Heart Rate Variability for Mind-Body Health and Athletic Performance with Karen Mueller, PT, DPT, PhD

Welcome back to the Healing Pain Podcast with Karen Mueller, PT, MCSP

We’re discussing heart rate variability for mind-body health, as well as athletic performance. Our expert guest is Professor Karen Mueller. Karen is a professor in the Department of Physical Therapy at Northern Arizona University and the author of the book, Communication from the Inside Out: Strategies for the Engaged Professional. With a career-long interest in the promotion of mind-body health throughout the lifespan, she has published and presented in the areas of mindfulness and brain-based communication strategies to support optimal living. Karen’s current research involves the study of compassion among healthcare students and burnout among physical therapy students. You’ll learn all about the importance of measuring heart rate variability, how training heart rate variability can help improve athletic performance and the importance of heart rate variability for both physical and mental wellbeing.

Before we begin, I wanted to let you know that my newest book called Radical Relief: A Guide to Overcome Chronic Pain, is available for pre-order on Amazon. Radical Relief is based on three science-backed methods, including pain, neuroscience education, Acceptance, and Commitment Therapy, and mindfulness, a topic which we’ll be discussing on this episode. Radical Relief is perfect for practitioners who treat chronic pain or for people living with pain, and it’s filled with brief exercises that use the power of the mind as well as easy to read chapters with full-color illustrations. Without further ado, let’s meet Professor Karen Mueller and learn all about heart rate variability.

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Heart Rate Variability for Mind-Body Health and Athletic Performance with Karen Mueller, PT, DPT, PhD

Karen, welcome. It’s great to have you here. It’s great to be here. Thanks for having me.

Karen, I love looking through your research. I’ve read your entire bio, but you’ve been a practicing physical therapist for several years. Probably about 30 of those years, you’ve been involved as a professor at a Doctorate program of Physical Therapy. You’ve got a vast range of knowledge and experience, seeing as you go from a Bachelor’s program to a Master’s to the DPT and doing the amazing work that many physical therapists are doing in the United States of America and around the globe to help people. A lot of what you talk about revolves around communication. Helping physical therapists be effective communicators, using principles of mindfulness as part of that. What led you to that discovery and to the interest with regard to communication?

It’s funny, I always like talking about this because I think it’s interesting to locate people’s interests in their background. I grew up in a family of psychiatrists. I had a father who was a psychiatrist and an uncle who was a psychiatrist, and eventually, my brother became one. I remember asking my dad, “What do you talk about in your sessions?” He kept patient confidentiality, but he said, “What I find is that people are either unhappy in their relationships and that’s related to poor communication, or they’re unhappy in their work.” In many of those cases, depression and some mental illness is a big factor, but underlying that is often a failure to communicate effectively. That struck me.

I would have become a psychiatrist myself, except I recognized early in my life that I’m too extroverted to do that and I don’t think I can sit all day and listen to people, but I never lost my interest in connecting the mind to the body. My years of PT school are faded memories, except for a class that I had with the medical school at the University of Missouri where I got my Bachelor’s degree and we were lucky enough to have a couple of professors who taught the medical students. One of the courses was Human Ecology. He started talking about an evolving field called health and wellness. I remember looking up at him going, “That is what I want to do.”

I have taken that interest in my profession. After I graduated in 1979, I took my first position at the Rehabilitation Institute of Chicago. I was 22. Here are people my age, we’re on the same street I was, but they got in the car accident, I didn’t. There was a lot of emotional adaptation to that which strengthened my interest in connecting with people deeply and meaningfully. I volunteered for the sexuality committee because I saw that as an area where communication is not happening. I did that as I worked at the Rehabilitation Institute of Chicago. I eventually became their center coordinator for clinical education. Teaching was my other passion. From my father, sneaking into his lectures on human sexuality in PT school was a highlight. I’ve taken the interest that my father instilled in me and have taken it through my career.

HPP 208 | Heart Rate Variability
Communication from the Inside Out: Strategies for the Engaged Professional

When I think back to my experience as a physical therapist, I was accepted into PT school in 1995. To get into school, you had to have two psychology courses. You had to have general psychology, abnormal psychology, and the psychology of the disabled. Those were the three prerequisites at that time. In PT school, there wasn’t a tremendous amount with regard to the psychosocial variables like we have in DPT programs. Have you seen that evolution when you’re on there and teaching?

