Welcome back to the Healing Pain Podcast with Ali Gholamrezaei, MD, PhD
Welcome back to the show. We’re discussing the impact of breathing on chronic pain and relaxation. Joining me for our expert guest and interview is Dr. Ali Gholamrezaei. Dr. Gholamrezaei originally trained and worked as a general physician and eventually became interested in the mind-body connection. He started clinical research, which involved looking at cognitive behavioral therapy, stress management and hypnotherapy for gastrointestinal conditions such as irritable bowel syndrome. He eventually pursued and completed a PhD where he conducted experiments on slow deep breathing and how it impacted chronic pain.
He is currently a research fellow at the Pain Management Research Institute at the University of Sydney in Australia, where he’s working on the development of a digital behavioral intervention for chronic pain management. In this episode, we’ll discuss techniques being used for slow deep breathing, the psychological and physiological effects of slow deep breathing, and the evidence supporting slow deep breathing to attenuate chronic pain.
I want to thank you again for joining us on the show. If you enjoy this episode or maybe a past episode, head on over to iTunes and give us a five-star review. Say something nice and make sure to tag me on Instagram. My Instagram handle is @DrJoeTatta. Without further ado, let’s begin and learn about slow deep breathing and pain with Dr. Ali Gholamrezaei.
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The Science Behind How Slow Deep Breathing Reduces Pain With Ali Gholamrezaei, MD, PhD
Ali, thanks for joining me for this episode of the show. It’s great to have you here.
I’m glad to be here.
People following along with our show’s title probably notice there’s an MD and a PhD after your name. You have lots of years into medicine and health. I know early in your career, you started as a general internist or general medicine. Now a lot of your research focuses on the brain and the mind-body connection, which is something we love talking about on this show. How did you transition from that more of general medicine, internal medicine perspective to now a strong focus on mind-body medicine and investigating that?
I was trained as a medical practitioner. My interest in mind-body medicine and complementary medicine started since the beginning of my medical training. I saw a flyer around about a hypnotherapy workshop. It was in 2002. I said, “That looks interesting.” I went to that workshop. That was the beginning of my journey in mind-body medicine, brain-body connection and research interest. I went to that workshop and I saw people talking about clinical applications of hypnosis in medicine, particularly. I said, “That’s interesting.” I started learning what hypnosis and hypnotherapy is.
We initiated the research group mainly composed of medical students. We had some senior students who supervised us, and then we read and researched around hypnotherapy. We started practicing it under supervision in our clinical courses. My focus was shifted to more research part of it, rather than just a clinical practice. One research after another and then I get into mental health, physical health, the importance of mental health in physical health, which is sometimes missed in the clinical field.
Now I know a lot of your work focuses on breathing. Distill it down to a specific topic.
I did a bit of research on how mind-body practice can be used in various medical conditions like hypnotherapy. In hypnotherapy, breathing is used in many complementary and mind-body therapies like hypnotherapy as a component. After I graduated in Medicine and did a bit of clinical practice, I was looking for a research group working in this field particularly. I searched and I found a good group at the University of Leuven in Belgium. I applied for a PhD position there. The research project was about the influence of slow deep breathing on pain and that matched exactly my interests. I moved to Belgium and I started doing research on breathing. It was mainly an experimental approach to breathing, its psychophysiological effects, and whether it can influence pain.
Your research focuses on the impact of slow deep breathing and the ability to reduce our impact pain. What is slow deep breathing?
A good point to start is defining what a breathing exercise is because slow deep breathing is a breathing exercise. The National Center for Complementary and Integrative Medicine gives a very good definition of what is a breathing exercise. A breathing exercise is any change in breathing behavior. It can be a change in breathing frequency or rate of breathing. It can be a change in breathing depth, how much air we take in and out. It can be a change in the airway that we use for breathing through the nose or to the nose or a combination of that and any other behavior that can accompany breathing behavior.
For example, diaphragmatic breathing or any of these combinations can generate lots of types of breathing exercises. Slow deep breathing is perhaps the most common type of breathing exercise that people practice for various physical and mental health conditions. Not only for disease or disorders but also to promote health and achieve mental states.
