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Ann. psychophysiol. 
ISSN 2412-3188 (Online) | 2410-1354 (Print) 

APP| Published By AEIRC| https://doi.org/10.29052/2412-3188.v9.i1.2022.56-63 

 
Protocol                                                                                  

Effect of EMG, RESP, and TEMP Biofeedback 
Training to reduce Anxiety among 
Undergraduate Students 
Ujala Sajid1,3 , Shamoon Noushad2,3  & Sadaf Ahmed1,3  
1Department of Physiology, University of Karachi, Karachi-Pakistan.  
2Department of Psychology, Malir University of Science & Technology, Karachi-Pakistan.  
3Psychophysiology Research Lab, M.A.H.Q. Biological research center, University of Karachi,  
Karachi-Pakistan.  
 

Abstract 
Background: It is evident that anxiety and stress are two of the main predominant 
issues that cause several mental health problems and disorders in university 
students, causing a negative impact on this population. Higher educational 
institutes in Pakistan have limited access and resources to face these issues. It is 
suggested that biofeedback-aided relaxation training has been effective in 
alleviating anxiety and stress symptoms among undergraduate students, 
especially during their examination season. Recent research has proven 
biofeedback to be effective training for anxious students. The current randomized 
control trial is planned to investigate the effectiveness of Electromyography-EMG, 
Respiration Rate-RESP, and Skin Temperature-TEMP biofeedback training for 
reducing anxiety symptoms among nursing students be receiving 8 sessions for 4 
weeks. 
Methodology: This study is planned to investigate the effectiveness of EMG, 
RESP, and TEMP Biofeedback Training in reducing symptoms of anxiety among 
the nursing students from one school, and to determine whether biofeedback 
training is associated with relaxing the minds and bodies of the anxious nursing 
students to cope with the distressing situation. Study subjects meeting the 
eligibility criteria will be randomized into two groups using randomly generated 
numbers: the Biofeedback training group and the Control group. Biofeedback 
training will be used as an intervention vs. the control. All the study subjects who 
give consent to participate will be made to complete the study questionnaires 
(Demographic, Screening for Anxiety using the State-Trait Anxiety Inventory –
STAI) at baseline and post-intervention (after 4 weeks). 
Discussion: This study might help us determine biofeedback as a possible effective 
and useful technique in helping nursing students manage their anxiety. Moreover, 
it is suggested that Individuals receiving biofeedback training tend to show 
significant changes for the three psychophysiological modalities, i.e., EMG, RESP, 
and TEMP. This study might also give us insight into the efficacy of biofeedback 
in the Pakistani population seeking help for stress and anxiety. 

Keywords 
Biofeedback Training, Anxiety, Nursing Students, EMG, Respiration, 

Temperature. 

Citation: Sajid U, Noushad S, Ahmed S. 
Effect of EMG, RESP, and TEMP 
Biofeedback Training to reduce Anxiety 
among Undergraduate Students. APP. 
2022;9(1):56-63 
 
Corresponding Author Email: 
ujalasajid97@gmail.com 
 
DOI: 10.29052/2412-3188.v9.i1.2022.56-63 
 
Received 10/04/2022 
 
Accepted 12/05/2022 
 
Published 01/06/2022 
 
Copyright © The Author(s). 2022 This  
 is an open access article distributed 
under the terms of the Creative 
Commons Attribution 4.0 International 
License, which permits unrestricted use, 
distribution, and reproduction in any 
medium, provided the original author 
and source are credited.  
 

 

Funding: The author(s) received no 
specific funding for this work. 

Conflicts of Interests: The authors have 
declared that no competing interests 
exist. 
 

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Introduction  
Biofeedback is a process/technique in which 
an individual can see the real-time recording 
of one or more physiological systems. 
Information from the psychophysiological 
recording from biofeedback training can be 
used to help manage several physical and 
mental health issues with optimal 
functioning. Biofeedback helps manage 
several disorders/diseases, including stress, 
depression, anxiety, pain, urinary 
incontinence, etc1. Using biofeedback, one 
can learn to control the physical and 
psychological effects of stress, anxiety, and 
depression. Moreover, it helps people relax 
their minds and bodies to cope with the 
distressing situation. 
 
