biofeedback and gaming-style smartphone applications as a … · biofeedback and gaming-style...

Biofeedback and Gaming-Style Smartphone Applications as a Stress Reduction Intervention

Alison Dillon

Trinity College Dublin Dublin 2, Ireland

Mark Kelly


Ian H Robertson


Deirdre A Robertson

Trinity College Dublin Dublin 2, Ireland & Galvanic

Ltd., Ireland [email protected]

ABSTRACT

Stress is a global epidemic affecting the mental and physical health of all demographics of society. Although interventions to reduce stress are available adherence and uptake are often relatively low perhaps due to time and cost considerations. The proliferation of smartphones along with advances in wearable technology offers a unique opportunity to expand the reach of stress reduction interventions and to implement them in everyday life. This research study demonstrates the potential effectiveness of a gaming-style smartphone application combined with a commercially-available biofeedback device in reducing physiological and psychological markers of stress in young adults. Although this is a short-term intervention it provides pilot evidence for the efficacy of a scalable solution to stress reduction in the modern world.

Author Keywords

Stress; technology; biofeedback; smartphones

ACM Classification Keywords

INTRODUCTION

Stress is a global health problem associated with multiple causes of death including heart disease, cancer and stroke and with many mental health problems including depression, PTSD and anorexia [1-3]. Health problems associated with stress, such as hypertension, cardiovascular disease and decreased mental health, lead to 120,000 deaths in America each year [4]. Stress-related problems are likely responsible for 5-8% of annual healthcare costs in the U.S. amounting to about $180 billion per annum [4].

A number of effective therapeutic interventions for stress have been developed [5,6]. One of these interventions involves biofeedback. Biofeedback detects physiological signals such as heart rate, respiration, muscle activity or skin temperature from the user’s body, and by subsequently making users aware of these signals, helps them to gain control over them. (The Association for Applied Psychophysiology and Biofeedback, 201; [7]). This concept has proved valuable for stress reduction for hospital nurses, pregnant women and veterans among others [e.g. 8,9]. It teaches users to recognize when they are stressed from their own physiological measurements, and teaches them how to control both their psychological stress levels and the physical symptoms.

Nevertheless, such interventions suffer several challenges related to delivery, namely low adherence rates and low engagement rates [12]. In addition, many stress programs teach participants to regulate stress in unchallenging conditions, something that may not transfer easily to more competitive or stressful conditions where the skill is really needed. Modern biofeedback devices are thus often combined with video games that contain a competitive element. They teach individuals to try to control stress in more complex and less controlled, competitive and distracting environments. For example, Volozni and colleagues developed a competitive videogame that taught breathing skills to children. The game operated via a positive feedback loop, whereby children learned deep breathing skills by observing an animated character on a computer screen who progressively moved as the children took deeper breaths [13]. Research of this nature opens many avenues for the combination of emerging technologies with age-old stress reduction techniques.

The proliferation of smartphone devices offers a new platform for delivering mobile stress management programs that users can engage with in any setting and that may therefore increase adherence. As summarized by Preziosa and colleagues (2009), mobile phones can respond to different clinical needs [14]. Firstly, the diffusion of mobile phones guarantees availability of contents anytime and anywhere. By 2020 90% of the world’s population over the age of six will have a mobile phone [15]. Secondly smartphones can provide brief and semi structured

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interventions aimed at helping individuals to manage their emotions. Thirdly, smartphones are equipped with several sensing capabilities which permit the detection, recognition, and identification of context information that can be converted into reports of personal health data [14].

The aim of this study was therefore to test the effects of a biofeedback stress management intervention which uses a mobile smartphone device and gaming style apps. The biofeedback device used in this study was the Personal Input Pod (PIP) (Galvanic Ltd., Ireland) which captures changes in the skin’s conductivity as a result of stress. This information is transmitted via Bluetooth to smartphone applications, where algorithms analyze the electrodermal activity and use it to determine progress in the games. The more relaxed the player, the greater the progress in the game. This study investigated whether two smartphone applications, ‘The Loom’ and ‘Relax and Race’, effectively reduced self-reported measures of stress and physiological measures of stress compared to a control game, ‘Flow Free’. We hypothesized that the combination of biofeedback with smartphone gaming technology would cause greater reductions in psychological and physiological levels of stress after a stress induction compared to a control distraction game.

METHODS

Fifty participants (32 female, 18 male, age: M=26.7, SD=5.1) were randomly allocated to the biofeedback gaming condition or the non-biofeedback gaming condition. The Beck Anxiety Inventory was initially completed to determine if there were any underlying anxiety problems, which would exclude participation in the study [16]. Participants with a score of 36 or above were excluded. Study protocols were all in accordance with the declaration of Helsinki and were approved by the Ethics Committee of Trinity College, Dublin.

Measures

A Visual Analogue Scale (VAS; [17] was used to determine participants’ level of stress. Participants were asked to indicate how stressed they currently felt with 1 being the lowest level of stress and all 10 being the maximum. An iHealth® wireless pulse oximeter was used to measure heart rate through participants’ right index finger (iHealth Lab Inc, 2012). The Personal Input Pod® (PIP®, Galvanic Ltd.) was used to measure skin conductance. The wireless PIP detects EDA in the player’s fingertips 8 times per second. This is transmitted via Bluetooth to the PIP’s Apps whereby a propriety algorithm analyses changes in EDA and use it to determine progress in the apps. An Apple iPhone 4S 16GB mobile phone with the games.