During the study of deep breathing, the breathing rate is reduced. At the same time, the breathing depth is increased. Some people call it slow breathing. Some people call it deep breathing. Some people call it resonance frequency breathing. I prefer to use the slow and deep breathing term because of its operational definition. It usually happens together because we have to increase our breathing depth when we reduce our breathing rate. We have the same amount of ventilation and gas exchange, so we don’t hyperventilate or hypoventilate. In summary, slow deep breathing is a breathing exercise during which we breathe more slowly compared to the normal breathing rate and more deeply.
Slower and deeper.
There are many techniques to do that, which we can discuss.
Let’s talk about some techniques. We’d love to share some simple things that people could do potentially if they’re home right now, maybe in a safe or a quiet space. They might be able to follow along with you.
There are different techniques. I don’t know how many techniques are available, but there are perhaps many. You can imagine you can combine many components that I taught first, like the way that we breathe through, the rate of the breathing, the tips of the breathing, the ratio between the inspiration and expiration. There are posters of the body. There are different techniques used for slow and deep breathing. Some of them are more commonly mentioned in the literature. For example, we have this pursed-lip breathing, which is breathing through the nose and breathing out through the mouth while pursing the lips. That’s called pursed-lip breathing, or you can simply narrow your mouth so you can better control the breathing out phase.
That’s a common technique that is used for pulmonary rehabilitation, like COPT. There are some reasons behind that, like the inter-thoracic pressure that is generated before the breathing out or expiration. That’s also commonly being used in research when we want to investigate the psychophysiological effects of slow deep breathing, or at least to elaborate, you would use it mainly. The other common technique is unilateral nostril breathing or alternate nostril breathing. That’s a common breathing.
It’s breathing through one nostril, closing the other, and either breathing out through the same nostril or changing. Sometimes there is this famous poster for hand. That’s also a common breathing exercise being used. There are some theories and hypotheses that you are breathing through one nostril activates unilateral or ipsilateral part of the brain, but not that much of evidence there. That’s why we breathe through one nostril or the other.
There are some modern techniques of a slow deep breathing. For example, some researchers used, inspiratory muscle training devices combined with the slow deep breathing. They found that it optimized the effect of a slow deep breathing on cardiovascular parameters. They use it for hypertension, which is similar to some maneuvers that we do during slow deep breathing like closing the glottis to create that pressure or during unilateral nostril breathing. We try to mimic that. That’s not the main reason, but the same thing happens during unilateral nostril breathing.
HRV biofeedback, I can say it’s a modern technique for doing slow deep breathing. There are other components to that as well, of course, but that’s also using devices and biofeedback to monitor your breathing and the final outcome of the breathing effect on the cardiovascular system. That is the heart rate. You try to follow your heart rate variability and increase it as much as possible. That may end up you breathing at a certain breathing frequency to the time.
There are also modern techniques for slow deep breathing and diaphragmatic breathing. There are many techniques. What is the difference between them? We need to investigate. That was one research that I did. There are some differences in terms of psychological and physiological effects. We didn’t investigate that. I can imagine the clinical applications can also be different.
That investigation looked in was around how slow deep breathing can impact pain or how it may modulate the pain experience of a certain group of people.
Our main focus was what is the mechanism of slow deep breathing in pain. We tried to increase the autonomic modulation as much as possible in a comfortable way. We tried to find a method that could generate the highest modulation in autonomic activity. Using the inspiratory load during slow deep breathing optimized the effect of slow deep breathing on reflex and subsequent cardiovascular response. We used that and compared it to pursed-lip breathing, which, in another study, my colleague found it to be effective in reducing pain.
We tried to compare them and see if it could be fair to reduce pain and how. In one of my studies, I compared pursed-lip breathing with loaded breathing and unilateral nostril breathing, left and right, because there were some studies inconsistent though that one may activate. One may modulate cardiovascular activity more than the other, which was not the case in our experiment. It was less influential on cardiovascular parameters than pursed-lip breathing. The reason was very interesting. Anyway, we dropped that one and we compared the other two in a subsequent experiment on pain.
The subject in your investigation is experimental pain. For example, these are not people with, let’s say, fibromyalgia or CRPS. You’re initiating pain during the experiment.
In all of my studies in Belgium, we used experimental models of pain. My focus was on research pain because of my background of research in gastrointestinal disorders. It looks a bit invasive, but that’s the easiest access to the resource. I inserted a tiny needle catheter into the nose. I sent it to the esophagus and delivered electrical stimulation to generate pain. I tried it on myself a lot of times to ensure that it was painful and see how my participants would feel. Our participants perform different types of breathing, and they receive short painful stimulation in random times.
