The Benefits of Breathwork

By: Laura Viner

Why is wellness important? 

Wellness is ‘maintaining and improving health through active pursuits that support and benefit, both physical and mental health’. We choose to share the evidence for certain practices to encourage our patients to explore these in relation to their personal health goals. Wellness practices have measurable, physiological effects on the nervous system, aiding in a positive mindset, stress management, and in some cases positively affecting the respiratory, vascular and digestive systems. In this article, we’ll discuss the benefits of breathwork for physical, mental and emotional health. 

Breathwork, also known as controlled breathing, mindful breathing, voluntary slow breathing (VSB) or deep, abdominal breathing refers to any deliberate control of the breath. Renewed interest in this field has generated research studies into how breathing differently can affect our health. 

Firstly, breath rate can influence our nervous system which maintains heart rate, blood pressure, breath rate, and other ‘automatic’ functions that we don’t have to think about. The nervous system has two branches with opposing actions; the parasympathetic nervous system activates rest, recovery, reproductive, digestive and immune function, while the sympathetic nervous system activates stress hormones, fight or flight responses, and is associated with more reactive, impulsive behaviours. Being in sympathetic mode increases our blood pressure, blood glucose levels and blood flow to muscles, while the parasympathetic mode does the opposite. We need these systems to be balanced to function optimally. When the sympathetic, or stress mode dominates, our digestive, immune, and reproductive function is suppressed, and brain activation shifts towards reactive, or impulsive actions. 

Incredibly, we can shift to more positive body and brain states just by using slow breathing, to decrease blood pressure, relax smooth muscle, slow heart rate and increase the amount of oxygen in the blood. Slow breathing with an extended exhale activates the vagus nerve, the main nerve for parasympathetic mode connecting brain to intestine. When stimulated by slow breathing, the vagus nerve releases acetylcholine, the main neurotransmitter, or messenger, for our nervous system, relaxing the heart, lungs and blood vessels. Various studies (using activities that reduce breath rate such as yoga, Qigong, prayer, and mindfulness) have shown that deliberately slowing breathing to 6 breaths per minute, (average rate is 15 per minute), results in slower heart rate, relaxed muscle tissue, reduced blood pressure and an ‘alpha’ brain state. This alpha state is associated with increased creativity and emotional control, and decreased psychological anxiety. Keeping in mind that many of these findings were from studies using healthy subjects, we’ll look at the evidence for specific applications in more detail below.

Breathwork and Stress  

A 2023 Stanford University controlled trial, comparing the effectiveness of different stress reduction techniques found breathwork had a faster, more positive impact on stress and physiology, than mindfulness meditation. Within the study they compared cyclic sighing, box breathing, and an extended exhale for just 5 minutes a day for a month, finding the breathing techniques equally effective. Slow breathing also increases heart rate variability (HRV) - a quality associated with greater physical adaptability, and resilience, including the stress-response system, according to a 2022 meta-analysis. People with high HRV self-report less stress, and increased happiness, and participants in slow breathing studies have reported less stress, anxiety, cravings, musculoskeletal  pain, and brain fog. One small study found breathing exercises significantly reduced cortisol levels in women with no physical or mental diagnosis, but did not have the same effect in those with a physical or mental health condition. A small intervention found that abdominal, and alternate nostril breathing 5 times a week for 2 weeks significantly decreased symptoms of anxiety or depression in patients with these diagnoses; these improvements were maintained up to 6 months later with once weekly maintenance. Significant effects  are associated with regular practice (4+ times/ week), and only minimal effects when used as an intervention before a stressful event. This suggests that cumulative practice provides prophylactic benefits. 

Breathwork and sleep

Effects of slow breathing on blood pressure and sleep follow similar principles to the physiological changes described that help reduce stress. Again the benefits for sleep are associated with restoring vagal function through slow breathing - 6 breaths per minute , or the 4-7-8 technique, across a number of studies using insomniacs. Results vary but on average 20 minutes of slow breathing before bed time reduced the time taken to fall asleep from average 25 minutes, to 10 minutes, but significantly they woke fewer times in the night and went back to sleep faster. Another study used 15 minutes of slow paced breathing before sleep for 30 days, to demonstrate improved sleep in healthy subjects citing cardiac vagal activity as the main mechanism. 

