demonstrated a positive Romberg Sign, marked kinesiophobia, and the hallmarks of pain catastrophizing. The conclusion of the initial visit included explanation and validation of the nociceptive and neuropathic components of her pain. A second visit involved collaboration with the clinic’s physiatrist and an HRV-b trained nurse clinician. The patient accepted the offer for a program centered on physiological grounding of fear ruminations with regular HRV-b practice and was led through introductory HRV concepts.

Treatment Regimen

Initial HRV-b training began on office visit #3 in July 2016 using a validated heart rate monitoring device. Subsequent HRV-b training sessions consisted of 50 minutes of coaching followed by a 10-minute office visit with the physiatrist. Although the clinic’s physical therapy team is also trained in HRV-b; the patient elected a home program due to her rural residence and associated travel time. The HRV-b sessions were not directed toward behavioral change or scrutinizing of past events, but rather toward shifting emotion, interoceptive awareness, educational analogies, acceptance, and forward-focused free-will healthy decision-making. Counseling and decision-making approaches typically take place once physiological grounding is achieved.

A home practice plan of 10 minutes twice per day (BID), and as needed (PRN), was prescribed. The patient purchased a home smartphone HRV-b device, but use was not mandated due to her obvious engagement and therapeutic partnership. (When necessary, an HRV-b smartphone device may be utilized for objective remote monitoring of compliance to assess opioid risk behavior.) This patient’s short-term goals were directed at physiologically defueling her fear ruminations of movement and open spaces. The patient had indicated that oxycodone increased her physical activity; she demonstrated no signs of addiction or diversion. Thus, opioid reduction was not an initial priority. Although the authors prefer the use of Schedule III high affinity partial agonist buprenorphine preparations in patients with chronic pain, oxycodone 7.5 mg was prescribed, never more than BID PRN.

Figure 1. HRV at rest with chronic pain.

Figure 2. HRV after shifting emotion objectively with HRV biofeedback.


After 1 year and seven total HRV-b sessions (July 2017), the patient’s ability to shift into and maintain HRV-c improved from an initial baseline 22% to 92% over a minimum of 3 minutes (see tachograms in Figures 1 and 2). The patient described her ability to settle her emotional state: “I feel like I can do it naturally all the time now.”

Medication adjustments over the first year included citalopram 20 mg changed to duloxetine 20 mg each day for improved management of pain, and gabapentin was weaned down to 900 mg per day to reduce fall risk. Functionally, the patient had progressed to become independent with basic housework and was walking her dog regularly, shopping, and attending church weekly without an assistive device. She proudly reported that she had become the primary caregiver to her two grandchildren for 2 months during a family crisis and had traveled out of state. Before her HRV-c skill achievement, she reported three emergency department visits over 10 months for falls, anxiety, and back pain totaling $9,129 in payer/patient reimbursement.

After 12 months of HRV-b sessions, HRV-b was stopped, and the patient was weaned off opioids over a 6-month period. At 18 months (November 2017) from initial office visit and now off opioids, the patient was released back to her primary care physician with a PCS rating of 3 out of 52; which had significantly improved from the initial 42 of 52 baseline. The total outpatient clinic payer/patient reimbursement was $3,659.

At 2.5 years (February 2019) from initial clinic visit, the patient’s PCS rating remained steady at 3 out of 52 despite having been diagnosed with cancer and having undergone surgical resection within the previous 12 months. This was confirmed by use of the state prescription monitoring program and system-wide health programs. She received only one post-operative opioid prescription for 2018. The patient had not received any follow-up coaching and yet still stated that she could ground herself “without even thinking about it.” Her skill acquisition with inducing and maintaining cardiorespiratory synchronization improved and persisted over time. Her original HRV-c assessment was for 22% of time over a 3-minute period that improved 1 year later to 92% over a 3-minute period. After another 1.5 years, she demonstrated HRV-c skill acquisition with 56% of the time over a 3-minute period without any pain management visits or coaching for over 1 year.


Advances in the study of the autonomic nervous system (ANS) are leading to paradigm shifts in clinical understanding of emotions.7 By presuming fear to be a root emotion of the sympathetic nervous system,8 providers may be able to specifically target fear ruminations. HRV-c techniques can induce optimal cardiorespiratory efficiency, creating parasympathetic vagal tone in the central autonomic network with the purposeful effect of reducing limbic hyperarousal and survival decision-making; reduce HPA axis triggering that leads to exhaustion,8 ANS dysfunction, and helplessness (see Figure 3). This physiologic grounding would ideally be followed by counseling directed toward free-will healthy decision making. This last goal is crucial, but subtly different from many population health behavioral change programs that have been used in the past. Therapeutic partnership with clinicians and regular practice may potentially reverse the chronic pain trajectory down the Yerkes-Dodson human performance curve of 1908.8

Anecdotally, the authors found the objective measure of compliance and engagement with HRV-b to be an important method in the assessment of opioid risk behaviors. To confirm this observation, objective engagement of healthy behaviors should be studied. Systematic review9 has shown catastrophizers may develop chronic pain after elective surgery. The authors’ clinic often uses HRV-c skill acquisition to improve coping and outcomes prior to costly or invasive elective procedures.

The HRV medical literature is robust, however widespread application of invalidated consumer performance products4,10 persists. As value-based healthcare alignment continues, truly medical-grade tools could propel HRV as an important biomarker for the variety of hyperarousal mood disorders, standardize care, and spur innovation. In the age of wearable monitoring devices, new 2019 remote monitoring billing codes and gamification of HRV software for real-time ANS modulation could also support the prescribing of HRV-b for 10 minutes BID and PRN as a regular practice. Innovative uses for wearable HRV monitors may further offer a value-based future for reducing the opioid crisis.

Overall, this case report demonstrates that appropriately framed HRV-c skill acquisition can be transformative, objective, cost-effective, and safe in the long term. The authors recommend that prescribed HRV-b be considered as a part of pain management associated with hyperarousal. Compared to other forms of biofeedback, HRV-b may offer the greatest combination of immediacy, durability, and versatility as the only form that induces optimal cardiorespiratory state. HRV-c diaphragmatic breathing could serve as the objective backbone of the health and brain plasticity benefits of meditation.5,11

The authors coined the term for this process as ANS rehabilitation8 and the HRV parameters are a measure of parasympathetic health and adaptation. Our goal is to specifically have providers consider this type of biofeedback from a late complementary treatment option and reframe HRV-b as standard early training for physiological grounding for chronic pain associated with hyperarousal based on evidence-based safety, objectivity, reproducibility, and resource utilization.


Rosemina Mehrdady, MD, and JP Ginsberg, PhD, also contributed to this report.

Last updated on: March 16, 2021
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