[00:00:00] Speaker A: Welcome to the Heart Rate Variability Podcast. Each week we talk about heart rate variability and how it can be used to improve your overall health and wellness.
Please consider the information in this podcast for your informational use and not medical advice. Please see your medical provider to apply any of the strategies outlined in this episode. Heart Rate Variability Podcast is a production of Optimal LLC and Optimal HRV. Check us out at optimalhrv.com Please enjoy the show.
Welcome friends to the Heart Rate Variability Podcast. I am Matt Bennett and I am excited to be here with Dr. Jennifer Alderman and Dr. Nicholas Lackey. Nicholas is a friend of the show. He wasn't Dr. Nicholas last time he was here. So I know how much hard work goes into both your degrees. So congratulations. I know to both of you.
I read your article and started bugging you about recording an episode. I know it was public. I got, I got April. Late April is when it went online. I think it was published maybe in the summer edition of the APB Journal. But that means you were working on it for months before April.
And I just found, I read, I think almost every HRV article published out there, which didn't used to be like 10 a day and now it is.
But this was one that I feel the field, the field needed this article and that's why I was so excited. And we've had to reschedule a few times. But I wasn't going to let you all go without talking about it because I really think you hit on a key piece of where we're at in the heart rate variability mainstream journey and I loved your approach to this.
Dr. Lackey, you want to start out. I know you've been on the show before. I encourage people go back to that article. But just in case maybe our listeners didn't listen to that, I'll give you a chance to introduce yourself first.
[00:02:07] Speaker B: Of course. And as getting through grad school and new experiences, much has changed. So I am Dr. Nicholas Lackey. I'm currently a psychology postdoctoral resident at Kaiser up here in Northern California. Now I, I was at VA Loma Linda last year for my internship. So I will soon hopefully be licensed once I do all that fun stuff.
I am board certified in biofeedback. I had the opportunity to be able to do that already throughout my grad school. It's something I'm very clearly passionate about.
Our last podcast and my dissertation was more about central sensitivity and chronic pain and its relation to heart rate variability and just overall body kind of sensitivity. So we'll, we'll see where my career Takes me. But this is definitely going to be a central point that I hope the rest of my career takes, and hence why I'm back.
[00:02:55] Speaker A: I. I'm excited to watch it as well. It's kind of like the nice thing about being the old guy is, you know, we. We met, I think two, three years ago now at the AAPB conference. And it's just like, boy, this fellow nerd and I, you know, we use nerd as a compliment on this podcast and just a fun dude to hang out with as well. So I'm glad to have you back on the show. Dr. Alderman, welcome. First time on the show. I'd love to. Introduction of yourself and just kind of. I would love to. With that introduction.
How did you come to heart rate variability? When did this hit your radar? And I just love to learn a little bit more about kind of leading up to some really great publications.
[00:03:44] Speaker C: Absolutely. Yeah. I'm Dr. Jennifer Adelman. I am a resident physician, currently training at Sutter Roseville for my first year of residency, and then I'll be completing the rest of my physical medicine and rehabilitation training at Stanford.
I'm also a strength and conditioning specialist. So I've coached a lot of athletes and active individuals through strength classes. So I'm just really passionate about movement. My plan is to eventually specialize in sports medicine.
And so HRV was a technology that I kind of found more personally. Initially, I was using various devices, kind of trying to learn more about the technology, figure out how it could be applied for my own fitness, but then really realizing that, you know, this has a place outside of just fitness, this has a place across medicine. And really, I think it will continue to influence my career as a clinician, as a physician, but. But not just in sports medicine. Hopefully eventually across the board as well.
And so that was kind of how I found HRV mostly in medical school, was when I was exploring it, which is when Nick and I met, became friends, and decided to publish some papers together.
[00:04:53] Speaker A: That's awesome. So I'll just kind of throw this out. Either of you can take this one. But I love the idea of a narrative review.
It was something you don't see a lot, especially the heart rate variability, where it's like, we're looking at. We're looking at hrv. We're looking at an intervention control group kind of study. This was very, very different. So I'll just throw. How did this idea come up to approach this literature review in this narrative format?
[00:05:28] Speaker B: As with almost everything, it hadn't really been done well. Yet and so I, as we would have loved to have done more, maybe even do a full meta analysis or do a systematic review where we can really deep dive in the literature. But given the literature that was kind of there at the time, we did not know if that effort would have paid off as much for going that deep, especially given some of the methodological limitations and stuff like that.
We were glad. And one of the actual recommendations that we got from the reviewers is there had been a brief brand New end of 2024 if I'm remembering correctly. Just hey, let's re standardize everything HRV since I believe the last one before that was the 90s and so fantastic, great we can include that because as you're saying with this article, what ended up being a full call to the field of hey, let's start this more it can be used for at least let's ask the question where can it be useful?
That then is exactly the article we want other people to also read so they can be standardized. Say hey, this is where it has validity and this is where it doesn't. We can be more confident.
[00:06:40] Speaker C: Yeah, I think to add on to that, we, each field that we explored had a very different amount of papers and a very different amount of depth.
