Can Slow Deep Breathing Reduce Pain? An Experimental Study Exploring Mechanisms

  • Hassan Jafari
    Address reprint requests to Hassan Jafari, PhD, Research Group Health Psychology, Faculty of Psychology and Educational Sciences, KU Leuven, Tiensestraat 102, Box 3726, 3000 Leuven, Belgium.
    KU Leuven - University of Leuven, Research Group Health Psychology, Leuven, Belgium

    Biostatistics and Health Informatics Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
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  • Ali Gholamrezaei
    KU Leuven - University of Leuven, Research Group Health Psychology, Leuven, Belgium

    KU Leuven - University of Leuven, Department Chronic Diseases, Metabolism & Ageing (CHROMETA), Translational Research Center for Gastrointestinal Disorders (TARGID), Leuven, Belgium
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  • Mathijs Franssen
    KU Leuven - University of Leuven, Research Group Health Psychology, Leuven, Belgium

    Center for the Psychology of Learning and Experimental Psychopathology, University of Leuven, Leuven, Belgium
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  • Lukas Van Oudenhove
    KU Leuven - University of Leuven, Department Chronic Diseases, Metabolism & Ageing (CHROMETA), Translational Research Center for Gastrointestinal Disorders (TARGID), Leuven, Belgium
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  • Qasim Aziz
    Wingate Institute of Neurogastroenterology, Centre for Neuroscience and Trauma, Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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  • Omer Van den Bergh
    KU Leuven - University of Leuven, Research Group Health Psychology, Leuven, Belgium
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  • Johan W.S. Vlaeyen
    KU Leuven - University of Leuven, Research Group Health Psychology, Leuven, Belgium

    Experimental Health Psychology, Maastricht University, Maastricht, the Netherlands
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  • Ilse Van Diest
    KU Leuven - University of Leuven, Research Group Health Psychology, Leuven, Belgium
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Published:January 21, 2020DOI:


      • Paced breathing can reduce pain.
      • The hypoalgesic effect is enhanced when breathing is paced at a lower frequency.
      • The hypoalgesic effect is more pronounced when expiration is longer.


      Slow deep breathing (SDB) is commonly employed in the management of pain, but the underlying mechanisms remain equivocal. This study sought to investigate effects of instructed breathing patterns on experimental heat pain and to explore possible mechanisms of action. In a within-subject experimental design, healthy volunteers (n = 48) performed 4 breathing patterns: 1) unpaced breathing, 2) paced breathing (PB) at the participant's spontaneous breathing frequency, 3) SDB at 6 breaths per minute with a high inspiration/expiration ratio (SDB-H), and 4) SDB at 6 breaths per minute with a low inspiration/expiration ratio (SDB-L). During presentation of each breathing pattern, participants received painful heat stimuli of 3 different temperatures and rated each stimulus on pain intensity. Respiration, heart rate, and blood pressure were recorded. Compared to unpaced breathing, participants reported less intense pain during each of the 3 instructed breathing patterns. Among the instructed breathing patterns, pain did not differ between PB and SDB-H, and SDB-L attenuated pain more than the PB and SDB-H patterns. The latter effect was paralleled by greater blood pressure variability and baroreflex effectiveness index during SDB-L. Cardiovascular changes did not mediate the observed effects of breathing patterns on pain.


      SDB is more efficacious to attenuate pain when breathing is paced at a slow rhythm with an expiration that is long relative to inspiration, but the underlying mechanisms remain to be elucidated.


