Appl Psychophysiol Biofeedback (2012) 37:131–144
DOI 10.1007/s10484-012-9185-2
The Effect of Heart Rate Variability Biofeedback on Performance
Psychology of Basketball Players
Maman Paul • Kanupriya Garg
Published online: 9 March 2012
 Springer Science+Business Media, LLC 2012
Abstract Coping with pressure and anxiety is an ineluc-
table demand of sports performance. Heart rate variability
(HRV) Biofeedback (BFB) shall be used as a tool for self
regulating physiological responses resulting in improved
psycho physiological interactions. For further analysis, the
present study has been designed to examine the relationship
between anxiety and performance and also effectiveness of
biofeedback protocol to create stress-eliciting situation in
basketball players. Thirty basketball players of university
level and above (both male and female) aged 18–28 years,
who scored a minimum of 20 in state trait anxiety inventory,
were randomly divided into three equal groups- Experi-
mental (Biofeedback) group, Placebo group and Control (No
Treatment) group. The BFB group received HRV BFB
training for 10 consecutive days for 20 min that included
breathing at individual’s resonant frequency through a pac-
ing stimulus; Placebo group was shown motivational video
clips for 10 consecutive days for 10 min, whereas No
Treatment Control group was not given any intervention.
Two way repeated measure ANOVA was applied to analyze
the differences within and between the groups. Anxiety,
coping self-efficacy, heart rate variability, respiration rate,
and performance (dribbling, passing and shooting) at session
1, 10 and 1 month follow up were statistically significant in
each group along with interaction of group and time
(p \ 0.001). Also, all the measures showed statistically
significant inter group difference (p \ 0.05). The findings
are harmonious with existing data on HRV BFB as a strategy
M. Paul (&)
K. Garg
Department of Sports Medicine and Physiotherapy, Guru Nanak
Dev University, Amritsar, India
e-mail: maman_paul20@yahoo.co.uk
K. Garg
e-mail: kannugr855@yahoo.co.in
for dealing with anxiety. The Placebo group showed
improvement in self efficacy and performance post training.
The Control group showed no change in any variable except
performance. The results of the study support the idea that
HRV BFB lowers the anxiety and thus there seems to be a
potential association between HRV BFB and performance
optimization.
Keywords HRV BFB
Anxiety
Self-efficacy