So that made a huge difference in you know, if we tried to do, you know, a very standardized meta analysis, we would not be able to do it with these, with the variability that's going on with all these papers. It was so heterogeneous. It, it just made a huge difference in how we would be able to analyze. And so even if we did a meta analysis, I don't think it would have worked. I don't think it would have been a good paper because we're just, I think the research isn't standardized enough, which we kind of talk about in the paper.
And so really the narrative review was the best way for us to kind of assess our. Where are we at when it comes to applying HRV across different healthcare fields and kind of being able to call out the differences in how much it's studied in one field or another without directly comparing them to each other, if that makes sense.
[00:07:39] Speaker A: Yeah, and one of the things that again, as somebody who obsessively reads HRV research, it's, it's an interesting thing how it's applied it and you know, with, with your, you know, you touched on this as well. There's five minute readings, there's 24, seven monitoring that there are all these different approaches and they lead to, I mean they're just different data too. And putting these pieces together, I mean, what I kind of like about HRV is it's kind of a new enough science. Whereas if you want to make a point that HRV is positive in some way, there's probably a article. Now whether it's a good article, whether there's a meta study is a different thing. But hey, if you want to show turmeric's impact on inflammation and hrv, probably there's something out there for it. So I'm curious as you, as you kind of go through this and you know, as you I know this kind of mirrors as your careers are kind of, you know, again, both of you newly minted doctors, you know, kind of how you kind of saw this across different fields and how they were using it.
[00:08:55] Speaker B: I personally wrote the psychology and psychiatry section, so I'll take that first. That is very evidently the hugest, largest amount of the HRV literature just because of the autonomics related to mood, flight, fight, freeze. Like that's just inherent and kind of there based on our perception. So like that I scratched the surface and did the best that I could. But really I was, I was quoting other reviews and meta analyses themselves unless there was something really specific when I was bringing up more the biofeedback stuff, which again is my bias.
But if anyone else did read kind of the paper that literature for maybe where HRV could be helpful, let alone clinical implications of biofeedback, just not even there.
Some fields were more of just the hey, this one specific diagnosis, which again very much get. We need a theoretical reason why HRV would be affected, while also why would HRV be a clinical indicator of said disease, let alone then asking the clinical improvement question. You really need to build that logic.
And so it just wasn't there for a lot. Clearly there was a little bit more in cardiology because the heart cardiology there and some of the foundational initial metrics of course came from cardiology and psychophysiology together.
And I know if I'm remembering correctly, there's still newer interest in pots that's ongoing, but specifically going into those other fields and other diagnoses, those haven't been explored as much yet. I'll let Jen talk a little bit more about critical care and things like that, given that medical side of the aisle and everything.
But the answer really was across the entire team that helped with this. There wasn't a lot of. And the methodology themselves, we heard our co authors get frustrated because it was just not standardized within even the Field of. Of, let's say, room cardiology, pulmonology, anything like that?
[00:10:57] Speaker C: Yeah, absolutely. I mean, I definitely had to hold Nick back from going too detailed on his psychology section because there simply is so much research there. And we know that. Right.
And definitely cardiology, you know, like you said, some very fundamental papers that really shaped hr, but there were definitely some other areas where there was less.
Interestingly, you know, there is one application actually of HRV that's really, like, already standardized, applied across the board. It's even taught in medical school, which I learned about.
And really that one area is infant health monitoring during labor. Right. So that is where we see it already integrated into health care. But really, in any other application, we're not applying it. We have plenty of patients throughout the hospital hooked up to telemetry, continuously monitoring their heart rate, continuously monitoring various measures, but HRV is absent from that.
And especially in critical care settings when, you know, every second can matter, every minute can matter. Right.
It would be helpful to have another tool that can maybe predict clinical deterioration before it happens. Right. That hemodynamic instability.
If we can detect that a few minutes in advance, even that sounds like a win.
There were definitely some really interesting papers talking about its application in critical care, especially in areas of the hospital that are already. Patients are already monitored on telemetry.
It could definitely be integrated into that technology already.
But also for chronic disease monitoring, there's a lot of diagnoses, like what Nick said with POTS and many other diagnoses, that we don't really have good monitoring established. Right. Some rheumatologic disorders as well. We kind of just wait for them to become a problem, and then we treat it in the moment. We treat the acute exacerbations.
And of course, there are chronic medications that people are on. But as far as a monitoring perspective, we just don't have a ton of options. Right. And so those are areas where, you know, I would almost suggest that hrv, we should really be not only studying it, but maybe even applying it, given that we just don't have much there to really support patients with these. With these diagnoses.
And in addition to the things like cardiovascular disease that we know, we'll see that with hrv, and we have a lot of other monitoring, but we could always add HRV on top of it. So lots of really, really interesting papers. But as far as teasing out, is it. Are we predicting prognosis? Are we predicting clinical deterioration? Are we predicting response to treatment? Progression of a disease, very variable, depending on the diagnosis and the papers varied a lot, even for one diagnosis. Lots of different answers.
We were really finding that our hands are still tied with some things, but hopefully we can start applying it more, getting more of that good research out and getting some of those answers.
[00:14:01] Speaker A: And Dr. Adelman, I. I'm curious about. About your kind of journey with this of, you know, being in the performance space there, really. And. And my background's in mental health. I. I was. I'll put an air quotes, because it was so long ago, an athlete at one point in my life, you know, so it's like, you know, in some ways, I mean, obviously, heart rate variability has been around for.