We also monitor lots of cardiovascular or respiratory parameters to investigate the mechanisms. We mainly focus on the experimental model of pain. That is a limitation of not being able to generalize what we find in experimental studies necessarily to a clinic, but also it brings some opportunities to precisely investigate mechanisms in the lab, but we need to replicate findings in the clinical field.
In that study, I’m wondering why the electrical shock was applied to the esophagus versus, let’s say, a hand or a foot or a different area on the body?
I did want to study and apply electrical stimulation on hand as a somatic model of pain. I had two other colleagues, Hassan Jafari, who is now in King’s College London. My colleagues focused on somatic pain. I focused on visceral pain. We had a very nice group that we always worked together. I used different models of pain, like heat pain, pressure pain, and electrical stimulation for pain. Hassan used electrical stimulation for pain. We had a combination of different models of pain. Our results were more or less consistent, which I will get into it.
I know you’re looking at mechanisms of pain relief for that, both psychological and physiological mechanisms. There are quite a number of mechanisms that you looked at and tested in that paper. Can you walk us through some of those so we see the full breadth of that?
We not only looked at the mechanisms or what is the psychophysical response to slow deep breathing, but also in normal, like what happens when we do slow deep breathing in the laboratory. It’s good to distinguish between the short-term and long-term effects because they are different. What’s consistent among different research by different groups is that in the short-term, like about 5 or 10 or 15 minutes, when we do slow deep breathing, we have some typical cardiovascular responses.
That’s consistent intra-individually and inter-individually. What we see is a typical increase in heart rate variability at the frequency of breathing. For example, if the breathing frequency is 10 breaths per minute or 6 breaths per minute, we see a peak in heart rate variability at that specific frequency. The mechanism is a combination of central and peripheral mechanisms and reflexes and feedbacks.
Usually, we don’t see a change or minimal change in average heart rate and average blood pressure in that short period. Sometimes you even see a small increase because slow deep breathing, especially for those who are novices and have no experience and are trying to follow breathing hard, is a bit of a cognitive task, I would say. That may increase heartbeat, but just 1 or 2 beats on average, so not that much.
In the laboratory for short-term practice, we usually don’t see that much of a change in affective state, but that’s very much contextual. For example, if you give a person a stress task or anticipate a painful stimulation, in the short-term, slow deep breathing can reduce their anticipatory or lower stress or anxiety. If you don’t give them any task or relaxation instruction or other mental tasks like mindfulness or things like this, we usually don’t see a change in activity. The long-term effect is a bit more complex. That’s a bit inconsistent across the studies, mainly due to having other components to slow deep breathing, relaxation, or lots of instructions.
There is evidence that long-term practice of slow deep breathing can reduce heart rate and blood pressure, especially in those with the earliest hypertension stage. It can reduce anxiety and distress in the clinical population but also in the general population when they face a stressful situation. Most studies usually have other components like instructions and relaxation. That’s part of the difficulty in investigating your mechanism. Is it a combination of them or is it purely slow deep breathing? When we bring it to the lab, sometimes you see it as different.
I know there are some studies that demonstrate deep breathing has an impact on emotional regulation, which will have an impact on pain.
We measured some emotional and autonomic parameters, trying to investigate if they are involved. Our studies found some effects of slow deep breathing on, for example, anticipatory, but that didn’t statistically mediate the effects on pain. Statistically, it’s not the best way, but what we could do. We didn’t see that much of a strong relationship there nor for the autonomic system. We think that in our studies, at least in the laboratory in the short-term, the main mechanism is a distraction, some expectancy.
That’s also one reason there is an inconsistency between some studies because expectancy is not something that is well controlled in many studies. I used a cover story in one of my studies, so people didn’t know what this study is about. We found no difference between controlled breathing at normal and slower frequencies. Both of them are lower than doing nothing. That’s mostly a distraction, I would say, which can bring some emotional effect, because when you are distracted from pain, you may have reduced arousal.
What stood out to me when I read your study is that there wasn’t a strong relationship with arousal or decreasing arousal, which a lot of people would tell you breathing exercises or deep breathing exercises help regulate arousal in people in general, but your study didn’t point in that direction too much.