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        • Arsenault M
        • Ladouceur A
        • Lehmann A
        • Rainville P
        • Piché M
        Pain modulation induced by respiration: Phase and frequency effects.
        Neuroscience. 2013; 252: 1-11
        • Barnes PM
        • Bloom B
        • Nahin RL
        Complementary and alternative medicine use among adults and children: United States, 2007.
        Natl Health Stat Report. 2008; 12: 1-24
        • Bernardi L
        • Porta C
        • Gabutti A
        • Spicuzza L
        • Sleight P
        Modulatory effects of respiration.
        Auton Neurosci. 2001; 90: 47-56
        • Berntson GG
        • Bigger JT
        • Eckberg DL
        • Grossman P
        • Kaufmann PG
        • Malik M
        • Nagaraja HN
        • Porges SW
        • Saul JP
        • Stone PH
        • van der Molen MW
        Heart rate variability: Origins, methods, and interpretive caveats.
        Psychophysiology. 1997; 34: 623-648
        • Berntson GG
        • Cacioppo JT
        • Quigley KS
        Respiratory sinus arrhythmia: Autonomic origins, physiological mechanisms, and psychophysiological implications.
        Psychophysiology. 1993; 30: 183-196
        • Botha C
        • Farmer AD
        • Nilsson M
        • Brock C
        • Gavrila AD
        • Drewes AM
        • Knowles CH
        • Aziz Q
        Preliminary report: Modulation of parasympathetic nervous system tone influences oesophageal pain hypersensitivity.
        Gut. 2015; 64: 611-617
        • Busch V
        • Magerl W
        • Kern U
        • Haas J
        • Hajak G
        • Eichhammer P
        The effect of deep and slow breathing on pain perception, autonomic activity, and mood processing–an experimental study.
        Pain Med. 2012; 13: 215-228
        • Busch V
        • Zeman F
        • Heckel A
        • Menne F
        • Ellrich J
        • Eichhammer P
        The effect of transcutaneous vagus nerve stimulation on pain perception—An experimental study.
        Brain Stimul. 2013; 6: 202-209
        • Cappo BM
        • Holmes DS
        The utility of prolonged respiratory exhalation for reducing physiological and psychological arousal in non-threatening and threatening situations.
        J Psychosom Res. 1984; 28: 265-273
        • Castegnetti G
        • Tzovara A
        • Staib M
        • Gerster S
        • Bach DR
        Assessing fear learning via conditioned respiratory amplitude responses.
        Psychophysiology. 2017; 54: 215-223
        • Chakravarthy K
        • Chaudhry H
        • Williams K
        • Christo PJ
        Review of the uses of vagal nerve stimulation in chronic pain management.
        Curr Pain Headache Rep. 2015; 19: 54
        • Chalaye P
        • Goffaux P
        • Lafrenaye S
        • Marchand S
        Respiratory effects on experimental heat pain and cardiac activity.
        Pain Med. 2009; 10: 1334-1340
        • Cooke WH
        • Cox JF
        • Diedrich AM
        • Taylor JA
        • Beightol LA
        • Ames JE
        • Hoag JB
        • Seidel H
        • Eckberg DL
        Controlled breathing protocols probe human autonomic cardiovascular rhythms.
        Am J Physiol. 1998; 274: H709-H718
        • Critchley HD
        • Garfinkel SN
        Interactions between visceral afferent signaling and stimulus processing.
        Front Neurosci. 2015; 9: 286
        • Di Rienzo M
        • Parati G
        • Castiglioni P
        • Tordi R
        • Mancia G
        • Pedotti A
        Baroreflex effectiveness index: An additional measure of baroreflex control of heart rate in daily life.
        Am J Physiol Regul Integr Comp Physiol. 2001; 280 (R744–R751)
        • Dunckley P
        • Aziz Q
        • Wise RG
        • Brooks J
        • Tracey I
        • Chang L
        Attentional modulation of visceral and somatic pain.
        Neurogastroenterol Motil. 2007; 19: 569-577
        • Duschek S
        • Dietel A
        • Schandry R
        • Reyes Del Paso GA
        Increased baroreflex sensitivity and reduced cardiovascular reactivity in individuals with chronic low blood pressure.
        Hypertens Res. 2008; 31: 1873-1878
        • Duschek S
        • Muckenthaler M
        • Werner N
        • Reyes del Paso GA
        Relationships between features of autonomic cardiovascular control and cognitive performance.
        Biol Psychol. 2009; 81: 110-117
        • Dworkin BR
        • Elbert T
        • Rau H
        • Birbaumer N
        • Pauli P
        • Droste C
        • Brunia CH
        Central effects of baroreceptor activation in humans: Attenuation of skeletal reflexes and pain perception.
        PNAS. 1994; 91: 6329-6333
        • Eckberg DL
        Point: Counterpoint: Respiratory sinus arrhythmia is due to a central mechanism vs. respiratory sinus arrhythmia is due to the baroreflex mechanism.
        J Appl Physiol. 2009; 106 (discussion 1744): 1740-1742
        • Edwards L
        • Inui K
        • Ring C
        • Wang X
        • Kakigi R
        Pain-related evoked potentials are modulated across the cardiac cycle.
        Pain. 2008; 137: 488-494
        • Faul F
        • Erdfelder E
        • Buchner A
        • Lang A-GG
        • Faul F
        • Buchner A
        • Lang A-GG
        Statistical power analyses using G*Power 3.1: Tests for correlation and regression analyses.
        Behav Res Methods. 2009; 41: 1149-1460
        • Frøkjaer JB
        • Bergmann S
        • Brock C
        • Madzak A
        • Farmer AD
        • Ellrich J
        • Drewes AM
        Modulation of vagal tone enhances gastroduodenal motility and reduces somatic pain sensitivity.
        Neurogastroenterol Motil. 2016; 28: 592-598
      1. Gerin W, Goyal TM, Mostofsky E, Shimbo D: The Measurement of Blood Pressure in Cardiovascular Research. Handbook of Physiological Research Methods in Health Psychology. Thousand Oaks, CA: SAGE Publications; page 115–132.