Well, it's been around since, you know, we.
[00:14:30] Speaker C: For a while, but for a long time.
[00:14:33] Speaker A: Hearts that are beating. But we've known about it for hundreds of years technically, but been studying it for decades now.
And then the. I'll call it the wellness slash performance space, not necessarily what I would call medical, kind of grabbed a hold of it, I think rightfully so. They saw, like, the potential even before my folks in mental health, I think, got there, per se. And so. But, you know, the wellness space is a very different space than the hospital, because I totally agree with you. If we're getting HRV data and we got a reason to hook somebody up, like, why aren't we paying attention to it? I think that's a brilliant point and just kind of like putting your two worlds together about how the wellness space is ahead of the curve in so many ways and we need medicine to catch up and just kind of how that experience has been holding both sides of that in your personal and professional experience.
[00:15:37] Speaker C: Absolutely. So that is one of the. One of my passions in my career is really bringing together the strength and conditioning world and the. In the sports medicine world kind of together. Right.
And especially being a coach myself, having worked with patients in that kind of a setting, work with clients in that setting, and then now on the other side, kind of on the medical side, it's interesting to kind of see how each group really sees HRV differently. And Nick and I actually published a different paper talking about HRV's applications in strength and conditioning specifically.
Not even sports medicine, but just strength and conditioning. Because HRV is really a technology that's being adapted for many different applications. And. And we were really trying to see how many of those applications are really researched thoroughly and how many of the claims that we're making about HRV from a. From a fitness perspective, how many of those are really backed by research just kind of evaluating what it looked like at that time. And there was definitely some interesting research. I mean, there was some. Were some good studies that showed that, you know, HRV guided training can be really helpful, where basically, you know, each day you would look at your HRV from overnight from one of these devices. You could see, you know, if my HRV is lower, you know, outside of like my window. So that would be like half a standard deviation below. There's a couple of different math equations you could use. But if it's outside of your normal window and it's too low, then you could do maybe a rest day or, you know, a lower intensity day compared to a day where your HRV is high or within your normal, then you could do a high or a moderate intensity training day. And there were some good studies that showed that that could be helpful. Again, very variable, lots of different athletes. This was applied to different sports, different training sessions. There was some heterogeneity in that literature as well.
But that is definitely a way that HRV is being applied in more of the strength and conditioning realm. But it's interesting to kind of see the intersection where it meets medicine because there's a lot of medical data that is protected.
And we were kind of realizing that this is medical data, but it's not technically claimed as such.
And so we are allowing lots of coaches have access to this data, lots of non medical providers have access to this data. What does that mean if we start making it more of a health metric and should that have the same data protections as other medical data? We found some really interesting things with that paper and really just trying to figure out, you know, what is within the scope of a strength and conditioning professional who is maybe seeing this data, what can they do with it compared to what a medical provider could do with it.
[00:18:27] Speaker A: Right.
And I'll still talk to cardiologists who. Oh, I think I remember learning about HRV in school like 20 years ago. Like, I, like Google it. Like, just Google it. You know, I'm not, you know, and then they come back to me and say, wow, I should be paying attention to this more. So it's just this. Yeah, it's kind of the Wild west, but with all this really hardcore science, we're not. Well, this is where I want to get to Nicholas here with this question. I want to say we're not making up this metric, but there is a gazillion readiness scores out there, if you want them, that aren't validated and aren't disclosed of how we figure these scores. And So I want Dr. Adelman to like me. I think Dr. Lackey is forced to like me because we're fellow nerds here. So. So I'll throw this. But Dr. Adelman, jump in here as well if you want to dive into this water.
So one of the things that I don't know what to do with is, you know, we published in this podcast this week in Heart rate Variability, where I think I probably catch most of the research published out there and then, you know, bring that into a condensed way where viewers can explore it in more or listeners can explore it in more detail.
You know, the, the one metric that keeps showing up is low frequency over high frequency. And this is where, this is where we get a little nerdy with it. There has been great articles, a great article published that we should not use that metric especially and say that it's a measure of sympathetic activation.
And I would say every third article I read, peer reviewed, has low frequency over high frequency as a sympathetic activation. And then, you know, being having a foot in the wellness space as well.
You know, one of the reasons I started a HRV company was what's a readiness score? And if I'm a clinician working with somebody who might self harm or relapse, I need to know how you're giving them data. And nobody, it was proprietary. So, you know, it speaks to kind of what you were saying about, you know, what are non medical people doing with this? And as a master's level clinician, I don't know what to do with it because you won't tell me how you figure it. So with that rant, Dr. Lackey, as you sort of did the deep dive and being in the mental health arena, and I know you did that for this paper, I'm curious, was it frustration? Was it curiosity?
As somebody I know wants good data? I'm just curious about your journey into this, you know, research.
[00:21:12] Speaker B: A heavy dose of pragmatism. Because I think with everything that Jen was even saying there about the medical side, there does need to be that heavy dose of pragmatism. The answer is we simply don't know right now.
And I don't think any of us can sit here and lie and say that everything is going to be helpful. No, there's going to be certain metrics, certain diagnoses, or even bringing up the cardiology example, there's a certain point when the heart's just freaking out because of another medical condition and HRV will be unreliable.
