Digital biomarkers reflect stress reduction after Augmented

Reality guided meditation: a feasibility study

Yihang Jiang Will Wang Tim Scargill
Department of Biomedical Department of Biomedical Department of Electrical and
Engineering Engineering Computer Engineering
Duke University Duke University Duke University
Durham, NC, United States Durham, NC, United States Durham, NC, United States
[email protected] [email protected] [email protected]

Max Rothman Jessilyn Dunn† Maria Gorlatova†

Department of Biomedical Department of Biomedical Department of Electrical and
Engineering Engineering Computer Engineering
Duke University Duke University Duke University
Durham, NC, United States Durham, NC, United States Durham, NC, United States
[email protected] [email protected] [email protected]

ABSTRACT
Meditation, a mental and physical exercise which helps to focus 1 Introduction
attention and reduce stress has gained more popularity in recent Meditation is a mental and sometimes physical exercise which
years. However, meditation requires a concerted effort and regular helps to focus attention and reduce stress by encouraging
practice. To explore the feasibility of using Augmented mindfulness of one’s self and surroundings [32]. According to
Reality(AR) Devices to assist in meditating, we recruited ten data from the 2017 National Health Interview Survey (NHIS), the
subjects to perform a five-minute meditation task integrated into number of American adults and children using meditation
AR devices. Heart Rate, Heart Rate Variability, and skin techniques increased more than threefold between 2012 and 2017
conductance response(SCR) are analyzed based on an [33]. Meditation has therapeutic effects on a range of physical
Electrocardiogram(ECG), Electrodermal activity to monitor the ailments including chronic pain, high blood pressure, anxiety,
physiological changes during and after a meditation session. depression and insomnia.[34] Meditation requires a concerted
Additionally, participants filled out surveys containing the effort and improves with practice. However, regular practice can
Perceived Stress Questionnaire (PSQ), a clinically validated be difficult because people are often in distracting environments
survey designed to evaluate stress levels before and after that do not facilitate relaxation. Augmented reality (AR), the
meditation to analyze the change in stress levels. Finally, we overlaying of virtual content onto a view of the real world
found significant differences in Heart Rate and Mean SCR environment, may improve the ability for meditation in
Recovery Time for participants between the three study procedure environments that are otherwise not conducive to relaxation.
periods (before, during, and after guided meditation). Additionally, AR devices can be used to improve attentiveness to
the practice of meditation, for example by projecting a
CCS CONCEPTS controllable virtual object on top of the real world that captures
• Applied Computing---Life and medical sciences • Human- the users’ attention. [3,7]. There is limited research that explores
centered computing---Ubiquitous and mobile computing AR applications to assist meditation. InnerGarden[20], which
presents an augmented sandbox using projected virtual content, is
KEYWORDS designed for self-reflection exercises and has been evaluated in
Augmented reality, Digital biomarkers, Meditation combination with respiratory and electroencephalogram (EEG)
monitoring. Another recent study integrated adjunctive
†
Corresponding Authors neurofeedback (measuring brain wave activity through an EEG
Permission to make digital or hard copies of all or part of this work for personal or and using that information to monitor and modify mental
classroom use is granted without fee provided that copies are not made or processes [23]) into an AR meditation process[9]. Participants
distributed for profit or commercial advantage and that copies bear this notice and
the full citation on the first page. Copyrights for components of this work owned reported no significant mood difference as a result of the
by others than ACM must be honored. Abstracting with credit is permitted. To neurofeedback; however, this study did not monitor the cardiac
copy otherwise, or republish, to post on servers or to redistribute to lists, requires
prior specific permission and/or a fee. Request permissions from and electrodermal signals, which eliminates the chance to observe
[email protected]. the connection between AR and responses of heart and skin to
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MobiSys’22, June, 2022, Portland, Oregon USA Y. Jiang et al.

