[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
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[00:00:32] Speaker B: Welcome, friends, to the Heart Rate Variability podcast. I'm Matt Bennett. I'm very excited because if you're not familiar, March is traumatic brain injury month, and I've been looking for a great guest to recognize this month. It's been such a powerful thing for me and my work, learning about traumatic brain injuries, concussions over the years. And if I were to pick one guest in the world to interview about this topic, Dr. Richard Gervertz would be my number one choice, and I am so fortunate to invite him back to the show. So, Dr. Gilbert, welcome back.
Maybe a quick introduction because I believe this is the third time you're on the episode. So I would just encourage our guests to go back to past episodes because they're all really some of the best we've recorded. So maybe a quick introduction. And I would love to just start out with the question of what got you interested in the idea of looking at heart rate variability, especially the biofeedback and concussions.
[00:01:42] Speaker C: Well, we know it's a big problem, and we know that the rehabilitation literature is kind of not very good.
I started with a number of my students wanting to look at concussions and athletes, and one of my former students is kind of the leading neuropsychologist in San Diego, dealing with, especially kids and teenagers head injuries.
And all along, we've noticed and literature has noticed that these folks, along with other problems, seem to have very low normal heart rate variability. Their resting levels are low.
And now there's an increasing literature that the autonomic nervous system is definitely involved in brain injury.
So as more and more we learn about the central autonomic system, Sayer and Lane's idea that the frontal areas of the brain and the peripheral nervous system are intimately related, the more we see that this is happening. So one of my students, Jason Liu, was very interested in this problem.
He's from Taiwan, and it turns out there's a lot of motor vehicle accidents with head injury in Taiwan. So it's a little bit different population than we're used to here from military.
But he was very insistent on trying to use heart rate variability, which worked for a lot of stuff. See how it would go.
Literature was a bit sparse, but it gave us some hope that maybe there was something that Sonia Kim in New York and Leo Lagos in Florida had done a little bit of work without much control. And so we thought it was a promising area to try.
And so Jason wanted to do it, and I said, OK, let's go for it.
[00:03:44] Speaker B: Awesome. And what a gift it was to us. Interested in this to one of the things that I think I struggled with initially, and you spoke to it a little bit, but as someone who has been an athlete and then has hit my head a few times, snowboarding and adulthood, I've racked up a number of concussions over the years, unfortunately. And back when I was young, when we played soccer, I probably hit the soccer ball thousands of times with my head that I wish I could take some of those back.
But when you think about a hit to the head and heart rate variability, in many ways, those two systems seem kind of so far apart in our traditional thinking about the connection between our heartbeat and a hit to the head. And I wonder if you could just help us kind of connect how something like controlling our breathing could help heal injuries to the brain.
[00:04:56] Speaker C: Yeah, it was a bit of a stretch for us to begin with as well, but we know from the MRI data that especially the mild traumatic brain injury doesn't really show up in an MRI. Basically, it's a shearing injury, where the brain kind of gets smooshed and then unsmooshed from the concussion, and it doesn't really show up in much of anything in an MRI. However, a number of people have noticed that that shearing industry injury probably has some effect on connections between the periphery and the brain itself.
And so it turns out that it shows up not because of affecting the heart directly, just because the heart rate variability is reflecting that central autonomic nervous system. It shows up in low autonomic function. And, of course, a number of the symptoms also, especially in those who don't heal very quickly, seem to have strong autonomic components as well. So it's a little bit non intuitive, but there is some literature that kind of connects those two systems and pretty strong literature that autonomic nervous system is affected, especially in those who are going on to have more severe injuries. We're just finishing another study right now with the military looking at those people who had concussive events, who didn't heal easily in a few months, and they definitely have lower heart rate variability than the group that did heal.
As well as some other indicators like the cicadic eye movements are abnormally. The variability is abnormal. So we're picking up on some kind of an offshoot of what's going on in the brain.
And that was the first step. Then, of course, then it's a push to say, well, how would heart rate variability biofeedback help that?
[00:06:56] Speaker B: Yeah.
[00:06:57] Speaker C: And so we weren't sure, but there was a little bit of suggestive evidence.