Procedure

All participants completed the Trier Social Stress Test (TSST; [18]) in order to induce moderate psychological stress. This consisted of three stages: an anticipatory stress

phase during which the participants were asked to prepare a 5 minute presentation, framed as a job interview for their dream job, the presentation phase during which interviewers maintained a neutral expression and observed the participant without comment and finally the mental arithmetic phase, during which the participants were asked to count backwards from 1,022 in steps of 13. If participants made a mistake they were asked to start again from the beginning.

After completing the TSST, participants’ heart rates were taken using the pulse oximeter, which required the participant to place his/her right index finger into plastic cuff for approximately 20 seconds until a heart rate measure could be read. Participants also marked on the Visual Analogue Scale their perceived level of psychological stress.

Each participant was directed to one of two experimental conditions. Participants in the biofeedback relaxation condition held the Personal Input Pod (PIP) device between their index finger and thumb. All participants were given instructions on how to play the games. The first biofeedback game, ‘Relax and Race’ is a competitive racing game in which the player is represented by a small green dragon. The dragon has three modes (walk, run and fly), with each mode being faster than the preceding one. As the player relaxes and their skin conductance decreases the dragon progresses through a series of movements: walking, running and finally flying. Should the player become stressed, and their electrodermal activity increase, the dragon slows down. Players compete to beat their personal best time. The second biofeedback game, ‘The Loom’ is a single player game, which commences with a visual image of a frozen snow covered scene. The objective of the game is to progress from the winter scene through to a summer scene. The more relaxed the player is, the faster the transition. As the player relaxes and their skin conductance decreases, the landscape responds and the snow begins to melt. The music adapts too, starting out as a single instrument with instrumental layers added as the scene moves from winter to summer. The control game, ‘Flow Free’ is a single player puzzle game with pairs of matching colors dotted in different locations across a board. The objective of the game is to connect matching color pairs with a pipe in order to create a flow. The puzzle is solved once each pair has been matched and the entire board is covered. If overlap of piping occurs, however, the pipes break and the game is lost. There are 30 different levels of ‘Flow Free’, level one is the most basic level and is very simple and relaxed, level thirty is the highest level and is very complex and frenetic. Flow Free was chosen as the control game as it is a cognitively stimulating game, yet does not induce high levels of stress when the player begins playing at a low level and progresses to higher levels at their own leisure and according to their own abilities. In addition, all games involved trying to beat a personal best. The participants who played the games ‘The Loom’ and

‘Relax and Race’ played each of the games for 15 minutes. The participants who played the control game, ‘Free Flow’ started on the easiest level and then worked their way up to more difficult levels at their own discretion and pace. Each participant played the smartphone application games for 30 minutes. After participants had played the games for 30 minutes, heart rate and perceived stress levels were recorded again. Participants were debriefed and informed of the purpose of the study and were then free to leave. RESULTS

A 2x2 mixed factorial ANOVA showed a significant main effect of time, F(1, 48) = 60.89, p <.001, partial η2=0.56, such that perceived stress levels decreased from pre to post measurement time (M = 5.01, SD = 1.96) to M = 3.27 SD = 1.83). There was no significant main effect of game F(1, 48) = 2.07, p>.05. There was a significant interaction between time and game type, F(1, 48) = 14.19, p< 0.001, partial η2=0.23 (Figure 1). Post-hoc analyses revealed that participants who played the biofeedback games had a statistically significant decrease in stress (M = -2.58, SD = 1.72), t(24)=55.98, p <0.001, two-tailed, while participants playing the control game did not (M = 0, SD = 0.11), t(24) =10.13, p >0.001, two-tailed. This indicates that the biofeedback games were more effective at reducing self-reported stress compared to the control game.

A 2x2 mixed factorial ANOVA showed a significant main effect of time for heart rate, F(1, 48) = 15.14, p <.05, partial η2=0.24, such that there was a significant reduction in heart rate over time, (M = 79.86, SD = 17.61 to M = 75.74, SD = 15.99). There was no significant main effect for game, F(1, 48) = 1.22, p > 0.05, partial η2=0.03. There was a significant interaction between time and game, F(1, 48) = 6.41, p< 0.05, partial η2=0.12 (See Figure 2). Post-hoc analyses revealed that participants who playing the biofeedback relaxation games had a statistically significant decrease in heart rate (M = 6.80, SD = 7.70), t(24)=4.41, p

<0.05, two-tailed. Participants who played the control game also had a decrease in heart rate but this was not statistically significant, (M = 1.44, SD = 7.26) t(24) = 0.99, p >0.05, two-tailed.

Figure 1. Perceived stress levels before and after

interventions. Relax = biofeedback game; Control =

control game. Error bars shown are standard errors.

Figure 2. Heart rate before and after interventions. Relax

= biofeedback game, Control = control game. Error bars

shown are standard errors.

CONCLUSIONS

We analyzed the effectiveness of smartphone application games combined with biofeedback in the reduction of physiological and psychological markers of stress. Thirty minutes of a biofeedback gaming-style application significantly reduced self rated stress and heart rate in a group of temporarily stressed participants compared to those playing a control distraction game. The biofeedback games reduced self-reported stress following a stress-induction procedure by 50% compared to 18% in a control group and heart rate by 8% compared to 2% in a control group. This reduction suggests that smartphone application biofeedback games may be an effective method to teach users to manage their stress. Although this was only a short intervention the efficacy of a smartphone and mobile biofeedback device in reducing physiological and psychological markers of stress illustrates the potential of scalability of these types of interventions to target stress. Gaming-style biofeedback applications on smart devices that can be, and are, carried anywhere may broaden the reach and appeal of stress management interventions and ultimately increase adherence to and efficacy of stress reduction interventions.