It’s important to see how we do this study in the lab. For example, in one study, the duration of each trial was just one minute. That may not be enough to reduce arousal. In another study, the duration of breathing before the participants received the pain was one minute. We found reduced arousal in that period when we measured it.
It’s also important when we measure their arousal. When we want to measure their arousal, the person has to stop doing the breathing and rate it on the monitor. There’s a bit of manipulation there. That is not what actually happens because when you do slow deep breathing, you close your eyes, you try to focus and then imagine that you’re doing that and suddenly someone asks you, “Rate something.”
There’s a bit of manipulation. It’s not the optimal thing that we can experience in real life. We have a reduction in the responses. That’s why we sometimes see a tiny difference, not what actually can happen in real life. We see a decrease in anticipated arousal. That’s also consistently shown by other studies. It’s something good to mention that maybe instead of focusing on just one parameter of pain experience, pain intensity, we should talk about the whole pain experience and how pain experience can be transformed through breathing. It’s not just the intensity of pain.
We know that pain has lots of other qualities or how pain interferes with our function and how doing slow deep breathing can reduce that interference because that’s an important outcome to achieve, not just the intensity of pain but also how it interferes with our function. To answer that, we need to go to the clinical field and see how it can help patients.
You also track pain catastrophizing, which has been looked at a lot with regard to pain intensity. What did your study find with pain catastrophizing?
One interesting finding in one of my experiments that’s different from the other distraction techniques was that those who had higher scores in the catastrophizing pain scale are on a scale that tries to capture concerns about pain, so people who have more concerns about pain or rate it that way. They benefit more from doing slow deep breathing and also overall controlled breathing.
They have more reduction in pain while they are doing controlled breathing at a slow or normal frequency compared to doing nothing. That suggests that when they are not doing slow deep breathing, they are thinking about pain. They are concerned about pain and are focusing on their pain. They are not distracted from the pain that may increase their pain, but when they are focusing on their breathing and all of those sensations during slow deep breathing, their pain reduces.
That is not what we see with other distraction techniques. That shows that when it comes to pain concerns, the technique that we use for distraction does matter. Maybe slow deep breathing can be a technique that can capture attention well because it is pleasant and relevant. It can bring some expectations and emotional responses as well, compared to a visual distraction, which is not necessarily emotionally helpful or seems relevant to a patient or someone doing a painful procedure, for example. That’s something interesting and potentially clinically useful.
Let’s say if we use a red dot and moving on a wall as a form of distraction and compare it to someone focusing on their own breathing as a form of distraction. It looks like slow attenuated, deep breathing will help decrease the pain catastrophizing.
To me, there’s a sense that one is an external distraction, the other is more internal insights, which might speak a little bit to interoceptive processing, which is an important part of pain and some parts of the brain that it goes through.
We use these visual guides, so the participants need to follow the visual guide, although, after a while, it’s rhythmic, so they don’t have to look at it. We always have this visual stimulus under monitor. Whether that has some effects, we don’t know. We need to purely compare it with the visual guide following thing. There are lots of sensations when you do practice slow deep breathing, lots of interceptive conscious and unconscious sensations because many interceptive is signaling you don’t consciously feel what in some of them you feel if you pay attention.
There is evidence consistently showing that did the attention task, how much it shifts your attention from the painful stimulation to that sensation does matter. It’s important that you use an engaging task. Slow deep breathing is engaging. It is also emotionally meaningful and relevant. All of these parameters help to make it engaging. That makes it a potentially useful distraction. It also has other effects.
I’m just wondering, in the instruction you provide to people for the slow deep breathing, or even the sustained breathing that you use, does the instruction influence what the person might experience even on an emotional level? If I said to someone, “Breathe in for three seconds and breathe out for three seconds,” versus, “Take a nice low relaxing breath in for three seconds and that cleansing breath out for three seconds.” There’s a different form of expectancy there potentially that happens with each of those instructions.
In his hypnosis, we say, “Your trance state deepens with each deep breath. With each deep breath, you become more relaxed.” Instruction is critical. Without instruction, what we investigated in the lab was purely reducing breathing rate, maybe a bit of focused attention, because we say, “Focus on your breathing,” but just a simple sentence to help them to not distract with other instruments, things hanging from the wall, lots of things in the laboratory. We didn’t have any relaxation instructions. That’s interesting.
