The world of high-level sports is characterised by intensive training, demanding competition, and public display of skills. These experiences can be overwhelming for the athletes, and there is evidence of negative long-term effects of the resulting stress on both their well-being and performances across the age envelope (Arnold and Fletcher, 2021). Excessive stress and tension represent a common experience for athletes in different sports and environments at all competition levels, from beginner to professional ones (Morgan, 1974; Greenspan and Feltz, 1989; Dugdale et al., 2002; Fletcher and Hanton, 2003). Stress-induced processes unfold over multiple aspects of individual functioning, consuming metabolic and attentional resources (Cañal-Bruland et al., 2010; Oudejans et al., 2011; Vine et al., 2016), and resulting in reduced enjoyment and a greater likelihood of injury (Nippert and Smith, 2008). Furthermore, stress represents a threat for the athlete’s ability to meet or exceed their performance goals (Davis and Sime, 2005) and subsequently leads to higher dropout rates (Dupee et al., 2016; Smith and Pollak, 2020). It is therefore not surprising that there is a growing body of research probing into the nature, determinants and impact of stress-related phenomena in sport. At the same time—drawing on both psychological (Jones, 2003; Balk and Englert, 2020) and technological (Dupee and Werthner, 2011) advances—researchers are exploring various stress-regulation techniques and interventions to help athletes deal with such demands and achieve more.

These endeavours rest upon the idea of maintaining the state of purposeful internal equilibrium in different conditions, referred to as psychophysiological self-regulation (Prinzel et al., 2001; Porges, 2007; Inzlicht et al., 2021). Research has shown that such a state is achieved through an efficient mind–body regulation, underlined by an adaptive interplay between sympathetic and parasympathetic nervous subsystems (Benarroch et al., 1995; Porges, 2007; Thayer and Lane, 2009). Recently, some authors have indicated that the efficiency of self-regulation is largely dependent on resilience, a key psychobiological capacity for maintaining normal functioning and health that involves adaptability to adversity (Fletcher and Hanton, 2003; Russo et al., 2012; Iodice et al., 2022). This theoretical framework is based on the neurovisceral integration model, which synthesizes extensive evidence linking the autonomic and central nervous systems in a functional and structural network involved in the emotional regulation of behaviour (Dworkin et al., 1994; Porges, 2007; Thayer and Lane, 2009; Pezzulo et al., 2018; Iodice et al., 2019; Yu et al., 2021). Particularly, stress can alter the flexibility of the circuitry underlying these delicate equilibria and thus lead to the suboptimal individual functioning (Marin et al., 2011; Mariotti, 2015; Anderson et al., 2019), with reduced degrees-of-freedom in the interactions with the environment (Damasio, 1998). Thus, given the ubiquity of the stress response and its documented negative impact on both short- and long-term health outcomes, as well as a variety of individual capacities (Thoits, 2010; O’Connor et al., 2021) and performances (Anderson et al., 2019; Lochbaum et al., 2022), an efficient stress management through self-regulation represents a highly desirable skill.

One of the most promising techniques for this purpose is biofeedback, a mind–body intervention that has the advantage of being unobtrusive, passive, and continuous (Brown, 1977; Sandweiss and Wolf, 1985; Bar-Eli et al., 2002; Dupee and Werthner, 2011; Strack et al., 2011). Unlike other stress-management techniques (for a review see Lehrer et al., 2000; Rumbold et al., 2012) biofeedback externalizes an individual’s physiological state, and allows the user to monitor changes in real time (Blumenstein et al., 1995; Schwartz and Andrasik, 2017; Kennedy and Parker, 2019). While many attempts to define biofeedback can be found in the scientific literature (for a review, see Peper and Shaffer, 2010; Schwartz and Andrasik, 2017; Schwartz et al., 2017), the core idea is simple: feedback is crucial for any kind of learning. By analogy with dancers practicing their craft in front of a mirror, biofeedback can be conceived as “a psycho-physiological mirror” (Peper and Schmid, 1983) which helps practicing and improving self-regulation (Dupee et al., 2016). Biofeedback instruments provide information about physiological processes that are normally beyond conscious access (such as cardiac rhythm, muscle or brain activity) in the form of auditory, visual or sensory signals (Peek, 2017). This information (i.e., feedback) helps to learn psychoregulatory control “for the purpose of improving health and performance” (Peek, 2017). Therefore, it can be said that individuals use biofeedback to create awareness of internal processes that are typically not consciously controlled (Landers, 1985; Zaichkowsky and Fuchs, 1988; Blumenstein and Weinstein, 2011). Once provided with feedback on physiological processes (in the form of heart rate or respiration rate), an individual can begin to formulate strategies for self-regulation.

