***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Background Physicians often experience work-related stress that may lead to personal harm and impaired professional performance . Biofeedback has been used to manage stress in various population s. Objective To determine whether a biofeedback-based stress management tool , consisting of rhythmic breathing , actively self-generated positive emotions and a portable biofeedback device , reduces physician stress . Design R and omized controlled trial measuring efficacy of a stress-reduction intervention over 28 days , with a 28-day open-label trial extension to assess effectiveness . Setting Urban tertiary care hospital . Participants Forty staff physicians ( 23 men and 17 women ) from various medical practice s ( 1 from primary care , 30 from a medical specialty and 9 from a surgical specialty ) were recruited by means of electronic mail , regular mail and posters placed in the physicians ’ lounge and throughout the hospital . Intervention Physicians in the intervention group were instructed to use a biofeedback-based stress management tool three times daily . Participants in both the control and intervention groups received twice-weekly support visits from the research team over 28 days , with the intervention group also receiving re-inforcement in the use of the stress management tool during these support visits . During the 28-day extension period , both the control and the intervention groups received the intervention , but without intensive support from the research team . Main outcome measure Stress was measured with a scale developed to capture short-term changes in global perceptions of stress for physicians ( maximum score 200 ) . Results During the r and omized controlled trial ( days 0 to 28 ) , the mean stress score declined significantly for the intervention group ( change –14.7 , st and ard deviation [ SD ] 23.8 ; p = 0.013 ) but not for the control group ( change –2.2 , SD 8.4 ; p = 0.30 ) . The difference in mean score change between the groups was 12.5 ( p = 0.048 ) . The lower mean stress scores in the intervention group were maintained during the trial extension to day 56 . The mean stress score for the control group changed significantly during the 28-day extension period ( change –8.5 , SD 7.6 ; p < 0.001 ) . Conclusion A biofeedback-based stress management tool may be a simple and effective stress-reduction strategy for physicians Biofeedback application is an evidence -based technique to induce relaxation . A primary mechanism of action is the improvement of self-efficacy , which is needed to facilitate the translation of health behavioral intentions into action . Obesity is often associated with low self-efficacy and dysfunctional eating patterns , including comfort eating as an inexpedient relaxation technique . This is the first study investigating the effects of biofeedback on self-efficacy and relaxation in obesity . In the present experiment , 31 women , mean body mass index 35.5 kg/m² , were r and omized to a food-specific biofeedback paradigm , a non-specific relaxation biofeedback paradigm , or a waiting list control . Eight sessions of biofeedback of the electrodermal activity were performed while presenting either a challenging food stimulus or a non-specific l and scape stimulus . Self-efficacy , stress , ability to relax , eating behavior , and electrodermal activity were assessed before , directly after , and 3 months after the intervention . The food-specific biofeedback predominantly showed effects on food-related self-efficacy and perceived stress . The non-specific relaxation biofeedback showed effects on the ability to relax . Self-reported improvements were confirmed by corresponding decrease in the electrodermal reaction to food stimuli .  Biofeedback treatment is effective in improving self-efficacy in individuals with obesity and might therefore be a valuable additional intervention in obesity treatment A large proportion of children experience sub clinical levels of anxiety and cognitive-behavioral therapy ( CBT ) aim ed at preventing anxiety disorders is moderately effective . However , most at-risk children do not seek help or drop out of programs prematurely because of stigma , lack of motivation , and accessibility barriers . Applied games have received increased attention as viable alternatives and have shown promising results , but direct comparisons between applied games and the gold-st and ard CBT are lacking . Our aim was to investigate whether the applied game MindLight is as effective as CBT ( i.e. , Coping Cat ) within an indicated prevention context . We conducted a r and omized controlled non-inferiority trial with a sample of 174 children ( 7- to 12-year olds ) with elevated levels of anxiety  , comparing MindLight to CBT .  