effectofdeepslowbreathingonpain-related ...downloads.hindawi.com/journals/prm/2019/5487050.pdfrecent...

Research ArticleEffect of Deep Slow Breathing on Pain-RelatedVariables in Osteoarthritis

Kalee L. Larsen, Lorrie R. Brilla , Wren L. McLaughlin, and Ying Li

Health and Human Development Department, Western Washington University, Bellingham, WA 98225, USA

Correspondence should be addressed to Lorrie R. Brilla; [email protected]

Received 8 March 2019; Accepted 6 May 2019; Published 3 June 2019

Academic Editor: Robert L. Barkin

Copyright © 2019Kalee L. Larsen et al.)is is an open access article distributed under the Creative Commons Attribution License,which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

)is study evaluated the effect of a six-week deep slow breathing (DSB) program on pain, physical function, and heart ratevariability (HRV) in subjects with lower extremity joint pain. Twenty subjects were assigned into training (n� 10) and control(n� 10) groups. )e training group participated in a six-week DSB program consisting of weekly training sessions and at-homebreathing exercises. DSB exercises focused on prolonging the exhalation and the pause following exhalation.)eWestern Ontarioand McMaster Universities Osteoarthritis Index (WOMAC) was used to assess pain and physical function, and HRV data wereobtained before and after intervention. Results revealed no significant interactions between group and time for any of thevariables. )ere was no significant main effect for group, but there was a significant main effect (p< 0.025) and a large effect sizefor time on both pain (η2p � 0.454) and physical function (η2p � 0.506). )ere were no significant main effects (p> 0.017) for groupand time on LF power (group η2p � 0.039, time η

2p � 0.061), HF power (group η

2p � 0.039, time η

2p � 0.039), and LF/HF ratio (group

η2p � 0.036, time η2p � 0.169). Results indicated that the six-week DSB program was not sufficient to alleviate pain or improvephysical function in subjects with lower extremity joint pain. Although the pain was not alleviated, other beneficial effects such asbetter coping with the pain were reported in the majority of training subjects. As this is the first study to examine the use of DSBfor lower extremity joint pain and dysfunction, further research is needed to investigate the efficacy and applicability of DSB.

1. Introduction

Arthritis is the leading cause of disability among adults in theUnited States, affecting an estimated 50 percent of peopleaged 65 and older.)e disease is associated with other healthdisorders such as diabetes, hypertension, obesity, and can-cer. Half of those with arthritis also suffer from cardio-vascular disease [1], the leading cause of death among bothmen and women in the United States [2]. Osteoarthritis(OA) is the most common form of arthritis, mainly affectingthe hands, hips, and knees. )ose suffering from OA ex-perience a great deal of pain, limiting physical activity, anddecreasing quality of life. Fear of pain or worseningsymptoms may discourage those with OA from beneficialexercise, leading to other health problems associated withOA such as weight gain and heart disease [1]. Interventiongoals for OA include reducing pain, improving quality oflife, losing excess weight, and making lifestyle changes that

improve health such as diet and physical activity. Becausepain is the major limiting factor for those with OA, mostinterventions are aimed at reducing pain. However, surgicalinterventions are expensive and nonsurgical interventions,such as analgesics and physical therapy, have low efficacy [3].Some interventions, such as pain medications, may produceother health complications including damage to the liver,kidneys, and gastrointestinal tract [4, 5].

)ere is a need for effective nonsurgical interventions.Exercise has been proposed as an effective and beneficialintervention for those with OA. Exercise reduces pain andimproves function, quality of life, mood, and confidence tomanage health [1]. Despite the benefits of exercise, 60percent of people suffering with the disease do not adhere tophysical activity guidelines and 23 percent are categorized asphysically inactive. )is decrease in physical activity in thosewith OA may be a result of pain or fear of worseningsymptoms with exercise [6]. Reduced physical activity

HindawiPain Research and ManagementVolume 2019, Article ID 5487050, 9 pageshttps://doi.org/10.1155/2019/5487050

mailto:[email protected]://orcid.org/0000-0003-2487-8283https://creativecommons.org/licenses/by/4.0/https://creativecommons.org/licenses/by/4.0/https://doi.org/10.1155/2019/5487050

progresses OA by increasing stiffness and weakness in thejoints and eliciting metabolic acidosis and chronic in-flammation, making exercise even more challenging [5].Aerobics and resistance training are effective nonsurgicalinterventions but many with OA will not participate, andtherefore, alternative exercises must be evaluated. Breathingexercises have been used for years in a clinical setting toreduce pain and improve health, especially in labor anddelivery [7]. However, they have not been studied as anintervention for OA.

