Towards the Design of a Smartphone-Based Biofeedback Breathing Training: Indentifying Diaphragmatic Breathing Patterns From a Smartphones\u27 Microphone

Asthma, diabetes, hypertension, or major depression are non-communicable diseases (NCDs) and impose a major burden on global health. Stress is linked to both the causes and consequences of NCDs and it has been shown that biofeedback-based breathing trainings (BBTs) are effective in coping with stress. Here, diaphragmatic breathing, i.e. deep abdominal breathing, belongs to the most distinguished breathing techniques. However, high costs and low scalability of state-of-the-art BBTs that require expensive medical hardware and health professionals, represent a significant barrier for their widespread adoption. Health information technology has the potential to address this important practical problem. Particularly, it has been shown that a smartphone microphone has the ability to record audio signals from exhalation in a quality that can be compared to professional respiratory devices. As this finding is highly relevant for low-cost and scalable smartphone-based BBTs (SBBT) and – to the best of our knowledge - because it has not been investigated so far, we aim to design and evaluate the efficacy of such a SBBT. As a very first step, we apply design-science research and investigate in this research-in-progress the relationship of diaphragmatic breathing and its acoustic components by just using a smartphone’s microphone. For that purpose, we review related work and develop our hypotheses based on justificatory knowledge from physiology, physics and acoustics. We finally describe a laboratory study that is used to test our hypotheses. We conclude with a brief outlook on future work

Exploratory psychometric validation and efficacy assessment study of an agoraphobia treatment based on virtual reality serious games and biofeedback