The idea that self-regulation and/or resilience can indeed be enhanced through biofeedback training has received empirical support for both athletic (Rusciano et al., 2017) and non-athletic (Iodice et al., 2022) populations. In the case of the former, beneficial effects have been found for athletes in different sports, both individual (Bar-Eli et al., 2002; Galloway, 2011) and collective (Paul et al., 2012; Rusciano et al., 2017). Specifically, one of disciplines where the results of such practices have been explored is gymnastics. Ever since the early studies of Duda and Gano-Overway (1996a,b) highlighting the stress loads experienced by gymnasts, the need for effective stress-management interventions have only reverbed by recent high-profile cases of gymnasts such as Simone Biles withdrawing from the competitions due to excessive stress toil. To that aim, Codonhato et al. (2018) investigated the relationship between resilience and stress tolerance in elite-level gymnasts. The authors show that resilience has indeed a direct impact on stress management and injury prevention in adult athletes. However, with the lowering age of access to professional competition, athletes are being exposed to stress ever sooner in their developmental trajectories, which could potentially have a snowball effect later, both in terms of sport performance and life experiences (Jurimae and Jurimae, 2001; Caine and Nassar, 2005; White and Bennie, 2015; Smith and Pollak, 2020). Namely, acquiring psychophysiological self-regulation competencies during childhood is a key indicator for subsequent psychological well-being, the adoption of a healthy lifestyle, adaptive interpersonal behaviours, and overall mental health (Tangney et al., 2004; Moffitt et al., 2011; Howard and Williams, 2018; Robson et al., 2020).

Thus, the present study aims to explore the effects of four-week biofeedback training on elite prepubescent gymnasts, with a particular focus on enhancing their ability to cope with specific stressful situations that are most likely to induce harmful overarousal. The choice of this population addresses the notable scarcity of research on high-performance female athletes. Consequently, this gender-specific approach—particularly considering its unique hormonal and physiological factors—aims to contribute to a more balanced understanding of gender dynamics in high-performance sports. Namely, we aim to explore the possibility of using this training method in elite sportswomen to prevent physical injuries and early talent drop-out in emotionally demanding sports such as gymnastics. Specifically, a research protocol and a training program were developed, informed by prior scholarship (McHugh et al., 2010) and the inherent specificity of the target population. The training methods were adapted to the age profile of the participants. Informed by the prior literature on the subject, two physiological parameters (i.e., skin conductance level and peripheral skin temperature) were chosen as biofeedback training modalities. Both the electrodermal (skin conductance) and thermal (peripheral skin temperature) biofeedback have been found as suitable modalities for a stress-regulation intervention (Shaffer et al., 2016; Schwartz and Andrasik, 2017; Candia-Rivera et al., 2022). The stress response was elicited in a standardised setting and both the profile and the intensity of the participants’ stress response were gauged across different physiological parameters (Yu et al., 2018; Slavikova et al., 2020). Additionally, the levels of interoceptive awareness (Mehling et al., 2012) were evaluated also, aiming for a comprehensive assessment of the individual functioning following the biofeedback training.

The results of our study will help clarify the mechanisms underlying the training of self-regulation and thus resilience skills in young women. Finally, the possibility of incorporating this method into the training toolkit of young elite athletes will be discussed. We have delineated a research paradigm with the aim of probing if a biofeedback training could be an effective method for the development of robust stress-management abilities in young female athletes.

In the present study, we investigated for the first time whether training self-regulatory skills through BF can influence resilience to stressful conditions in prepubescent elite female athletes. Our results show that BF training in elite athletes (1) increased self-regulation and psychological resilience under stressful conditions and (2) it seemingly decreased sensitivity to gymnastics-specific stress. Taken together, these two findings support the idea that psychophysiological self-regulation is trainable.