Breathing plays an important role in pain signalling andautonomic nervous system (ANS) activation, emotionregulation, acid/base balance, and anti-inflammatory pro-cesses [8–12]. Recent studies suggest that deep slowbreathing (DSB) relieves pain [9] and sleep disruption frompain [12] and improves mood [8]. Studies in healthy subjectsreveal that DSB reduces pain by increasing the painthreshold, increasing parasympathetic (P-ANS) activity [9],decreasing (S-ANS) sympathetic activity [8], and alteringpCO2 and pH [13]. Breathing also improves mood, whichwould largely impact those with OA, since many suffer fromdepression as well [8]. Deep slow breathing has not beenstudied as an intervention for OA but may be an effectivemethod for improving pain, function, and mood. )is maybe appealing to patients with OA because the time com-mitment and cost are less than those in traditional thera-peutic measures. In addition, DSB puts no mechanical stresson the joints and may be relaxing for those with OA. Assymptoms improve with the use of DSB, those with OA maybe more likely to participate in other physical activities,resulting in further health benefits.

)e purpose of our study was to determine if a significantdifference existed in joint pain perception and autonomicactivity following a six-week breathing exercise program.We hypothesized that the DSB program would lead tosignificant differences in pain, physical function, and au-tonomic activity between training and control groups [14].As the prevalence of OA rises, effective interventions thattarget pain are highly valuable.)e role of DSB in improvingchronic pain is not well researched. Specifically, the effect ofDSB has not been studied in patients with joint pain. A betterunderstanding of the effects and mechanisms of DSB mayprovide novel and practical approaches to treating jointpain.

2. Materials and Methods

2.1. Description of Study Population. Twenty subjects par-ticipated in the study. Subjects had been diagnosed by theirphysician with knee osteoarthritis (OA) and had received anormative score of less than 50 on the American Academy ofOrthopaedic Surgeons (AAOS) Hip and Knee Question-naire. Subjects were recruited from local senior centers anduniversity campus through informational posters followingapproval of the study from the University Human Subjects’Committee. Subjects with unilateral joint pain had no his-tory of joint replacement surgery, and subjects with bilateraljoint pain that had undergone joint replacement surgery ononly one joint were allowed to participate in the study. )e

joint that had not been operated on was used for assessmentwith the Western Ontario and McMaster Universities Os-teoarthritis Index (WOMAC). For subjects with bilateraljoint pain who had not undergone joint replacement sur-gery, the extremity with more severe pain, determined by theWOMAC pain score, was used forWOMAC assessment. Nosubjects had undergone joint surgery within the last sixmonths. All subjects obtained medical clearance from aphysician to participate in the study. Breathing practiceswere novel to the subjects.

2.2. Design of the Study. )is study utilized a pretest-posttestexperimental design in which subjects were assigned toeither the control or training group based on their avail-ability for training. )ose who could meet the time com-mitment for the training group were assigned to the traininggroup on a first come-first serve basis.

2.3. Experimental Protocol

2.3.1. Training Protocol. )e study was conducted over a six-week period. All subjects were instructed not to alter theirdiet or physical activity level during the study.)ree-day dietand three-day physical activity logs were completed beforeand after breathing intervention. )ese logs were used toverify that no substantial changes were made in diet orphysical activity. A medication log was submitted before andafter the study. Subjects were instructed to notify the in-structor if they began a new pain medication during the six-week study period. )e control group did not attend weeklybreathing training sessions.

2.3.2. Weekly Breathing Training. Subjects were instructedto wear comfortable and loose-fitting clothes for 30-minutebreathing sessions. Subjects were divided into groups of 2–4subjects for each session. During DSB training, all subjectssat upright on a chair with back support. Subjects wereinformed of the discomfort or “air hunger” they may ex-perience during DSB training. Subjects were assured thatthey could take a break from the breathing exercises if theyfelt dizzy or out of breath. All training sessions were con-ducted at the local senior center.

During the first twenty minutes of breathing training, ascript or outline was used to guide subjects through thebreathing exercises. A script was used during the first weekand outlines were used for the remaining weeks so that thetrainer could more easily monitor the subjects. )e scriptand outlines were timed, and all subjects received the sametraining.)e focus of the breathing exercises was on inhalingdeeply, prolonging the exhalation, and performing the ex-piratory pause. Each week, subjects were given a focus topicto keep their interest in the program. Weeks one and twofocused on awareness of breathing, weeks three and fourfocused on relaxation and tension release, and weeks five andsix focused on breath control. )e control group was notgiven any education or training.

2 Pain Research and Management

Specific parameters for controlling depth and frequencyof breathing were not used in this study. )e goal of thebreathing exercises was to increase the depth and decreasethe frequency of respiration from initial values for eachsubject. )e expiratory pause aided subjects in reducingbreath frequency.)e remaining ten minutes of training wasused to record respiratory rate and expiratory pause for eachsubject. Subjects performed the expiratory pause followingnormal inhalation and exhalation. Following exhalation,subjects plugged their nose with their fingers and closedtheir mouth. )is was held until the subject felt the very firsturge to inhale. )e amount of time that a subject could holdthis pause was recorded as the expiratory pause [13].