Tese de mestrado integrado em Engenharia Biomédica e Biofísica (Sinais e Imagens Médicas), Universidade de Lisboa, Faculdade de Ciências, 2020Uma fobia é um tipo de perturbação ansiosa, definida por um medo persistente e excessivo em relação a um objeto ou situação, tendo um impacto bastante limitativo na vida do doente fóbico. Atualmente, as perturbações mentais são ainda vistas como tabu, e existe uma elevada incidência de pessoas que sofrem de fobias (~ 83M na União Europeia, e 32M no Estados Unidos da América). Os métodos atuais para tratamento de perturbações mentais baseiam-se sobretudo em psicoterapia e em farmacologia. Especificamente, o tratamento de perturbações fóbicas baseia-se em terapia por exposição in vivo. Esta técnica foca-se em alterar a resposta do doente ao objeto ou situação que é alvo de medo, através de exposição repetida ao mesmo. A título de exemplo, um doente de fobia de elevadores pode iniciar a sua terapia apenas a pensar em entrar num elevador. De seguida, o terapeuta pode levar o doente a andar de elevador apenas de um andar para o seguinte, a andar de elevador durante vários andares, e a entrar num elevador muito lotado. Este método designa-se assim por dessensibilização fóbica. No entanto, os métodos convencionais possuem várias limitações. Nomeadamente, o tratamento de fobias peca pela falta de quantificação (não são retiradas quaisquer métricas de avaliação), personalização ao doente (a personalização é apenas dependente da opinião subjetiva do terapeuta), ritmo terapêutico gradual e controlado, e segurança, visto que se baseia em terapia por exposição in vivo. A investigação tem demonstrado a eficácia da utilização alternativa de terapia por exposição virtual, baseada em jogos sérios em Realidade Virtual (RV). No entanto, apesar deste método permitir um ritmo terapêutico gradual e em segurança (permitindo uma exposição fóbica virtual no ambiente clínico seguro, ao invés de in vivo – em estágios terapêuticos iniciais e intermédios), não soluciona a falta de quantificação e personalização. Assim, surgiu a hipótese de adicionar biofeedback – uma técnica emergente que utiliza sinais vitais para controlar diretamente a adaptação de um dado sistema, amplamente aplicada em sistemas de treino cerebral – para personalizar e quantificar a terapia por exposição virtual. A técnica é bastante utilizada recorrendo a sinais cerebrais (Neurofeedback), no entanto também são utilizados sinais cardiovasculares, por exemplo. É atualmente conhecido que, a nível fisiológico, as emoções (especificamente o medo) e a ansiedade são correlacionáveis com respostas fisiológicas do sistema cardiovascular. Por exemplo, o sistema cardiovascular responde ao stress, em conjunto com o sistema endócrino, com elevados níveis de cortisol e com um ritmo cardíaco e uma pressão sanguínea aumentados. O presente estudo avalia a eficácia de um novo método de tratamento de agorafobia (ansiedade/medo extremos de espaços abertos ou fechados com multidões) baseado em jogos sérios em RV e biofeedback, como complemento aos métodos terapêuticos convencionais. A adição de uma técnica complementar de relaxamento em RV – seguinte à exposição fóbica – é também avaliada. Como primeiro passo, o estudo avalia se a ansiedade suscita respostas cardíacas e cerebrais diferenciadas, isto é, se é possível retirar biomarcadores da ansiedade. Seguindo investigação prévia, uma experiência preliminar foi conduzida com 156 pessoas saudáveis que assistiram a um conjunto de videoclipes que suscitavam respostas emocionais diferentes, enquanto que as suas atividades cerebrais e cardíacas foram monitorizadas através de sensores de Eletroencefalografia (EEG) e Fotopletismografia (PPG), respetivamente. Foram estudadas seis categorias emocionais: Medo, Alegria, Raiva, Nojo, Neutro, Tristeza, e Ternura. A categoria emocional de Ansiedade/Medo suscitou respostas diferenciadas nos sinais fisiológicos, sugerindo que componentes podem ser utilizadas como biomarcadores da ansiedade. A categoria emocional Ternura foi também alvo de uma análise detalhado, dado que esta é uma emoção ainda pouco conhecida, não sendo consensual a sua natureza. De seguida, um teste de prova-de-conceito de 8 sessões foi conduzido com 5 doentes de agorafobia, dos quais 3 deles foram submetidos ao protocolo terapêutico convencional com a adição do novo método de RV + biofeedback, enquanto que os restantes 2 doentes foram submetidos apenas ao protocolo convencional (psicoterapia e farmacologia). O protocolo do novo método inicia-se com questionários de auto-avaliação de agorafobia e de ansiedade, de seguida passa para o cenário RV de exposição fóbica, e finalmente para o cenário RV de relaxamento. O cenário RV de exposição fóbica consiste numa sala de cinema, na qual o número de pessoas varia de sessão para sessão consoante os resultados fisiológicos e auto-reportados do doente na sessão anterior (biofeedback manual). Por outro lado, o cenário RV de relaxamento consiste numa praia paradísica numa ilha, na qual a turbulência das ondas do mar varia automaticamente consoante os resultados fisiológicos e auto-reportados do doente na sessão anterior (biofeedback preliminar). O objetivo do cenário RV de exposição fóbica é assim expor o doente gradualmente ao cenário de fobia, personalizando o nível de exposição em cada sessão consoante a sua resposta, através do biofeedback. Ou seja, se na sessão anterior o doente conseguiu