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Biofeedback-assisted Stress Management Training on

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http://www.ericsson.com/mobility-report

Smartphone applicat ions ut ilizing biofeedback can aid

stress reduction

Alison Dil lon1, Mark Kel ly

1, Ian H. Rober t son

1, Dei rdre A. Rober t son

1*

1Trini t y Col lege Dubl in, Ireland

Submit t ed t o Journal:

Front iers in Psychology

Specialt y Sect ion:

Human-Media Int eract ion

ISSN:

1664-1078

Art icle t ype:

Or iginal Research Ar t icle

Received on:

09 Nov 2015

Accept ed on:

18 May 2016

Provisional PDF publ ished on:

18 May 2016

Front iers websit e l ink:

www. f r ont i er si n. or g

Ci t a t ion:

Di l lon A, Kel ly M, Robert son IH and Robert son DA(2016) Smart phone appl icat ions ut i l izing biofeedback

can aid st ress reduct ion. Front . Psychol . 7: 832. doi : 10.3389/ f psyg.2016.00832

Copyr ight st at ement :

© 2016 Di l lon, Kel ly, Robert son and Robert son. This is an open-access ar t icle dist r ibut ed under t he

t erms of t he Creat ive Commons At t r ibut ion License (CC BY). The use, dist r ibut ion and reproduct ion

in ot her f orums is permi t t ed, provided t he or iginal aut hor (s) or l i censor are credi t ed and t hat t he

or iginal publ icat ion in t his j ournal is ci t ed, in accordance wi t h accept ed academic pract ice. No use,

dist r ibut ion or reproduct ion i s permi t t ed which does not comply w i t h t hese t erms.

This Provisional PDF cor responds t o t he ar t icle as i t appeared upon accept ance, af t er peer-review. Ful l y f ormat t ed PDF

and ful l t ext (HTML) versions wi l l be made avai lable soon.

Front iers in Psychology | www. f ront iersin.org

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ional

Conflict of interest statement

The authors declare a potent ial conflict of interest and state it below.

Ian H Rober t son is t he Chai r of t he Scient i f ic Advisory Board of Galvanic Lt d.

Dei rdre A Rober t son si t s on t he Scient i f ic Advisory Board of Galvanic Lt d. and act s as a paid consul t ant f or t he company.

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Smartphone applications utilizing biofeedback can aid stress 1

reduction 2

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Alison Dillon1, Mark Kelly1, Ian H Robertson1, Deirdre A Robertson1* 4

5 1. Trinity College Dublin, Ireland 6

7 Correspondence: Deirdre A Robertson, Trinity College Dublin, Ireland 8

[email protected] 9

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Keywords: Stress, Biofeedback, Technology, Skin Conductance 11

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mailto:[email protected]

Biofeedback Smartphone Applications as Stress Reduction Tools

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Abstract 50

51

Introduction 52 Stress is one of the leading global causes of disease and premature mortality. Despite 53

this, interventions aimed at reducing stress have low adherence rates. The 54

proliferation of mobile phone devices along with gaming-style applications allows for 55

a unique opportunity to broaden the reach and appeal of stress-reduction interventions 56

in modern society. We assessed the effectiveness of two smartphone applications 57

games combined with biofeedback in reducing stress. 58

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Methods 60 We compared a control game to gaming-style smartphone applications combined with 61

a skin conductance biofeedback device (the Pip). 50 participants aged between 18 and 62

35 completed the Trier Social Stress Test. They were then randomly assigned to the 63

intervention (biofeedback game) or control group (a non-biofeedback game) for thirty 64

minutes. Perceived stress, heart rate and mood were measured before and after 65

participants had played the games. 66

67

Results 68 A mixed factorial ANOVA showed a significant interaction between time and game 69

type in predicting perceived stress (F(1, 48) = 14.19, p < .001). Participants in the 70

biofeedback intervention had significantly reduced stress compared to the control 71

group. There was also a significant interaction between time and game in predicting 72

heart rate (F(1, 48) = 6.41, p < .05). Participants in the biofeedback intervention 73

showed significant reductions in heart rate compared to the control group. 74

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Discussion 76 This illustrates the potential for gaming-style smartphone applications combined with 77

biofeedback as stress reduction interventions. 78

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1. Introduction 100 101

Stress is a major health problem (Kalia, 2002) which is associated with multiple causes 102

of death including heart disease, cancer and stroke (Cohen, Janicki-Deserts & Miller, 103

2007) and with most major mental health problems including depression, PTSD and 104

anorexia (Marin, Lord, Andrews, Juster, Sindi, Arsenault-Lapierre, Fiocco & Lupien, 105

2011). A recent paper from Harvard and Stanford Business Schools on mortality 106

relating to stress, found that problems associated with job stress such as hypertension, 107

cardiovascular disease and decreased mental health lead to 120,000 deaths in America 108

each year (Goh, Pfeffer & Zenios, 2015). This makes work related stress and its 109

associated maladies a greater source of morbidity than diabetes, Alzheimer’s Disease 110

or influenza. Additionally the study found that stress-related problems could be 111

responsible for between 5-8% of annual healthcare costs in the U.S. amounting to about 112

$180 billion per annum. 113

114

A number of effective therapeutic interventions for stress have been developed (Carson 115