Now, we know from the Mara Mather group studies at USC that we're really having a pretty powerful effect on brain function networks when we do Harvey variability biofeedback on a regular basis.
So I don't know if you've gone over that data on your podcast, but it's very powerful.
[00:07:24] Speaker B: Not, not yet. This would be the first time we'd be touching on that. So I'd love for you to share any insight maybe you've gathered from that.
[00:07:31] Speaker C: Well, so Julian Thayer and a very noted neuroscientist and Mara Mather at university of southern California. After years of us, we know them very well, and after years of us talking about biofeedback, they decided actually maybe there was something to this, doing lots of other research.
So Mara got a big grant and did a very amazing controlled trial using hardware. Variability biofeedback really kind of the minimal conditions for the feedback just using a PPG. But she had an ingenious control group that basically was told to do sort of lower their variability and lower their heart rate. She calls it oscillation negative. And that group believed, they believed they were the experimental group because it made more sense to them.
[00:08:27] Speaker B: That's a sign of a great researcher.
[00:08:31] Speaker C: Yeah. So it's by far the best. I mean, we've used EMG facial feedback as a control that works pretty well too. But this one was amazing. So basically what she showed in a whole number of publications, and I urge your listeners to look it up. M A t h E R. Mather is a lab, and there's a bunch of other authors.
She showed that regular practice over the course of about five, six weeks of HRV biofeedback had a really powerful effect on the left amygdala, right frontal lobe affect arousal network. And the control group showed none of this at all. And actually, the other side of the right amygdala to the left frontal lobe did not show this at all either, which is exactly the pathway we're interested in. So we know that what seemed to be corrected by HRV biofeedback is some powerful rekindling of the wiring between the amygdala and the inhibitory pathways in a left frontal lobe.
And so that gives us some reason to believe that we're really having a pretty powerful effect on the brain itself when we do this kind of biofeedback. And again, gave us some reason to believe we could try to do this with MTBI.
[00:10:00] Speaker B: Amazing.
I think that that's the interesting thing about the study, is that you could identify some of those specific connections that the biofeedback was strengthening. Because one of the questions when I first started reading, well, we know there's a lot of just generalized benefits of HRV biofeedback. And was this sort of addressing anything concussion specific instead of just kind of raising, just giving the user a whole lot of the other benefits? And it sounds like finding that, to me, was just a remarkable finding, that you could nail it down to something so crucial for concussion recovery.
[00:10:44] Speaker C: Yeah, well, we knew we could improve heart rate, resting level, heart rate variability. We now have lots of studies, although this study was probably because probably the population was so compliant with the practice, this is probably the best study that we've ever seen in terms of. There were 21 people in each group. All 21 of them raised their HRV. And in the psychoeducational control group, only two or three people did. Over the course of time we've had from previous literature, we know that we can raise resting level HRV, and since that's correlated, at least with mild traumatic brain injury symptoms, we were hoping that that relationship would work. Also, there's a lot of other literature on other sort of correlated phenomena, like attentional matters, certainly mood. So now we have even a meta analysis on HIV biofeedback for depression and for anxiety. We have two good meta analysis on anxiety. So we knew that those associated symptoms should improve. This population wasn't very depressed, but they were mildly depressed and they were mildly anxious. And lo and behold, both of those improved dramatically, even though they didn't start off with terribly severe.
So it was a bit of a risk to try it, but Jason wanted to do it, and I thought, go for it. He's a very meticulous researcher. He was able to go back during COVID He went back to Taiwan.
We have a real good connection with a neuropsychologist there, and he was able to pull this off. And we want to double the sample size. But COVID made it difficult to do, but still did a great job.
[00:12:40] Speaker B: Yeah, just kind of the innovation, but the creativity of pulling this study off during COVID I just give you all credit for that as well, because I know that wasn't the easiest thing to likely pull off. So it was great to see that creativity, to not stop the study and to get these findings out there to the world.
[00:13:03] Speaker C: Yeah, well, PhD students have a strong incentive.
[00:13:11] Speaker B: Yes, they do.