estar confortável no cenário, o que se traduz nos seus sinais fisiológicos, na sessão seguinte é exposto a um cenário de maior intensidade, obrigando-o assim a habituar-se gradualmente ao cenário. Contrariamente, o objetivo do cenário RV de relaxamento é relaxar gradualmente o doente, expondo-o a um cenário cujo caráter relaxante se intensifica à medida que o doente relaxa, seguindo uma metodologia de biofeedback semelhante. Os resultados mostraram que a diminuição dos sintomas ansiosos e agorafóbicos, entre a primeira e a última sessões, no grupo experimental, foi 3,28 e 5,02 vezes mais elevada, respetivamente, do que a diminuição desses sintomas no grupo de controlo. Resultados relativos a potenciais biomarcadores de estados ansiosos e relaxados foram também adquiridos. De um modo geral, estas conclusões sugerem e quantificam o valor acrescentado deste novo método terapêutico, como complemento à psicoterapia convencional, demonstrando, como foi conjeturado, que a abordagem mista de exposição fóbica + relaxamento permite uma maior redução sintomática. O presente trabalho constitui assim um avanço no estado-da-arte, dado que se retiraram resultados conclusivos relativamente à eficácia e valor acrescentado de um método terapêutico inovador, ainda não explorado na literatura. Trabalho futuro irá avaliar a eficácia e o valor acrescentado do biofeedback, através de um grupo de controlo com biofeedback placebo. Os jogos sérios poderão também ser melhorados, desenvolvendo outros cenários e também os triggers da ansiedade, alvo do controlo automático via biofeedback. Pretende-se também otimizar o biofeedback, através de algoritmos de Aprendizagem Automática de reconhecimento emocional, nomeadamente utilizando algoritmos de redes neuronais. Especificamente, o presente trabalho servirá de base para o desenvolvimento e avaliação de um classificador de estados ansiosos baseado nos biomarcadores encontrados. Por fim, planeia-se ainda avaliar o valor acrescentado de uma abordagem terapêutica no domicílio, como complemento à terapêutica clínica.Current treatment methods for mental disorders – namely, psychotherapy and pharmacology – have several limitations. Specifically, phobias’ treatment lack quantification, personalization to the patient, a gradual and controlled therapy pace, and safety, since it relies on in vivo exposure therapy (phobic desensitization). Research has shown the efficacy of using virtual exposure therapy, based on Virtual Reality (VR) serious games. However, although this method enables a gradual and controlled therapy pace, it does not solve quantification and personalization. Thus, the hypothesis to add biofeedback – an emergent technique that uses vital signs to directly control a system’s adaptation, widely used for brain training systems – to personalize and quantify virtual exposure therapy, arose. This study aims to assess the efficacy of a novel agoraphobia (extreme anxiety/fear of crowded open or closed spaces) treatment method based on VR serious games and biofeedback, as a complement to the conventional methods. The addition of a complementary VR relaxation technique – following the phobic exposure – was also studied. As a first step, the study aims at evaluating if anxiety elicits differentiated brain and heart activity responses, i.e., it aims at evaluating if anxiety biomarkers can be retrieved. Following previous research, a preliminary study was conducted with 156 healthy subjects that watched a set of videoclips that elicited different emotional responses, while their brain and heart activity was monitored through Electroencephalography (EEG) and Photoplethysmography (PPG) sensors, respectively. The fear/anxious emotional category elicited differentiated responses on heart and brain activity, suggesting that certain features can be used as anxiety biomarkers. It was retrieved conclusions regarding the best anxiety biomarker performer, showing the strongest correlations with the self-reporting emotional states, suggesting that the Anxiety/Fear emotional state elicited most differentiated responses on the cardiovascular system, rather than on the Central Nervous System and providing insights into the not yet consensual literature on the topic. Then, a proof-of-concept trial of 8 sessions was conducted with 5 agoraphobic patients, in which 3 of them underwent the conventional treatment protocol with the addition of the novel VR + biofeedback method, while the other 2 only underwent the conventional protocol. The novel method’s protocol begins with agoraphobia and anxiety self-assessment questionnaires, then moves to the VR phobic exposure scenario, and, lastly, to the VR relaxation scenario. Results showed that the decrease of anxious and agoraphobic symptoms, between the initial and last sessions, in the experimental group was 3.28 and 5.02 times greater, respectively, than the decrease of those symptoms in the control group. Results regarding anxious and relaxed states’ biomarkers were also retrieved. Overall, these findings show and quantify the added-value of this novel therapy method – innovative in the literature –, as a complement to the conventional psychotherapy, showing that, as hypothesized, the mixed exposure + relaxation approach enables a more significant symptom reduction. Future work will assess the efficiency and added-value of biofeedback, using Machine Learning methods, as well as of a home-based approach