2.3.3. At-Home Breathing Protocol. DSB subjects wereinstructed to complete the DSB exercises with the expiratorypause at home five days a week, 20–30minutes a day [13].DSB subjects were given written instructions and a link to aninstructional YouTube video on the expiratory pause to helpthem practice during the week. DSB subjects were educatedon the importance of relaxation during DSB and instructednot to complete the breathing exercises while doing anattentive task such as reading, watching TV, conversing withfamily, or other tasks. Subjects were instructed to do thebreathing exercises in a quiet room in an upright, seatedposition on a chair with back support. Both feet were to beplaced on the floor. On the day of the weekly group trainingsession, subjects were not required to complete additionalDSB at home. Subjects kept a training or practice log andreturned the log to the trainer each week to ensure com-pliance with the study.

2.4. Measurement Techniques and Procedures

2.4.1. Western Ontario and McMaster Universities Osteo-arthritis Index. In order to evaluate the effect of DSB on painand physical function in those with OA, a valid and reliablemeasurement must be used.)eWOMAC is one of the mostcommonly used self-reported measures of lower extremitysymptoms and function. It was specifically designed toevaluate pain, function, and stiffness in subjects with OA ofthe hip and knee. )e WOMAC is supported as a valid andreliable measurement of pain and physical function insubjects with hip or knee OA [15–19]. )is measurementtool may be applied to studies examining the efficacy of paininterventions for hip and knee OA.

In this study, permission to use the WOMAC visualanalog scale (VAS) was granted by Dr. Bellamy. )eWOMAC VAS [20] was used to measure pain (five items)and physical function (17 items). Responses were based onthe 1–100mm VAS. Responses were scored using a ruler tomeasure the distance in millimeters from the left end to thesubject’s pencil mark. Scores for each item were summed toobtain scores for each category: pain and physical function.Higher scores indicated worse pain and physical function.)e minimal clinically important improvement (MCII)values, defined as the smallest change in measurement thatindicates substantial improvement in symptoms for hip and

knee OA, were defined as −15.3 and −19.9mm, respectively,for pain and −7.9 and −0.1mm, respectively, for physicalfunction [21].

2.4.2. Heart Rate Variability. Heart rate variability (HRV)may be used to evaluate the efficacy of DSB in those with OA.HRV is recognized as an indicator of ANS activity and maybe used to assess the balance between P-ANS and S-ANSactivity [22]. Since previous studies have shown a link be-tween breathing, changes in sympathovagal balance, anddecreased pain [8, 9], HRVwas a goodmeasurement tool forthis study.

HRV was measured using Biopac Systems MP150 [23].HRV measurements were taken with a standard 3-electrode,1-lead EKG setup which examined lead II. AcqKnowledgesoftware [24] was used for data recording, collection, anddata reduction. HRV variables were obtained from the rawEKG data, which used algorithms following the frequencydomain guidelines established by the Task Force of theEuropean Society of Cardiology and )e North AmericanSociety of Pacing and Electrophysiology. Power frequencyfor HRV variables were defined by Task Force guidelines asvery low frequency (VLF), ≤0.04Hz, low frequency (LF),0.04–0.15Hz, high frequency (HF), 0.15–0.4Hz, and veryhigh frequency (VHF), ≥0.4Hz [22]. LF power indicatessympathetic ANS activity, and HF power indicates para-sympathetic ANS activity [9].

For HRV assessment, within 48 hours of completing the6-week training program, subjects were instructed to lie stillon an examination table in the laboratory for five minutes.)e laboratory was kept quiet and at a comfortable tem-perature. )ree electrodes were configured to examine leadII. )e AcqKnowledge software [24] recorded HRV data forfive minutes. )e subject was instructed to close their eyesand remain still and relaxed during the measurement. )edata collection was terminated and restarted if the subjecttalked or moved during collection.

2.4.3. Expiratory Pause. )e expiratory pause was measuredas an indicator of breathing training efficacy. )e expiratorypause was measured using a SportLine 220 stopwatch.Subjects were taught to perform the expiratory pause byclosing their eyes and inhaling and exhaling as usual. Fol-lowing exhalation, subjects were instructed to close theirmouth, plug their nose, and hold this until they felt the veryfirst urge to breathe. At the very first urge to breathe, subjectswere instructed to release from plugging their nose andresume breathing. )e expiratory pause was recorded withthe stopwatch from the time the subject plugged their noseto the time at which they released or inhaled, whicheveroccurred first. Subjects were allowed to practice the expi-ratory pause 1–2 times before the pause was recorded. )eexpiratory pause was then recorded three times, and the bestof these recordings was used for data analysis.

2.5. Data Collection and Analysis. Data were collected priorto and following the six-week DSB program. Data were

Pain Research and Management 3

collected at the same time period for the control and ex-perimental groups. WOMAC scores, HRV, and expiratorypauses were obtained and recorded. Posttest data werecollected 48 hours after the end of the DSB program.

Analysis was separated into three facets: subjective as-sessment using WOMAC scores (pain and physical), ob-jective assessment using HRV variables (LF, HF, and LF toHF ratio), and evaluation of the training program using theexpiratory pause. Change scores were calculated for eachvariable by subtracting the preintervention measurementfrom the postintervention measurement. Variables wereanalysed using three separate mixed ANOVAs. Changescores were analysed using a one-way ANOVA. )e alphalevel for analysis was set at less than 0.05. Effect sizes werealso calculated. Statistical analysis was used to evaluate ifthere was an interaction between group and time or a maineffect for group or time. Data analysis was completed withExcel and IBM SPSS 25 [25].