[00:21:40] Speaker A: Yeah.
[00:21:40] Speaker B: But right now we don't even know when and where that switch is within cardiology. Right. And that's the field, the medical field that studies the heart.
Getting back to just that LFHF and thinking about how the field communicates it. That's why already in the first few minutes of this podcast I brought up that other paper because however we can do to perpetuate the understanding of core HRV norms just like thinking even core understanding of statistics for why we have a replication crisis of things like the more we can make sure that we are doing the best that we can, the more the meta analyses we already talked about can also be more helpful and more valid because it's not just about the effect sizes. They also look at methodological quality, methodological rigor and even a lot of those are not as great as we would hope it is is pretty well known that like the the pharmacology studies for mental health medications, they're great because of their large sample size which means they have a higher methodological quality but the effect size is relatively similar. Right.
So the unfortunate answer is we don't know. I do think it is still very helpful with their HRV is at to be pragmatic and just like hey great we these associations so we can start continue to build that logic to clinical efficacy or delineating between different diagnoses and everything like that.
It was interesting when we were doing the study with Dr. De Blah.
That's his name, right? John, I believe I'm butchering it. Okay. Yeah.
He was a researcher back on the east coast that we were were doing. Jen was able to get a good relationship with him and he came on and him and I had a solid 30 minutes where Jen was just sitting there and him and I were going back and forth about just kind of some of those metrics. And he was also more in a similar thing of pragmatism of just like what is helpful right now, what is presenting with us good data that is still very helpful right now. I I hope within my lifetime we get that switch to well now we can be very specific. We know this HRV change is because of this diagnosis, not because the anxiety they also have on the inpatient unit, not because also they just got this medication. And now that's another complication to interpreting HRV at that point.
It's so much methodological that also going back to the like what epoch, what what time unit are we studying doing biofeedback. I can minimize it to the one hour and how I'm talking to them and being able to see the data on the screen. So that eliminates so many other variables that I, as a clinician, can then trust it.
I, I do see that as, as much as I want to be hopeful, and I am hopeful about it, we need to be honest about those limitations. And this is going to sound terrible for other medical providers, but like, putting even more on nurses for, okay, are there other behaviors and other things we need to be looking out for, somehow coding for so that, that way we can trust HRV in an inpatient setting. Right. That would be another thing. Like, midway through that literature, we'd also have to start controlling for or maybe even do that earlier so we can do more effective HRV ideology in those settings.
[00:25:04] Speaker C: Yeah, I mean, Nick is bringing up a really good point that, you know, HRV is very sensitive, but so nonspecific that in a medical setting with patients with many comorbidities all going on at the same time, you know, we have the, the congestive heart failure on, renal failure, on, you know, everything coming together.
You know, I think it is an incredible technology that I think we'll need to really fine tune to figure out the nuances. But I think from a provider perspective at this time, it's really hard to be able to say, you know, HRV alone is going to determine my clinical decision making. And which is why, you know, the, one of the great things about medicine is that we have lots of other measures too, right? So, you know, you can look at somebody's blood pressure and go, am I concerned about this blood pressure or am I not concerned about it? And then you could see maybe the blood pressure in combination with the heart rate and then in combination with the HRV and go, oh, like something is going on. Right.
So it really is just, we don't expect, I definitely don't expect that HRV is going to become a standalone measure that will give us any clinical decision making ability, but in parallel, and in addition to all of the other monitoring tools that we do have access to for chronic disease monitoring and on inpatient units, let's do it, let's use it. You know, but we do need better information to be able to really cite, you know, what does this mean? And how, how do I use this in a clinical setting? Like, if somebody had a stroke recently and they're in an inpatient unit, how do I use hrv? And then, you know, let's say it's weeks after they're in rehab, you know, now how do I use HRV after their stroke? What about six months after, you know, so really Trying to tease all of that out. We just need a lot more good information.
[00:27:03] Speaker A: Do you, I mean, as a medical doctor, you know, do you feel like, let's say you see heart rate variability, you get an alert that, let's say somebody's in the hospital and their heart rate variability has dropped 20% over the last three or four hours. I'm just kind of curious because your point is so incredibly just brilliant. Like we've got to take these things into account.
You know, I, I just assume that it's one marker and it may be a leading marker, it may be a lagging marker, depending on the condition. But it just seems like, you know, it's another piece of data in that environment that we've got to be paying attention to.
And if it's going, I always like, if it's dropping, ask the question why, you know, and that gets us part. But I just kind of like, do you think were. Or how do we get HRV on people's radar enough to say we need to include this in the data that you're looking at, you know, in, in the er, in the ICU or in a inpatient sort of setting?
[00:28:19] Speaker C: Absolutely. I mean, I'm not going to pretend like I will work in the ICU in the future. Yeah, I did my one month in residency. I will not be working in the ICU you ever again.
But you know, in that setting, it's, you know, often one to, hopefully one to one nurses, where there's one nurse per one patient.
And a lot of times, you know, these patients are under a lot of monitoring already.