A Review of Commercial and Medical-Grade Physiological Monitoring Devices for Biofeedback-Assisted Quality of Life Improvement Studies

With the rise in wearable technology and "health culture", we are seeing an increasing interest and affordances in studying how to not only prolong life expectancy but also in how to improve individuals' quality of life. On the one hand, this attempts to give meaning to the increasing life expectancy, as living above a certain threshold of pain and lack of autonomy or mobility is both degrading and unfair. On the other hand, it lowers the cost of continuous care, as individuals with high quality of life indexes tend to have lower hospital readmissions or secondary complications, not to mention higher physical and mental health. In this paper, we evaluate the current state of the art in physiological therapy (biofeedback) along with the existing medical grade and consumer grade hardware for physiological research. We provide a quick primer on the most commonly monitored physiologic metrics, as well as a brief discussion on the current state of the art in biofeedback-assisted medical applications. We then go on to present a comparative analysis between medical and consumer grade biofeedback devices and discuss the hardware specifications and potential practical applications of each consumer grade device in terms of functionality and adaptability for controlled (laboratory) and uncontrolled (field) studies. We end this article with some empirical observations based on our study so that readers might use take them into consideration when arranging a laboratory or real-world experience, thus avoiding costly time delays and material expenditures.info:eu-repo/semantics/publishedVersio

Physiological Self Regulation with Biofeedback Games

Mental stress is a global epidemic that can have serious health consequences including cardiovascular diseases and diabetes. Several techniques are available to teach stress self-regulation skills including therapy, meditation, deep breathing, and biofeedback. While effective, these methods suffer from high drop-outs due to the monotonic nature of the exercises and are generally practiced in quiet relaxed environment, which may not transfer to real-world scenarios. To address these issues, this dissertation presents a novel intervention for stress training using games and wearable sensors. The approach consists of monitoring the user’s physiological signals during gameplay, mapping them into estimates of stress levels, and adapting the game in a way that promotes states of low arousal. This approach offers two key advantages. First, it allows users to focus on the gameplay rather than on monitoring their physiological signals, which makes the training far more engaging. More importantly, it teaches users to self-regulate their stress response, while performing a task designed to increase arousal. Within this broad framework, this dissertation studies three specific problems. First, the dissertation evaluates three physiological signals (breathing rate, heart rate variability, and electrodermal activity) that span across the dimensions of degrees of selectivity in measuring arousal and voluntary control in their effectiveness in lowering arousal. This will identify the signal appropriate for game based stress training and the associated bio-signal processing techniques for real-time arousal estimation. Second, this dissertation investigates different methods of biofeedback presentation e.g. visual feedback and game adaptation during gameplay. Selection of appropriate biofeedback mechanism is critical since it provides the necessary information to improve the perception of visceral states (e.g. stress) to the user. Furthermore, these modalities facilitate skill acquisition in distinct ways (i.e., top-down and bottom-up learning) and influence retention of skills. Third, this dissertation studies reinforcement scheduling in a game and its effect on skill learning and retention. A reinforcement schedule determines which occurrences of the target response are reinforced. This study focuses on continuous and partial reinforcement schedules in GBF and their effect on resistance to extinction (i.e. ability to retain learned skills) after the biofeedback is removed. The main contribution of this dissertation is in demonstrating that stress self-regulation training can be embedded in videogames and help individuals develop more adaptive responses to reduce physiological stress encountered both at home and work

An ambient assisted living solution for mobile environments

An Ambient Assisted Living (AAL) mobile health application solution with biofeedback based on body sensors is very useful to perform a data collection for diagnosis in patients whose clinical conditions are not favourable. This system allows comfort, mobility, and efficiency in all the process of data collection providing more confidence and operability. A physical fall may be considered something natural in the life span of a human being from birth to death. In a perfect scenario it would be possible to predict when a fall will occur in order to avoid it. Falls represent a high risk for senior people health. Those falls can cause fractures or injuries causing great dependence and debilitation to the elderly and even death in extreme cases. Falls can be detected by the accelerometer included in most of the available mobile phones or portable digital assistants (PDAs). To reverse this tendency, it can be obtained more accurate data for patients monitoring from the body sensors attached to the human body (such as, electrocardiogram (ECG), electromyography (EMG), blood volume pulse (BVP), electro dermal activity (EDA), and galvanic skin response (GSR)). Then, this dissertation reviews the related literature on this topic and introduces a mobile solution for falls prevention, detection, and biofeedback monitoring. The proposed system collects sensed data that is sent to a smartphone or tablet through Bluetooth. Mobile devices are used to process and display information graphically to users. The falls prevention system uses collected data from sensors in order to control and advice the patient or even to give instructions to treat an abnormal condition to reduce the falls risk. In cases of symptoms that last more time it can even detect a possible disease. The signal processing algorithms plays a key role in the fall prevention system. These algorithms in real time, through the capture of biofeedback data, are needed to extract relevant information from the signals detected to warn the patient. Monitoring and processing data from sensors is realized by a smartphone or tablet that will send warnings to users. All the process is performed in real time. These mobile devices are also used as a gateway to send the collected data to a Web service, which subsequently allows data storage and consultation. The proposed system is evaluated, demonstrated, and validated through a prototype and it is ready for use