Basketball
STAI
Performance
Introduction
Heart Rate Variability
The term ‘‘Heart rate variability’’ (HRV) refers to the
waveform of beat to beat changes in the duration of RR
intervals (RRIs) (Lagos et al. 2008). Earlier HRV was
analyzed by means of time and frequency domain tech-
niques, referred to as spectral analysis. Time domain
analysis provides measures such as standard deviation of
Normal to Normal interval (SDNN). The frequency domain
technique analyzes the frequency information obtained in
the recording and result is shown on a power spectrum,
which depicts a breakdown of all the frequencies (Very
Low Frequency, Low Frequency and High Frequency).
A new approach to HRV monitoring and feedback is
the analysis of heart rhythm patterns which analyzes the
varying shape of the HRV waveform (Task Force of the
European Society of Cardiology and the North American
Society of Pacing and Electrophysiology 1996).
HRV analysis represents the most reliable and quanti-
tative assessment of autonomic nervous system functioning
(Sutarto et al. 2010). The heart rate may be increased by
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slow acting sympathetic activity or decreased by fast acting
parasympathetic (vagal) activity. The balance between
these systems produces an ongoing oscillation, an orderly
increase and decrease in heart rate. Higher HRV indicates
an optimal interplay between the sympathetic and para-
sympathetic nervous system and thus epitomize as an index
of emotional expression (Lagos et al. 2008).
A healthy heart doesn’t beat with absolute regularity. A
certain amount of variability is required so that it can adapt
to life’s routine challenges. In recent years, potential
prognostic value of HRV has been given forethought due to
association between HRV parameters and several physical
and psychological health problems. Reduced HRV is an
indicator of cardiovascular problems, generalized anxiety
disorder, panic disorder and post traumatic stress disorder
(Wheat and Larkin 2010).
Techniques for Stress Management
A variety of relaxation techniques exist in the field of sport
psychology for management of stress. When practiced
regularly, techniques like deep breathing, visualization,
progressive muscle relaxation, meditation and yoga negate
the ill effects of stress and evokes a relaxation response, a
state of deep rest and/or a functionally efficient relaxed
state during performance. The psychophysiological symp-
toms of stress can also be relieved by cognitive training
which includes positive self talk, mental rehearsal, mental
imagery and visuo motor behavior rehearsal therapy
(Lagos et al. 2008). Most of the methods focus on psy-
chological symptoms of stress rather than addressing the
imbalance of sympathetic and parasympathetic system in
the body.
Training for psychological skills has become a widely
accepted practice in the athletic setting now. Managing and
improving performance of a player involves maintenance
of systematic records and analysis of past performances
through ‘‘evaluation’’ and ‘‘feedback’’ so as to discover his/
her potential in pursuit of better performance.
The principle of training specificity by Zupan et al.
(2006) states that athletes’ should train themselves as if
they are competing in an event. Athletes when train like as
if they are competing, impact their psychological processes
on autonomic states of their body. Wilmore and Costill
(2004) expands this concept further, the training program
must stress the physiological systems that are critical for
optimal performance in the given sport. This statement
highlights and characterizes the concept that body system
specificity has a direct link with actual sport task. When
athletes’ train while considering themselves in pseudo
competitive situations, there is an impact on their psy-
chological processes in cognizance to the changes occur-
ring in the autonomic states of their bodies.
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Appl Psychophysiol Biofeedback (2012) 37:131–144
Heart Rate Variability Biofeedback Training
and Resonant Frequency
Efforts to identify effective treatment that target HRV
and baroreflex function therefore are warranted. Biofeed-
back (BF) has been implemented as a method for altering
physiological activity which in turn results in improved
psychology and performance (Babiloni et al. 2008; Ham-
mond 2007; Strack 2003).
Resonant properties in cardiovascular system result from
heart rate baroreflex activity. Resonance frequency of an
individual can be estimated as the highest amplitude of heart
rate oscillations elicited by breathing (Hassett et al. 2007).
The resonant characteristic of HRV is generated by paced
breathing at a frequency of about 0.1 Hz (six breaths per
minute). The 0.1 Hz is in the lower frequency band which
reflects the autonomic control and action of baroreflex (Lehrer
et al. 2006). Thus, when individuals breathe at their resonant
frequency, high-amplitude oscillations in heart rate are elic-
ited and the closed loop system of the baroreflex modulates
the respiratory effects on HRV (Lehrer et al. 2003).
Breathing at one’s resonant frequency aims at producing
maximal increases in respiratory sinus arrhythmia (RSA)
amplitude. Variation in heart rate is accompanied by
breathing (RSA) which is controlled by parasympathetic
reflexes (Lagos et al. 2008). RSA usually occur in the
frequency range of 0.15–0.4 Hz in a healthy adult (Lehrer
et al. 2000).
Heart Rate Variability and Psychological Stressors
A variety of factors can cause increase in specific rhythms
of heart including anxious thinking, breathing, emotions,
pressure sensors (baroreceptors) in the arteries, and other
physiological and behavioral changes (Lagos et al. 2008).
Anxiety is important especially in a sporting context and in
a team game such as basketball; it may be the determining
factor between winning and losing. Anxiety is highly
complex phenomenon acting within both the central ner-
vous system and autonomic nervous system (especially
cardiovascular and respiratory systems). It comprises of
two different components: State and Trait anxiety. State
anxiety is situational in nature, characterized by heightened
autonomic nervous system activity whereas trait anxiety is
a world view that an individual uses when coping with
situations in his or her environment (Spielberger 1966).
Dealing with anxiety is especially important for an
athlete, as an anxious athlete has trouble concentrating,
focusing and in decision making (Wilson and Pritchard
2005). This results in detrimental performance and they
seldom reach the desired result. Reduction in anxiety will
be facilitated if one’s self efficacy is reinforced as anxiety
is associated with low self efficacy (Nicholls et al. 2010).
Appl Psychophysiol Biofeedback (2012) 37:131–144
Self-efficacy is a powerful predictor for sports performance
which is associated with the perceived ability to cope with
fear or with anxiety-arousing events. Self-efficacy expec-
tations are beliefs that one can successfully organize and
execute the action required to produce particular outcomes