meditation. In our study, we not only use AR devices to meditate, First, our custom AR stimuli were designed with the goal of
but we also employ wearable sensors to record digital biomarkers immersing the participant in a relaxing environment for their
that can be used in the future to modify guided meditations in real meditation exercise, similar to the approach taken in [5]. Upon
time using physiological feedback systems. app startup, we detect horizontal planes in the real environment
and cover them with a virtual grass texture. Spatialized ambient
Digital biomarkers are defined as objective, quantifiable audio is played using sound effects from a real forest environment
physiological and behavioral data that are collected and measured [31]. We then instruct the participant to place a virtual tree in a
by means of digital devices such as portables, wearables, place of their choosing on the plane generated by the desk in front
implantables, or digestibles. [35] There is a variety of existing of them, by looking at a spot on the desk and pulling the Magic
research which focuses on observing the effects of meditation on Leap One control trigger. This will be the focus of the
digital biomarkers. In [2,9,17], digital biomarkers which quantify participant’s visual attention during the exercise, so we allow
sleep quality, such as total sleep time and sleep efficiency, are them to adjust the tree position as many times as required until it
measured after meditation. In [13,29], heart rate variability (HRV) is in a comfortable position for them to watch. The tree model is
and respiratory rhythm are seen to be positively influenced by animated so that its branches and leaves appear to be swaying in a
meditation exercises. In [12], it is indicated that body temperature light wind. We also implement an experimental biofeedback
can be controlled during meditation. In [36], the effects of feature, such that when a participant’s exhalations are detected
meditation on heart rate and blood pressure are analyzed, where through the Magic Leap One’s onboard microphone, the tree
both are found to have a significant decrease. These studies animation swaying speed increases then decays over a period of
demonstrate the feasibility of assessing the effects of meditation three seconds to imitate a gust of wind. An example screenshot of
using digital biomarkers to reveal changes in underlying the participant’s view through the Magic Leap One is shown in
physiology. Figure 1.

In our study, we use AR to support meditation in settings that are

not inherently relaxing, for example in an office or laboratory
space. Selected digital biomarkers are monitored during the
procedure to explore the physiological changes during and after a
meditation session.

2 Methods
2.1 Participants
This study was approved by the relevant IRB. Participants (n=10) Figure 1: Participant’s vista during meditation
chose a convenient time of day to perform the meditation to
minimize disruption to their schedules. Eight of the participants The second component of our app design is a pre-recorded
were male, and all participants were over 18 with a mean age of meditation audio track. Once the participant is comfortable in
27.6 years (SD = 1.54). Five participants were Caucasian, four their AR environment, they start the meditation audio by pressing
were Asian or Pacific Islander, and one participant did not report the Magic Leap One ‘bumper’ button on the control. This audio
their race or ethnicity. Exclusion criteria included wearing glasses, guides the participant through a deep breathing exercise; for this
as the AR headset does not fit over glasses, and sensitivity to study we use the 5-minute ‘Breathing Meditation’ exercise made
flashing lights and/or images. All participants either did not available by the Mindful Awareness Research Center at UCLA
require glasses to see or were wearing contact lenses, and none [37], which has been used in a variety of previous studies on the
reported a history of sensitivity to flashing lights. impact of meditation, including [25,30].

2.2 AR Devices and Software Design Finally, the third component of our app concerns the collection of
Our AR-based meditation app was developed using Unity eye tracking data using the video-oculography-based eye tracker
2020.3.14f1. The app consists of three main components: our onboard the Magic Leap One. From app startup until the
custom AR stimuli, a meditation audio track, and eye tracking participant removes the AR headset, we record the participant’s
functionality. It was built for and run on a Magic Leap One AR 3D gaze position (in the coordinate space defined by the Magic
headset (Fig 2a), though the nature of our design would enable it Leap One), the pupil diameter of both eyes, and a ‘gaze
to be implemented for other AR devices with minor changes. confidence’ indicator provided by the eye tracker, which estimates
Some types of eye tracking data we capture are only available on the quality of eye tracking data, all at 60Hz.
the Magic Leap One headset, (e.g., pupil diameter), hence our
choice to use this device. 2.3 Test Procedure

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Digital biomarkers reflect stress reduction after Augmented Reality
MobiSys’22, June, 2022, Portland, Oregon USA
guided meditation: a feasibility study