& Kuipers, 1998; Doherty, Coyle & Sharry 2012). However, often interventions suffer 116

several challenges related to delivery, namely low adherence rates and low engagement 117

rates (Paredes, Gilad-Bachrach, Czerwinski, Roseway, Rowan & Hernandez, 2014). 118

One type of intervention uses biofeedback as an aid to stress reduction. 119

120

Biofeedback detects and presents physiological signals such as heart rate, respiration, 121

muscle activity or skin temperature from the user’s body, and by making users aware 122

of these signals, helps them to gain control over them (The Association for Applied 123

Psychophysiology and Biofeedback, 2011; Micoulaud-Franchi et al., 2014). The 124

concept has demonstrated value for stress reduction in studies on stress management 125

for hospital nurses (Cutshall, Wentworth & Wahner-Roedler, 2011) and for veterans 126

suffering with Post Traumatic Stress Disorder after 9/11 (Reyes, 2014). Biofeedback is 127

a component of a number of stress reduction programmes (e.g. improving stress 128

management skills in soldiers (Bouchard, Bernier et al., 2012) and reducing stress in 129

pregnant women (Keeney, 2009) because it teaches users to recognise when they are 130

stressed from their own physiological measurements, and teaches them how to control 131

both their psychological stress levels and the physical symptoms of stress. 132

133

Many of these stress programmes, however, teach participants to regulate their stress 134

response in quiet, peaceful surroundings and in unchallenging conditions, something 135

that may not transfer easily to more stressful conditions where the skill is really needed. 136

Modern biofeedback devices are thus often combined with video games that contain a 137

competitive element. They teach individuals to try to control stress in more complex 138

and less controlled, competitive and distracting environments. For example, Volozni 139

and colleagues (2001) developed a competitive videogame that taught breathing skills 140

to children. The game operated via a positive feedback loop, whereby children learned 141

deep breathing skills by observing an animated character on a computer screen who 142

progressively moved as the children took deeper breaths (Vilozni, Barker, Jellouschek, 143

Heimann & Blau, 2001). Similarly Bouchard, Bernier, Boivin and Robillard, (2012) 144

found that soldiers who received three sessions of biofeedback assisted stress 145

management training while immersed in a competitive shooter game were more 146

effective in controlling stress (as measured by cortisol response and heart rate) in a 147

subsequent stress induction task, compared to a control group who received no stress 148

management training. In relation to stress management for health, a study conducted 149

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by Leahy and colleagues (1998) found that patients with irritable bowel syndrome, a 150

condition to which stress is a major contributor, had reduced global and bowel 151

symptoms scores after four 30 minute biofeedback sessions on a competitive computer 152

game (Leahy, Clayman & Mason, 1998). Research of this nature opens many avenues 153

for the combination of emerging technologies with age-old stress reduction techniques. 154

However most of this research has been conducted in the laboratory or using desktop 155

computers that mean users have to be in one place to avail of the interventions. 156

157

The proliferation of smartphone devices offers a new platform for delivering mobile 158

stress management programmes that users can engage with in any setting. As 159

summarized by Preziosa and colleagues (2009), mobile phones can respond to different 160

clinical needs. Firstly, the diffusion of mobile phones reduces the digital divide and 161

guarantees the availability of the contents anytime and anywhere. According to a recent 162

study by Andersson and colleagues (2014) 90% of the world’s population over the age 163

of six will have a mobile phone by the year 2020 (Björn, Carson, Frost, Godor, & 164

Kersch, 2014). Secondly smartphones can provide brief and semi structured 165

interventions aimed at helping individuals to manage their emotions. Finally, 166

smartphones are equipped with several sensing capabilities which permit the detection, 167

recognition, and identification of a number of activities and context information which 168

can be converted into reports of personal health data (Preziosa, Grassi, Gaggioli & Riva, 169

2009). 170

171

The advantages of mobile phones for health interventions have been shown in a number 172

of studies. One study used mobile phone applications to provide stress inoculation 173

training to oncology nurses (Villani, Grassi, Cognetta, Toniolo, Cipresso & Riva, 174

2011). Another recent study successfully taught individuals relaxation exercises via a 175

competitive respiratory biofeedback game (Parnandi, Ahmed, Shipp & Gutrierrez-176

Ohuna, 2014), and another used a heart rate biosensor device connected to a free 177

positive technology app to successfully teach breathing exercises and thereby reduce 178

levels of arousal (see Serino, Cipresso, Gaggioli, Pallavicini, Cipresso, Campanaro & 179

Riva (2014)). 180

181

The utility of biofeedback has been demonstrated in a number of forms, most notably 182

by Galvanic Skin Response (GSR) devices, which has proven to be a reliable method 183

of measuring activity of the sympathetic medullary system. This system is responsible 184

for the secretion of adrenaline and noradrenaline during the stress response (El Sheikh, 185

Erath, Buckhalt & Granger, 2008; Graeff-Parente, Del-Ben & Guimaraes, 2003; Allen, 186

Kennedy,Cryan, Dinan & Clarke, 2014). GSR measures the electrical conductance of 187

the skin. When the sympathetic branch of the autonomic nervous system is highly 188

aroused, sweat gland activity also increases, which in turn increases skin conductance 189

(Graeff-Parente et al., 2003). Previous studies have used skin conductance as the 190

physiological marker for biofeedback interventions (e.g. Leahy et al., 1998). 191