(Anyadubalu 2010). Different individuals have distinct
efficacy-related beliefs. One such belief refers to a person’s
ability to excogitate strategies that will assist him/her in
coping with various fears and stressors, which is referred to
as Coping Self Efficacy (Nicholls et al. 2010). Treating
anxiety will be more difficult when evaluation of self
efficacy is associated with poor results and self assessments
(Dehdari et al. 2008).
Basketball is a sport that requires great amount of physical
energy and does not solely rely on physical abilities for
performance success. For a basketball player to deliver a
winning performance there is a firm need to cultivate strong
psyche. In a game like basketball, where players often run up
and down the court, heart rate is driven by physical demands
on the court and also by their emotional intensity. Some-
times, even before they begin the competition, their heart rate
is unusually high. So the aim of athletic performance training
is to improve the cardiorespiratory efficiency thus, saving
cardiac and respiratory energy and helping athletes to train
according to their resonant frequency (Lagos et al. 2008).
The physical fitness of basketball players and, consequently,
game performance can be influenced by the balance in
autonomic nervous system.
Thus, the current study is an attempt to further explore
the effectiveness of HRV BFB on performance skills of
anxious basketball players.
Methodology
Participants and Study Design
Thirty basketball players (Male = 17, Female = 13)
ranging in age from 18 to 28 years (21.13 ± 2.82 years)
Fig. 1 Intergroup comparison of state and trait anxiety for experi-
mental, placebo and control groups
133
were recruited from Amritsar who met the following
inclusion criteria: (a) scored 20 and above on Spielberger
state trait anxiety inventory (STAI), (b) has not received
any kind of psychological intervention previously. There
was no known medical or psychiatric diagnoses reported
from the participants. The subjects represented a wide
range of skills from university (46.66%), state (20%) to
national (33.33%) standards. Ethical clearance was
obtained from the Institutional Ethics Committee of Fac-
ulty of Sports Medicine and Physiotherapy, Guru Nanak
Dev University, Amritsar, India.
The study was experimental in nature with double blind
study design.
The participants were randomly assigned into three
equal groups (N = 10):
1. Experimental Group received Heart rate variability
(HRV) biofeedback training (Male = 8, Female = 2;
Mean Age: 21.1 years; University: 0.4%; State: 0.2%;
National: 0.4%)
2. Placebo Group was shown motivational basketball
visual clips (Male = 2, Female = 8; Mean Age:
20.6 years; University: 0.2%; State: 0.3%; National:
0.5%)
3. Control Group (No Treatment) did not receive any
training (Male = 7, Female = 3; Mean Age:
21.7 years; University: 0.3%; State: 0.3%; National:
0.4%).
During the initial visit, players selected according to the
inclusion criteria completed an informed consent, a
demographic questionnaire, STAI and coping self efficacy
scale. After filling the questionnaires; dribbling, passing
and 3-min shooting tests were performed. Players were
then fitted with plethysmographic sensor on the finger and
abdominal strain gauge for baseline measures of HRV and
respiration rate respectively. The study was conducted at
the Sports Psychology Lab, Department of Sports Medicine
and Physiotherapy, Guru Nanak Dev University, Amritsar,
India.
Pre and post recording of the following measures were
done.
Psychological Measures
Anxiety was measured by STAI: It is an instrument used
for identifying anxiety in adults. This questionnaire con-
sists of two sets of 20 items each that are answered on a
4-point Likert scale. The first subscale measures state
anxiety, and the second measures trait anxiety. The test–
retest correlations for A- Trait scale ranges from 0.73 to
0.86 and 0.16 to 0.54 for A- State scale. The reliability
coefficient for A-trait ranges from 0.86 to 0.92 and 0.83 to
0.92 for A- state scale (Spielberger et al. 1970) (Fig. 1).
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Fig. 2 Intergroup comparison of self efficacy for experimental,
placebo and control groups
Self-Efficacy was measured by coping self-efficacy
scale (CSES): It is a 26-item measure, with three higher-
order dimensions: use problem-focused coping, stop
unpleasant emotions and thoughts, and get support from
family and friends. It is measured on 11-point scale, rating
the extent to which the participants feel that they can
perform behaviour important to effective coping. The
CSES assesses the athletes’ confidence with regard to their
coping strategies. Thus, a higher CSES score would sug-
gest that a person is more confident in his or her ability to
cope. The scale has adequate reliability with a Cronbach
alpha of 0.95 (Chesney et al. 2006) (Fig. 2).
Physiological Measures
Heart rate variability and respiration rate were measured
with the utilization of electrodes and a respiration strap
connected to an encoder. These measures were recorded
into a computer and analyzed by a specialized BFB soft-
ware program (Biograph Procomp Infiniti 5.0 Thought
technology Ltd., Canada) (Figs. 3 and 4).
Fig. 3 Intergroup comparison of total HRV, LF HRV and HF HRV
for experimental, placebo and control groups
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Appl Psychophysiol Biofeedback (2012) 37:131–144
Performance Measures (Fig. 5)
Dribbling Test
The dribbling test was part of the Harrison Basketball
Battery. It involves weaving in and around cones contin-
uously for 30 s while dribbling the ball. Each cone suc-
cessfully passed earned one point. The test–retest reliability
coefficient of battery is 0.95 (Barrow and McGee 1979).
Passing Test
The Stubbs’ Ball Handling Test was utilized. On a vertical
flat wall, three adjacent circles each one 30 cm in diameter
were drawn at a distance of 160 cm from each other. The
first circle was drawn at 151 cm above the floor, the second
at 121 cm, and the third circle at 136 cm above the floor.
The athlete stood behind a painted line located at 450 cm
away from the wall. On the verbal signal ‘‘Ready, … Go’’
the athlete threw the ball towards the first circle using a
chest pass, retrieved the ball and passed to the second
circle, retrieved the ball and passed to the third circle, then
retrieved the ball and passed to the second circle again,
then to the first, second, third, etc. The athlete continued
passing the ball to the three circles for 30 s consecutively.
Each bounce, either inside the painted circle or on its
perimeter, earns one point. According to Stubb, a validity
coefficient of 0.74 was achieved when the ratings were
correlated with best of two trials on the test (Barrow and
McGee 1979).
Shooting Test
A 3-min shooting test was used. The participant was asked
to execute as many shots as possible from any position on a
marked perimeter of 366 cm radius from the hoop for 90 s.
Fig. 4 Intergroup comparison of respiration rate for experimental,
placebo and control groups
Appl Psychophysiol Biofeedback (2012) 37:131–144 135

