Which Breathing exercises are best?
The title has a ? because this blog is based on scientific data looking at what is the best breathing exercises for anxiety and stress, and also pain. While its nice to have the data, the best breathing exercises are the ones you enjoy and the ones you do. They are all good!
Several months ago a systemic review came out on breathing exercises for anxiety and stress. It was a comprehensive analysis looking at 58 different studies and included 72 different types of breathing interventions on 5407 participants.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10741869/
Chronically dealing with anxiety and stress wears down ones body and mind. Decades of science and a millennia of practicing through yogic traditions has proven breathing exercises are an effective tool for mitigating stress and anxiety.
Not only that! They are cost free outside of a lesson or two, accessible to anyone who wants to do them, and scalable to the individual.
Through this latest research they are trying to figure out what is the most effective breathing exercises to reduce anxiety. They looked at slow breathing, deep diaphragmatic breathing, alternate nostril breathing, single nostril breathing, fast breathing, breathing with breath holds, extended exhale breathing, pursed lips breathing, and normal breathing.
Results showed conscious breathing reduced stress and anxiety in 54 of the 72 interventions. They then looked at what characteristics separated the 54 effective interventions from the 18 ineffective:
- Slow breathing or a combination of slow and fast breathing. Slow breathing pace, pauses, or ratio of inhale vs exhale didn’t seem to make a difference, what mattered is the breath is slow not the precise pace.
- I would like to note that only 2 of the studies used fast breathing only, if that was increased maybe benefit would be seen there too? Maybe not though, common sense tells me that if one is anxious fast breathing could possibly exacerbate the anxiety. Fast breathing exercises stimulate the sympathetic nervous system in a good way, they are energizing. Anxiety responds better to more calming practices.
- Duration — at least 5 minutes. Thats it! There was no statistical difference between 5 minute and 20 minute breathing sessions.
- Human Guidance – at least one session with human guidance. The guidance can be live in person, virtual, or from a recording. It didn’t matter if the practice was done in a group or individually.
- Multiple sessions throughout a week. Consistency is important in any practice; as the body learns something it becomes quicker and easier to do.
- Long term practice showed even better results. The longer one continues to practice they better they get at noticing anxiety and then applying their breathing techniques to squelch it.
There are some limitations of course, some of the studies looked at were poor quality studies in that researchers were not always blinded, some of the study group sizes were small, or the intervention were not clearly described. Such is the nature of scientific studies. Yogis know the breathing practices are effective from many years of teaching and practicing them regardless of the science.
This study is good news. More people than ever complain of anxiety over the past four years (since covid anxiety has gone up in the general population). Five minutes per day of slow conscious breathing is doable!
Pain and Breath
We can use our breathing efficacy to help reduce pain too. I came across a systematic review of pain and breath.
The review looked at 31 studies from 1984 – 2015. It pointed out that when in pain the breath changes, it increases its flow, frequency, and volume (and it tends to be through the mouth). However by consciously shifting our breathing pattern away from the habitual “pain breathing response” we may be able to reduce the pain. And that is indeed what the study found; when we mindfully slow the pace of the breath it reduces pain. Of course … it ends with “evidence elucidating the underlying physiological mechanisms of this effect is lacking” And of course further research is needed.
Regardless mindful slow breathing reduces pain. There is a lot in the body science can not explain.
Another study from 2020 looked at different breathing patterns on experimental heat pain. They had four groups; unpaced breathing, slow breathing self governed, 6 breaths per minute with longer inhales, and 6 breaths per minute with longer exhales. All 3 slow breathing groups showed a reduction in pain, however the slow breathing with extended exhales was more effective. And again it ends with “the underlying mechanisms remain to be elucidated”.
Then I looked at a meta-analysis on acute pain in burn victims. It was heavily screened for accuracy; out of almost 12,000 studies only 7 were used because they were the highest quality with no bias. And again the results showed slow deep breathing significantly lowered pain scores albeit with a lot of variance.
All the studies I looked at said the same thing as far as they can’t explain why slow breathing reduces pain. Most of the studies looked to the cardiovascular system as the means for the pain reduction but concluded it was not related to changes in cardiovascular functioning by slowing the breath. Though there was some correlation made with slow breathing lowering blood pressure.
Makes me chuckle … because breath is a process of the cardiovascular system the medical community can’t seem to stretch its benefits to other systems —as if the whole body is not connected
Well breath also greatly affects the nervous system. There might be a connection there but none of the studies I looked at made that correlation. Or perhaps breath influences the immune system?
And then there’s substance P. All pain is processed through the brain. Substance P signals the felt experience of pain. While I’m not here to put science to the magical practices of yoga and mindfulness this is interesting.
Substance P was first discovered in horses’ brains and guts, it was first found in a powdery form, hence the P stands for powder and not pain. Substance P also has strong blood pressure lowering and smooth muscle contractile properties. It is a neurotransmitter that is widely dispersed throughout the body with high levels in the gut, brain, and spinal cord.
It influences pain perception, stress, mood, nausea and vomiting, inflammation, smooth muscle contraction, saliva production, wound healing, allergies, and more.
It is released during stressful or anxiety provoking events, and when feeling pain. The amount released is proportional to the intensity of the feelings.
It transmits pain signals from different parts of the body to the spinal cord and brain, where the pain is perceived in the brain. It widens blood vessels and can improve circulation, perhaps this is to get its message received quicker? The body has its own magic in that way.
It can both increase the intensity of pain through inflammation but it can also have a pain relieving effect.
It improves learning and memory but also causes nausea and can cause vomiting. It stimulates histamine and can cause skin itching issues including eczema and psoriasis yet it can also enhance wound healing.