3. Results

3.1. Subject Characteristics. Twenty subjects (14 female, 6male), aged 20–82 (67± 9) years old, participated in thisstudy. Subjects had been diagnosed with osteoarthritis oftheir hip or knee (n� 13) or received a normative score ofless than 50 on the American Academy of OrthopaedicSurgeons (AAOS) Hip and Knee Questionnaire (n� 7). )etwo younger subjects in this study had been diagnosed withosteoarthritis secondary to sports-related injuries. Subjectcharacteristics are presented in Table 1.

3.2. Subjective Outcomes: WOMAC VAS Pain and PhysicalFunction. For WOMAC pain scores, there was not a sig-nificant interaction between group and time (p � 0.191,η2p � 0.093) and there was not a significant main effect forgroup (p � 0.812, η2p � 0.003). )ere was a significant maineffect for time (p � 0.001), and the effect size was large(η2p � 0.454). For WOMAC physical function scores, therewas not a significant interaction between group and time(p � 0.848, η2p � 0.002) and there was not a significant maineffect for group (p � 0.671, η2p � 0.01). )ere was a signifi-cant main effect for time (p< 0.001), and the effect size waslarge (η2p � 0.506). Means and standard deviations for painand physical function are presented in Table 2.

Changes scores were not statistically significant for pain(p � 0.191, η2p � 0.093) or physical function (p � 0.848,η2p � 0.002). Means and standard deviations for painand physical function change scores are presented inFigures 1 and 2. )e change scores indicated that pain andphysical function scores decreased for both training andcontrol groups, but the changes were not statistically sig-nificant. Higher WOMAC scores indicate worse pain andphysical function. )e decreases in pain and physicalfunction scores signify decreases in pain and improvementsin physical function.

3.3. Objective Outcomes: LF Power, HF Power, and LF/HFRatio. For LF power, there was not a significant interaction

between group and time (p � 0.478, η2p � 0.03). )ere wasnot a significant main effect for group (p � 0.418, η2p � 0.039)or for time (p � 0.306, η2p � 0.061). For HF power, there wasnot a significant interaction between group and time(p � 0.945, η2p < 0.001). )ere was not a significant maineffect for group (p � 0.419, η2p � 0.039) or for time

Table 1: Subject characteristics (mean± standard deviation (SD)).

Subject characteristics Training (n� 10) Control (n� 10)Age (years) 67± 9 48± 19Height (m) 1.6± 0.1 1.7± 0.1Weight (kg) 70.5± 13.6 73.8± 13.4

Table 2: WOMAC pain and physical function scores (mean± SD)and changes in WOMAC pain and physical function scores(mean± SD) for each group before and after the test.

Pretest PosttestPain

Training 148± 94 84± 89Control 123± 87 92± 73

Physical functionTraining 434± 268 276± 287Control 482± 346 338± 274

Change in WOMAC scores Pain Physical functionTraining −64± 69 −158± 160Control −31± 34 −144± 155

–140–120–100

–80–60–40–20

0

Chan

ge in

pai

n sc

ore

WOMAC VAS pain change score followingdeep slow breathing

TrainingControl

Figure 1: Graphical representation of change in WOMAC painscores from pretest to posttest for each group. )e error barsrepresent the standard deviation of measurements.

TrainingControl

–350–300–250–200–150–100

–500

Chan

ge in

phy

sical

func

tion

scor

e

WOMAC VAS physical function change scorefollowing deep slow breathing

Figure 2: Graphical representation of change inWOMAC physicalfunction scores from pretest to posttest for each group. )e errorbars represent the standard deviation of measurements.


(p � 0.417, η2p � 0.039). For LF/HF ratio, there was not asignificant interaction between group and time (p � 0.439,η2p � 0.036). )ere was not a significant main effect for group(p � 0.439, η2p � 0.036) or for time (p � 0.08). Means andstandard deviations for LF power, HF power, and LF/HFratio are presented in Table 3.

Change scores for HRV indicate that there were nosignificant differences between the training and controlgroups. Change scores were not statistically significant forLF power (p � 0.478, η2p � 0.030), HF power (p � 0.945, η

2p

Sherman [29] investigated the role of social support in wellbeing and found that social support partially mediated painperceptions in relation to depressive symptoms while op-timism partially mediated pain perceptions in relation to lifesatisfaction. Both social support and optimism seem to beimportant mediators of OA pain [28].

)e importance of social support may offer an expla-nation for the significant decrease in pain and improvementin physical function seen in both groups in the present study.Results of the present study combined with previous re-search highlight the potential importance of psychosocialfactors in the adjustment to chronic pain. )ese resultssupport a biopsychosocial model of pain. While the DSBexercise program was not sufficient to significantly alterWOMAC pain and physical function scores between groups,social support may have played a role in the improvementsseen in both training and control groups. )ere is currentlyno research found that evaluates the use of research as adimension of social support. More research is needed toconfirm the theory that participation in a research study mayincrease perceived social support and improve self-reportedOA outcomes.