Absolutely. I was fortunate enough when I took the position at Northern Arizona University to be able to teach those classes, Clinical Communication and Psychosocial Elements and Disability in particular. I realized quickly, there was no textbook. Carol Davis had a great one and I will shout-out to her for her Patient Practitioner Interaction book. I wanted to take her work and expand it to my own research. What got me to write the textbook Communication from the Inside Out was my Ph.D. research in work satisfaction among physical therapists. I looked at, “How long did you leave the profession? How satisfied were you with the profession? If you weren’t satisfied, what was getting in the way?” What I found is that it was all communication.

It was communication at the team level, at the intercollegiate level, working with colleagues and it was your own attitude. I developed a three-level communication strategy, internal communication, which is what you tell yourself, which affects how you talk with others. If you’re not empowered in those dialogues, you’re not going to move to the higher level, which is instrumental education, which is the teaching. That’s the model of my book. I don’t track at the success that well, but I have been to PTA educational meetings where people have talked to me about the book. I hope it’s been helpful. I had fun writing it.

In addition to the psychosocial variables, communication, and mindfulness, you also have done some research with regard to heart rate variability. You have a great paper that you did. Tell us first what heart rate variability is.

You do an EKG, that tells you your heart rate, but what we’re not able to pick up unless you have sophisticated instrumentation is the beat-to-beat interval between ours and the EKG. That varies by milliseconds. Undetectable, unless you were in a 12-lead EKG or use another form of instrumentation. The variability of that is a level of responsiveness within the central nervous system, particularly the parasympathetic nervous system. Heart rate variability is a measure of homeostasis. If you have low heart rate variability, we want low cholesterol, but we don’t want low heart rate variability, because what that suggests is that you are stuck in a rigid pattern of lack of responsiveness. What we’re learning with the research is that relates to a higher level of sympathetic drive.

If you think about being stressed all the time, your inability to return to a baseline is evidence of a lack of flexibility within the parasympathetic nervous system. High heart rate variability means that you are able to put your parasympathetic nervous system online when you need to. I got interested in that because part of my upbringing too was learning how to meditate. My father and I, my brother, all took the early transcendental meditation, but I was interested in, “How do we know if it’s working? I feel good, but how do we know?” When I learned about heart rate variability, I was interested because there is a robust biomarker. If you think about biomarkers that we use, they usually involve a blood draw or they involve some other sophisticated instrumentation. What we know is HRV can be measured on your smartphone. We can give you an indication of your homeostasis and it may be able to do that before your body knows it, or it can correlate if you’re feeling cruddy, it gives you an explanation.

HPP 208 | Heart Rate Variability
Low heart rate variability suggests that you are stuck in a rigid pattern of lack of responsiveness.


Our interval is important for practitioners to look at. It’s a measure of your parasympathetic nervous system response. It’s a biomarker that can be measured in a way that’s non-invasive, and you can use your smartphone. All of that is so important, both for people who are interested in their health and wellness as well as professionals, because what you’re saying is as licensed health professionals, we can take that basic cardiopulmonary knowledge that we all learned in physical therapy school and start to translate that to practice in a way that’s beneficial for people with regard to modulating their sympathetic, parasympathetic nervous system.

To give you an idea of what you’re reading, how do we measure HRV? There is a sophisticated logarithm, but it’s based on the Mean Root Square of Successive Differences, MRSSD. It’s a logarithm related to a mean of those R-R intervals and then the logarithm converts it to a score between 1 and 100. If you have high HRV, you’re going to have a higher RMSSD, and it will come out depending on what instrument you’re using, 1 to 10, 1 to 100, there’s not a whole lot of research on what means are, but there are enough that you can get a general idea of what you’re trying to aim for. Higher is better. There are some subtle changes related to age and gender too that are slightly different, but those are mean.

With regard to overall health and wellbeing, both physical wellbeing, as well as emotional and mental wellbeing, heart rate variability is important for what type of populations we might see in clinical practice and what type of conditions that people are looking to obviously overcome and mitigate?

