Media-Dependent Effects in Heart Rate Variability Biofeedback: A Systematic Review of Extended Reality and Screen-Based Training Approaches (2025)

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Published Online: 9 May 2025

Authors: Nathan Miner https://orcid.org/0000-0003-2440-8521 [emailprotected], Karmen Gill, Casper Harteveld, Christopher Bono, and Darshan H. Mehta

Publication: Journal of Medical Extended Reality

Volume 2, Issue Number 1

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Abstract

Heart rate variability (HRV) is an indicator of autonomic nervous system function and cardiovascular health. Through biofeedback (BF), individuals can increase their HRV, which is ideal, by using audiovisual cues to monitor and adjust their breathing. HRV-BF training has demonstrated effectiveness in alleviating stress and anxiety, enhancing cardiac autonomic function, and supporting psychological treatments for conditions, such as depression and chronic pain. Despite their benefits, traditional HRV-BF approaches are limited by the need for frequent clinical visits, specialized equipment, and trained personnel, limiting accessibility and scalability. Extended reality (XR) technologies, including virtual reality, augmented reality, and mixed reality, offer a promising alternative by creating immersive, interactive environments that can deliver HRV-BF without traditional constraints. This review examines the available literature on reported differences in user experience (UX), HRV metrics, psychological outcomes, and BF performance, which are documented by research comparing HRV-BF using XR media to traditional screen-based methods. We searched PubMed, PsycINFO, Embase, Cochrane, Science Direct, ACM, and IEEE databases. Our search yielded 382 results. Four studies met our review criteria. Using HRV-BF research reporting guidelines, we extracted and summarized study objectives, design strategies, hypotheses, and related outcomes to evaluate the evidence for media-dependent effects. Findings indicate that both XR and screen-based implementations of HRV-BF positively affect HRV physiology. Furthermore, XR-based HRV-BF implementations showed more pronounced effects on outcomes for psychological and UX variables. These studies suggest that XR media can offer advantages in terms of user engagement and psychological benefits (e.g., stress relief, relaxation) over traditional screen-based modalities. Improvements in UX and psychological outcomes stem from the relaxing, immersive contexts created in XR, supporting user motivation and attentional control during XR-based HRV-BF training. However, design-based inquiries and longitudinal studies are needed to understand the role of design and the potential of the specific mechanisms contributing to these results.

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Cite this article as: Miner N, Gill K, Harteveld C, Bono C, Mehta DH (2025) Media-dependent effects in heart rate variability biofeedback: A systematic review of extended reality and screen-based training approaches. Journal of Medical Extended Reality 2:1, 114–131, DOI: 10.1089/jmedxr.2024.0060.

Information & Authors

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Published In

Media-Dependent Effects in Heart Rate Variability Biofeedback: A Systematic Review of Extended Reality and Screen-Based Training Approaches (1)

Journal of Medical Extended Reality

Volume 2Issue Number 12025

Pages: 114 - 131

Copyright

© The Author(s) 2025. Published by Mary Ann Liebert, Inc.

Open Access

Media-Dependent Effects in Heart Rate Variability Biofeedback: A Systematic Review of Extended Reality and Screen-Based Training Approaches (2)

This Open Access article is distributed under the terms of the Creative Commons License [CC-BY] (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

History

Published online: 9 May 2025

Published in print: 2025

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Authors

Affiliations

Nathan Miner* https://orcid.org/0000-0003-2440-8521 [emailprotected]

Department of Orthopaedics, Massachusetts General Hospital, Boston, Massachusetts, USA.

College of Arts, Media and Design, Northeastern University, Boston, Massachusetts, USA.

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Karmen Gill

Department of Biology, Union College, Schenectady, New York, USA.

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Casper Harteveld

College of Arts, Media and Design, Northeastern University, Boston, Massachusetts, USA.

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Christopher Bono

Department of Orthopaedics, Massachusetts General Hospital, Boston, Massachusetts, USA.

Department of Orthopaedic Surgery, Harvard Medical School, Mass General Brigham, Boston, Massachusetts, USA.

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Darshan H. Mehta

Benson-Henry Institute for Mind Body Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.

Osher Center for Integrative Health, Harvard Medical School and Brigham and Women’s Hospital, Boston, Massachusetts, USA.

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Notes

*

Address correspondence to: Nathan Miner, MS, Northeastern University, Massachusetts General Hospital, Boston, MA 02115-5005, USA, [emailprotected]

Authors’ Contributions

N.M.: Conceptualization, writing—original draft, and data analysis. K.G.: Writing—review and editing and data analysis. C.H.: Supervision and writing—review and editing. C.B.: Supervision and writing—review and editing. D.H.M.: Conceptualization and writing—review and editing.

Author Disclosure Statement

D.H.M. serves on the medical advisory board of SoundHealth, Inc. All other authors declare that they have no relevant financial or non-financial interests to disclose.

Funding Information

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

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