4.2. Objective Outcomes: LF Power, HF Power, and LF/HFRatio. In this study, the DSB training program did notsignificantly alter ANS activity in the training group com-pared with the control group. Results of the present studycontrast with previous studies which indicate that DSBdecreased S-ANS activity [8, 31, 32] and increased P-ANSactivity [9, 31, 32]. However, a caveat is made that LF as anindicator of sympathetic tone has been challenged, notingthat parasympathetic influence may impact LF especiallyduring slow breathing rates [33–35]. Due to the strongrelationship between pain and ANS activity [8, 9], it issurprising that the significant changes in WOMAC painscores in the present study were not accompanied by sig-nificant changes in ANS activity. However, pain was self-reported in the present study. Studies supporting the re-lationship between pain and ANS activity have objectivelymeasured pain perception by measuring heat pain thresholdand tolerance [8, 9]. Further research is needed to examine

the relationship between self-reported pain and ANSactivity.

In contrast to the present study, a recent study [36]demonstrated a significant (p< 0.05) impact of post-exhalation pause on HF. However, this study collected HRVdata during the breathing training cycles and did not havethe latency of 48 hours after a longer breathing program of6weeks, as in the present study.

Discrepancies between the present study and other re-search may be due to the methodology. )is study measuredHRV within 48 hours of the last at-home breathing exercisesession. Subjects were allowed to breathe naturally duringHRV recording. Many studies evaluating the effect ofbreathing on HRV use controlled breathing during HRVrecording or measured HRV immediately after the DSBsession [8, 9]. Chandla et al. [31] studied the effects of a six-week DSB program, using pranayama, and found significantincreases in HF power and decreases in LF power and LF/HFratio. However, they did not report the procedures usedduring HRV recording, and they did not identify the timingbetween last training and data collection. It is unknown ifsubjects breathed naturally or used controlled breathingduring HRV recording for this study.

Breathing patterns during HRV recording may signifi-cantly impact HRV results. In a study of 24 healthy males,the effect of different breathing patterns on HRV wasassessed. Results indicated that the breathing pattern had amoderate effect on LF power (η2p � 0.125) and LF/HF ratio(η2p � 0.082) and a strong effect on HF power (η2p � 0.204)[32]. )ese results are supported by a study which suggeststhat changes in HRV at variable respiratory frequencies(0.15–0.5Hz) may be due to respiration. Beda et al. suggestthat respiratory parameters such as respiratory period, tidalvolume, and the tidal volume power account for 79 percentof HRV changes [37]. )ese results reveal the relationshipbetween respiratory variability and HRV and suggest that itis important to measure and assess respiration with HRV.

)e methods of Kulur et al. may be an effective way ofmeasuring the effects of a DSB program on HRV. Kulur et al.trained subjects to breathe at a rate of six respiratory cyclesper minute, five seconds for inhalation and five seconds forexhalation, during HRV recording. During the intervention,subjects were trained with diaphragmatic breathing andfollow-up recording was completed at three months and oneyear [38]. )is methodology may help control for thechanges in autonomic activity associated with respiratoryvariability during HRV recording.

Due to the influence of respiration on HRV [38–40],controlling for respiratory variability during preinterventionand postintervention HRV data collection may provide amore accurate assessment of the effects of a breathing in-tervention on HRV. Previous research on the relationship ofrespiratory variability and HRV may partially explain thelack of significant changes in HRV in the present study.Furthermore, the large standard deviations seen in thetraining group may be the result of greater respiratoryvariability due to increased breathing awareness [40]. Whilebreathing patterns may impact changes in HRV, it is im-portant not to dismiss HRV results in studies without

TrainingControl

–15–10

–505

1015

Expi

rato

ry p

ause

(s)

Expiratory pause change scores followingdeep slow breathing

Figure 4: Graphical representation of change in expiratory pausefrom pretest to posttest for each group.)e error bars represent thestandard deviation of measurements.


controlled breathing. Although the present study did notshow significant changes in LF/HF ratio, there was amoderate effect size for time (η2p � 0.169) for LF/HF ratio.)e moderate effect size suggests that both training andcontrol groups shifted towardmore parasympathetic activityduring the course of the study. More research is needed toexamine the effects of DSB programs on HRV, utilizingcontrolled breathing during HRV data collection.

4.3. Training Outcome: Expiratory Pause and AnecdotalOutcomes. Results from this study demonstrate that theDSB exercise did not effectively increase the expiratorypause. While there is anecdotal evidence that the expiratorypause may be increased through training [12], there is noscientific evidence supporting this claim. )is may explainwhy there were no significant changes in the expiratorypause during the study. More research is needed to de-termine if the expiratory pause can be increased and theamount of training and time needed to induce changes in theexpiratory pause.