If we could have the telemetry devices be able to communicate HRV to us, even if it's a leading measure, like you said, you know, if, if a nurse communicated to me, hey, you know, my patient's HRV went down by this much, I'm noticing it. You know, maybe I'm in, in addition to that, I'm noticing some, you know, changes in mental status or maybe in addition to that, I'm noticing, you know, their blood pressure is kind of going down. Right. It's, it's always the, all those measures together. Whenever I get like a piece of information, if I'm, you know, in a different area of the hospital and somebody communicates to me, you know, somebody's blood pressure went down, I'm not just going to say, you know, let's give them fluids or let's put them on pressers or we're going to, you know, give them this really hardcore medication to, to fix it. I'm always going to go, well, what else is happening? Right? Like, did they just sit up from laying down for a while? Like, what? Give me more, more information. I can't, you know, I want more of the vitals. I want, I want more information. I can't make a clinical decision based on only one value, and I think it should always come back to that. And in an inpatient unit, there's less monitoring outside of the icu. So I don't know exactly what the nursing ratios are. Varies dramatically depending on where you're at.
Usually it's not as good as it could be, but with that aside, you know, there's less monitoring. Some patients are on telemetry continuously, so they're getting that continuous monitoring, but other patients are not on telemetry at all.
So then we just kind of have to figure out, you know, how, depending on what that patient's diagnosis is, you know, what kind of monitoring is necessary for them and then what information in addition to HRV gives us the full picture.
So, for example, like a patient with a neurological injury, like a stroke or spinal cord injury, something like that, maybe the other information, the other metrics I need to leverage are different than somebody who had a heart attack. You know, maybe those measures are going to be different. We really have to tease out, you know, how, how we use HRV not just standalone, but all the other metrics that are best used in combination.
[00:30:52] Speaker B: Yeah.
[00:30:53] Speaker A: Dr. Lackey, let's put that sort of thinking on psychology, psychiatry, because, I mean, a little bit different situation. I mean, you can be an inpatient psychiatric treatment, you know, that, that's. But outside that realm, somebody in an outpatient situation, what do you, you know, what do you think we should be doing? What could we be doing?
Do we hit the same thing as SDNN is going this way, RMSSD is going this way, but not quite as much, and then High Frequency is doing its thing as well. You know, do we hit some of the same issues?
Could hrv? I kind of see it. It gives us a warning sign potentially, but I'd love to get as people are trying to use it for diagnosing.
I don't think were there yet, and I don't think many authors and researchers would say we're there. You know, just kind of what you kind of see with all these different metrics out there and maybe any best practices in that arena.
[00:32:01] Speaker B: Best practices, I would argue, are still just like we actually recommend in strength and conditioning, like, what's your baseline and what's that fluctuation there is still just like too much about perception. How are you integrating like there's some of the newer literature on looking at HRV and racial discrimination and experiences over time and those are some very large numbers. We're having some good correlations and other things like that. But we just need to nest that in context too of like how is their day like earlier. But there's not really good ways to measure and or do that. Right. So that's why I talked about that clinical context earlier. Again with using biofeedback. I know I have that hour. I can check in with them in that first five to 10 minutes of how they're doing. Does that perception line up with how their HRV was maybe the last appointment or other things like that. Then as you continue to talk about other things or maybe even as you're practicing the resonance frequency, how are kind of things changing and going? Yes, always disclaimer. You cannot interpret HRV when they're doing resonance frequency breathing. And yet still it's that checking in. And what is their perception matching up with what their body is telling them? Right.
Our brain does so many amazing things but then that inherently makes it that much more difficult to study and quantify. And specifically, specifically say it's this thing and not that thing. Is the ANS at that point responding to the physical physio physiological thing rather than the psychological thing that's affecting the physio and however that relationship goes around. Right.
It is a hard question.
So it from a clinical psych perspective, definitely always nest it in, in patient perception and what they're telling you just as much as what the data is telling you. Right. There are two side of a individual's experience story and what's going on.
And it's just we need to fill, we need to fill in more holes. I want more of our holes in our logic kind of filled in. We're never going to be perfect.
We could go philosophical right there. We're never going to be perfect. We cannot understand everything in the universe as much as we want to. And so it really is. That's why again I said earlier that like pragmatic side of the aisle, my research brain can go a million miles a minute. But that's not helpful for the patient, the individual in front of you that you need to nest that data within to help them.
[00:34:25] Speaker C: I think that's what was really cool about us doing a narrative review rather than a different kind of paper. It really just allowed us to, to have that time to really investigate each of these different areas of Health care and really kind of evaluate, like, where are we and how much work do we need to do in each of these settings?
[00:34:44] Speaker A: Yeah. And then. Then it's always the hard thing, I think the point. And this is where, you know, as somebody who's lucky enough to be fairly healthy, I usually get my vital signs taken and my blood drawn once a year, and I'm fortunate to have that. What the heck does that say?
It probably says more about what I ate in the last 24 hours. I remember I went, unfortunately, to a Nepalese buffet before one of my annual blood draws. And it wasn't pretty. Like, it kind of wrecked some stuff. But, you know, so I got retaken a few days later and, you know, I was back to normal. Normal, you know, so it's just this interesting thing. And all these hr, not all HRV studies, but so many of them. You go into a lab, you take a baseline. Yeah. What's that? I mean, tells you a snapshot of that. And you may have had the worst day of your. Your worst night's sleep of the last three months the night before. And then how's that influence the results of whatever we're trying to measure too? Which is a frustrating thing about this and why I think, you know, baselines over time are probably our best bet, whether it's performance, whether it's. I love the part on chronic disease management because I think it's so key to that is we. We need those. You know, whether you.