Low levels of it are associated with Alzheimer’s, and at higher levels it promotes learning and memory.
Levels of it vary widely from individual to individual.
Natural substances that lower it (certain drugs can lower it too like Nk-1 receptor blockers and morphine):
- Capsaicin in chili peppers. I used to put cayenne in my relax and heal salves to help lower substance P but decide to take it out after I read more about the complexities of this substance!
- Internal opioids
- Adenosine and certain hormones like testosterone, serotonin, and estrogen (and somatostatin).
- Massage therapy can lower it
Certain drugs can also raise it, as can THC. And stress raises levels of substance P.
Anyway enough on Substance P! I’ve decided to not try to influence my body in either direction with Substance P because its highly variable and the body knows best. I’m trusting the intelligence of my body on this one. I didn’t mean to get into it so much but it is something that perplexes me and it might be the link between slow breathing and pain reduction —especially since substance P is released during stress and breathing lowers stress.
Visualizations and Guided Imagery reduce pain too
I also have pages of reviews on using visualization methods to improve healing. We can use slow breathing to reduce pain while using our mind to visualize healing.
Believe it! You can use your breath to reduce pain and your mind to heal from the pain.
Placebos are getting some exciting attention, it seems among Americans the placebo effect is increasing. To receive FDA approval a pharmaceutical company has to prove they can outperform a placebo. For some reason this is getting harder and harder to do.
What the pharmaceutical companies look at as a hassle we can use to our advantage.
There was some research done on placebos vs. pain meds, surgery, or other pain management therapies. Some placebo treatments works better than others. Placebo means “to please you”. That’s a nice thought Here is what the study found :
- Placebo surgery worked better than placebo injections
- Placebo injections worked better than placebo pills
- Color and size of the placebo pill makes a difference
- Sham acupuncture works better than a placebo pill
- The more expensive the more effective the placebo, and the more administered the more effective
- Telling the patient “this will relieve your pain” is better than saying “this might help”.
Clearly our beliefs have a powerful effect on our body and healing. Scrutinize the quality of your thoughts.
Imagery is a type of mind body medicine that works like a placebo. Guided imagery reduces stress, and improves immune function by increasing white blood cells and lymphocytes. If you are ill, have disease, or planning a surgery you can use guided imagery to improve your healing response.
I did some research on using the power of your mind, here is what I found:
To use your mind power, you have to know how to employ it — the best way to do that is to know what it is you want to do and to think it often;
- The thoughts you think most often are more likely to happen
- If you put your mental energy into the same thoughts day after day they become stronger — and eventually affect your attitude and behavior.
- Not every thought turns into reality, a thought has to be repeated and believed to carry power.
- Doubts, fears and worries tend to destroy what you build with the power of your mind. It is helpful to clear your mind of negative thoughts and doubts.
Your daily exercise or yoga practice is a good place to put your thoughts into the healing of your body. The gentle movements increase blood and lymph flow, while our breath lowers pain, and our mind improves healing. Now thats putting more yoga into your yoga!
Below is some of the data I’ve collected over the years on Guided Imagery and Visualizations:
Imagery and Wound Healing
“A brief intervention reduces stress and improves surgical wound healing response: A randomized trial.”
Broadbent, E. et al. (2011). Brain Behav Immun June 28.
Guided Imagery: Mind Does Matter!
“Studies suggest that: GI can reduce stress and elevate the immune system; cell-specific imagery affects corresponding WBCs, neutrophils, or lymphocytes”
Int J Neurosci. 2008 Jun;118(6):839-55.
“…the longer the duration that they had practiced guided imagery program once a day regularly, the lower scores of their stress were and the higher scores of their health were. We suggest that the regular daily practice of a guided imagery program might be connected to less stress and better health.”
BMC Complement Altern Med. 2005 Dec 20;5:21.
Demonstrated attenuation of pain:
Onieva-Zafra, MD., etal.(2015) Effectiveness of guided imagery relaxation on levels of pain and depression in patients diagnosed with fibromyalgia. HolisDc Nurs Pract. Jan-Feb;29 (1): 13-21.
Posadzki, P, etal. (2011)Guided imagery for Musculoskeletal Pain a systematic review. Clin J Pain. March 22.
Gonzalas, EA., etal.(2010)Effects of guided imagery on postoperative outcomes in patients undergoing same-day surgical procedures: a randomized, single-blind study. AANA J. Jun;78(3):181.
Kwekkeboom, K. ,et al.(2008) PaDents perception of the effectiveness of guided imagery and progressive muscle relaxation interventions used for cancer pain. Complementary Therapies in clinical practices. 14, 185-194.
Imagery Research
Gerik, S.M.(2005)Pain management in children: developmental considerations and mind-body therapies. South Med J. March, 98 (3):295-302.
Lewandowski W., et al.(2005) Changes in the meaning of pain with the use of guided imagery. Pain Manag Nurs. June, 6(2):58-67.
Trakhtenberg, EC.(2008) The effects of guided imagery on an immune system: a critical review. Int J Neurosci. Jun; 118(6): 839-55.
Lengacher, CA. et al.(2008) Immune response to guided imagery during breast cancer. (2008) Jan 9(3):205-14 .
Collins, M.P., Dunn L.F.(2005)The effects of meditation and visual imagery on an immune system disorder dermatomyositis. J AlternaDve Comp. April, 11(2) 275-84.
Achterberg, J and Rider MS.(1989)Effects of music- assisted Imagery on neutrophils and lymphocytes. Biofeedback Self Regul ;14(3): 247-257