        • Gholamrezaei A
        • Van Diest I
        • Aziz Q
        • Vlaeyen JWS
        • Van Oudenhove L
        Influence of inspiratory threshold load on cardiovascular responses to controlled breathing at 0.1 Hz.
        Psychophysiology. 2019; 56: e13447
        • Hirsch J
        • Bishop B
        Respiratory sinus arrhythmia in humans: how breathing pattern modulates heart rate.
        Am J Physiol. 1981;
        • Horsman HM
        • Peebles KC
        • Tzeng YC
        Interactions between breathing rate and low-frequency fluctuations in blood pressure and cardiac intervals.
        J Appl Physiol. 2015; 119: 793-798
        • Jafari H
        • Courtois I
        • Van Den Bergh O
        • Vlaeyen JWS
        • Van Diest I
        Pain and respiration: A systematic review.
        Pain. 2017; 158: 995-1006
        • James JE
        • Hardardottir D
        Influence of attention focus and trait anxiety on tolerance of acute pain.
        Br J Health Psychol. 2002; 7: 149-162
        • Janner H
        • Klausenitz C
        • Gürtler N
        • Hahnenkamp K
        • Usichenko TI
        Effects of electrical transcutaneous vagus nerve stimulation on the perceived intensity of repetitive painful heat stimuli: A blinded placebo- and sham-controlled randomized crossover investigation.
        Anesth Analg. 2018; 126: 2085-2092
        • Jennings JR
        • Berg WK
        • Hutcheson JS
        • Obrist P
        • Porges S
        • Turpin G
        Committee report. Publication guidelines for heart rate studies in man.
        Psychophysiology. 1981; 18: 226-231
        • Kardos A
        • Rau H
        • Greenlee MW
        • Droste C
        • Brody S
        • Roskamm H
        Reduced pain during baroreceptor stimulation in patients with symptomatic and silent myocardial ischaemia.
        Cardiovasc Res. 1994; 28: 515-518
        • Karemaker JM
        Counterpoint: Respiratory sinus arrhythmia is due to the baroreflex mechanism.
        J Appl Physiol. 2009; 106 (discussion 1744): 1742-1743
        • Levine JD
        • Gordon NC
        • Smith R
        • Fields HL
        Post-operative pain: Effect of extent of injury and attention.
        Brain Res. 1982; 234: 500-504
        • Lutz A
        • Slagter HA
        • Dunne JD
        • Davidson RJ
        Attention regulation and monitoring in meditation.
        Trends Cogn Sci. 2008; 12: 163-169
        • Malik M
        • Bigger T
        • Camm J
        • Robert K
        • Malliani A
        • Moss A
        • Schwartz P
        Heart rate variability. Standards of measurement, physiological interpretation, and clinical use. Task Force of the European Society of Cardiology and the North American Society of Pacing and Electrophysiology.
        Eur Heart J. 1996; 17: 354-381
        • Martin SL
        • Kerr KL
        • Bartley EJ
        • Kuhn BL
        • Palit S
        • Terry EL
        • Delventura JL
        • Rhudy JL
        Respiration-induced hypoalgesia: exploration of potential mechanisms.
        J Pain. 2012; 13: 755-763
        • Mason H
        • Vandoni M
        • Debarbieri G
        • Codrons E
        • Ugargol V
        • Bernardi L
        Cardiovascular and respiratory effect of yogic slow breathing in the yoga beginner: What is the best approach?.
        Evid Based Complement Altern Med. 2013; 2013743504
        • McMahon S
        • Koltzenburg M