To collect physiological data, we utilized three distinct devices: 2.4.1 ECG Signal Processing Preprocessing of the Faros ECG
the Bittium Faros 180, an FDA-approved 3-lead wearable data included signal filtering, peak detection, and metric
electrocardiogram (ECG) device (Fig 2b), an Empatica E4 calculation. First, a Butterworth filter (3rd order, 5Hz low-pass
wristband (Fig 2c) that collects heart rate, skin temperature, filtering frequency) was applied to remove high frequency noise.
electrodermal activity (EDA), and an Omron 7900K blood Then, a double-sided moving average window (width=0.75
pressure cuff (Fig 2d). seconds) was applied . R-peaks were searched for in regions
where the signal amplitude exceeds the moving average[8,11].
Each participant wore the E4 and the Faros for one hour before Lastly, the RR intervals are calculated based on the position of the
the meditation exercise to establish a baseline. During this time, R-peaks. Heart rate, and two HRV parameters, RMSSD (the
participants were free to perform usual low-effort activities, but square root of the mean squared differences between adjacent
were asked not to eat or exercise. We additionally asked normal RR intervals), and SDNN (the standard deviation of mean
participants to complete a pre-study survey which assessed their of all normal RR intervals), are calculated based on the peak-to-
level of perceived stress, as well as their perceived ability to peak intervals.
perform mental visualization tasks. After this baseline period,
blood pressure was measured with the Omron device according to 2.4.2 EDA Signal Processing The E4 EDA preprocessing
the standard clinical protocol [28] and then the participant began pipeline consisted of valid window selection, filtering, artifact
the AR-assisted meditation exercise using the Magic Leap One removal, signal decomposition, and peak detection. During the
AR headset. A visual calibration was completed first to ensure study, we recorded when the participant started wearing the
proper eye tracking, and then the participant opened the devices, as well as when the participant removed the device.
meditation app and was guided through instructions about the Using these timestamps, we removed signals during non-use to
app’s functionality. Once they felt comfortable using the app, the ensure a valid window for data processing and analysis. The data
participant began the 5-minute meditation exercise. During this is then filtered using a method adapted Taylor et al. [24] to reduce
time, the participant was left alone in the conference room with noise in the data while still preserving variations that represent
the lights slightly dimmed to facilitate a calming experience. The physiological responses. Next, we removed motion artifacts using
meditation environment and devices are shown in Figure 2. the Neurokit function eda_clean()[15]. The EDA signal is then
decomposed into the fast varying phasic component and the slow
varying tonic component using the Neurokit function
eda_phasic(). Statistical features are calculated on each
component, including maximum, mean, standard deviation and
kurtosis. Lastly, peaks in the EDA recordings, deemed as skin
conductance responses (SCRs), were detected through the
Neurokit function eda_process(). Relevant features are calculated
surrounding each SCR, including height, amplitude, rise time, and
recovery time.

2.4.3 Statistical Analysis Differences in signal features

between the three study procedure periods (before, during, and
after guided meditation) were calculated individually for all 10
participants. Non-parametric Wilcoxon Rank Sum tests, which
make no distributional assumptions and are robust to outliers,
were used to determine whether these differences are sufficiently
Figure 2: Meditation environment and devices different from zero, indicating a change in the signal value
between the procedure periods.
After the exercise had been completed, the participant removed
the AR headset and the same blood pressure measurement 2.4.4 Pre & Post Survey Pre- and post-experiment surveys
procedure was repeated as before the meditation. The participant (administered electronically via Qualtrics [38]) were completed
was asked to complete a post-meditation survey assessing stress by each participant to determine study eligibility, record self-
levels after meditation, as well as their level of comprehension of reported relaxation and stress levels, and examine the possible
the study procedures. The participant then continued to wear the effects of prior experience with AR or VR and current levels of
Faros and the E4 for an additional hour after the exercise to tiredness and stress on our results. To record self-reported
measure physiology and activity in the period after the meditation. relaxation and stress levels, in the post-experiment survey
participants rated their level of relaxation relative to before the
2.4 Data Analysis Method meditation exercise on a 5-point Likert scale, with the following
responses: ‘Much more relaxed”, “A little more relaxed”, “The

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MobiSys’22, June, 2022, Portland, Oregon USA Y. Jiang et al.