So I would love to get your opinion, because in my world, mental health, just kind of general mental health, traumatic brain injury has been, I think, a tricky issue for us because I think in a lot of ways, we're not. Well, I'll just say this from my own. There's no training given to really address traumatic brain injury referrals to maybe occupational therapy, other things. And over the years working with this population, I've really celebrated the fact that other professions, I think, have done a really good job. But it almost seemed, especially when you think about psychological trauma and then the rates of TBI in our incarcerated population and others, it just seemed like, oh, there's an injury there.
I wouldn't say hopeless is the right word, but it's like we got so much else to deal with. How do we build expertise and bring this on? So that's one of the things I was really excited about this, because if we could get the biofeedback information to people working, I think, just generally in mental health, that this could be a real tool that they could have for something that has, I think, historically been a real struggle for us. And so if you just think about, let's say, a typical therapist who's knowing or assuming TBI is part of their work, are there any suggestions that you would have for folks who might not be biofeedback specific practitioners to maybe start to integrate some of this into their work?
[00:14:55] Speaker C: Well, one of the challenges is that the large majority of people who have a concussive event, who don't show up with any obvious brain injury do recover within a few months.
You yourself, in your own experience, you got your bell rung a bunch of times and you just coach said, take an e, take a few days off, you'll be fine. Right. However, we do know now that we have a couple of biomarkers of people who are likely to go on to have longer term problems. And of course, those problems are associated with a lot of psychological problems, too.
If the symptoms don't start improving pretty quickly, we all would be affected psychologically by that phenomena. Right.
So it's tricky, but one thing that I think will become, we're hoping will become more common is for neuropsychologists to begin using resting level HRV as a biomarker also maybe cicadic eye movements. Those two are somewhat independently predictive of who's going to go on to have problems from our current study.
And those folks then might be the ones that you would try to put into some HRV biofeedback to try to prevent those long term effects.
And maybe clinicians dealing with this would understand that.
By and large, I think it's going to be a push to get that to happen. But the neuropsychologists, if somebody gets a referral for a neuropsychoval, that means they're having some symptoms beyond the first few weeks.
So one of our targets is to try and get those neuropsychologists to understand this stuff. They don't get it right now.
[00:16:45] Speaker B: Right.
[00:16:46] Speaker C: But our job is to try and get that word out there, and fairly simple, using your equipment or any of the less expensive equipment, you can get a resting baseline HRV for very little, very little invasiveness and very little money. And I would say somebody who came out with, of course, we don't have the pre morbid HRVs, but on the young athletes, you kind of assume probably were pretty good. And if you see them come in with a 25 or a 27 after the injury, after a few weeks, I think it might encourage them to send them to somebody like us to get some training along with what else they're doing. In this study, the psychoeducational intervention, which has been shown to be effective previously, didn't seem to work at all.
And I don't know if it's specific to Taiwan or to. I mean, we used a manualized program that's been used in many studies, but that remains to be seen. We may have done something wrong with that.
[00:17:55] Speaker B: This may be a little bit out of the scope of the actual study, but I know you were sort of looking at more of the mild side of concussions and TBI.
Do you see any kind of. This translates into more severe head injuries?
I'm assuming that we would be working to help heal those same systems that your study showed those connections strengthen.
Do you have any other thoughts how this might. And speculation is fine here, just to throw that out there to maybe more severe traumatic brain injuries that people might.
[00:18:37] Speaker C: Yeah, we're talking about it, and it's a little harder to recruit those folks, but I think it's definitely worth a try. One of my current students, Katie Freeman Baez, is going to do a study with a whole range of.
She's going to kind of replicate that. We're going to try and replicate it with kids.
[00:18:56] Speaker B: Awesome.
[00:18:57] Speaker C: But we're getting the referral pattern. Looks like we're going to get kids, but also young adults from a lot of different places. So I think we're going to have a little bit of an inkling of how well it works on more severe injuries and then you can go beyond that. How about not even severe TBI? But how about where there's actual brain injury? Documented brain injury?
I don't know if I can get a student to try that dissertation, but that would be worth a try.
It's not a very expensive or intensive treatment.
And there are anecdotal reports of people with real brain injury benefiting from HIV biofeedback. Usually they report the anxiety, but not so much the neuropsych measures. But I would love to see somebody do that study.
[00:19:56] Speaker B: Yeah.