You got the aura ring or whoop, that takes it at night, or you put it something on in the morning to take it. That. That regular measurement is, I think, where the gold lies now.
Because I have more confidence than that, than pretty much anything else at this point.
[00:36:24] Speaker C: Absolutely. I mean, we just don't have a lot of other options. And continuous monitoring of many different metrics are really becoming more popular now. I mean, we have continuous glucose monitors that people are wearing even though they don't have diabetes. Right. So this continuous monitoring is really becoming much more popular nowadays. And I think there's a. There's a good point to it. Right. Even with glucose, if you get it measured once a year, you know, for most people, that's probably fine until something is wrong. Right. And it's so dependent. You know, even your A1C is dependent only on the last three months. Right. So even that one is like, okay, that's. That's a one measure of three months. What about before that? What about after? You know, and. And really being able to look at, like, continuous Measurements are really the key. It's cool that a lot of these devices also share other metrics. So talking about like resting heart rate, heart rate, recovery after, like a high intensity effort. Like, there's other really cool metrics that we can be detecting with these, with these monitors, which is great.
But hrv, like you said, is unfortunately behind the proprietary algorithm of whatever device you're using. And so, you know, we don't have full access to how these things are calculated.
But you know, really, like you said, I mean, we know of a, we call it white coat hypertension when a patient comes in and they have hypertension only when they're in the office. Right. Like that is a thing. It is real.
And so we have to have an understanding of, you know, okay, we'll give you five minutes, you know, chill out a little bit and then we'll check it again. If it's still high, we'll say go check it at home, you know, and if it's normal at home, we're not going to treat it. Right. So at least for most people. So, you know, it's, it's interesting. I think if we understand that that's how it is with, you know, blood pressure, for example, like, we could imagine that heart rate variability could give us a better measure of, you know, that over the last year, how has your health been right. Like, let's look at trends a little bit better rather than like that once a year marker, you know, And I think it would just give us some.
[00:38:36] Speaker B: Really great insight and to just validate that more. Thinking about the chronic pain side of the aisle is just because there may be damage in one sense or another doesn't mean they have chronic pain.
[00:38:47] Speaker A: Right.
[00:38:48] Speaker B: I'm gonna butcher the numbers. I don't fully remember the exact numbers of the study, but there was a big study that came out a little while ago looking at scans of the spine and thinking about how many normal people at like 50, 60, 70 actually had a damage of the spine. And, and like 60, 70% did, and way less than that actually complained of pain. Yeah. So with that ideology, it really comes down to, and I'm going to sum up both with what you both said is if I'm remembering correctly from my methodology class, it's the demand characteristics of what is the situation presenting in our perception. Just like Jen said with the white coats, just like you, Matt, were saying earlier, with what else was going on in their day, did they have a stomach bug or something else? Right. Like those demand characteristics matter and need to be nested in the interpretation of what's going on. And that's part of why the resting HRV is so helpful or the, the nighttime HRV so helpful, because what else are we doing? Our body is at least sleeping, regardless of stage of sleep. That may or may not affect hrv. And like we can control for so many other things without needing to be a self report of our own brain supposedly interpreting something accurately about our bod.
[00:40:00] Speaker A: Yeah, absolutely. And I find it fascinating too. We kind of talk about this 25. I think a lot of people who wear, you know, the 247 wearables think that their HRV is being monitored 24, 7. And you can do that, you know, but. And I think it sounds like if I'm reading the research right, certain heart conditions, things like pots, for example, there may be like ultra low frequency might be something that is going to be useful. But I think for most people, you know, you're just going to get a lot of artifact throughout the day and it's going to be meaningless. So it's, you know, all this stuff. And I, I see a lot of research out there for people who haven't thought this deeply about some of this stuff. And it's like, oh, I just, you know, we measured HRV during, you know, a tennis match. Well, okay, yeah.
[00:41:01] Speaker C: You're monitoring on their wrists.
[00:41:02] Speaker A: Yeah.
[00:41:03] Speaker B: Like, let alone just what parasympathetic activity is going to be there when your body's actively responding to stimulus that are activating the body. Why are you trying. That does not make sense. There's a relaxation response, maybe at certain moments, but not consistently.
[00:41:20] Speaker A: Yeah, exactly.
[00:41:22] Speaker C: For us to really explore with the strength and conditioning paper too is we kind of talked about, you know, different metrics that are better for different situations. Like heart rate recovery is such a good dynamic measurement of recovery from a highly sympathetic activity, from a highly exhaustive activity. And it's not really used all that often, but I mean, it's a great metric. And so, you know, getting the HRV side from a more parasympathetic perspective and then getting the heart rate recovery from that recovery from sympathetic. Like you have more of a complete picture.
[00:41:59] Speaker A: Yeah, I love that. So I always like to wrap up and I'm going to give a little bit more of a Runway for us because I really think we've already kind of set this.
Usually my final question, but I'm sure it'll lead to some more is, so let's say five years from now I go the Adam and lab at Stanford NIH just gives You a billion dollars to fix this.