Why don’t we have any relaxation instructions? Why do we see that reduction in arousal? That can be partially because they are distracted from pain, which can also reduce their arousal. Not necessarily distraction that can also be due to some center on mechanism. This study in a mouse model of slow deep breathing published in science found that when they update some neurons in the respiratory center, their mouse becomes calmer.
They found that’s two connections between the respiratory center and some nuclei in the brain responsible for motion and arousal. There are direct and indirect mechanisms of slow deep breathing, reducing. Instruction can be used to potentiate that and direct that toward, for example, in mindfulness to paying attention non-judgmentally or paying attention to pain but changing the sensation from pain to something else. That’s some technique using hypnosis, that changing pain to tingling or changing the site of the pain. Instead of ignoring that sensation, you pay attention to the sensation, trying to change it. That may not work for any situation, but that’s some variation in the technique.
That’s what I like about your study with the breathing aspect because I think people are focused on pain and many people with pain don’t want to focus on their body because they see their body as a place that’s unsafe. However, bringing them to the breath or awareness of it introduces them to potentially the bodily sensation they can begin to approach. They have some control over and they realize when they approach it in a way that’s, for example, non-judgmentally and they start to regulate their own breathing, and they find that it has an impact on their pain, let’s say, or maybe their emotion regulation, then they have a bit of empowerment that they experience.
They feel like, “I can do something for myself. I can do something to impact this pain.” What are the questions that remain unanswered in this area with regards to breathing? If you asked any yogi, they would say, “Deep breathing is a panacea for almost everything, especially chronic pain,” but there are a lot of questions we don’t know on a mechanism level and on an investigative level.
Summary on evidence, of course, I’m not on top of the evidence. Any day you search, there is a new study going on. I saw a systematic review and meta-analysis on the influence of slow deep breathing on acute pain. There is some low certainty evidence in terms of evidence rating that slow deep breathing can reduce acute procedural pain, like in burn, for example. That’s also what we saw in experimental studies. Slow deep breathing can reduce acute pain. We think it’s mostly a distraction and cognitive. A combination of expectations and any clinical situation you can imagine, a clinician, nurse, or practitioner standing behind or sitting next to the patient.
There is that relationship and communication, as well as expectation, distraction, and a bit of emotion. Not that much of an autonomic motivation, I would say. What happens to chronic pain? There is not that much evidence. Some studies show no effect, but 1 or 2 studies that’s not enough to investigate. We need more studies on chronic pain, definitely.
Slow deep breathing is combined together with other interventions, like in the context of yoga, mindfulness meditation, or HRV biofeedback. There are lots of studies out there. Whether the effect is due to slow deep breathing or how much of the effect is due to slow deep breathing or whether you take out slow breathing, how much is the effect? These are interesting questions that I think should be answered if you are interested in mechanism.
If you understand the mechanism, we can enhance it. We can find for what person this technique may work. I had one participant in one experiment. Instead of doing slow deep breathing, the participant was doing mental imagery. After each test, I interviewed my participants qualitatively, “What was your experience with it?”
The participant used mental imagery. It was much more effective than slow deep breathing. It’s not going to work for everyone. It can bring some unwanted effects, like for example, hyperventilation, which can be reduced by using good instructions. It’s not a panacea. It’s not something that can work for everybody or for every condition. We need to test it in experiments in experimental models, indicate for what condition and for what person it may work, find those predictors, and then use those predictors to use different techniques for different conditions for different people. If I want to summarize the mechanisms, our experiments helped a lot because we tried to monitor lots of physiological parameters.
I can say which monitor breathing read precisely. We used B2B blood pressure measurement to monitor bioreflex activity and heart rate variability. Although we saw a typical cardiovascular response to slow deep breathing in all of the studies, it didn’t statistically mediate the effect on pain. I should say that statistical analysis may not be a proper way of investigating that. Perhaps there are other methods like the pharmacological blockade of the autonomic nervous system.
That’s why we think it’s more distraction and expectation in the short-term. In the long-term, maybe the autonomic nervous system can be modulated with long-term practice. Our studies found that for those who had lower heart rate in baseline and higher heart rate ability, we use these indexes for measuring cardiac activity. They had lower pain intensity. Maybe if we practice slow deep breathing for long-term by having some long-term change in the autonomic nervous system, we can impact through the nervous system.