Working with youth with traumatic brain injuries in my career, when I got exposed to occupational therapy, it just totally expanded my view because these were children with severe behavioral problems, partially, if not fully, as a result of the traumatic brain injury. There was a lot of psychological trauma there as well. But I just was amazed how brushing and a bouncy chair and these different sort of stimulus could help with emotional regulation. We weren't quite, when I was doing the work, at least connecting that with long term changes. We were more like, how do we get this young person regulated to sit in class for five minutes without throwing a book at somebody?
That was the population we were working with. But it's just really cool to see how we're kind of shifting out of, hey, how do we just get ten minutes of regulation to maybe, how do we help to repair and build and strengthen some of those circuits? Because that was sort of out of our scope. And again, this was a decade plus ago now that I was really ingrained in that work. But I was so excited to see your all's research because it's like, oh, we could again give the short term regulation probably supplementing and all this working together for autonomic regulation, which to throw biofeedback in there, is incredibly exciting.
[00:21:26] Speaker C: Yeah. And we would never discourage them getting a physical modality. Obviously, that would be something we'd love to work with in the process.
But one of the lessons from this study that's beyond TBI is that if you can get people to really practice 20 minutes a day of the HRV biofeedback, which Jason did, these folks were incredibly compliant with the instructions.
The results in every measure were better than we've seen elsewhere. And I'm sure you see this, and we see this in our clinic. Getting people to actually practice is one of our giant.
So what I've been doing with our clinic now is I run a clinic. We have a big, long wait list, and it's really frustrating when there are 40 kids out there waiting to be treated and we see the kids adolescents and they're not practicing. It's really kind of keeping someone else from getting treatment. So we're actually showing them these results in a simple way and saying, here's how important practice is. So this is a lesson for all of us feedbackers that we need to come up with whatever techniques we can to get people to practice daily. Because whatever we do in the clinic is pretty minimal compared to what they do daily. Yeah, exactly.
[00:22:46] Speaker B: Well, I may have shared this with you before. We put all this money into developing a web dashboard to track low frequency, high frequency, even the time domains. And we're really excited to get this all to clinicians. And the number one piece of feedback we get is it's really an accountability tool, because if somebody knows we're seeing whether or not they practiced, especially with adolescents, like, all of a sudden, again, it's hard to compare data against somebody kind of lying to you, but it's like, all of a sudden they see compliance go way up, which, hey, like you said, maybe the best gift and function that we can provide is to help with compliance. But it's that, again, that 20 minutes a day can be so powerful, yet so elusive to people to find that time, or even with medical professionals who I think I convince the importance of it still, to get them to practice 20 minutes a day can be a challenge.
[00:23:53] Speaker C: Of course, we don't know how much that time can be elusive, and maybe ten minutes a day is enough for many people. So we always say 20, hoping for ten.
[00:24:04] Speaker B: Yeah, I try to get people for five to start out, just maybe 50, low and slow breath, just start there, and then we'll build you up over time. Because I remember the first time I tried to sit down and do 20 minutes right off the bat. I think that's been one of. I know my mistakes is you got to get to 20 minutes a day, but, boy, if you start there, you're probably not going to do it the next day because it is a miserable experience, especially for those of us whose brain spins at a million miles an hour.
[00:24:41] Speaker C: Exactly.
[00:24:42] Speaker B: Yeah, I just love to kind of, as we start to wrap up here, any other sort of insights, questions, future questions? You've already mentioned a couple of them that has come out of this work that has you thinking into the future?
[00:25:03] Speaker C: No, just mainly the things we're talking about branching off into biomarkers, trying to enhance the practice.
Something I think a lot of us could do is there are some very simple neuropsych measures that most clinicians could probably do without having a full neuropsych valve, which are really worth tracking because the neuropsych findings in the study were really dramatic along with, I mean, basically everything was. But the neuropsych that was the most convincing thing to the editors were that not that depression and anxiety and baseline HRV improved, but that some very performance based neuropsych measures improved dramatically only in the one group. The other group actually showed almost no improvement. So that's something that I think is a little bit unique to what we usually do. We usually are kind of dependent on self report measures in our world, but here we have something that's a little bit more performance based, like trails A, trails B, executive function, things like that. And it makes you wonder about other kinds of phenomena that might be targeted where those things are a problem. So it does open up some possibilities in other areas.