You know, we've got AI, which I think a lot of our frustrations. I wonder if SDNN tells us something that rmssd. I've never got a great answer to that question. And is it even worth, is even worth asking? Because I don't know, like so. But let's just say, you know, you got a billion dollars, you got your lab at Stanford.
I'm curious what you would like to do.
Let's just say you have 100 staff working for you. So, so you can really be ambitious with this to, to address some of these issues that you see. Where would you think using these, this, these resources, the money, the staff, the opportunity, where would you start to fill in some of the gaps you found through the narrative?
[00:43:20] Speaker C: Absolutely. I think we really need more prospective studies. We have a lot of retrospective studies and a lot of them are not randomized completely. So we need to start there. Let's just get some good prospective, randomized studies really isolating HRV as a measure initially for each of the diagnoses that we talked about. You know, some being chronic, some being acute, some being acute on chronic. You know, lots of variety in the, in the diagnosis that we talk about across different specialties.
And if we can really get, figure out what measure of HRV is best applied for that scenario for that diagnosis, is it best measured in an inpatient setting, in an outpatient setting, in both. And then figuring out how do we apply HRV with other clinical measures in these clinical settings when there are other things going on and understanding how, you know, really giving providers the confidence that they can use heart rate variability to give them some meaningful clinical information that they can then make a clinical decision based off of, not just like, oh my, you know, the patient's HRV went down, what am I going to do with that information and helping really provide that confidence for providers to then utilize HRV in all of these different settings for all these different diagnoses. So I would just be pumping out paper after paper with big, big sample sizes and really just getting some good information kind of across the board.
[00:44:54] Speaker A: Love it. Okay, so now let's visit the Lackey Center. Like, what are we, what are we going to be? You get, you get the other part of that big billion dollar grant. You'd probably be surrounded by 18 screens at that point, I'm sure. But what, what would you like to be, what would you use that money for to start, you know, plugging some of these holes and, and pushing the research forward?
[00:45:20] Speaker B: I mean, I, I Honestly think rather similarly. I know we talked during the last time I was here. Is in chronic pain even like HRV is a general measure. So no matter if somebody's got fibromyalgia, CRPs, they're coming in with a lot of severe arthritis pain whatever it may be. Well the body's responding to that threat. So HRV is going to be decreased no matter what you do. Right. It's a little bit less specific there. I think if we could I might actually go a little bit larger than where Jen went. Right there is.
[00:45:51] Speaker C: I do think it's hard to do.
[00:45:53] Speaker B: I do think that that the retrospective right now if we had a big enough data set from a large hospital system that was effectively coded. Right.
Like trauma surgery centers need to code all of their cases to make sure that they're meeting standards that they've done everything. So that's some would be some very good reliable data if they were also looking at hrv. I think that could actually be a very helpful if they were all measuring hrv. Big caveat. But that could be a very big thing there of just are there any big data ideologies of HRV could be helpful to then spawn further supplemental research. Now that's a very big health psych side of the aisle. Otherwise as always very pragmatic. What other diagnoses and conditions could biofeedback be helpful with?
There is the rather large study that I overtly wanted to put in this paper and I did of biofeedback helping with dropout rates with trauma treatment. That is such a huge deal with such a high dropout rate for from trauma treatment that the fact that biofeedback just reduced the amount of dropout and was just similar symptom reduction or I think maybe a little more. I'd have to reread that article but. But the fact that it's having that big of an effect just doing our small adjunct biofeedback to help with their autonomic regulation. Fantastic and great. I I am hopeful. I I would want to add spaces like that where. Where can this thing because the body's going to respond to stimuli. We're going to be stressed out. Is giving more tools that calm down the physiology to also help calm down the psychology of everything going on. Where else is that helpful in the medical setting to then also help people's patient outcomes. Just that's it. How do we help people? Because that's hopefully what this is all about at the end of the day. Right.
[00:47:40] Speaker A: Yep. And I'm curious Dr. Lackey I want to also come to you, Dr. Adelman as well.
HRV bio. It's another whole interesting thing with swimming in the research because we've sort of been talking about HRV metrics.
5 minute, 3 minute, you know, RMSSD, breathing normal.
And then there's like something that's so related yet so separate. And you know, I love how you speak about this because you, you bring them a little bit together. But I think a lot of people who use HRV as a metric in their studies, especially if they are measuring a couple different things, I don't even know if they know HRV biofeedback exists out there. And kind of technically, if you take, if you look at your overnight HRV score, you're getting some biofeedback there. But I know we're talking about meaning, so I Wonder, you know, Dr. Lackey, is there any room for integration there or do you just think these two fields will develop kind of independently moving forward?
[00:48:55] Speaker B: I would bet independently at first. I do think in the conditions where, yeah, there is a clear difference between disease progression and changes in hrv, we could then jump in with biofeedback and say, does that help with regulating the body? But as we kind of said all along too, it needs to be a condition that's, that's could be helped by that. Or maybe it just has a lot of comorbid anxiety and depression and we can help treat that with the hrv so they can then focus on the other medical care. Right.