The Effectiveness of Neurofeedback and Heart Rate Variability Biofeedback for Individuals with Long-Term Post-Concussive Symptoms

Case studies have shown that low resolution electromagnetic tomography (LoRETA) neurofeedback is effective for many psychological disorders, but it’s effectiveness for individuals experiencing persistent post-concussive symptoms (PPCS) is uncertain. Individuals with PPCS (n = 7) received an eight-week LoRETA neurofeedback and heart rate variability biofeedback intervention. Change in symptoms, driving simulation performance, electroencephalographic z-score deviations, and heart rate variability were compared to PPCS (n = 9) and healthy (n = 8) control groups. Statistical analyses revealed that the intervention significantly reduced electroencephalographic z-score deviations (p \u3c 0.005) compared to PPCS controls. Additionally, headache, nausea, and dizziness symptoms were reduced in the intervention group (p = 0.003) and the PPCS controls (p = 0.001) compared to healthy controls. Participants responded variably to the intervention, therefore case analyses were considered and revealed that some individuals responded to the intervention while others did not. Future studies with larger populations and longer follow-up times may help evaluate whether there are commonalities between positive responders

Beyond mobile apps: a survey of technologies for mental well-being

Mental health problems are on the rise globally and strain national health systems worldwide. Mental disorders are closely associated with fear of stigma, structural barriers such as financial burden, and lack of available services and resources which often prohibit the delivery of frequent clinical advice and monitoring. Technologies for mental well-being exhibit a range of attractive properties, which facilitate the delivery of state-of-the-art clinical monitoring. This review article provides an overview of traditional techniques followed by their technological alternatives, sensing devices, behaviour changing tools, and feedback interfaces. The challenges presented by these technologies are then discussed with data collection, privacy, and battery life being some of the key issues which need to be carefully considered for the successful deployment of mental health toolkits. Finally, the opportunities this growing research area presents are discussed including the use of portable tangible interfaces combining sensing and feedback technologies. Capitalising on the data these ubiquitous devices can record, state of the art machine learning algorithms can lead to the development of robust clinical decision support tools towards diagnosis and improvement of mental well-being delivery in real-time

A Serious Game to Improve Emotion Regulation in Treatment-Seeking Individuals With Gambling Disorder: A Usability Study

Background: Serious games have shown positive results in increasing motivation, adherence to treatment and strengthening the therapeutic alliance in multiple psychiatric disorders. In particular, patients with impulse control disorders and other disorders in which the patient suffers from inhibitory control deficits (e.g., behavioral addictions) have been shown to benefit from serious games. Aim: The aim of this study was to describe the characteristics and to evaluate the usability of a new serious videogame, e-Estesia. This serious videogame was designed to improve emotion regulation in patients with gambling disorder (GD). Preliminary results from a pilot sample are also reported. Method: A pilot sample of 26 patients undergoing treatment for GD was recruited (ranging from 22 to 74 years, mean = 41.2 and SD = 12.9; 80.8% men). Participants used e-Estesia on a tablet, which was connected to a thoracic band that sent heart rate (HR) and heart rate variability (HRV) data to the videogame platform in order to provide biofeedback. The System Usability Scale was completed by patients to determine the usability of e-Estesia. Results and Discussion: e-Estesia performed comparatively well for all the explored groups (i.e., sex, age, and online vs. offline gambling: mean usability score = 83.8, SD = 13.1). Around 84.6% of the patients endorsed that it was easy to use. Female patients with GD presented higher HRV during the use of the serious videogame compared to men