In addition to measured outcomes of this study, anec-dotal results were also recorded. While no control subjectsreported perceived changes during the study, eight trainingsubjects reported a decrease in their stress level and anincrease in their perceived ability to effectively managestress. Eight subjects reported that the breathing exerciseshelped them to cope with their joint pain, even when thepain did not subside following the DSB exercises. Eighttraining subjects reported increased awareness of both theirbreathing patterns and awareness of tension in their bodies.All training subjects reported being able to effectively releasetension in their body and relax using the breathing exercises.

4.4. Limitations. Limitations of this study involve the lack ofcontrol for other variables such as age, body mass index,knee pain intensity, and disease severity. )e small, non-random nature of the sample may have also affected theresults and limited the generalizability of the results. )esmall sample size may have resulted in large standard de-viations of all variables in this study.

5. Conclusion

Six weeks of DSB did not significantly alter pain-relatedvariables in subjects with lower extremity joint pain.However, both training and control groups experiencedsignificant decreases in pain and significant improvementsin physical function over the course of the study. Changes inpain and physical function appear to be the result of socialsupport that subjects received by participating in the study.)e lack of significant changes in HRV variables may havebeen due to the large standard deviations and methodologyused during HRV data collection. Further research is neededas the present study is the first to evaluate the use of DSB asan intervention for arthritis-related pain and physical lim-itation. )is research will provide more information aboutthe role of DSB as an intervention for joint pain. A betterunderstanding of the effects and mechanisms of DSB may

provide novel and practical approaches to treating jointpain. Future research would ideally identify subjects witharthritis who would benefit most from DSB and specify theamount of DSB needed to produce clinically importantimprovements in pain and physical function. At this time,DSB does not appear to produce significant changes in OAjoint pain or physical function.

Data Availability

)e data used to support the findings of this study areavailable from the corresponding author upon request.

Disclosure

)is manuscript was developed from the graduate thesiswork of Kalee L. Larsen at Western Washington Universityin Bellingham, WA.)e graduate thesis committee includedLorrie R. Brilla, Wren L. McLaughlin, and Ying Li.)e thesismay be found at https://cedar.wwu.edu/wwuet/447.

Conflicts of Interest

)e authors declare that there are no conflicts of interestregarding the publication of this paper.

Acknowledgments

Western Washington University provided a grant in theamount of three hundred and twenty-nine dollars to fundthe purchase of the WOMAC questionnaire. No otherfunding was received for this study.

Supplementary Materials

Video demonstrations of the full and modified expiratorypauses that were provided to the study participants as re-minders for them to review. (Supplementary Materials)

References

[1] Centers for Disease Control and Prevention (CDC), “Prev-alence of doctor-diagnosed arthritis and arthritis-attributableactivity limitation—United States, 2010-2012,” Morbidity andMortality Weekly Report, vol. 62, no. 44, pp. 869–873, 2013.

[2] Centers for Disease Control and Prevention (CDC), “Millionhearts: strategies to reduce the prevalence of leading car-diovascular disease risk factors--United States, 2011,”MMWR. Morbidity and Mortality Weekly Report, vol. 60,no. 36, pp. 1248–1251, 2011.

[3] E. Losina, A. D. Paltiel, A. M. Weinstein et al., “Lifetimemedical costs of knee osteoarthritis management in theUnited States: impact of extending indications for total kneearthroplasty,” Arthritis Care and Research, vol. 67, no. 2,pp. 203–215, 2015.

[4] M. B. Max andW. F. Stewart, “)emolecular epidemiology ofpain: a new discipline for drug discovery,” Nature ReviewsDrug Discovery, vol. 7, no. 8, pp. 647–658, 2008.

[5] J. W.-P. Michael, K. U. Schlüter-Brust, and P. Eysel, “)eepidemiology, etiology, diagnosis, and treatment of osteoar-thritis of the knee,” Deutsches Aerzteblatt Online, vol. 107,no. 9, pp. 152–162, 2010.


https://cedar.wwu.edu/wwuet/447http://downloads.hindawi.com/journals/prm/2019/5487050.f1.zip

[6] S. Austin, H. Qu, and R. M. Shewchuk, “Association betweenadherence to physical activity guidelines and health-relatedquality of life among individuals with physician-diagnosedarthritis,” Quality of Life Research, vol. 21, no. 8, pp. 1347–1357, 2012.

[7] J. A. Lothian, “Lamaze breathing,” Journal of Perinatal Ed-ucation, vol. 20, no. 2, pp. 118–120, 2011.

[8] V. Busch, W. Magerl, U. Kern, J. Haas, G. Hajak, andP. Eichhammer, “)e effect of deep and slow breathing onpain perception, autonomic activity, and mood proc-essing—an experimental study,” Pain Medicine, vol. 13, no. 2,pp. 215–228, 2012.

[9] P. Chalaye, P. Goffaux, S. Lafrenaye, and S. Marchand,“Respiratory effects on experimental heat pain and cardiacactivity,” Pain Medicine, vol. 10, no. 8, pp. 1334–1340, 2009.