Anxiety was assessed with self- and parent-reports at pre- and post-program , and at 3- and 6-month follow-ups . Intention-to-treat and completers-only confidence interval approach and latent growth curve modeling showed an overall significant quadratic decrease in child- and parent-reported anxiety symptoms over time and , as predicted , the magnitude of improvement was the same for MindLight and CBT . The within-group effect sizes were small to medium at post-test ( − 0.32 to − 0.63 ) , and medium to large ( − 0.60 to − 1.07 ) at 3- and 6-month follow-ups . Furthermore , MindLight and CBT were rated equally anxiety inducing , difficult , and appealing ;  CBT was rated as more relevant to daily life than MindLight . The current study adds to the growing research on applied games for mental health and shows that these games hold potential as alternative delivery models for evidence -based therapeutic techniques Although r and omized studies have high internal validity , generalizability of the estimated causal effect from r and omized clinical trials to real-world clinical or educational practice may be limited . We consider the implication of r and omized assignment to treatment , as compared with choice of preferred treatment as it occurs in real-world conditions . Compliance , engagement , or motivation may be better with a preferred treatment , and this can complicate the generalizability of results from r and omized trials . The doubly r and omized preference trial ( DRPT ) is a hybrid r and omized and nonr and omized design that allows for estimation of the causal effect of r and omization versus treatment preference . In the DRPT , individuals are first  r and omized to either r and omized assignment or choice assignment . Those in the r and omized assignment group are then r and omized to treatment or control , and those in the choice group receive their preference of treatment versus control . Using the potential outcomes framework , we apply the algebra of conditional independence to show how the DRPT can be used to derive an unbiased estimate of the causal effect of r and omization  versus preference for each of the treatment and comparison conditions . Also , we show how these results can be implemented using full matching on the propensity score . The methodology is illustrated with a DRPT of introductory psychology students who were r and omized to r and omized assignment or preference of mathematics versus vocabulary training . We found a small to moderate benefit of preference versus  r and omization  with respect to the mathematics outcome for those who received mathematics training Flaws in the design , conduct , analysis , and reporting of r and omised trials can cause the effect of an intervention to be underestimated or overestimated . The Cochrane Collaboration ’s tool for assessing risk of bias aims to make the process clearer and more Objective : Chronic pain is an emotionally and physically debilitating form of pain that activates the body 's stress response and over time can result in lowered heart rate variability ( HRV ) power , which is associated with reduced resiliency and lower self-regulatory capacity . This pilot project was intended to determine the effective-ness of HRV coherence biofeedback ( HRVCB ) as a pain and stress management intervention for veterans with chronic pain and to estimate the effect sizes . It was hypothesized that HRVCB will increase parasympathetic activity result ing in higher HRV coherence measured as power and decrease self-reported pain symptoms in chronic pain patients . Study design : Fourteen veterans receiving treatment for chronic pain were enrolled in the pre-post intervention study . They were r and omly assigned , with 8 subjects enrolled in the treatment group and 6 in the control group . The treatment group received biofeedback intervention plus st and ard care , and the other group received st and ard care only . The treatment group received four HRVCB training sessions as the intervention . Measures : Pre-post measurements of HRV amplitude , HRV power spectrum variables , cardiac coherence , and self-ratings of perceived pain , stress , negative emotions , and physical activity limitation were made for both treatment and control groups . Results : The mean pain severity for all subjects at baseline , using the self-scored Brief Pain Inventory ( BPI ) , was 26.71 ( SD=4.46 ; range=21—35 ) indicating a moderate to severe perceived pain level across the study subjects . There was no significant difference between the treatment and control groups at baseline on any of the measures . Post-HRVCB , the treatment group was significantly higher on coherence ( P=.01 ) and lower ( P=.02 ) on pain ratings than the control group . The treatment group showed marked and statistically significant ( 1-tailed ) increases over the baseline in coherence ratio ( 191 % , P=.04 ) and marked , significant ( 1-tailed ) reduction in pain ratings ( 36 % , P<.001 ) , stress perception ( 16 % , P=.02 ) , negative emotions ( 49 % , P<.001 ) , and physical activity limitation ( 42 % , P<.001 ) . Significant between-group effects on all