192

The aim of this study was to test the efficacy of a biofeedback stress management 193

intervention which combines a mobile smartphone device and gaming style apps. The 194

biofeedback device used in this study was the Pip (Galvanic Ltd., Ireland) that captures 195

changes in skin conductivity. This information is transmitted via Bluetooth to 196

smartphone applications, where algorithms analyse the electrodermal activity and use 197

it to determine progress in the games. The more relaxed the player, the greater the 198

progress in the game. This study aimed to investigate whether two smartphone 199

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applications, ‘The Loom’ and ‘Relax and Race’, effectively reduced self-reported 200

measures of stress and physiological measures of stress compared to a control game, 201

‘Flow Free’. In conjunction with this aim, changes in self-reported measures of mood 202

were also under investigation. We hypothesised that the biofeedback related game 203

would cause greater reductions in psychological and physiological levels of stress after 204

a stress induction compared to a control game. 205

206

2. Materials and Methods 207 208

2.1 Participants 209 Fifty healthy adults participated in the study (32 female, 18 male, age: M=26.7, 210

SD=5.1). Participants were randomly allocated to the experimental biofeedback (B) or 211

the control condition (C). There were 25 participants in each condition and participation 212

lasted 60 minutes. The Beck Anxiety Inventory (Steer & Beck, 1997) was initially 213

completed to determine if there were any underlying anxiety problems, which would 214

exclude participation in the study. Participants with a score of 36 or above were to be 215

excluded, however this did not apply to any participants in the sample. Study protocols 216

were all in accordance with the declaration of Helsinki and were approved by the Ethics 217

Committee of Trinity College, Dublin. 218

219

2.2 Design 220 The study was an independent groups design with repeated measures over a time of 30 221

minutes. Participants in the biofeedback condition played the mobile phone application 222

games ‘Relax and Race’ and ‘The Loom’ (Galvanic Ltd, 2012). Participants in the 223

control condition played the mobile phone application game ‘Flow Free’ (Big Duck 224

Games, 2012) (see details below). Participants’ heart rates, mood and perceived stress 225

levels were recorded before and after playing the games. We hypothesised that 226

participants in the biofeedback condition would have a greater decrease in heart rate, 227

perceived stress levels and improved mood after playing the intervention games 228

compared to the control condition. 229

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2.3 Measures 231

232

2.3.1. Anxiety 233 Participants completed the Beck Anxiety Inventory (Steer & Beck, 1997). This 234

consisted of a list of 21 symptoms such as ‘fear of worst happening’ and ‘hands 235

trembling’. Participants were asked to rate how much they had been bothered by each 236

symptom over the past month on a four-point scale of 0 to 3 (‘not at all’ to ‘severely’). 237

The measure has been shown to have good reliability and validity (Steer & Beck, 1997). 238

The Anxiety Inventory was used to exclude participants with potential clinical levels 239

of anxiety as evidenced by a score greater than 36. No participants were excluded on 240

this basis. 241

242

2.3.2 Mood 243 The UWIST Mood Adjective Checklist (UMACL; Matthews, Jones & Chamberlain, 244

1990) was used to analyse participants’ mood. The UMACL consists of a list of 34 245

adjectives rated on a 4 point response scale; participants judge the extent to which these 246

terms describe their current mood on a scale ranging from ‘definitely’ to ‘definitely 247

not’ and circle the number beside the adjective that best describes their mood at the 248

present time. This instrument was designed to model the entire affective space and 249

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includes adjectives to measure the affective dimensions of Tense Arousal (Cronbach’s 250

alpha for this sample = .78), Hedonic Tone (α = .74) and Energetic Arousal (α = .42) 251

(Matthews et al., 1990). 252

253

2.3.3 Stress level 254 A Visual Analogue Scale (VAS; Lesage, Berjot & Deschamps, 2012) was used to 255

determine participants’ level of stress. Participants were asked to indicate how stressed 256

they currently felt with 1 being not at all and 10 being the maximum possible feeling 257

of being stressed. 258

259

2.3.4 Heart Rate 260 An iHealth® wireless pulse oximeter was used to measure heart rate through 261

participants’ right index finger (iHealth Lab Inc, 2012). 262

263

2.3.5 Galvanic Skin Response 264 The Pip (Pip®, Galvanic Ltd.) was used to measure skin conductance. The Pip is a 265

wireless biofeedback device that measures electrodermal activity (EDA). The sensors 266

detect EDA in the player’s fingertips 8 times per second. This is transmitted via 267

Bluetooth to the Pip’s Apps whereby a propriety algorithm analyses changes in EDA 268

and uses this to determine progress in the apps. 269

270 An Apple iPhone 4S 16GB mobile phone with the games; the Loom, Relax and Race 271

and Flow Free installed was used by all participants. 272

273

2.3.6 Trier Social Stress Test 274 All participants completed the Trier Social Stress Test (TSST; Kirschbaum, Pirke & 275

Hellhammer, 1993) in order to induce moderate psychological stress. This consisted of 276

three stages. The first was the anticipatory stress phase during which participants were 277

brought into a room at which 2 people were already sitting at a table. The participant 278

was asked to stand in front of them and was given the following instructions: “You must 279

imagine you are applying for you dream job. You have dreamt about working in this 280

job for as many years as you can remember. After seeing an advertisement for this 281

perfect job, you have decided to apply. After submitting the application you have been 282

invited for an interview. The salary for this job is very high, there is a lot of competition 283

for the job, and the final selection will be made based on your ability to convince us, 284

the interviewers of how your experiences, abilities and education make you a better 285

candidate than anyone else. You will have three minutes to prepare a detailed speech 286

explaining why you are the ideal candidate for this job and you will be given a sheet of 287