        • Tracey I
        • Turk D
        Wall & Melzack's Textbook of Pain: Expert Consult.
        6th ed. Saunders, Philadelphia2013
        • Mini A
        • Rau H
        • Montoya P
        • Palomba D
        • Birbaumer N
        Baroreceptor cortical effects, emotions and pain.
        Int J Psychophysiol. 1995; 19: 67-77
        • Nahman-Averbuch H
        • Dayan L
        • Sprecher E
        • Hochberg U
        • Brill S
        • Yarnitsky D
        • Jacob G
        Sex differences in the relationships between parasympathetic activity and pain modulation.
        Physiol Behav. 2016; 154: 40-48
        • Novak V
        • Novak P
        • de Champlain J
        • Le Blanc AR
        • Martin R
        • Nadeau R
        Influence of respiration on heart rate and blood pressure fluctuations.
        J Appl Physiol. 1993; 74: 617-626
        • Parati G
        • Di Rienzo M
        • Mancia G
        How to measure baroreflex sensitivity: from the cardiovascular laboratory to daily life.
        J Hypertens. 2000; 18: 7-19
        • Peltola MA
        Role of editing of R-R intervals in the analysis of heart rate variability.
        Front Physiol. 2012; 3: 148
        • Reyes del Paso GA
        • González I
        • Hernández JA
        Baroreceptor sensitivity and effectiveness varies differentially as a function of cognitive-attentional demands.
        Biol Psychol. 2004; 67: 385-395
        • Reyes del Paso GA
        • Hernández JA
        • González MI
        Differential evaluation of the baroreceptor cardiac reflex effectiveness as a function of sequence length.
        Int J Psychophysiol. 2006; 59: 91-96
        • Reyes del Paso GA
        • Montoro C
        • Muñóz Ladrón de Guevara C
        • Duschek S
        • Jennings JR
        The effect of baroreceptor stimulation on pain perception depends on the elicitation of the reflex cardiovascular response: Evidence of the interplay between the two branches of the baroreceptor system.
        Biol Psychol. 2014; 101: 82-90
        • Sin PYW
        • Galletly DC
        • Tzeng YC
        Influence of breathing frequency on the pattern of respiratory sinus arrhythmia and blood pressure: Old questions revisited.
        Am J Physiol Heart Circ Physiol. 2010; 298: H1588-H1599
        • Song H-S
        • Lehrer PM
        The effects of specific respiratory rates on heart rate and heart rate variability.
        Appl Psychophysiol Biofeedback. 2003; 28: 13-23
        • Spruyt A
        • Clarysse J
        • Vansteenwegen D
        • Baeyens F
        • Hermans D
        Affect 4.0: A free software package for implementing psychological and psychophysiological experiments.
        Exp Psychol. 2010; 57: 36-45
        • Stephens CL
        • Christie IC
        • Friedman BH
        Autonomic specificity of basic emotions: Evidence from pattern classification and cluster analysis.
        Biol Psychol. 2010; 84: 463-473
        • Strauss-Blasche G
        • Moser M
        • Voica M
        • McLeod DR
        • Klammer N
        • Marktl W
        Relative timing of inspiration and expiration affects respiratory sinus arrhythmia.
        Clin Exp Pharmacol Physiol. 2000; 27: 601-606
        • Tarvainen MP
        • Niskanen J-P
        • Lipponen JA
        • Ranta-Aho PO
        • Karjalainen PA
        Kubios HRV–heart rate variability analysis software.
        Comput Methods Programs Biomed. 2014; 113: 210-220