It has applicability to a wide number of populations. A big thing is an athletic performance. Avoiding over-training. Avoiding that non-functional overreach where you work a little bit harder in the hope of increasing your performance, but you go too far. Constantly dropped HRV will tell you, “You’re getting into that dangerous zone. You should back off.” I’m an athlete, you probably are too. You want to keep going on, and you have those days where you work out against your better knowledge. Having that number in front of you can be helpful. There’s the athletic population. Chronic pain, we’re learning more about what happens. You would imagine that people with chronic fatigue syndrome are starting to look at HRV in that population as well. We’re seeing similar things. What’s interesting they’re often exhausted, then you can see changes in their baseline HRV turning downward.

You started to talk about elite athletes, and I know you did a paper. I want everyone to check out this paper. It’s in the Cardiopulmonary Physical Therapy Journal, 2019. It’s called Heart Rate Variability Biofeedback Improves Sports Performance in an Elite Female Athlete. It’s a great case study. There’s a tremendous amount of not only useful back information here, but also useful information for people to use in clinical practice. Tell us why you decided to conduct this case report.

I’ve been experimenting with HRV meditation myself. I’m always willing to try new things. I had been using an application called Inner Balance from HeartMath. It is an application you download on your phone, and then you attach an ear clip to your phone, and it uses a plethysmographic reading of your HRV on your ear. It also cues your breathing, because we know that we can activate our vagus nerve and our parasympathetic nervous system by slow breathing. We have a name for that called resonance frequency breathing, which is a breath rate of about six per minute. You can count 5 in, 5 out, to have the application was useful. I think this is interesting.

I would love to do a case study and I had this student who was trying to improve her own athletic performance. I asked her, “Would you be interested in doing this?” Laura was an elite athlete who barely misses the Olympics by five minutes. This is a high-level athlete, plus she was a DPT student. Those of you who are new grads of MPT school, need I say more about the stress of PT school. Here she was trying to keep up her twice-daily regimen. It seemed like a perfect opportunity to assess whether this could be helpful to her. We let her pick the parameters, “What is it you want to measure?” She said, “I want to measure school stress. I want to measure my sense of subjective performance. Do I feel better working out and do I have better post-workout energy?” Those are the three things we tracked.

What we did is she did four weeks of baseline where she did a regular workout and recorded her stress. We had a spreadsheet where she recorded those three parameters. We took a week break and then we did another four weeks of fifteen minutes a day, the Inner Balance HRV meditation.

She chose to do it at night. It doesn’t matter when you do it. We got some interesting results out of this. One thing we noticed she increased her workout time. She didn’t mean to do that. It wasn’t the plan, but she had and her post-workout stress drops significantly. Her median HRV went up significantly, and she had more days of peak performance where she felt like, “This I’m on.” She had twice as many subjective ratings of high morning readiness.

The other thing I needed to add, how do we measure HRV with her? She’s doing the meditation, but we needed to measure her HRV. We used an application that you could use in a clinical practice called Elite HRV. It involves a chest strap and a smartphone application, and it provides you a morning readiness score between 1 and 10, which is related again to that logarithm. She rated her morning readiness. She did that through trial A and trial B so that we could compare her HRVs during the baseline and during her meditation. The only thing that changed in the experimental part was her doing the meditation.

HPP 208 | Heart Rate Variability
In positive psychology, gratitude is one of the best emotions to focus on.


Tell me about the morning readiness a bit more. What does that mean?

It’s a logarithm. Elite HRV was developed by people who were involved in athletic performance. Out of 1 to 10, 1 to 3 is considered low morning readiness. You should do something a little bit different. Maybe relax, take a break. Four to six is medium, go at your normal, don’t go over it. Seven to ten is high, go for it.

She is ready to start her day and potentially engage in more training.

You have to get an accurate HRV rating. The literature is consistent in saying that you should do it supine first thing in the morning. No coffee, get up, do that first, so you’ve got your baseline for the day. In order to use it to titrate your training, it is recommended that you do that for two weeks so that you have a baseline. We did it for four.