measures were found when pre-training values were used as covariates . Conclusions : HRVCB intervention was effective in increasing HRV coherence measured as power in the upper range of the LF b and and reduced perceived pain , stress , negative emotions , and physical activity limitation in veterans suffering from chronic pain . HRVCB shows promise as an effective non-pharmacological intervention to support st and ard treatments for chronic pain BACKGROUND Patients with coronary heart disease ( CHD ) who experience depressed mood or psychological stress exhibit decreased vagal control of heart rate ( HR ) , as assessed by spectral analysis of HR variability ( HRV ) . Myocardial infa rct ion and sudden cardiac death are independently associated with depression and stress , as well as impaired vagal HR control . This study examined whether a behavioral neurocardiac intervention to reduce stress or depression can augment cardiovagal modulation in CHD patients . We hypothesized that ( 1 ) cognitive-behavioral training with HRV biofeedback would augment vagal recovery from acute stress , and ( 2 ) vagal regulation of HR would be inversely associated with stress and depression after treatment . METHODS This r and omized controlled trial enrolled 46 CHD patients from 3 clinics of CHD risk reduction in Toronto and Vancouver , Canada . Subjects were r and omized to five 1.5-hour sessions of HRV biofeedback or an active control condition . Outcome was assessed by absolute and normalized high-frequency spectral components ( 0.15 - 0.50 Hz ) of HRV , and by the Perceived Stress Scale and Centre for Epidemiologic Studies in Depression scale . RESULTS Both groups reduced symptoms on the Perceived Stress Scale ( P = .001 ) and Centre for Epidemiologic Studies in Depression scale ( P = .004 ) . Hierarchical linear regression determined that improved psychological adjustment was significantly associated with the high-frequency index of vagal HR modulation only in the HRV biofeedback group . Adjusted R 2 was as follows : HRV biofeedback group , 0.86 for stress ( P = .02 ) and 0.81 for depression ( P = .03 ) ; versus the active control group , 0.04 ( P = .57 ) and 0.13 ( P = .95 ) , respectively . CONCLUSION A novel behavioral neurocardiac intervention , HRV biofeedback , can augment vagal HR regulation while facilitating psychological adjustment to CHD Introduction : Stress is one of the leading global causes of disease and premature mortality . Despite this , interventions aim ed at reducing stress have low adherence rates . The proliferation of mobile phone devices along with gaming-style applications allows for a unique opportunity to broaden the reach and appeal of stress-reduction interventions in modern society . We assessed the effectiveness of two smartphone applications games combined with biofeedback in reducing stress . Methods : We compared a control game to gaming-style smartphone applications combined with a skin conductance biofeedback device ( the Pip ) . Fifty participants aged between 18 and 35 completed the Trier Social Stress Test . They were then r and omly assigned to the intervention ( biofeedback game ) or control group ( a non-biofeedback game ) for thirty minutes . Perceived stress , heart rate and mood were measured before and after participants had played the games . Results : A mixed factorial ANOVA showed a significant interaction between time and game type in predicting perceived stress [ F(1,48 ) = 14.19 , p < 0.001 ] . Participants in the biofeedback intervention had significantly reduced stress compared to the control group . There was also a significant interaction between time and game in predicting heart rate [ F(1,48 ) = 6.41 , p < 0.05 ] . Participants in the biofeedback intervention showed significant reductions in heart rate compared to the control group . Discussion : This illustrates the potential for gaming-style smartphone applications combined with biofeedback as stress reduction interventions The aim of this study was to examine the effect of resonant breathing biofeedback training for reducing stress among manufacturing operators .  Resonant breathing biofeedback works by teaching people to recognize their involuntary heart rate variability and to control patterns of this physiological response . Thirty-six female operators from an electronic manufacturing factory were r and omly assigned as the experimental group ( n = 19 ) and the control group ( n = 17 ) . The participants of the intervention received 5 weekly sessions of biofeedback training .  Physiological stress profiles and self-perceived depression , anxiety , and stress scale ( DASS ) were assessed at pre- and post-intervention . Results indicated that depression , anxiety 
    Output:
    
Nevertheless , there is preliminary evidence that the use of biofeedback can improve both physiological and psychological indicators of stress .
Biofeedback could provide an accessible and low-cost addition to stress interventions .