A4 paper to make notes on.” After the three minutes preparation time had elapsed, one 288

of the interviewers took away the A4 sheet with the participant’s notes on it and the 289

second phase began. The participant had to deliver a five minute speech explaining why 290

he or was the ideal candidate for the job. Throughout this the interviewers maintained 291

a neutral expression and observed the participant without comment. The third phase 292

was the mental arithmetic task in which participants were asked to count backwards 293

from 1,022 in steps of 13 as fast and as accurately as possible. If the participants made 294

a mistake, they were asked to start again from the beginning. This phase lasted for 5 295

minutes. The TSST has been shown to be a valid and reliable instrument for inducing 296

physiological and psychological stress responses in people of all ages (Hellhammer & 297

Schumbert, 2011). In a recent meta-analyses of 165 laboratory stress studies, the TSST 298

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was found to produce the most robust physiological stress responses as compared with 299

several other stress tasks (Dickerson & Kemeny, 2002). 300

301

2.3.7 Interventions 302 The first intervention game, ‘Relax and Race’ is a competitive racing game in which 303

the player is represented by a small green dragon. As the player relaxes and their skin 304

conductance decreases, as measured by the Pip, the dragon flies higher and faster. 305

Should the player become stressed, and therefore have an increase in skin conductance, 306

this causes the dragon to slow down. Therefore, the player who relaxes most wins the 307

race. In the single player version – used in this study - the player competes against a 308

‘ghost dragon’ representing his most recent best score so that he can compete against 309

himself’ and improve his relaxation over time. Winning the race provides a motivating 310

reward for achieving a relaxed state. 311

312

The second intervention game, ‘The Loom’ is a single player game, which commences 313

with a visual image of a frozen snow covered scene. The objective of the game is to 314

progress from the winter scene through to a summer scene. The more relaxed the player 315

is, the faster the transition. As the player relaxes and their skin conductance decreases, 316

the landscape responds. 317

318

The control game, ‘Flow Free’ is a single player puzzle game with pairs of matching 319

colors dotted in different locations across a board. The objective of the game is to 320

connect matching color pairs with a pipe in order to create a flow. The puzzle is solved 321

once each pair has been matched and the entire board is covered. If overlap of piping 322

occurs, however, the pipes break and the game is lost. There are 30 different levels of 323

‘Flow Free’, level one is the most basic level and is very simple and relaxed, level thirty 324

is the highest level and is very complex and frenetic. Flow Free was chosen as the 325

control game as it is a stimulating game, yet does not induce high levels of stress when 326

the player begins playing at a low level and progresses to higher levels at their own 327

leisure and according to their own abilities. 328

329

2.4 Procedure 330 331

Study participants were given an information sheet with study information and a signed 332

consent form. All participants were tested individually between the times of 10am and 333

4pm, participation lasted one hour. On arrival, participants rested for 10 minutes in 334

Room A. After 10 minutes they were taken to a second room (Room B) in which the 335

TSST would take place (see materials). After completing the TSST, participants’ heart 336

rates were taken using the pulse oximeter, which required the participant to place 337

his/her right index finger into plastic cuff for approximately 20 seconds until a heart 338

rate measure could be read. Participants then completed the perceived stress and mood 339

measures. Following this participants were randomly selected to take part in the 340

biofeedback or the control conditions. Participants in the biofeedback condition held 341

the Pip between their index finger and thumb. All participants were given instructions 342

on how to play the games. The participants who played the games ‘The Loom’ and 343

‘Relax and Race’ played each of the games for 15 minutes. Participants who played the 344

control game, ‘Free Flow’ started on the easiest level worked their way up to more 345

difficult levels at their own pace. Each participant played the smartphone application 346

games for 30 minutes. After participants had played the games for 30 minutes, heart 347

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rate measures, perceived mood and stress levels were recorded again. Participants were 348

then debriefed and informed of the purpose of the study. 349

350

3. Results 351

352

3.1 Self-reported levels of stress 353 354

The means and standard deviations for all treatment conditions are shown in Table 1. 355

All assumptions were met and therefore it was appropriate to continue with a mixed 356

factorial ANOVA. A 2x2 mixed factorial ANOVA showed a significant main effect of 357

time, F(1, 48) = 60.89, p <.001, partial η2=0.56, such that there was a significant 358

reduction in stress levels over time, as measured from the pre-gaming time (M = 5.01, 359

SD = 1.94) to post gaming (M = 3.27 SD = 1.97). There was no significant main effect 360

of game F(1, 48) = 2.07, p>.05. 361

362

xxx Table 1 around here xxx 363

364

There was a significant interaction between time and game type, F(1, 48) = 14.19, p< 365

.001, partial η2=0.23 (See Figure 1). Paired sample T-Tests were used as post-hoc 366

analysis to identify the source of the interaction. Participants who played the 367

biofeedback games had a statistically significant decrease in stress levels (Mean Before 368

= 5.08 (SD = 2.05)); Mean After = 2.5 (SD = 1.68), t(24)=7.48, p <.001, two-tailed). 369

Participants who played the control application game, also had a reduction in stress 370

levels but to a lesser amount (Mean Before = 4.94 (SD = 1.86), Mean After = 4.04 (SD 371

= 1.97), t(24) =3.18, p <.01, two-tailed). These results indicate that the biofeedback 372

applications ‘Relax and Race’ and ‘The Loom’ were more effective at reducing self-373

reported levels of stress in participants compared to the ‘Flow Free’ game. 374

375

Xxx Figure 1 around here xxx 376

377

3.2 Mood Analysis 378 The UWIST Mood Adjective Scale was analysed from the perspective of three separate 379

dimensions: hedonic tone, tense arousal and energetic arousal. Three mixed factorial 380