The normal reaction of the body to stress is 
anxiety. It is a sensation of dread for what is 
ahead. Most people may experience dread 
and nervousness on the first day of school, 
during a job interview, before tests, or when 
giving a speech2. It is suggested that anxiety 
belongs to a group of mental health 
diagnoses that cause excessive trepidation, 
fear, worry, or apprehension2,3.  Studies 
suggest that computer-based biofeedback 
systems help reduce anxiety in college and 
university students. Moreover, nursing 
students experience anxiety and stress 
throughout their education and training. 
Several factors might increase their anxiety, 
including academic, clinical, financial, 
interpersonal, family, physical and mental 
health issues. Above all, poor coping skills of 
an individual may contribute the most to 
developing anxiety3-5. Several studies have 
shown effective and significant use of 
biofeedback in reducing anxiety symptoms 
in undergraduate and nursing students4,5. 
 
The transition to university happens for 
most students near the end of adolescence, a 

period marked by mental instability due to 
the need to cope with psychological and 
psychosocial changes6. Although reasonable 
amounts of stress are prevalent and 
adaptable in students' lives, excessive and 
ongoing stress may be linked to increased 
anxiety, and depression symptoms, among 
other manifestations7,8. The effects of 
psychological morbidity far-reaching effects, 
not only on students' health, development, 
scholastic success, and quality of life, but it is 
suggested to extend to their families, 
institutions, and even other people's lives9. 
Depression and anxiety are two of the most 
typical psychological responses to stressful 
events encountered in university. During 
these times, students may experience a 
variety of emotional disturbances, including 
an increase in depressive and anxiety 
symptoms, which may drive them to engage 
in incorrect coping strategies, self-
medication, or needed professional care10.   
 
Regarding biofeedback, limited research 
using this on students has been conducted 
but has shown promising results. A 
computer-based biofeedback system was 
found to be beneficial in lowering anxiety in 
college students by Henriques et al. in 2011, 
and they recommended an interventional 
decrease in anxiety levels11. In a similar vein, 
research indicates that EMG biofeedback 
and relaxation training may help students 
avoid anxiety-related academic failures and 
that therapy sessions can successfully lessen 
physical and mental signs of worry12. 
Similarly, experimental studies show lower 
state anxiety in the experimental group 
compared to the control when augmented 
with GSR biofeedback13. Similarly, 
biofeedback-assisted relaxation training, 
including diaphragmatic breathing and 
progressive muscle relaxation training, is 
also shown to help improve physiological 
measures using an influential training 



 
 
 

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strategy, improving respiratory, skin, 
temperature, and pulse rate of the nursing 
students14. Still, the effectiveness and 
efficacy of Biofeedback intervention training 
compared to other intervention training and 
programs are under discussion, and studies 
are being done to investigate whether it is 
effective in reducing anxiety traits and stress 
among undergraduate students. This 
randomized control trial aims to investigate 
the effectiveness of biofeedback training for 
reducing anxiety symptoms among the 
nursing students who are associated with 
anxiety. 
 

Methodology 
Study Design 
This study will be conducted as a 
randomized control trial using subjects from 
one nursing school. Study subjects meeting 
the eligibility criteria will be randomized 
into two groups: the Biofeedback training 
group receiving EMG, RESP, and TEMP 
Biofeedback Training. While second group is 
the Control group in which subjects will be 
asked to take three 20-minute writing 
sessions and write about the given control 
topic about their daily events of the past 
week. All the study subjects providing the 
consent to participate will be made to 
complete the study questionnaires 
(Demographic, Screening for Anxiety using 
the State-Trait Anxiety Inventory –
STAI)15,16,17 at baseline and post-intervention 
(after 4 weeks). 
 
Ethical Concerns 
The study protocol was consulted and 
approved by AEIRC Committee on Ethics 
with the approval number ERC/S20/P-015. 
And registered by the Clinicaltrial.gov 
(Registration number  NCT05508919) 
 
Participants 
Study participants will be recruited from the 
School of Nursing, Koohi Goth Women 

Hospital, Karachi-Pakistan. Students from a 
variety of ethnic backgrounds who reported 
to be anxious during the pre-screening 
utilizing the anxiety scale will make up our 
targeted population and will be consider 
eligible for participation. Through an 
advertisement on the institute's notice board, 
students would be contacted and asked to 
take part in the study. Each participant will 
be informed of the study's aims, length, and 
purpose before obtaining their written 
consent. 
 
Eligibility Criteria 
Inclusion Criteria 
All subjects fulfilling the below given criteria 
will be included. 
1. The subject must not have any evidence of 

any metastatic disease. 
2. Must be able to properly write and speak 

Urdu or English Language. 
3. Must be a first- or second-year student. 
4. Should have high anxiety that will be 

assessed using the State-Trait Anxiety 
Inventory-STAI. 
 