The protocol of this study was based on the previous research that demonstrated the efficacy of thermal and electrodermal (Peper and Schmid, 1983; Rusciano et al., 2017; Iodice et al., 2022) biofeedback in the case of self-regulation training for the gymnasts. Our results confirm the positive influence of BF training on both psychological and physiological dimensions of self-regulation. In particular, the former was assessed using the MAIA test, which has been used extensively in studies of both healthy and clinical populations (Park et al., 2021; Phillipou et al., 2022) and to assess training-induced changes in the case of mind–body interventions such as meditation (Bornemann et al., 2015) and biofeedback (Iodice et al., 2022). Indeed, while all the factors showed improvements after the BF training, statistical significance was found for more sophisticated interoceptive awareness sub-abilities such as not-distraction (the tendency not to use distraction to cope with discomfort), attention regulation (the ability to maintain and control attention to bodily sensations), emotion awareness (the ability to attribute specific bodily sensations to physiological manifestations of emotions), and self-regulation (the ability to regulate distress through attention to bodily sensations). On the contrary, sub-abilities that can be considered as precursors of these more sophisticated ones (such as noticing or the ability to be aware of body sensations, or body listening, i.e., the tendency to actively listen to the body for insights) were not significantly increased after training. This is partly in contrast to Bornermann and colleagues who reported a significant increase in all the sub-abilities after three months of contemplative training (Bornemann et al., 2015). A possible explanation for this difference may lie in the intrinsic differences between the two employed training procedures. The authors of the study required participants to complete structured modules based on meditation techniques during which no objective feedback were provided (thus stimulating participants’ subjective ability to predict their physiological state), our training was based on objectification of internal physiological state (thus avoiding participants’ to firstly focus on “recognising” phase (e.g., noticing and body listening), concentrating their resources on training their ability to modify physiological signals, thus skipping faster to the “regulating phase”) (Bornemann et al., 2015).

Similarly, Lima-Araujo et al. (2022) reported a significant increase in five of the eight MAIA sub-abilities (i.e., Body Listening, Trusting, Self-Regulation, Attention Regulation and Emotional Awareness) following a brief mindfulness training that focused heavily on body scan abilities and learning of breathing patterns. Although the participants in their training did not receive objective feedback on their performance, this protocol nonetheless presents many similarities to the one we used, which may explain the greater overlap between our respective results.

Also, it should be considered that the uniquely female composition of our sample did not allow us to test and/or control for possible effects related to gender difference. Recent evidence has in fact shown that gender can influence each of the sub-components of interoception and therefore a comparison between the responses in the two genders could have possibly helped to explain why lower-level skills (e.g., noticing; not worrying) did not significantly differ after training. For example, Grabauskaitė et al. (2017) showed significant differences on some sub-components in female and male participants. In particular, male participants reported higher values on the not worrying and trusting dimensions, whereas female participants reported higher scores on emotional awareness and body listening. Additionally, children’s ability to handle internal body cues based on interoceptive awareness typically improves as they grow and develop (Schmitt and Schoen, 2022). In particular, children are expected to present five stages of maturing of their interoceptive awareness capacity: (i) Noticing—the child notices that the interoceptive sensation is occurring; (ii) Naming—the child is able to label and describe the interoceptive sensation; (iii) Linking—the child is able to connect an emotions to the interoceptive sensation; (iv) Understanding and recognising the impact—the child understands the impact of the interoceptive sensation and this requires the second-order cognitive skills of reasoning, reflection, organization and planning; (v) Handling, managing and coping—the child needs to be able to cope with the interoceptive sensation and regulate it (Cheung et al., 2023). Therefore, another possibility to consider is that given the age of our sample (i.e., pre-pubescent), the participants did not show post-training differences with respect to the low-level components, as these components were already acquired and mastered.