The participant was responsible for shooting and retrieving
the ball himself. Each successful shot earned one point.
Test–retest reliability has been reported at 0.91 (Weinberg
et al. 1991).
Protocol
variables on day one, day ten and 1 month follow-up along
with inter-group comparison Two-way Repeated Measure
ANOVA was used. Statistical significance was accepted at
p B 0.05. Tukey’s HSD post hoc comparison was con-
ducted to study the intergroup differences and to provide
specific information on associated variables (Table 1).

Group A: Experimental Group

The protocol designed by Lehrer et al. (2000) for HRV
BFB training was implemented with the participants. Fol-
lowing the pre-test measurements, the subject sat with
closed eyes in a chair for 5 min with hands resting on arm
rest in a peaceful room before commencement of HRV
biofeedback training. In the first session, the subject was
asked to breathe at variable respiratory rates for about
2 min each (6.5, 6, 5.5, 5, 4.5 breaths/minute) for deter-
mination of resonant frequency. A ‘‘pacing stimulus’’: a
light display that moved up and down on the computer
screen at the target respiratory rate was provided. The
subject was instructed to breathe at that particular rate of
stimulus. The resonant frequency was determined as the
maximum point in the peak amplitude signal of the reso-
nant frequency detection monitor on the biofeedback
equipment. The subject was then asked to breathe at his
resonant frequency and relax. The BFB sessions were
given for 10 consecutive days for 20 min each. Throughout
the training, the subject was instructed for natural shallow
breathing, to avoid hyperventilation, as can be provoked by
this technique. The feedback to the subject was given in the
form of beat-to-beat heart rate and respiratory rate on the
screen. In addition, the subject was taught breathing
through pursed lips abdominal procedure to elicit high
amplitude oscillations in heart rate at his resonant fre-
quency to achieve a relaxed state.
Results
Psychological Measures
The means and standard deviation for pre, post and follow
up state anxiety for the three groups is shown in Table 2.
Variation in state anxiety measured over time (i.e. pre, post
and follow up) was statistically significant in each group
along with interaction of group and time (F = 66.503,
p \ 0.001). The inter-group difference in state anxiety was
also statistically significant (F = 10.767, p \ 0.001).
However the post hoc analysis using Tukey’s-HSD
revealed statistically significant difference between group
1(Experimental) and 2(Placebo) and group 1 and 3(Con-
trol); whereas no significant difference was found between
group 2 and 3 (Table 2).
Similarly the means and SD for pre, post and follow up
trait anxiety for the three groups is shown in Table 3.
Variation in trait anxiety measured over time (i.e. pre, post
and follow up) was statistically significant in each group
along with interaction of group and time (F = 157.573,
p \ 0.001). The inter-group difference in trait anxiety was
statistically significant (F = 6.628, p \ 0.05). However
the post hoc analysis using Tukey’s-HSD revealed statis-
tically significant difference between group 1 and 2 and
group 1 and 3; whereas no significant difference was found
between group 2 and 3 (Table 3).

Group B: Placebo Group Table 1 Univariate ANOVA for pre experimental, placebo and no
treatment control group

Subjects were shown motivational basketball video clips Measures Pre

for 10 min daily for 10 days. Sum of squares df Mean square F

State anxiety 97.067 2 48.533 0.984NS

Group C: No Treatment Control Group
Trait anxiety 85.400 2 42.700 0.786NS
This group did not receive any training. Self efficacy 1,955.400 2 977.700 1.878NS
Players in all the three groups were allowed to continue Total HRV 731,752.958 2 365,876.479 1.045NS
with normal practice schedule. LF HRV 5,945.262 2 2,972.631 0.074NS
HF HRV 335,268.092 2 167,634.046 2.074NS
Respiration rate 2.651 2 1.326 0.337NS
Statistical Analyses Dribbling 471.800 2 235.900 3.628**
Passing 8.267 2 4.133 0.467NS
The data was statistically analysed using the Statistical Shooting 0.067 2 0.033 0.007NS
Package for Social Sciences (SPSS)/16.0 (Copyright NS
p [ 0.05: not significant; * p \ 0.001: highly significant;
SPSS Inc.). For examining the changes in the dependent ** p \ 0.05: significant

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Table 2 Showing state anxiety

Group Time of measurement
in three groups
Pre Post Follow up

1. Experimental 40.90 ± 7.66 21.40 ± 1.43 20.10 ± 1.28

2. Placebo 38.90 ± 5.95 38.70 ± 6.12 38.60 ± 6.15
3. Control 36.50 ± 7.33 36.40 ± 7.38 36.30 ± 7.34
Test of within subject effect
Source Sum of squares df Mean square F value p value

Two-way repeated measure ANOVA for state anxiety

Time 942.200 2 471.100 70.652 \0.001*
Time 9 group 1,773.733 4 443.433 66.503 \0.001*
Error 360.067 54 6.668
Test of between subject effect
Group 2,121.867 2 1,060.933 10.767 \0.001*
Error 2,660.533 27 98.538
Comparison Mean difference p value

Post hoc analysis

Group 1 versus 2 11.27 \0.001*
NS
p [ 0.05: not significant; Group 1 versus 3 8.93 \0.05**
* p \ 0.001: highly significant;
** p \ 0.05: significant Group 2 versus 3 2.33 0.639NS

The means and SD for pre, post and follow up coping
self efficacy for the three groups is shown in Table 4. Vari-
ation in coping self efficacy measured over time (i.e. pre, post
and follow up) was statistically significant in each group
along with interaction of group and time (F = 79.688,
p \ 0.001). The inter-group difference in coping self effi-
cacy was statistically non significant (F = 2.269, p =
0.123). Post hoc analysis using Tukey’s-HSD revealed sta-
tistically no significant difference between group 1 and 2,
group 1 and 3 and group 2 and 3 (Table 4).
Physiological Measures
Paced stimulus breathing in response to rhythmical simu-
lation of individual’s resonant frequency elicits high
amplitude heart rate oscillations during HRV BFB training.
When the participant breathes at or close to resonant fre-
quency, the respiratory component is most prominent.
Also, HRV and respiration are in phase with each other,
that is, heart rate increases with inhalation and decreases
with exhalation.
The means and SD for pre, post and follow up Total
HRV for the three groups is shown in Table 5. Variation in
Total HRV measured over time (i.e. pre, post and follow
up) was statistically significant in each group along with
interaction of group and time (F = 20.850, p \ 0.001).
The inter-group difference in Total HRV was statistically
significant (F = 6.610, p \ 0.05). However the post hoc
analysis using Tukey’s-HSD revealed statistically
significant difference between group 1 and 2 and group 1
and 3; whereas no significant difference was found between
group 2 and 3 (Table 5).
The means and SD for pre, post and follow up LF HRV
for the three groups is shown in Table 6. Variation in LF
HRV measured over time (i.e. pre, post and follow up) was
statistically significant in each group along with interaction
of group and time (F = 12.707, p \ 0.001). The inter-
group difference in LF HRV was statistically significant
(F = 6.969, p \ 0.05). However the post hoc analysis
using Tukey’s-HSD revealed statistically significant dif-
ference between group 1 and 2 and group 1 and 3; whereas
no significant difference was found between group 2 and 3
(Table 6).
High frequency HRV decreases after the BFB training
whereas it increases across the sessions. The means and SD
for pre, post and follow up HF HRV for the three groups is
shown in Table 7. Variation in HF HRV measured over
time (i.e. pre, post and follow up) was statistically signif-
icant in each group along with interaction of group and
time (F = 17.193, p \ 0.001). The inter-group difference
in LF HRV was also statistically significant (F = 6.176,
p \ 0.05). However the post hoc analysis using Tukey’s-
HSD revealed statistically significant difference between
group 1 and 2 and group 1 and 3; whereas no significant
difference was found between group 2 and 3 (Table 7).
The means and SD for pre, post and follow up Respi-
ration Rate for the three groups is shown in Table 8.
Variation in Respiration Rate measured over time (i.e. pre,