Breathwork and Blood Pressure

Overall the results of slow breathing interventions are modest, but significant for patients with hypertension. A recent meta analysis covering 17,000 patients suggested that slow breathing interventions of under 10 breaths per minute for 5 or more minutes, on 3 or more days per week for 4 weeks can have benefits for prehypertensive, or hypertensive patients that wish to avoid or delay medication. Studies reveal slightly better outcomes when slow breathing instructions come via a person in a medical setting, rather than a device (app, monitor, biofeedback) but devices are backed by research. One study of 95 non-hypertensive participants found 12-weeks of instructor-led slow breathing exercises resulted in a significant reduction of blood pressure, especially in those with elevated blood pressure rates. 

Breathwork, memory and decision making. 

Higher cardiac vagal activity leads to better executive functioning, and very slow breathing or paced breathing has been shown to enhance executive function i.e. improved decision making, attention, working memory, and cognitive flexibility. A controlled intervention found that people who completed 3 rounds of 5 minutes of slow breathing performed better with fewer errors in executive function tests for cognitive flexibility and memory, compared to people that watched TV for the same time period (reaction times were not improved). Interestingly this study proved that effect was not not mediated by cardiac vagal activity, suggesting an alternative pathway leading to the cognitive improvements. 

Breathwork and Athletic Performance

Slow abdominal breathing improves overall cardiovascular fitness by increasing oxygen to cells, increasing lung capacity and supporting stamina and endurance. Slow breathing also improves the body’s ability to recover from exercise by facilitating the removal of waste products, i.e. lactic acid, from muscles. Athletes also benefit from the enhanced cognitive function described above. 

Breathwork and Pain Management

The evidence for paced breathing and pain relief is mixed, however one 2004 study demonstrated that very slow abdominal breathing of 3–4 breaths per minute significantly reduced peak alpha frequency - a measure of pain sensitivity, compared to standard breathing. Another study in 2015 found increased blood oxygenation during paced breathing at breaths per minute, compared to 10 breaths per minute in healthy subjects. A large meta analysis brought together research to conclude that deep slow breathing with relaxation, reduced pain perception and increased pain thresholds, but the same breathing without relaxation, did not demonstrate these effects.

KEY POINTS 

• A longer exhale than inhale is key to activating the parasympathetic nervous control of the heart. 
• Aim for 6 breaths per minute. This app allows you to gradually reduce the breath rate. Work towards this gradually, avoiding breath holds and stop at any sign of discomfort.
• Alternate day practice over 2-4 weeks (5-10 mins/ day) for stress, depression, and anxiety.
• Daily practice for sleep (at bedtime), and blood pressure benefits.
• Posture is key; seated, shoulders back and down, neutral hips, hold yourself straight to facilitate free movement of the ribs and diaphragm.

Breath Holding

Popularised by Wim Hoff, another theory for the health benefits of controlled breathing relate to carbon dioxide and oxygen exchange. Increased levels of carbon dioxide in the body prompts us to take a breath, with some experts suggesting that deeper, longer breaths allow us to fully expel carbon dioxide, enabling greater oxygen inhalation, and oxygenation of the body. However, this is associated with breathing exercises designed to increase carbon dioxide tolerance and encourages breath holding which has serious risks such as tingling, risk of fainting and hypoxic brain injury and is not what we are exploring in this post. 

Controlled breathing is not advised for people having a panic attack due to interoceptive anxiety. Reported side effects include hot flushes, shortness of breath and sweating. 

We hope this article has been useful for you. As with many areas of lifestyle medicine, the evidence to support different approaches is constantly growing and developing. Some experts believe there is inadequate evidence to recommend breathwork for patients with pre-existing health problems, suggesting it could have a preventative role. The current evidence is limited due to a lack of standardization of design, and breathing techniques across studies.

References 

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