        • Thayer JF
        • Ahs F
        • Fredrikson M
        • Sollers JJ
        • Wager TD
        A meta-analysis of heart rate variability and neuroimaging studies: Implications for heart rate variability as a marker of stress and health.
        Neurosci Biobehav Rev. 2012; 36: 747-756
        • Tingley D
        • Yamamoto T
        • Hirose K
        • Keele L
        • Imai K
        Mediation: R package for causal mediation analysis.
        J Stat Softw. 2014; 59: 1-38
        • Toska K
        • Eriksen M
        Respiration-synchronous fluctuations in stroke volume, heart rate and arterial pressure in humans.
        J Physiol. 1993; 472: 501-512
        • Tracy LM
        • Koenig J
        • Georgiou-Karistianis N
        • Gibson SJ
        • Giummarra MJ
        Heart rate variability is associated with thermal heat pain threshold in males, but not females.
        Int J Psychophysiol. 2018; 131: 37-43
        • Usichenko T
        • Laqua R
        • Leutzow B
        • Lotze M
        Preliminary findings of cerebral responses on transcutaneous vagal nerve stimulation on experimental heat pain.
        Brain Imaging Behav. 2017; 11: 30-37
        • Van Diest I
        • Bradley MM
        • Guerra P
        • Van den Bergh O
        • Lang PJ
        Fear-conditioned respiration and its association to cardiac reactivity.
        Biol Psychol. 2009; 80: 212-217
        • Van Diest I
        • Verstappen K
        • Aubert AE
        • Widjaja D
        • Vansteenwegen D
        • Vlemincx E
        Inhalation/exhalation ratio modulates the effect of slow breathing on heart rate variability and relaxation.
        Appl Psychophysiol Biofeedback. 2014; 39: 171-180
        • Vaschillo E
        • Lehrer P
        • Rishe N
        • Konstantinov M
        Heart rate variability biofeedback as a method for assessing baroreflex function: A preliminary study of resonance in the cardiovascular system.
        Appl Psychophysiol Biofeedback. 2002; 27: 1-27
        • Vaschillo EG
        • Vaschillo B
        • Lehrer PM
        Characteristics of resonance in heart rate variability stimulated by biofeedback.
        Appl Psychophysiol Biofeedback. 2006; 31: 129-142
        • Verhoeven K
        • Van Damme S
        • Eccleston C
        • Van Ryckeghem DML
        • Legrain V
        • Crombez G
        Distraction from pain and executive functioning: An experimental investigation of the role of inhibition, task switching and working memory.
        Eur J Pain. 2011; 15: 866-873
        • Wang Y-P
        • Kuo TBJ
        • Lai C-T
        • Chu J-W
        • Yang CCH
        Effects of respiratory time ratio on heart rate variability and spontaneous baroreflex sensitivity.
        J Appl Physiol. 2013; 115: 1648-1655
        • Wang Y-P
        • Kuo TBJ
        • Lai C-T
        • Lee G-S
        • Yang CCH
        Effects of breathing frequency on baroreflex effectiveness index and spontaneous baroreflex sensitivity derived by sequence analysis.
        J Hypertens. 2012; 30: 2151-2158
        • Wheat AL
        • Larkin KT
        Biofeedback of heart rate variability and related physiology: A critical review.
        Appl Psychophysiol Biofeedback. 2010; 35: 229-242
        • Wilkinson M
        • McIntyre D
        • Edwards L
        Electrocutaneous pain thresholds are higher during systole than diastole.
        Biol Psychol. 2013; 94: 71-73