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Table 3 Showing trait anxiety

Group Time of measurement
in three groups
Pre Post Follow up

1. Experimental 45.30 ± 5.88 26.20 ± 2.89 25.40 ± 2.67

2. Placebo 41.30 ± 7.18 41.20 ± 7.13 41.10 ± 6.95
3. Control 42.40 ± 8.75 42.50 ± 8.84 42.40 ± 8.66
Test of within subject effect
Source Sum of squares df Mean square F value p value

Two-way repeated measure ANOVA for trait anxiety

Time 855.356 2 427.678 160.157 \0.001*
Time 9 group 1,683.111 4 420.778 157.573 \0.001*
Error 144.200 54 2.670
Test of between subject effect
Group 1,834.156 2 917.078 6.628 \0.05**
Error 3,735.800 27 138.363
Comparison Mean difference p value

Post hoc analysis

Group 1 versus 2 8.90 \0.05**
NS
p [ 0.05: not significant; Group 1 versus 3 10.13 \0.05**
* p \ 0.001: highly significant;
Group 2 versus 3 1.23 0.913NS
** p \ 0.05: significant

Table 4 Showing coping self

Group Time of measurement
efficacy in three groups
Pre Post Follow up

1. Experimental 176.30 ± 31.67 223.30 ± 24.74 224.80 ± 25.71

2. Placebo 195.80 ± 14.14 196.40 ± 14.11 196.30 ± 14.15
3. Control 188.90 ± 18.93 188.80 ± 18.91 188.80 ± 19.01
Test of within subject effect
Source Sum of squares df Mean square F value p value

Two-way repeated measure ANOVA for coping self efficacy

Time 5,166.022 2 2,583.011 81.943 \0.001*
Time 9 group 10,047.778 4 2,511.944 79.688 \0.001*
Error 1,702.200 54 31.522
Test of between subject effect
Group 5,694.689 2 2,847.344 2.269 0.123NS
Error 33,887.800 27 1,255.104
Comparison Mean difference p value

Post hoc analysis

Group 1 versus 2 11.97 0.403NS
NS
p [ 0.05: not significant; Group 1 versus 3 19.30 0.107NS
* p \ 0.001: highly significant;
** p \ 0.05: significant Group 2 versus 3 7.33 0.705NS

post and follow up) was statistically significant in each p \ 0.001). However the post hoc analysis using Tukey’s-
group along with interaction of group and time HSD revealed statistically significant difference between
(F = 202.989, p \ 0.001). The inter-group difference in group 1 and 2 and group 1 and 3; whereas no significant
Respiration Rate was statistically significant (F = 41.874, difference was found between group 2 and 3 (Table 8).

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Table 5 Showing total HRV in

Group Time of measurement
three groups
Pre Post Follow up

1. Experimental 808.89 ± 817.73 2,224.11 ± 1,624.81 2,287.21 ± 1,641.80

2. Placebo 760.10 ± 482.32 760.05 ± 482.04 760.17 ± 482.16
3. Control 455.89 ± 386.51 455.75 ± 386.68 455.88 ± 386.47
Test of within subject effect
Source Sum of squares df Mean square F value p value

Two-way repeated measure ANOVA for total HRV

Time 4,657,710.465 2 2,328,855.232 20.847 \0.001*
Time 9 group 9,316,509.147 4 2,329,127.287 20.850 \0.001*
Error 6,032,317.874 54 111,709.590
Test of between subject effect
Group 2.855E7 2 1.428E7 6.610 \0.05**
Error 5.832E7 27 2,159,910.664
Comparison Mean difference p value

Post hoc analysis

Group 1 versus 2 1,013.29 \0.05**
NS
p [ 0.05: not significant; Group 1 versus 3 1,317.56 \0.05**
* p \ 0.001: highly significant;
Group 2 versus 3 304.26 0.705NS
** p \ 0.05: significant

Table 6 Showing LF HRV in

Group Time of measurement
three groups
Pre Post Follow up

1. Experimental 253.40 ± 219.30 1,220.10 ± 1,010.92 1,263.41 ± 1,027.79

2. Placebo 277.98 ± 140.97 277.86 ± 141.00 277.97 ± 140.90
3. Control 244.75 ± 227.45 244.78 ± 227.15 244.78 ± 227.16
Test of within subject effect
Source Sum of squares df Mean square F value p value