ANOVAs were conducted to determine if there was a change in self-reported mood 381

levels before and after the stress reduction period. The means and standard deviations 382

for all treatment conditions are shown in Table 1. 383

384

There was no interaction effect between time and condition in predicting hedonic tone 385

(F(1,48) =.02, p>.05), tense arousal (F(1,48)=0.05,p>.05) or energetic arousal 386

(F(1,48)=0.08,p>.05). These results indicate that there was no significant change in 387

mood following the stress reduction intervention. 388

389

3.3 Heart Rate 390 A 2x2 mixed factorial ANOVA showed a significant main effect of time for heart rate, 391

F(1, 48) = 15.14, p <.001, partial η2=0.24, such that there was a significant reduction 392

in heart rate over time, as measured from the pre-gaming time (M = 79.86, SD = 17.48) 393

to post gaming (M = 75.74, SD = 16.30). 394

395

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There was no significant main effect for game, F(1, 48) = 1.22, p > .05, partial η2=0.03. 396

There was a significant interaction between time and game, F(1, 48) = 6.41, p< .05, 397

partial η2=0.12 (See Figure 2). 398

399

Xxx Figure 2 around here xxx 400

401

Paired sample T-Tests were used as a post-hoc analysis to identify the source of the 402

interaction. Participants who played the biofeedback games had a statistically 403

significant decrease in heart rate (Mean Before = 78.64 (SD = 17.08), Mean After = 404

71.84 (SD = 13.82)), t(24)=4.41, p <.001, two-tailed). Participants in the control 405

condition did not have a statistically significant reduction in heart rate (Mean Before = 406

81.08 (18.13), Mean After = 79.64 (SD = 17.89)), t(24) = 0.99, p>.05). 407

408

4. Discussion 409 410

In the present study we analysed the effectiveness of smartphone application games 411

combined with biofeedback in the reduction of physiological and psychological 412

markers of stress. We found that 30 minutes of biofeedback training significantly 413

reduced self-rated stress and heart rate in a group of temporarily stressed participants 414

compared to a control procedure. Specifically smartphone games ‘Relax and Race’ and 415

‘The Loom’, played via an electrodermal sensor (the Pip), for 15 minutes each, reduced 416

self-reported stress following a stress-induction procedure by 50% compared to 18% in 417

a control group and heart rate by 8% compared to 2% in a control group. This significant 418

reduction suggests that smartphone application biofeedback games may be an effective 419

method to teach users to manage their stress. Although this was only a short 420

intervention the efficacy of a smartphone and mobile biofeedback device in reducing 421

physiological and psychological markers of stress illustrates the potential of scalability 422

of these types of interventions. Gaming-style biofeedback applications on smart devices 423

that can be, and are, carried anywhere may broaden the reach and appeal of stress 424

management interventions thereby increasing adherence and efficacy. 425

426

One key aspect of biofeedback is that it gives users a tangible external measure of their 427

stress response. As they are able to monitor their stress responses they then learn to 428

control them more effectively. The resulting perceived control over stress could be a 429

vital cognitive outcome of the game, as it has often been stated that stress is induced 430

due to a perceived lack of control over a particular situation or stimulus (Eysenck, 431

2013). Leotti, Iyengar, & Ochsner (2010) showed that perceived control over a situation 432

or stimulus can inhibit autonomic arousal. Also of note is the fact that removing control 433

can produce heightened sensitivity towards a stressor, resulting in increases in 434

rumination and negative thought patterns. Wallston, Stein and Smith (1994) showed 435

that a person’s ‘locus of control’ or the perception that they have control over their own 436

health can affect the health of the individual. 437

438

Using competitive games as a means to teach relaxation techniques through 439

biofeedback may lead to better transfer of relaxation skills to other stressful tasks in the 440

real world. This was evident in prior research on stress exposure in military settings 441

(Bouchard, Bernier et al., 2012) which showed that for many tasks normal training 442

procedures do not improve performance when the task is later to be performed under 443

stress. Combining multiple-parameter biofeedback with training, however, resulted in 444

improved stress management in simulated situations indicating that the skills learnt 445

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could be effectively carried over. Similarly, Parnandi at al (2014) compared a 446

competitive respiratory biofeedback smartphone game to a conventional non-447

biofeedback version of the game and to traditional relaxation based on deep breathing. 448

They found that heart rate levels for participants in the biofeedback gaming condition 449

reduced significantly from pre gaming to post gaming compared to those in the other 450

two conditions indicating successful transfer of relaxation skills. 451

452

Lichstein (1988) outlines a number of meditative practices and relaxation techniques 453

that may help to prevent stress from building up to unmanageable levels. Within these 454

practices runs the theme of trying to become aware of unconscious bodily processes. 455

The skin conductance response sensor utilised with ‘Relax and Race’ and ‘The Loom’ 456

is capable of measuring very minute changes in physiological processes, making it 457

possible for users to become aware of these unconscious bodily responses. Given the 458

nature of today’s mobile phone centric society, engaging games utilised with 459

biofeedback is a very practical means of helping individuals reduce their stress levels 460

in a number of settings. In 1980, for example, Allen and Blanchard provided evidence 461

that biofeedback was capable of reducing levels of stress in business managers. Since 462

then, biofeedback has developed in terms of its practicality and is much more accessible 463

to the public due to the advances in mobile phone technology. 464

465

Most studies, including our own, investigated only short-term interventions using 466

biofeedback and gaming interventions. There is, however, some evidence that these 467

types of interventions can be used for longer term outcomes. Yahav and Cohen (2008) 468

found that an 8-week long intervention for adolescents involving biofeedback 469

combined with a game reduced state anxiety and improved self-esteem. Similarly, 470