Your research is great because this one particularly goes into all the different mechanisms, which is great. If you can figure out those mediators, we can start to exploit them in clinical practice and use them for different individuals and different phenotypes in populations. Pulling out into the big area of mind-body medicine, which is your stomping ground looking at the brain and mind-body medicine, where would you like to see the overall research go in the area of mind-body medicine in general? Mind-body medicine still is looked at as a complementary alternative, integrative method. Many people feel like, “There’s enough there now that this should be mainstream and it should be part of the zeitgeists of what’s happening in healthcare, especially pain care.”
I should say I’m a beginner in the field. It’s a very big field. It has a good direction. If you see what’s happening in interception research and how interception influences cognition emotion and how that can be used to enhance therapeutic techniques, like desensitization for phobia. Some trials use the stimuli to adjust the time of the stimuli based on the cardiac cycle. It is shown that if you see a visual stimuli emotion or the relevance if you show it during the system, the response is different when you show it during the system. It’s different. There are some studies on using nerve stimulation based on the respiratory cycle.
As we understand the connection between brain and body, I don’t necessarily say you have to have a brain and body thing. We need a connection. We have a brain and a body. If they are separate, which they are not, there is this brain-body connection and this dialogue between them both way. As we understand physiology and mechanisms, we can harness this information and use them to enhance therapeutic techniques.
These are already being used. For example, the whole four years of my PhD were focused on this slow deep breathing technique. We had this question, “Can slow deep breathing reduce pain?” We had this as a title in one of our papers. A reviewer said, “It can. Why did you put it in the title of your paper?” We thought, “We don’t know yet. There’s no consistent evidence out there.”
When we want to scientifically test something, we need to test it. We need to consider our assumptions as assumptions and bring them into the laboratory or clinical field, test it, interpret it, and report it unbiased. There are also some problems there, like a publication by us, for example, where we see more positive results than negative results. I experienced it very much because many of my studies were negative results. We need to test them more carefully. We are doing that.
I appreciate that. I’ve spoken to many professionals who say, “The first place you should start with every chronic pain patient is diaphragmatic breathing.” Your research points to the fact that it might have an impact on some people and it might not have an impact on some people. Let’s do a little bit more investigation to find out who it can help and then we apply that and that becomes efficient clinical practice versus who it cannot help and then we can use other methods to help them. It’s been great speaking with you about breathing and pain. A niche topic that I appreciate because I know it’s used a lot in physical therapy and psychology and other mind-body approaches. Tell our readers how they can learn more about you and follow your work.
I’m focused on using digital health technology for people with chronic pain and trying to use it to support them. I try to use this breathing intervention in our intervention as much as it’s relevant and scientifically sound. If you want to see my work in this area, you can follow my Twitter, which is @AGholamrezaei. I’m also on ResearchGate. If you have any questions about slow deep breathing, you can always email me or send me a message on Twitter or on ResearchGate. I’m very active in ResearchGate. I’d like to contribute to the discussions about the psychophysiology of respiration and slow deep breathing. Feel free to contact me.
I want to thank Ali for joining us. It’s been great joining you this episode. Make sure to tune in next episode. We’ll see you then. Take care.
About Ali Gholamrezaei
I studied Medicine and worked as a General Physician in Iran between 2010 and 2015. I also worked as a Clinical Research Associate in Medical Research Institutes for about 10 years and led and contributed to interdisciplinary researches in chronic medical conditions. I was interested in ‘mind-boy connection’ and interventions and started clinical and research practice on using cognitive-behavioural therapy, stress management, and hypnotherapy for gastrointestinal conditions like irritable bowel syndrome and inflammatory bowel disease. I then started my PhD program at the Translational Research Center for Gastrointestinal Disorders and Health Psychology Research Group, University of Leuven (KU Leuven, Belgium) between 2015 and 2019 and conducted experiments on slow deep breathing and pain. I am currently a Research Fellow at the Pain Management Research Institute, University of Sydney working on development and evaluation of digital behavioural interventions for chronic pain management. I am also interested in Experimental Health Psychology and Psychophysiology and I have international collaborations in these fields.