[10] R. Jerath, J. W. Edry, V. A. Barnes, and V. Jerath, “Physiologyof long pranayamic breathing: neural respiratory elementsmay provide a mechanism that explains how slow deepbreathing shifts the autonomic nervous system,” MedicalHypotheses, vol. 67, no. 3, pp. 566–571, 2006.

[11] O. Nepal, B. Pokharel, K. Khanal, S. Mallik, B. Kapoor, andR. Koju, “Relationship between arterial oxygen saturation andhematocrit, and effect of slow deep breathing on oxygensaturation in Himalayan high altitude populations,” Kath-mandu University Medical Journal, vol. 10, no. 3, pp. 30–34,2013.

[12] R. Jerath, C. Beveridge, and V. A. Barnes, “Self-regulation ofbreathing as an adjunctive treatment of insomnia,” Frontiersin Psychiatry, vol. 9, 2019.

[13] L. Chaitow, D. Bradley, and C. Gilbert, Recognizing andTreating Breathing Disorders: A Multidisciplinary Approach,London, GK, Elsevier, 2nd edition, 2014.

[14] K. L. Larsen and K. Lynn, “)e effect of deep slow breathingon pain-related variables in osteoarthritis,” WWU GraduateSchool Collection, vol. 447, 2015, https://cedar.wwu.edu/wwuet/447.

[15] M. Averbuch and M. Katzper, “Assessment of visual analogversus categorical scale for measurement of osteoarthritispain,” Journal of Clinical Pharmacology, vol. 44, no. 4,pp. 368–372, 2004.

[16] N. Bellamy, W. W. Buchanan, C. H. Goldsmith, J. Campbell,and L. W. Stitt, “Validation study of WOMAC: a health statusinstrument for measuring clinically important patient rele-vant outcomes to antirheumatic drug therapy in patients withosteoarthritis of the hip or knee,” Journal of Rheumatology,vol. 15, no. 12, pp. 1833–40, 1988.

[17] M. J. Dunbar, O. Robertsson, L. Ryd, and L. Lidgren, “Ap-propriate questionnaires for knee arthroplasty,”?e Journal ofBone and Joint Surgery, vol. 83, no. 3, pp. 339–344, 2001.

[18] S. McConnell, P. Kolopack, and A. M. Davis, “)e WesternOntario and McMaster Universities osteoarthritis index(WOMAC): a review of its utility and measurement prop-erties,” Arthritis and Rheumatism, vol. 45, no. 5, pp. 453–461,2001.

[19] Y.-H. Pua, S. M. Cowan, T. V. Wrigley, and K. L. Bennell,“Discriminant validity of the Western Ontario and McMasterUniversities osteoarthritis index physical functioning subscalein community samples with hip osteoarthritis,” Archives ofPhysical Medicine and Rehabilitation, vol. 90, no. 10,pp. 1772–1777, 2009.

[20] N. Bellamy, WOMAC Osteoarthritis Index User Guide, vol. 5,Brisbane, Australia, 2002.

[21] F. Tubach, “Evaluation of clinically relevant changes in patientreported outcomes in knee and hip osteoarthritis: the minimal

clinically important improvement,” Annals of the RheumaticDiseases, vol. 64, no. 1, pp. 29–33, 2005.

[22] M. Malik, J. T. Bigger, A. J. Camm et al., “Heart rate vari-ability: standards of measurement, physiological in-terpretation, and clinical use,” European Heart Journal,vol. 17, no. 3, pp. 354–381, 1996.

[23] Biopac Systems MP 1500, Biopac Systems Inc, Goleta, CA,USA, 2019.

[24] AcqKnowledge Software, Biopac Systems Inc, Goleta, CA,USA, 2019.

[25] IBM Corp, IBM SPSS Statistics for Windows, Version 25.0,IBM Corp, Armonk, NY, USA, 2017.

[26] A. Escobar, J. M. Quintana, A. Bilbao et al., “Effect of patientcharacteristics on reported outcomes after total knee re-placement,” Rheumatology, vol. 46, no. 1, pp. 112–119, 2007.

[27] O. Ethgen, P. Vanparijs, S. Delhalle, S. Rosant, O. Bruyère, andJ.-Y. Reginster, “Social support and health-related quality oflife in hip and knee osteoarthritis,” Quality of Life Research,vol. 13, no. 2, pp. 321–330, 2004.

[28] V. M. Ferreira and A. M. Sherman, “)e relationship ofoptimism, pain and social support to well-being in olderadults with osteoarthritis,” Aging & Mental Health, vol. 11,no. 1, pp. 89–98, 2007.

[29] A. E. López-Mart́ınez, R. Esteve-Zarazaga, and C. Ramı́rez-Maestre, “Perceived social support and coping responses areindependent variables explaining pain adjustment amongchronic pain patients,” Journal of Pain, vol. 9, no. 4,pp. 373–379, 2008.

[30] L. Sharma, S. Cahue, J. Song, K. Hayes, Y.-C. Pai, andD. Dunlop, “Physical functioning over three years in kneeosteoarthritis: role of psychosocial, local mechanical, andneuromuscular factors,” Arthritis and Rheumatism, vol. 48,no. 12, pp. 3359–3370, 2003.