Exclusion Criteria 
1. The subject must not have any evidence of 

any metastatic disease. 
2. Must be able to properly write and speak 

Urdu or English Language. 
3. Must be a first- or second-year student. 
4. Should have high anxiety that will be 

assessed using the State-Trait Anxiety 
Inventory-STAI. 

 
Study participants who match the 
requirements will be randomly divided into 
two groups: the Biofeedback training group 
and Control group 
 
Interventions 
The experimental intervention 
The Alive Pioneer with the GP8 Amp 
(Biofeedback device) will be used for this 
study. GP8 Amp can record ECG Heart Rate, 



 
 
 

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EMG for muscle tension, Hand 
Temperature, and Skin conductance. 
 
The sequence of the biofeedback training 
sessions is given below: 
 

1. Subjects in this group will get 
biofeedback intervention training. 

2. The training consists of a total of 8 
sessions for every individual, with 2 
sessions per week for 4 weeks.  

3. Each session will be approximately 1 to 
1.30 hours. 

4. Subjects will be instructed not to use 
chocolate, coffee, tea, and cocoa drinks 
at least 3 hours before the training 
session. 

5. Since it is suggested that anxiety tends 
to change with time so we might 
consider a one-month pretreatment 
measure as well as a just before 
treatment measure; that way, we can be 
sure if our baseline is stable or not. 

6. Baseline session: The subject will be 
asked to sit quietly for 15 minutes, and 
their breathing rate, skin temperature, 
and muscle tension using EMG will be 
measured without any intervention. 

7. Subjects will then be given biofeedback 
training gradually to control their 
breathing rate and relax their muscle 
activity and temperature through RESP 
biofeedback, assisted EMG biofeedback, 
and TEMP biofeedback, from the 1st 
session till their 8th session. 

 
The control intervention 
In control intervention, the subjects will be 
asked to take three 20-minute writing 
sessions18 and write about the given control 
topic about their daily events of the past 
week. 
 
1. For example, in Session 1, we may ask the 

Subjects to write about how they will use 
their time. 

2. Similarly, we will ask the subject to give 
more detail and write briefly about the 
given control condition in sessions 2 and 
session 3.    

3. At the end of three writing sessions, we 
will measure their EMG, RESP, and 
TEMP to compare with the Biofeedback 
training group. 

 
At the end of biofeedback training and 
writing sessions, the participants of both 
groups will also be asked to again fill the 
State-Trait Anxiety Inventory –STAI scale. 
 
Recruitment and Assessment Procedure 
One or more researchers will be involved in 
the process of recruitment and evaluation. 
The principal investigator will conduct prior 
training sessions regarding study aims and 
procedures for all the researchers involved 
in the study. An information sheet including 
the subject's socio-demographic 
characteristics will be provided to each 
individual. Written informed consent will be 
taken from each subject before the initiation 
of the study. Confidentiality will be 
maintained during and after the study for 
the Biofeedback training group and the 
control group. A baseline questionnaire 
(Demographic, Screening for Anxiety using 
the State-Trait Anxiety Inventory –
STAI)15,16,17 at baseline and post-intervention 
(after 4 weeks) will be conducted. 
 
Procedure 
The Screening questionnaire will be utilized 
for assessment. Subjects reporting 
experiencing anxiety with the cut-off score at 
or above the 75th percentile on the STAI will 
be kept inclusive. 
 
Study Hypothesis 
1. We hypothesized to determine 

biofeedback as a possible effective and 
useful technique in helping individuals 
manage their anxiety. 



 
 
 

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2. Moreover, individuals receiving 
biofeedback training will show significant 
changes for the three psychophysiological 
modalities, i.e., EMG, RESP, and TEMP. 

3. Throughout training of 4 weeks, study 
subjects will be trained to decrease EMG 
and RESP while they will be able to 
increase their skin TEMP. 

 
Measures 
Anxiety  
The State-Trait Anxiety Inventory-STAI will 
be used for anxiety screening. Higher scores 
indicate a greater level of anxiety. It consists 
of 20 items on a 4-point Likert scale (1 for 
"almost never" to 4 for "almost always"). The 
STAI Y has been widely used in numerous 
studies and is regionally tailored. The STAI 
Y-2's psychometric results in Portuguese are 
favorable: with the reliability Cronbach's 
alpha .90, while the test-retest Pearson 
correlation coefficient of .8818. Subjects 
reporting experiencing anxiety with the cut-
off score at or above the 75th percentile on 
the STAI will be kept inclusive. 
 