Leahy et al. (1998) found that patients with Irritable Bowel Syndrome continued to use 471

a computerized biofeedback game to manage symptoms at long-term follow up after 472

the study despite there being no further contact with the hospital where the study was 473

carried out. More studies are needed to assess the long term efficacy of these types of 474

interventions but these studies indicate the feasibility of game-based biofeedback as a 475

long-term intervention. Similarly, the aim of this study and many others is to assess the 476

efficacy of a game-based biofeedback intervention for stress in a non-clinical sample. 477

There is some indication, however, that game-based biofeedback could be useful for 478

clinical samples as well. Knox, Lentini, Cummings, McGrady, Whearty and Sancrant 479

(2011) found that an 8 week intervention using game-based biofeedback was successful 480

in reducing symptoms of anxiety and depression in a group of 9-17 year olds presenting 481

with clinically relevant symptoms compared to waiting list controls. More studies in 482

this area are needed before recommending interventions for this and other clinical 483

populations but in future it may be possible to use game-based biofeedback as an 484

adjunct therapy for those on waiting lists or between psychological sessions. 485

486

The study indicates the potential efficacy of biofeedback smartphone applications as 487

stress reduction tools. There are, however, a number of limitations to this study. Firstly, 488

although we found a statistically significant difference the size of the effect was 489

relatively small. Secondly, we could not distinguish between the efficacy of the Relax 490

and Race and Loom games and it may be that one was more effective than the other. 491

We chose to use two games in the biofeedback condition to avoid the negative effects 492

of boredom which may have confounded results had we only included one. The control 493

game moved through different levels as participants progressed and thus using two 494

biofeedback games (that did not progress through levels) made this condition more 495

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similar to the control game. However the control and biofeedback interventions did use 496

different games leading to the question as to whether group differences may have arisen 497

because of differences in the games rather than biofeedback. We attempted to control 498

for this by comparing games which were presented on the same medium (ie a 499

smartphone) and both of which had a competitive element involving beating a personal 500

best. The control game was chosen to control for the possibility that mere distraction 501

from a stressful task through gaming would reduce stress. However only participants 502

playing the biofeedback-related games showed a reduction in both heart rate and 503

perceived stress following the stressful task indicating that distraction was not the 504

driving factor in stress reduction. 505

506

A further point to note is that we did not take measurements of heart rate at baseline 507

(prior to the TSST) meaning we do not know what participants’ normal heart rate levels 508

are. However our aim in this study was to create an equivalent state of stress in the two 509

groups and compare change from this stress-state baseline to post-intervention. As can 510

be seen by the mean level of heart rate in the two groups following the TSST 511

(Biofeedback = 78.64 (17.08); Control = 81.08 (18.13)) we achieved similar levels of 512

stress in the two groups. 513

514

Finally, the internal reliability of the energetic arousal subscale was low (α = .42). It is 515

not clear why this was the case, however we did not have a directional hypothesis for 516

this specific subscale and did not find significant changes for the two mood subscales 517

that did show good reliability suggesting that it is unlikely the low reliability for this 518

one subscale significantly affects the overall study findings. 519

520

In conclusion, two 15 minute biofeedback-controlled smartphone games produced 521

significant short-term reductions in psychological and physiological measures of stress, 522

compared to a control smartphone game. This study complements other research and 523

highlights the fact that biofeedback enabled applications offer a potential solution to 524

the demand for efficient, low cost and stigma-reducing interventions in the treatment 525

of stress (Litz & Salters-Pedneault, 2008). Future research may look to test the 526

applications outside of the laboratory environment and for a longer period of time as 527

well as in a clinical population. 528

529

530

531

532

533

534

535

536

537

538

539

540

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542

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Tables and Figure Legends 861

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863 Table 1. 864

The mean and SD for heart rate and stress levels for participants in the biofeedback 865

and control groups before and after they completed the games, are represented in the 866

table. 867

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Figure 1. Perceived stress measurements for participants in the biofeedback and 873

control groups, before and after they completed the games. 874 875

Figure 2. Heart rate measurements for participants in the biofeedback and 876

control groups, before and after they completed the games. 877

Variable

(Possible Range)

Biofeedback Condition

Mean (SD)

Control Condition

Mean (SD)

Perceived Stress Before 5.08 (2.05) 4.94 (1.86) Perceived Stress After 2.5 (1.68) 4.04 (1.97) Heart Rate Before 78.64 (17.08) 81.08(18.13) Heart Rate After 71.84 (13.82) 79.64 (17.89) Hedonic Tone Before 14.84 (3.30) 15.84 (3.16) Hedonic Tone After 14.72 (1.62) 15.60 (2.38) Tense Arousal Before 26.32 (2.67) 24.24 (3.80) Tense Arousal After 27.68 (3.44) 25.36 (4.11) Energetic Arousal Before 26.92 (3.34) 23.20 (3.15) Energetic Arousal After 27.52 (3.90) 23.52 (4.15)

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Figure 01.JPEG

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Figure 02.JPEG

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biofeedback and gaming-style smartphone applications as a … · biofeedback and gaming-style...

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