Furthermore, our results may contribute to the ongoing debate about the components of interoception—accuracy, sensitivity and awareness—and their relationships, as recently highlighted by Garfinkel et al. (2015). Indeed, the authors suggest that the aforementioned categorization could be reconceptualised in terms of a distinction between objective interoceptive processes (i.e., accuracy: the ability to correctly monitor changes in internal body state), subjective (i.e., sensibility: the tendency to focus on internal body state), and metacognitive process (i.e., awareness or error awareness: quantifiable difference between self-reported judgement of interoceptive accuracy and objectively assessed interoceptive accuracy). This idea is also seemingly supported by recent findings suggesting differences in the neural underpinnings of different interoceptive components (Du et al., 2023), feedback-based training bases its effectiveness (at least in part) on its potential to highlight errors in the interoceptive monitoring process, allowing the subject to immediately compare the actual (real) state with the perceived one, thus allowing for continuous adjustment of the predicted state. This focus on the metacognitive component of interoception is the distinctive feature that distinguishes neuro- and biofeedback procedures from other methods commonly used to train the ability to consciously manage psychophysiological states. As a result, our findings contribute to the under-documented literature on interoceptive processes and feedback-based training in the young athletic population.

Indeed, while the efficacy of the BF-based procedures has been widely studied in clinical contexts (e.g., ADHD, Kuznetsova et al., 2022), and their usefulness was recently confirmed in a systematic review of the effects of biofeedback training in children and adolescents (Dormal et al., 2021), their potential application in the case of young athletes is still relatively unexplored (see Zadkhosh et al., 2018). The recorded physiological parameters show a main effect of condition (CTRL vs. BF, p < 0.001) for the temperature parameter. In particular, our data suggest a lower sensitivity to the stress stimuli after BF training. We also note that in the control condition, before training with BF, prepubescent female athletes were not able to regain the homeostatic balance, once perturbed by the stress stimuli.

On the other hand, while the overall trend manifests the expected behaviour, the observed changes in the skin conductance level parameter did not reach statistical difference, nor did the interaction between the experimental conditions. Our best a posteriori hypothesis regarding such data concerns the nature of the physiological signals investigated and the age of the participants. Indeed, while the concept of body temperature is relatively straightforward to grasp., conductance is a more abstract notion. Referring to classical theories of child development (Piaget, 1952), it would appear that, from this point of view, the participants in this study are at the end of the concrete operations stage (or at the very beginning of the formal stage). At this stage, the ability to use abstract concepts is not yet fully acquired.

Therefore, our findings firstly corroborate those of previous studies suggesting that when the subjects receive interoceptive feedback on their neurovisceral state during targeted training, it allows for the adaptation of self-regulatory control mechanisms (e.g., Mirifar et al., 2017; Meyerholz et al., 2019). Furthermore, our study extends the findings on the influence of self-regulatory capacity on the stress management process to prepubertal athletes and contributes to the understanding of the relationship between stress, psychophysiological responses and training capacity. Finally, we suggest that our approach introduces a new procedure for training young elite athletes to protect their psychophysical balance during the long training sessions (24 h per week in our sample), which could be crucial for injury prevention, as suggested by some authors (Rusciano et al., 2017). Our study demonstrates the effectiveness of biofeedback training in improving elite athletes’ self-regulation and psychological resilience, particularly their ability to cope with stress-related challenges. This training appears to reduce their sensitivity to gymnastics-specific stressors, highlighting its potential benefits in a sporting context.

Furthermore, our study emphasizes the importance of psychophysiological self-regulation, which involves an individual’s ability to manage emotional and cognitive states while adapting to different environmental conditions. This ability is crucial for maintaining balance in response to complex situational demands. In summary, our research supports the idea that interoceptive feedback training can significantly enhance an individual’s self-regulatory mechanisms.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

The studies involving humans were approved by the Ethical Committee of the University of Rouen Normandy, France, Protocol n. 2020-04-A. The studies were conducted in accordance with the local legislation and institutional requirements. Written informed consent for participation in this study was provided by the participants’ legal guardians/next of kin.

GP: Conceptualization, Investigation, Writing – original draft, Methodology. MB: Data curation, Supervision, Writing – review & editing. AC: Data curation, Formal analysis, Software, Writing – review & editing. LC: Writing – original draft, Data curation, Formal analysis, Methodology. RP: Supervision, Validation, Visualization, Writing – review & editing. RT: Conceptualization, Methodology, Supervision, Validation, Writing – review & editing. PI: Conceptualization, Investigation, Methodology, Project administration, Resources, Supervision, Validation, Writing – original draft, Writing – review & editing.