I, I am not about to say and set up on a high hill with commandments saying that biofeedback or HRV are going to cure diseases. Absolutely not. And I, as much as that would be cool, that's just not reasonable or pragmatic. HRV is detecting, helping to not only yourself but our modern science understand, hey, something is up. Whatever that is perception, something wrong with the body just changes the temperature even. Right. Like it is the integration system that we are just able to interact with without it being actual neural signals in the brain. Yeah. And so I want them to be closer together. But just like I was explaining earlier with the like methodological jumps that we kind of need, we kind of need the HRV first. Unless we have that theoretical reason why this disease is very autonomically regulated. We now believe that given whatever other things, let's already jump in with the biofeedback as an adjunct and we can also, through doing that, get the HRV metrics at the same time. But I really do think for most conditions or Other fields in general, it's going to need to be the HRV first so we can say ah, there's a perception difference. There's something in the body that's being picked up to give us that HRV difference. To then connect the. Maybe biofeedback or something about it could be helpful because although I'm talking about HRV biofeedback, you bring up the good point. All of it in some respects is kind of the biofeedback. That's why we also do temperature, we do emg, neurofeedbacks. Its own separate rabbit hole I will not touch. But still it's all elements of getting feedback from the biology that's going on that we may not always be aware of or as sensitive to and feeding it back so our brains can integrate it whether conscious or not.
[00:51:12] Speaker A: I love it. Dr. Adelman, we'll. We'll kind of wrap up. I haven't talked much about the biofeedback but I know in the performance space it is there as well. I'm just curious, you know, sort of your experience with, with that side of it.
I just love to out of curiosity kind of know how that sort of maybe inform of your work or thinking as well.
[00:51:37] Speaker C: Yeah. You know, I would say this is definitely more Nick's wheelhouse than it is mine. More of my time learning about HRV was spent as a metric and really most of the things that I've learned were kind of along the way with crafting this paper as well as learning from Nick himself because this is definitely an area that he's incredibly knowledgeable about and I'm just kind of only on the edge of it. So I can't really speak much to how it's. It's applied more in like a sports performance realm because I haven't been exposed to it as much.
[00:52:09] Speaker A: Yeah, I just think it's an interesting space that does not overlap. I even see biofeedback research that doesn't necessarily measure HRV as a metric sometimes too, you know, and in the psychiatry psychology space, I think the most, the two most powerful probably over the last three months research I've seen is there's indication that HRV biofeedback could and I'm using could may we need the next step of research be a standalone treatment for things like trauma and substance use. Now I'm not there to say it is but there's some really well done research too that just shows as palfrey care I'm still in the place case it's the ideal homework But I also think it's probably the ideal homework for everybody.
You know, whether your performance brings you into this or mental health issues or chronic disease, it seems like a regulated autonomic nervous system is pretty important.
[00:53:16] Speaker B: So it's for, for anybody listening to this podcast that is aiming to become a licensed psychologist and or has taken the EPPP in the past, you. It sounds as if you're kind of basically just calling out how we conceptualize humans and people and perception and our level of awareness. So matter what kind of theoretical theory, what from psychology, psychiatry or whatever of how we conceptualize the mind, it goes back to this idea. How aware are you and how engaged are you in your life from whatever perspective, conscious, unconscious, all the way back from Freudian to modern cbt of just what's going on and being able to think and integrate and not have automatic reactions to our experiences. Right. It's another tool to get in there, no matter what theory you're coming at it from. And I think that's what's kind of shining through and everyone's guilty of it, but these things incentivize really being disconnected. And so.
Wow, this is an interesting research question you have just brought up in my brain. I wonder if there would be an interesting difference between if we took somebody from 50 or 60 years ago, like a 30 year old, from 50 or 60 years ago to a 30 year old now, would there be a difference in their base kind of level of awareness? It'd be very subjective, but still just given of are people more or less connected in that way and then relate that to are they perceiving some of those differences in that anxiety and that HRV in their body?
[00:54:44] Speaker A: Well, it sounds like a great next episode once we publish that paper. So I love it. Dr. Adelman, it's such a pleasure to have you on the show, Dr. Lackey.
Yeah, it's just great to have you back.
[00:54:59] Speaker B: So I'm sure I'll be back when I can get more engaged with the lab at some point in the future.
[00:55:05] Speaker A: There we go. We just need all that billion in funding to solve all these problems. So I appreciate you. We'll link to the article.
I'll get the links to the previous article as well, if that, that's available for folks too.
It's a must read.
Like I said, I, I like Nick somewhat just for me and him.
I was like, you know, and he does really good work. And I was like, oh, he's got a good partner with this one. Because this is, it was just such an important piece of research that it's just desperately it almost needs needed probably every three months with the amount of research that's coming out. So I want to thank you both for, you know, the brilliance to pick this approach and to give this gift to to all of us out there. So thank you both very much.
[00:55:58] Speaker C: Thank you so much. Matt. It was great to be here. Very nice to meet you.
Hopefully I'll be back eventually too but you know it'll take a little bit of time in my training to to be out there publishing more papers.
[00:56:09] Speaker A: Well, we'll come we'll get to the Adelman center at Stanford soon enough or wherever it's located. I know Stanford just might be a stop along the way so but thank you. I appreciate you both and as always you can find show notes, resources, more information about our
[email protected] thanks everybody so much and as always we will see you soon.