You have your baseline, then you can raise your morning readiness as you’re using the application or using the training that you use in the study. You mentioned that her heart rate variability increased, which is positive, which means that she’s more able to enter a parasympathetic response which can be helpful for recovery with regard to physical activity.

Her ability to have a better sense of workout energy, post-workout performance, and increase the amount of time. She was working out 638 minutes a week in trial A. It went up to 747 minutes a day because she felt good.

That’s pretty crazy, that alone and being in DPT school. You’re taking a subject that is under stress, especially a somewhat psychological-emotional load that’s high in DPT school. You’re proving with this app and with that heart rate variability and breathing intervention, that wasn’t necessarily a factor in her training.

We found her school stress stayed high, but everything else improved. There’s a caveat to that because we did this in the spring when students are getting ready for a comprehensive exam. The most stressful time in PT school is the second year before you go on internships. Many people decompensate. She stayed stable. To me, that is a good outcome.

The athletic part is fascinating to me, but as I’m reading the study, I was like, “This has implications just for DPT students and other types of students who are under stress in general, which is important.”

I teach mindfulness to my students and my communication class because I see that as a critical internal communication skill. I tell them about this instrumentation. A lot of them pick it up on their own. If you’re interested in seeing how this works, because there are always people who don’t buy into it, this is useful. Wouldn’t it be cool if we all use that as our daily biomarker? We might use it to get out of work when we should, but it gives you guidelines which I love of days where you can go out there and it’s game day.

Tell us what she had to do because she was only involved in this for fifteen minutes a day, five days a week. Walk us through piece by piece what did she do to engage her heart rate variability. With regard to the breathing aspect of it, what did she have to do?

What the app allows you to do is provides a mandala that changes color or changes tone when your HRV gets higher or lower. You can use the auditory signal while you are breathing. Ideally with the HeartMath, what they believe, and I think there’s truth to it, you breathe slowly and you also engage positive emotions. We know there’s a direct connection between the parasympathetic nervous system and positive emotion through the ventral vagus. What she told me she would do is she would sit up in her bed before she went to sleep, put the clip on her ear, and breathe for fifteen minutes. That’s how she did the meditation. Listening to the tone whenever it goes, whenever you were getting an indication that it wasn’t good, then you could read again or bring your attention back to positive emotion. You always had an anchor.

She engaged in the breathing exercise for fifteen minutes and there was some positive reappraisal that was part of that experience.

What’s interesting is that Barbara Fredrickson’s work in positive psychology, another favorite area for me, that gratitude is one of the best emotions to focus on, what you’re thankful for.

HPP 208 | Heart Rate Variability
Focusing on something you like is one way to deal with anxiety.


What I love about this study is that it’s quite simple, not the analysis is not simple. You put a lot of work into the study design and the analysis and describing everything that is associated with heart rate variability. That’s the science part that you’re brilliant, but the actual intervention itself is quite simple. You mentioned you teach mindfulness to your students. Is that something we should adopt more in the world of physical therapy?

Yes, absolutely. I am a health coach too, Joe. I believe that one of the elements of health is stress. If I’ve got a patient with me who’s stressed, meditation can be so helpful. I can give you a concrete example. I had a young patient with a stroke who is recovering well, except for dynamic balance. Working with her, I began to notice how anxious she would get when she was confronted with a balance challenge. I said, “Do you think perhaps it is your anxiety that’s getting in the way?” She’s like, “Absolutely, I’m so nervous.” We started, it’s so low tech, I’m like, “How would you want to practice using breathing to calm yourself so that maybe you can attenuate some of that anxiety.” She was all over it. We found a simple guided meditation on YouTube. I tell my students to find something you like. Find a voice you like. She did that and it made a remarkable difference.

That relates well to the research with regard to pain as well, because pain-related anxiety or fear associated with pain has a lot to do with how it impacts our physical function.

I haven’t done as much work in chronic pain as you have, but what I have found is that not only is there a sense of pain, but there’s almost a sense of aversion to that body part. It’s like, “Can you allow it?” A lot of it, for physical therapists, it’s the languaging we use. You don’t have to do anything but notice and follow it. Where does it go? You engage their curiosity if you can make an adventure and get their head out of the pain part of it. I’ve played with that as well. I haven’t studied it specifically, but it could be useful.