Electromyography Biofeedback (EMG) 
The surface EMG disposable sticky sensors 
will be attached to the bicep or flexor muscle. 
The ground sensor will be attached to the 
subjects' fingertips to read the heart rate. To 
enhance the connection on hairy places, a 
conductive paste, such as Ten20 Conductive 
Paste can be used. The electrodes can be set 
up consecutively. To view the EMG signals, 
the white, black, and green leads from the 
GP8 Amp will be connected to the 
disposable electrodes. 
 
Respiration Biofeedback (RESP) 
In this training, the GP8 Amp Reparation 
belt will be used. To gauge the subject's 
breathing, the Respiration Belt is wrapped 
over the chest or abdomen. The belt expands 
somewhat with each breath the subject takes, 
and this stretch (near the middle of the belt) 

is measured. In the breath pacer region of the 
Alive Bottom Graphs, the respiration data is 
displayed as a yellow line. The subject's 
breathing impacts his or her heart rate and 
smoothness, as seen by the yellow 
respiration line. 
 
Temperature Biofeedback (TEMP) 
As suggested, the temperature in hand 
increases when one gets to relax. Using GP8 
Amp, we can teach the subjects to increase 
their hand temperature dramatically. The 
mini-USB slot closest to the 4 leads is where 
the temperature sensor is connected to the 
GP8 Amp. Using one of the skin conductance 
Velcro finger straps to secure the 
temperature sensor, the other end will be 
placed on the subject's finger. The 
temperature will need to calibrate for 30 to 
60 seconds or until it stops rising before the 
training can start. 
 
Expected Outcomes 
Primary outcomes 
We hypothesized to determine Biofeedback 
as a possible effective and useful technique 
in helping individuals to manage their 
anxiety 
 
Secondary Outcomes 
1. Individuals receiving biofeedback 

training will tend to show significant 
changes for the three psychophysiological 
modalities i.e., EMG, RESP, and TEMP. 

2. Over the duration of training of 4 weeks, 
study subjects will be trained to decrease 
EMG and RESP, while they will be able to 
increase their skin TEMP. 

 
Sample Size  
The participants of this study will consist of 
50 second-year nursing students, both males, 
and females, from the School of Nursing, 
Koohi Goth, Karachi-Pakistan. The age range 
of study subjects will be between 18-21 



 
 
 

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Years. This sample size is selected based on 
the Glantz book's prior power analysis. 
 
Randomization 
According to the eligibility requirements, 
subjects will be randomly assigned in a 1:1 
ratio to the Biofeedback Training Group or 
control group. Randomization will be 
accomplished using computer-generated 
numbers. The study center will provide each 
participant a special code after collecting the 
necessary information from them. Each form 
for each subject will have a reference to the 
code. 
 
Statistical Analysis 
All STAI and biofeedback measurements 
(EMG, RESP, and TEMP) will be entered into 

the SPSS version 22.0 program, and all data 
will be analyzed using a Multivariate 
Analysis of Covariance (MANCOVA) to 
compare pre- and post-measures of the STAI 
scale, as well as a Repeated Measures 
Analysis of Variance (ANOVA) to compare 
the experimental group in two physiological 
modes during the baseline (0) and eighth 
sessions of the biofeedback training. 
Moreover, to determine which subject met 
the criteria for learning the skills during 
biofeedback training, we will be using 
percent change scores while analyzing 
changes in anxiety. Wilcoxon signed-rank 
test will be done to compare the measures 
among the subjects.

 

 
Figure 1: Flowchart of the study procedure 



 
 
 

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Discussion 
Using biofeedback, one can learn to control 
the physical and psychological effects of 
stress, anxiety, and depression. Moreover, it 
also helps people to relax their minds and 
bodies to cope with a distressing situation. 
Psychophysiological studies have 
demonstrated that biofeedback training can 
help in reducing symptoms (psychological 
and psychophysiological) of stressful 
academic scenarios in undergraduate 
students. Biofeedback training and different 
therapeutic sessions for anxious students 
seem to help them in reducing the muscle 
tension and respiration rate, especially 
during the time of their final examinations.  
 
Biofeedback training/treatment is 
considered a self-regulation technique, 
suggesting an association of stress and 
anxiety features with sympathetic arousal of 
the nervous system. Subjects getting 
biofeedback training are taught to alter the 
performance of their autonomic nervous 
system, which results in a reduction of 
activity of the sympathetic nervous system. 
This is done by giving the subjects an 
awareness session regarding their 
physiological functioning. Moreover, such 
biofeedback training is suggested to increase 
the individual's control over their 
involuntary actions and help them to 
dominate their activities. Overall, 
biofeedback training is suggested to improve 
the symptoms of anxiety, stress, and 
depression in undergraduate students.   
 

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