same”, “A little less relaxed”, “Much less relaxed”. Additionally, Table 1: Changes of metrics pre-, during and post-meditation
both the pre- and post-experiment surveys contained the Perceived
Stress Questionnaire (PSQ), a clinically-validated survey designed
to evaluate levels of stress in the participant’s life [14]. The PSQ
Digital Post- Meditation Meditation
contains 30 descriptive statements such as “You feel rested”, Biomarker meditation vs Post- vs Baseline
“You have too many things to do”, and “You have many worries”. vs meditation
Participants are asked to rate these statements using a 4-point Baseline
Likert scale to indicate how frequently they feel the statement
applies to their life. Scoring the PSQ yields a stress index between Heart Rate -5.051 ± -3.596 ± -8.646 ±
0 and 1, with higher scores indicating higher levels of stress. To (bpm) 3.691 3.985 3.760
study the possible effects of prior AR or VR experience on our
(p=0.006) (p=0.037) (p=0.002)
results, participants were asked to rate how frequently they have
used AR and VR headsets, including the Magic Leap One
specifically. To study the possible effects of tiredness and stress RMSSD 5.111 ± 3.842 ± 8.953 ±
levels on our results, participants self-reported these levels prior to 4.773 10.311 9.437
the experiment on two respective 5-point Likert scales, and for (p=0.037) (p=0.132) (p=0.006)
stress we also analyzed data from the aforementioned PSQ.
SDNN 5.269 ± -14.768 ± -9.499 ±
12.367 27.066 17.773
3 Results
(p=0.193) (p=0.131) (p=0.193)
We explored whether HR, HRV, and/or EDA changed between
the baseline, meditation exercise, and post-meditation exercise
EDA Mean -0.162 ± -0.030 ± -0.192 ±
periods. We also explored the correlation between the biosignals
and the stress level in the survey. Based on the
SCR Rise 0.252 0.298 0.367
literature[13,19,21,22,27,36], we expected that HR would Time (p=0.084) (p=0.846) (p=0.131)
decrease and that HRV (both RMSSD and SDNN) would increase
between baseline and meditation. Since lower SCR amplitude and EDA Mean -2.072 ± -9.352 ± -11.424 ±
recovery time indicate lower stress or emotional arousal levels [4], SCR 14.457 8.923 15.328
we also expected that EDA, as represented by the mean SCR Recovery (p=0.432) (p=0.002) (p=0.027)
recovery time, rise time, and amplitude, would decrease along Time
with reported stress levels [16] [6].
EDA Mean -0.013 ± -0.036 ± -0.049 ±
We also hypothesized that post-meditation stress levels as
reported through the PSQ would decrease. Finally, we explored SCR 0.066 0.045 0.086
the experience of wearing AR or VR headsets, hypothesizing that Amplitude (p=0.770) (p=0.037) (p=0.160)
the effects of our meditation app would be weaker in participants
who have less experience wearing AR or VR headsets, as
relaxation effects may be diminished by stimulation related to a 3.2 Pre & Post Survey Analysis
new or unfamiliar experience. The range of self-reported tiredness and stress levels (with 1 being
the least and 5 being most) in the pre-experiment survey spanned
3.1 Statistical Analysis of Biosignals four out of five tiredness levels (1:1 participant, 2:5 participants,
To determine the effect of meditation on the body, Wilcoxon 3:3 participants, 4:1 participant) and all five stress levels (1:2
Rank Sum tests are performed for 18 hypotheses regarding the participants, 2:1 participant, 3:4 participants, 4:1 participant, 5:2
changes in digital biomarkers between the baseline, meditation, participants). In our post-meditation survey, when asked to rate
and post-meditation periods. The results are summarized in Table how relaxed participants felt compared to before the meditation
1: bolded results indicate a p-value less than 0.05, and results exercise on a 5-point Likert scale, 9 out of 10 responded ‘A little
highlighted in red have p-value less than the Bonferroni-corrected more relaxed’ and one participant responded ‘Much more
significance threshold of 0.00278. We observe statistically relaxed’. The majority of participants (7 out of 10) had no
significant differences in two specific digital biomarkers: heart previous experience with headset AR (with four of those having
rate shows a significant difference between the baseline and no experience with VR either), while two participants had used it
meditation periods, and EDA mean SCR recovery time shows a once or twice for a brief period, and one participant used it
significant difference between meditation and post- meditation frequently. These results indicate that our approach can help
periods. users with varying levels of tiredness and stress, as well as those
new to headset AR, to increase their level of relaxation. The fact
that we found no statistically significant differences between pre-

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Digital biomarkers reflect stress reduction after Augmented Reality
MobiSys’22, June, 2022, Portland, Oregon USA
guided meditation: a feasibility study

and post-meditation stress levels reported in the PSQ was will add another pair of baseline and mediation task (baseline-
expected because many PSQ questions are focused on longer-term meditation-baseline-meditation-baseline). In this way, the
sources of stress, while our meditation session was designed to activities of subjects will not affect the second and third baseline
alleviate short-term stressors. Finally, we observe that the greatest period.
reduction in heart rate, which is the biomarker most strongly
impacted by meditation, occurred in two of the three subjects who
had prior experience with AR. This supports our hypothesis that 5 Conclusion
the effects of AR-based meditation are strongest for users who are In this work, we collected biosignals from subjects who
already familiar with AR. performed a guided meditation using an AR headset. We
compared the biosignals between the baseline, meditation, and
post-meditation periods and discovered a statistically significant
4 Discussion decreases in heart rate during the meditation period as compared
Biofeedback works by providing a perceptible, real-time metric to the baseline and mean SCR recovery time during the post-
indicating the physiological state of the body, which allows the meditation period compared to the meditation period, as well as a
subject to make a conscious effort to improve that metric [39]. By trend toward decreased self-reported stress. Our work indicates
providing visual or auditory cues to the subject about the state of that biosignals recorded during AR-based meditation warrant
their body, such as how happy, focused or relaxed they are, further study to examine physiological changes resulting from
meditation outcomes can be improved [23,26]. In this study, the meditation, and to determine how AR can play a role in improving
only biofeedback mechanism that was implemented was meditation outcomes.
associating the swaying of the AR tree with the participant’s
breaths. While the study included physiological signal analysis to ACKNOWLEDGMENTS
determine the effect of meditation on the body, we did not use any This work was supported in part by the NSF grant CNS-1908051
of these signals to provide feedback to the subjects during and the NSF CAREER Award IIS-204607.
meditation. In future work, we will further explore whether using
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