Two-way repeated measure ANOVA for LF HRV

Time 2,173,803.014 2 1,086,901.507 12.706 \0.001*
Time 9 group 4,347,964.257 4 1,086,991.064 12.707 \0.001*
Error 4,619,404.576 54 85,544.529
Test of between subject effect
Group 8,491,253.184 2 4,245,626.592 6.969 \0.05**
Error 1.645E7 27 609,234.514
Comparison Mean difference p value

Post hoc analysis

Group 1 versus 2 634.36 \0.05**
NS
p [ 0.05: not significant;
Group 1 versus 3 667.53 \0.05**
* p \ 0.001: highly significant;
** p \ 0.05: significant Group 2 versus 3 33.16 0.985NS

Sport Performance Measures
The means and SD for pre, post and follow up dribbling for
the three groups is shown in Table 9. Variation in dribbling
measured over time (i.e. pre, post and follow up) was
statistically significant in each group along with interaction
of group and time (F = 20.444, p \ 0.001). The inter-
group difference in shooting was also statistically signifi-
cant (F = 14.181, p \ 0.001). The post hoc analysis using
Tukey’s-HSD revealed statistically significant difference

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Table 7 Showing HF HRV in

Group Time of measurement
three groups
Pre Post Follow up

1. Experimental 385.73 ± 463.24 669.29 ± 523.28 686.68 ± 534.86

2. Placebo 223.14 ± 113.76 222.89 ± 113.96 222.75 ± 113.92
3. Control 129.90 ± 122.29 129.88 ± 122.36 129.80 ± 122.12
Test of within subject effect
Source Sum of squares df Mean square F value p value

Two-way repeated measure ANOVA for HF HRV

Time 189,807.883 2 94,903.942 17.125 \0.001*
Time 9 group 381,115.324 4 95,278.831 17.193 \0.001*
Error 299,258.986 54 5,541.833
Test of between subject effect
Group 3,397,030.388 2 1,698,515.194 6.176 \0.05**
Error 7,425,026.910 27 275,000.997
Comparison Mean difference p value

Post hoc analysis

Group 1 versus 2 357.63 \0.05**
NS
p [ 0.05: not significant; Group 1 versus 3 450.70 \0.05**
* p \ 0.001: highly significant;
Group 2 versus 3 93.06 0.773NS
** p \ 0.05: significant

Table 8 Showing respiration

Group Time of measurement
rate in three groups
Pre Post Follow up

1. Experimental 15.30 ± 2.00 6.26 ± 0.26 6.00 ± 0.16

2. Placebo 15.23 ± 2.12 15.25 ± 2.09 15.33 ± 2.17
3. Control 14.64 ± 1.81 14.64 ± 1.75 14.83 ± 1.72
Test of within subject effect
Source Sum of squares df Mean square F value p value

Two-way repeated measure ANOVA for respiration rate

Time 180.741 2 90.370 192.734 \0.001*
Time 9 group 380.715 4 95.179 202.989 \0.001*
Error 25.320 54 .469
Test of between subject effect
Group 678.204 2 339.102 41.874 \0.001*
Error 218.651 27 8.098
Comparison Mean difference p value

Post hoc analysis

Group 1 versus 2 6.08 \0.001*
NS
p [ 0.05: not significant; Group 1 versus 3 5.51 \0.001*
* p \ 0.001: highly significant;
Group 2 versus 3 0.56 0.721NS
** p \ 0.05: significant

between group 1 and 2 and group 1 and 3; whereas no
significant difference was found between group 2 and 3
(Table 9).
The means and SD for pre, post and follow up passing
for the three groups is shown in Table 10. Variation in
passing measured over time (i.e. pre, post and follow up)
was statistically significant in each group along with
interaction of group and time (F = 115.739, p \ 0.001).
The inter-group difference in shooting was also statistically
significant (F = 9.860, p \ 0.001). However the post hoc

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140 Appl Psychophysiol Biofeedback (2012) 37:131–144

Table 9 Showing dribbling in

Group Time of measurement
three groups
Pre Post Follow up

1. Experimental 40.30 ± 10.75 50.40 ± 8.60 56.60 ± 8.24

2. Placebo 35.90 ± 6.35 37.00 ± 6.34 33.20 ± 12.40
3. Control 30.60 ± 6.25 32.60 ± 6.51 31.70 ± 6.12
Test of within subject effect
Source Sum of squares df Mean square F value p value

Two-way repeated measure ANOVA for dribbling

Time 436.200 2 218.100 17.587 \0.001*
Time 9 group 1,014.133 4 253.533 20.444 \0.001*
Error 669.667 54 12.401
Test of between subject effect
Group 5,076.267 2 2,538.133 14.181 \0.001*
Error 4,832.633 27 178.986
Comparison Mean difference p value

Post hoc analysis

Group 1 versus 2 13.73 \0.001*
NS
p [ 0.05: not significant; Group 1 versus 3 17.47 \0.001*
* p \ 0.001: highly significant;
Group 2 versus 3 3.73 0.534NS
** p \ 0.05: significant

Table 10 Showing passing in

Group Time of measurement
three groups
Pre Post Follow up

1. Experimental 9.40 ± 3.02 16.60 ± 2.27 22.10 ± 2.13

2. Placebo 9.60 ± 3.62 11.90 ± 3.75 10.80 ± 4.07
3. Control 10.60 ± 2.06 12.00 ± 2.35 11.90 ± 2.72
Test of within subject effect
Source Sum of squares df Mean square F value p value