[00:26:29] Speaker B: Awesome. Well, I would love to ask you one more thing, if you could, is I know we have the AAPB conference coming up, and let me applied psychophysiology, physiology and biofeedback conference. I always get the psychophysiology wrong with the P, but I know you've been a long standing member of this organization. Let's say we have a reader or a listener who's never been to this conference.
I would just love as one of sort of the founders of this movement, why would you say to somebody interested in HRV biofeedback why they might want to consider making the trip to Denver this spring to attend the conference?
[00:27:18] Speaker C: Yeah, that's great. Prompt.
So I've attended many other scientific conferences over the years because I'm old and this is by far my favorite conference. So why is that? Well, it's a conference that's a mixture of researchers and clinicians.
So it isn't just clinicians who are not very scientifically savvy. It's also a lot of savvy researchers and a lot of enrichment speakers from really high level Mara Mathers speaking, the person I was just talking about in this meeting. So to come personally is really a great experience. And my students who I've get to come, and there are scholarships for students who want to come, have just a wonderful experience with the people, treat them very respectfully.
Other meetings I've gone to. The students are kind of the peons. They're not really talked to by anybody in our meeting. Everybody really loves to talk. There's a lot of time set aside to sit around in the exhibit hall and chitchat and talk. There's exhibitors who are really wonderful at showing their equipment, and you get to meet all the leaders in the field who are coming and are very happy to talk to everybody. So also there's a series of workshops that are pretty intensive workshops that get people.
So generally speaking, it's just a lovely kind of a conference.
For years, people have thought it was a very good conference to go to.
In terms of HRV, there's a two day workshop that Paul Air and I do the second day, and Don Moss and Fred Schaefer and Ina do the first know, we're the people who are kind of the founders of HRV, Biofeedback. So you want to get it. So we say two old bald guys will teach you HRV the second day. You want to get the younger people in the first.
[00:29:30] Speaker B: Well, and if you're new to the field as well, I know Freud is somebody we don't talk about favorably anymore. But to sit in the room with you, like, it's like in the early days of psychology for me, like Carl Jung and Rogers, and you get exposed to really, you all who are the reason I'm doing this work, because you really set the foundation of this and provided the research to show, yeah, this is worth doing, and then it's worth doing in these certain areas and focus and just sit at the feet of the masters, literally, and the founders of a field, it's just a special thing. And I will also give that two day workshop, which I'm trying to squeeze my way back into it because I was in there last year, and if I could find a way, I would just take it over again because it was such great information. And just being present in the room of not only great teachers, but also the students and their expertise as well, just provided.
If I could sit in that classroom every day, I think I could take it ten times and learn just so much each and every time. So I'll just reinforce that. And the fact that I can go there and sit at a table with you, my friend, and hear stories of the history and the future in the present is just spectacular. So I'll reinforce all of that. And my only complaint is there's almost too many good workshops. So having to choose sometime which workshop you'll go to is my only complaint, which is only a compliment in disguise.
Well, my friend, I appreciate you. This is such a near and dear topic to my heart that I'm so glad we were going to got to squeeze you into march, too, so we can add to the conversation. I know that's going on, on social media and other folks just trying to bring recognition to traumatic brain injuries, concussions. And your work is such a valuable addition to that. So I want to thank you so much for your continued work and sharing this with our listeners.
[00:31:57] Speaker C: Yeah, well, you guys are the future, so we're so excited to see all the enthusiasm that your generation is bringing to this.
That's wonderful for us to see.
[00:32:08] Speaker B: Well, thank you so much. It's an honor to follow in such big footsteps. So to our listeners, thank you. As always. You can find show notes. We'll put some information about Dr. Gebert. I'll put a link to the AAPB conference and some of the articles that we talked about today also give you a link at optimal. We're doing a training series with Dr. Hopper, Dr. Ina on this year as well, so we'll put a little information on that, too. So I want to thank everybody for joining us. Dr. Gerverse, thanks again so much for your work, and we'll see you all next week.