Another part of your study which I found refreshing is that without saying it specifically, it puts the mind and the body together. As physical therapists, we’re not throwing the body out. We study cardiopulmonary physical therapy. We understand the function of the cardiovascular system and how important the pulmonary system is. We understand the biomechanics behind sports. With that intervention and with the help of the app, it’s creating a mind-body, body-mind continuum to help someone with, in this case, sports enhancements, sports performance. In a lot of ways, also with regard to stress, with regard to school and being able to handle a large load of work in DPT school. Why in our profession do you think using the mind is still considered a radical idea?

I hope we’re past that, but when we started talking about soft science and hard science, I think that started the whole thing. I heard that in PT school and perhaps you did too. As a PT student, you’re concerned about the heart science, because those are the grades are. What I’m learning to call it is, let’s not call it soft science or soft skills. Let’s call it success skills. I engage my students in dialogue about who are the people you admired most in the profession? Are they good communicators or are they the top clinicians? When they learn how important that is, there’s evidence. There wasn’t when I was in PT school. There is so much compelling evidence. I gave a lecture on the impact of adverse childhood events. We did not know this. We did not know that the health issues of our patients and even ourselves are related to what we experienced as children. As this science comes out, it becomes hard to ignore that you have got to think about this, or you’re not doing a good service to your patients.

It’s no longer an option at that point?

In my mind, it’s never been an option. I was seeing what my father dealt with, but I am so grateful that there is a community of people who are looking into this and are sharing this information. This is what got me interested in pursuing health coaching. This is another interesting thing as we’re getting more into that as physical therapists. We’ll come full circle and that will be truly the art of science. The art of caring and the science of healing as we’ve always talked about.

The cognitive change process is so important with regard to every population we see in physical therapy and physiotherapy across the globe. It’s wonderful. It’s great to see you put all this together in a nice case study. Case studies are so useful for a clinical practice where therapists can read this and say, “I have a similar patient to this I can try this with. I have a patient that is not exactly like this, but I think this might work,” and they can apply that.

That’s what I wanted to do with this. To also assure them, you’ll do no harm. If somebody is deeply traumatized, we’re not trying to get into the realm, but I think that’s another concern. Are we going to start becoming counselors? We should do a lot of support and a lot of listening, and through that astute support and listening, we know when it’s time to refer. We can do more good by connecting our patients. We can be better interprofessional collaborators if we listen to our patients.

HPP 208 | Heart Rate Variability
Interprofessional collaboration can be improved by listening to our patients.


Karen, it’s been great speaking with you. How can people learn more about your work and your information and how can they follow you?

I am at NAU, [email protected]. I often get emails after I give talks. I am in the Wellcoaches’ site of certified coaches. I’m not a social media cult. I speak often at APTA conferences. Probably every other year, I give a talk at APTA. The other area that I’ve been involved in because it’s such a deep area of connection is end-of-life care. I am on the advisory board for the Hospice and Palliative Care Special Interest Group through the Academy of Oncology. We meet every year at CSM.

With regard to Professor Karen Mueller’s episode, you can find her by going to the website. You can look up the physical therapy faculty and staff at Northern Arizona University. Her bio is there, as well as information to contact her. I want to thank Professor Mueller for joining us. Make sure to share this episode out with your friends, family, and colleagues who are interested in mindfulness and heart rate variability, biofeedback, and how it relates to sports performance, as well as health and wellness.

Important Links:

About Karen Mueller, PT, DPT, PhD

HPP 208 | Heart Rate VariabilityKaren Mueller is a Professor in the Department of Physical Therapy and Athletic Training at Northern Arizona University, where she has served since 1987. She is the author of Communication from the Inside Out: Strategies for the engaged professional. (FA Davis, 2010). With a career-long interest in the promotion of mind-body health throughout the lifespan, Karen has published and presented in the areas of end of life care, mindfulness, and brain-based communication strategies to support optimal wellbeing. Karen’s current research involves the study of compassion among healthcare students and a longitudinal study of factors contributing to burnout among physical therapy students.

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