Two-way repeated measure ANOVA for passing

Time 409.267 2 204.633 214.984 \0.001*
Time 9 group 440.667 4 110.167 115.739 \0.001*
Error 51.400 54 0.952
Test of between subject effect
Group 488.267 2 244.133 9.860 \0.001*
Error 668.500 27 24.759
Comparison Mean difference p value

Post hoc analysis

Group 1 versus 2 5.27 \0.001*
NS
p [ 0.05: not significant; Group 1 versus 3 4.53 \0.001*
* p \ 0.001: highly significant;
** p \ 0.05: significant Group 2 versus 3 0.73 0.837NS

analysis using Tukey’s-HSD revealed statistically signifi- The means and SD for the parameter of shooting at pre,
cant difference between group 1 and 2 and group 1 and 3; post and follow up for the three groups is shown in
whereas no significant difference was found between group Table 11. Variation in shooting measured over time (i.e.
2 and 3 (Table 10). pre, post and follow up) was statistically significant in each

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Appl Psychophysiol Biofeedback (2012) 37:131–144 141

Table 11 Showing shooting in

Group Time of measurement
three groups
Pre Post Follow up

1. Experimental 5.30 ± 2.66 10.80 ± 2.34 14.70 ± 2.90

2. Placebo 5.20 ± 1.68 6.70 ± 2.11 6.00 ± 1.82
3. Control 5.30 ± 2.00 5.80 ± 2.04 5.70 ± 2.16
Test of within subject effect
Source Sum of squares df Mean square F value p value

Two-way repeated measure ANOVA for shooting

Time 198.022 2 99.011 125.507 \0.001*
Time 9 group 260.711 4 65.178 82.620 \0.001*
Error 42.600 54 0.789
Test of between subject effect
Group 404.022 2 202.011 15.206 \0.001*
Error 358.700 27 13.285
Comparison Mean difference p value

Post hoc analysis

Group 1 versus 2 4.30 \0.001*
NS
p [ 0.05: not significant; Group 1 versus 3 4.67 \0.001*
* p \ 0.001: highly significant;
** p \ 0.05: significant Group 2 versus 3 0.37 0.920NS

group along with interaction of group and time
(F = 82.620, p \ 0.001). The inter-group difference in
shooting was statistically significant (F = 15.206,
p \ 0.001). However the post hoc analysis using Tukey’s-
HSD revealed statistically significant difference between
group 1 and 2 and group 1 and 3; whereas no significant
difference was found between group 2 and 3 (Table 11).
Discussion and Future Directions
The primary objective of the present study was to examine
the oppugn of heart rate variability biofeedback (HRV
BFB) as a stress coping tool. Application of biofeedback is
pragmatic in helping an individual modulate his/her emo-
tions. Biofeedback also monitors nervous system activation
level to ascertain psychophysiological readiness of the
body imperative for supreme performance (Jordanova and
Demerdzieva 2010). The results of the present study indi-
cate that the BFB group exhibited considerable reduction in
state and trait anxiety post training as compared to placebo
and no treatment control groups, this mitigation in psy-
chological stress effect persisted at 1 month follow up also.
The effect of reduction in anxiety could be attributed to
regulation and stimulation of baroreflexes by breathing at
one’s resonant frequency through HRV BFB technique.
The psychological states and processes can cause dra-
matic impact on autonomic control of the heart. Psycho-
logical stressors such as anxiety are often associated with
an increase in sympathetic cardiac control, decrease in
parasympathetic control, or both. Biofeedback induced
effects on HRV indices and respiration rate helps to mod-
erate the heightened sympathetic activity. Total and LF HRV
increased post training and at follow up whereas decrease in
HF HRV was observed post BFB training while it increased
across the sessions for experimental group. Statistically non
significant results were acknowledged for HRV parameters
and respiration rate in placebo and no treatment control
groups. The desired respiration rate of six breaths per minute
was achieved in the experimental group after biofeedback
training. The subject was trained to produce the smooth
sinusoidal wave form (RSA) in which respiration rate and
heart rate varies in phase with each other, that is, heart rate
rises with inhalation and decreases with exhalation. Findings
of physiological measures in the present study fortifies that
the cardiovascular system has the property of resonance at a
frequency near 0.1 Hz (six breaths per minute) consistent
with preliminary studies (Lagos et al. 2008; Lehrer et al.
2003, 2006; Hassett et al. 2007).
Breathing at or near resonance frequency help subjects
to change their tonic level of physiological arousal by
increasing HRV amplitude, hence directly resulting in
training and exercising the bodies’ own physiological
control mechanisms (Sutarto et al. 2010). The HRV BFB
training helps to restore the autonomic balance and
improves autonomic control that supports emotional regu-
lation and performance coordination (Lagos et al. 2008;
Lehrer et al. 2003). The high amplitude oscillations