[31] S. S. Chandla, S. Sood, R. Dogra, S. Das, S. K. Shukla, andS. Gupta, “Effect of short-term practice of pranayamicbreathing exercises on cognition, anxiety, general well beingand heart rate variability,” Journal of the Indian MedicalAssociation, vol. 111, no. 10, pp. 662–665, 2013.

[32] G. K. Pal, S. Velkumary, and Madanmohan, “Effect of short-term practice of breathing exercises on autonomic functionsin normal human volunteers,” ?e Indian Journal of MedicalResearch, vol. 120, no. 2, pp. 115–121, 2004.

[33] G. A. Reyes Del Paso, W. Langewitz, L. J. M. Mulder,A. Van Roon, and S. Duschek, “)e utility of low frequencyheart rate variability as an index of sympathetic cardiac tone: areview with emphasis on a reanalysis of previous studies,”Psychophysiology, vol. 50, no. 5, pp. 477–487, 2013.

[34] F. Shaffer and J. P. Ginsberg, “An overview of heart ratevariability metrics and norms,” Frontiers in Public Health,vol. 5, no. 258, pp. 1–17, 2017.

[35] M. Weippert, K. Behrens, A. Rieger, M. Kumar, andM. Behrens, “Effects of breathing patterns and light exerciseon linear and nonlinear heart rate variability,” AppliedPhysiology, Nutrition, and Metabolism, vol. 40, no. 8,pp. 762–768, 2015.

[36] M. E. B. Russell, A. B. Scott, I. A. Boggero, and C. R. Carlson,“Inclusion of a rest period in diaphragmatic breathing in-creases high frequency heart rate variability: implications forbehavioral therapy,” Psychophysiology, vol. 54, no. 3,pp. 358–365, 2017.

[37] A. Beda, D. M. Simpson, N. C. Carvalho, andA. R. S. Carvalho, “Low-frequency heart rate variability isrelated to the breath-to-breath variability in the respiratorypattern,” Psychophysiology, vol. 51, no. 2, pp. 197–205, 2014.


https://cedar.wwu.edu/wwuet/447https://cedar.wwu.edu/wwuet/447

[38] A. B. Kulur, N. Haleagrahara, P. Adhikary, andP. S. Jeganathan, “Effect of diaphragmatic breathing on heartrate variability in ischemic heart disease with diabetes,”Arquivos Brasileiros De Cardiologia, vol. 92, no. 6, pp. 423–429, 2009.

[39] I. Van Diest, K. Verstappen, A. E. Aubert, D. Widjaja,D. Vansteenwegen, and E. Vlemincx, “Inhalation/exhalationratio modulates the effect of slow breathing on heart ratevariability and relaxation,” Applied Psychophysiology andBiofeedback, vol. 39, no. 3-4, pp. 171–180, 2014.

[40] S. Telles, N. Singh, and A. Balkrishna, “Heart rate variabilitychanges during high frequency yoga breathing and breathawareness,” BioPsychoSocial Medicine, vol. 5, no. 1, pp. 4–7,2011.


Stem Cells International

Hindawiwww.hindawi.com Volume 2018


MEDIATORSINFLAMMATION

of

EndocrinologyInternational Journal of



Disease Markers


BioMed Research International

OncologyJournal of



Oxidative Medicine and Cellular Longevity


PPAR Research

Hindawi Publishing Corporation http://www.hindawi.com Volume 2013Hindawiwww.hindawi.com

The Scientific World Journal

Volume 2018

Immunology ResearchHindawiwww.hindawi.com Volume 2018

Journal of

ObesityJournal of



Computational and Mathematical Methods in Medicine


Behavioural Neurology

OphthalmologyJournal of


Diabetes ResearchJournal of



Research and TreatmentAIDS


Gastroenterology Research and Practice


Parkinson’s Disease

Evidence-Based Complementary andAlternative Medicine

Volume 2018Hindawiwww.hindawi.com

Submit your manuscripts atwww.hindawi.com
https://www.hindawi.com/journals/sci/https://www.hindawi.com/journals/mi/https://www.hindawi.com/journals/ije/https://www.hindawi.com/journals/dm/https://www.hindawi.com/journals/bmri/https://www.hindawi.com/journals/jo/https://www.hindawi.com/journals/omcl/https://www.hindawi.com/journals/ppar/https://www.hindawi.com/journals/tswj/https://www.hindawi.com/journals/jir/https://www.hindawi.com/journals/jobe/https://www.hindawi.com/journals/cmmm/https://www.hindawi.com/journals/bn/https://www.hindawi.com/journals/joph/https://www.hindawi.com/journals/jdr/https://www.hindawi.com/journals/art/https://www.hindawi.com/journals/grp/https://www.hindawi.com/journals/pd/https://www.hindawi.com/journals/ecam/https://www.hindawi.com/https://www.hindawi.com/

effectofdeepslowbreathingonpain-related ...downloads.hindawi.com/journals/prm/2019/5487050.pdfrecent...

Documents