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142
Fig. 5 Intergroup comparison of dribbling, passing and shooting for
experimental, placebo and control groups
stimulate and exercises autonomic reflexes, particularly the
baroreflexes, thus restoring and regulating the balance
between sympathetic and parasympathetic systems (Lehrer
et al. 2003).
Sport psychologists suggest that motivational sphere of an
athlete is a nucleus of his/her personality which should be
given equal importance. However, an athlete’s performance
suffers when their tension exceeds the capacity for maximal
functioning. The potential interaction of specific stress
responses like anxiety with performance has a debilitative
effect. Thus, it is important for athletes to be able to control
their anxiety to accomplish peak performance during train-
ing and competition. According to Humara (1999), athletes
who score high on self efficacy interpret their anxiety as
being facilitative instead of debilitative and they also achieve
success more easily. The significantly improved scores of
self efficacy suggest interesting finding as it indicates the
fostering of self confidence in subjects of the experimental
group. The potential interdependence between raised levels
of self efficacy and self confidence with ability to cope with
diverse threats and stressors may help the subject negate the
deteriorating consequences of anxiety. Thus according to
Anyadubalu (2010), it can be considered meaningful and
impulsive for regulation of motivation.
Nicholls et al. (2010) suggested that Coping self efficacy
beliefs undoubtedly put forth strong influences on situational
appraisals and the manner in which any personage retort to
these appraisals such as anxiety. The lowered state and trait
anxiety could be attributed to restructuring of cognitive
processes and lowered sympathetic arousal accomplished
through HRV BFB training. This finding is also concluded by
Dahlbeck and Lightsey (2008), who showed that high self
efficacy, predicts lower anxiety and better psychological
adjustment in an individual. Reduction in anxiety could also
be ascribed to the attention and importance given to the
subject during the HRV BFB procedure. During follow up
interactions, the subjects appeared to be emotionally com-
posed and felt greater control over their apprehensions.
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Appl Psychophysiol Biofeedback (2012) 37:131–144
Placebo group also demonstrated statistically significant
improvement in self efficacy due to visualization of moti-
vational basketball videos.
Within the last decade, biofeedback practitioners have
suggested that HRV BFB may be useful in increasing the
performance of wrestlers, dancers, baseball players and
golfers (Lagos et al. 2008; Raymond et al. 2005; Strack
2003). The improved sport performance in the experi-
mental group, as indicated by the findings of the present
study, could be attributed to the HRV BFB procedure
eliciting resonance in the cardiovascular system. The HRV
BFB training monitors autonomic nervous system homeo-
stasis and reflects a positive psycho physiological shift.
Basketball performance tests including dribbling and
passing were established to be statistically significant for
all the involved three groups post training. Shooting skill
was significant for experimental and placebo groups post
training while non significant for no treatment control
group. At 1 month follow up, significant results were
noticeable for experimental group for dribbling, passing
and shooting. Improvement in performance for placebo and
no treatment control groups could be due to the regular and
consistent practice of their game during the study period.
It is apparent from the findings of the present study that
HRV BFB training is a self regulatory intervention aimed
at reducing psychophysiological stressors resulting in
optimal performance. The cumulative effects of the psy-
chosocial processes directly target the elevated sympathetic
arousal, ultimately achieving the ‘‘flow state’’ of the mind
which is imperative for peak performance (Jordanova and
Demerdzieva 2010).
Future Directions
Different individuals gain knowledge of their specific game
skills at different pace, and thus some players may not
acquire and gain self-regulatory skills in ten sessions. Further
research is warranted to assess the effects of HRV BFB over
durations that would include more than ten sessions. Sec-
ondly, as individual biofeedback sessions were used in this
study, it would be helpful to investigate the effects of the
same intervention using group training sessions. The inter-
vention may be more practical to implement if athletes learn
the self-regulation skills in a group setting as it could be of
great help to players involved in team sports. Third, the
resonant frequency BFB procedure may be combined with
relaxation imagery intervention so as to generate physio-
logical and psychological domains more consistently and
extensively. Also, future studies may aim at exploring the
role of BFB relative to the advanced skills of the basketball
players like rebounding, moving with and without the ball,
position specific skills to bring into focus the necessary
transition in the performance of the player.
Appl Psychophysiol Biofeedback (2012) 37:131–144
Strength and Limitation of the Study
A major strength of the current study was inclusion of
placebo group to compare and evaluate the efficacy of
HRV BFB more specifically on the trained players. Pre-
vious studies which examined the effect of HRV BFB on
sport performance did not incorporate the placebo condi-
tions. Placebo group in this study helped in minimizing
possible Hawthorne effects. Further, potential threats to the
internal validity of the current study were addressed
through random distribution of players into three equal
groups. Inclusion of both male and female players with
skills ranging from university, state to national standards
ensures that findings are generalized for both gender and
different levels of the game. Recording of the tested
measures after a period of 1 month helped in the assess-
ment of long term effects of HRV BFB on sports perfor-
mance and predicted whether training effects remain
consistent over time. Limitation of the present study was
the small sample size and retrieving the ball himself/herself
during shooting test that might influence the player’s per-
formance during pre and post recording.
Conclusion
The existing study was sufficiently powered to examine the
effect of HRV BFB on performance skills of anxious
basketball players.
In spite of the limitations inherent in the present study,
the findings of the study suggest that cardiac variability
biofeedback (HRV BFB) training focalizes on simulating
physiological requirements with psychological thus, help-
ing athletes find their ‘‘zone of excellence’’. An interesting
finding which emerged from results of the present study
was the improvement in the construct of self efficacy after
the biofeedback training which was persistent even after a
month. This suggests the profound influence of biofeed-
back on psychosocial processes which may serve as an
index of sports performance. Thus, HRV BFB may serve as
a powerful strategy in the area of sports psychophysiology
for emotional and cognitive restructuring.
Continued research is required in the emerging field of
HRV BFB as it may be incorporated with physical training
to become an integral part of performance and rehabilita-
tion psychology in contemporary sports medicine.
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