heart rate variability

How Slow Deep Breathing Results in Positive Emotions and More Creativity

Key Points

  • Dominance of the calming parasympathetic nervous system is associated with positive emotions and can be evoked through slow breathing.

  • Slow breathing leads to “hyperpolarization,” which literally makes neurons less excitable.

  • Slow breathing reduces activity in the amygdala, which increases relaxation and boosts creativity.

The Breathing Diabetic Summary

You probably know by now that emotional states are linked to breathing.  When you’re stressed, you breathe faster.  When you’re calm, you breathe slower.  Intuitively, it makes sense.  But how exactly does it occur?  That’s what this current paper explores.  It’s a fascinating look at how cardiorespiratory coherence can potentially influence emotions.  Of course, what matters most is simply that it works.  But here, we learn how it might be working…and it’s pretty amazing.

 

Feedforward or Feedback?

The fundamental hypothesis is that cardiorespiratory coherence (which I’m going to refer to as slow breathing for simplicity, although that’s not 100% correct) can regulate the autonomic nervous system and brainstem.  This, in turn, modulates the emotional regions of the brain.

This is a unique hypothesis because we typically think of emotions through a “feedforward” lens.  An emotion arises in the brain and “feeds” its signal to the rest of the body.  But here, they’re saying feedbacks from slow breathing, namely the ones on the nervous system and brain, can elicit positive emotions.

That is, you might be able to breathe yourself into happiness.

 

How Emotional States Correspond to Autonomic Function

 The most important indicator that this is possible is the link between positive emotional states and higher levels of cardiorespiratory coherence.  Of course, correlation doesn’t mean causation.  Still, the general conclusion from most studies is that positive emotions are associated with parasympathetic (calming) dominance, and negative moods are associated with sympathetic (fight or flight) dominance.

 This supports their hypothesis.  If we simply induce relaxation and parasympathetic dominance through slow breathing, maybe positive emotions will follow.

 

Hyperpolarization might Explain the Calming Effects of Slow Breathing and Meditation

 One fascinating way they propose this feedback might occur is through neuronal “hyperpolarization.”   Hyperpolarization seems to be a fancy way of saying that the neurons are harder to “excite.”  Meaning it actually takes a lot more energy to fire the neurons that make you stressed or anxious.  This helps explain why we feel relaxed after we meditate or breathe slowly.  These practices actually change our cells, making it harder to feel stressed…pretty crazy.

As an aside, I know I feel most joyful and optimistic after my morning breathing practice.  It feels like magic, but I guess it’s just hyperpolarization at its finest : )

 

Inhibition of the Amygdala from Slow Breathing

And here is a critical implication of hyperpolarization: inhibition of the amygdala. 

When we meditate or practice slow breathing (~4-6 breaths/minute), the neuronal hyperpolarization reduces activity in our amygdala.  This turns down negative thinking and turns up creativity.

As Steven Kotler tells us in The Art of Impossible, ““Unfortunately, to keep us safe, the amygdala is strongly biased toward negative information. …This crushes optimism and squelches creativity. When tuned toward the negative, we miss the novel.

Perhaps this is why, after interviewing the most creative people on the planet, Tim Ferriss discovered that “More than 80% of the interviewees have some form of daily mindfulness or meditation practice.

These practices naturally lead to cardiorespiratory coherence, quieting the pessimistic amygdala, allowing us to see the novelty all around us.

A Summary of How Slow Breathing Modifies Emotions 

Let’s wrap it all together to see how slow breathing can improve our emotional state. 

Positive emotional states are associated with high levels of cardiorespiratory coherence.  These states induce hyperpolarization, which inhibits the excitability of neurons.  This then modifies regions of the brainstem and inhibits the action of the amygdala and other limbic areas.  However, the opposite might also be true: simply breathing slowly will inhibit amygdala activity, allowing us to experience positive emotions, less stress, and more creativity.

Abstract

The brain is considered to be the primary generator and regulator of emotions; however, afferent signals originating throughout the body are detected by the autonomic nervous system (ANS) and brainstem, and, in turn, can modulate emotional processes. During stress and negative emotional states, levels of cardiorespiratory coherence (CRC) decrease, and a shift occurs toward sympathetic dominance. In contrast, CRC levels increase during more positive emotional states, and a shift occurs toward parasympathetic dominance. The dynamic changes in CRC that accompany different emotions can provide insights into how the activity of the limbic system and afferent feedback manifest as emotions. The authors propose that the brainstem and CRC are involved in important feedback mechanisms that modulate emotions and higher cortical areas. That mechanism may be one of many mechanisms that underlie the physiological and neurological changes that are experienced during pranayama and meditation and may support the use of those techniques to treat various mood disorders and reduce stress.

 

 

Journal Reference:

Jerath R, Crawford MW. How Does the Body Affect the Mind? Role of Cardiorespiratory Coherence in the Spectrum of Emotions. Adv Mind Body Med. 2015 Fall;29(4):4-16. PMID: 26535473.

 

2020 Meta-Analysis: Slow Breathing Improves A Variety of Behavioral and Physiological Outcomes

Key Points

  • Across 58 studies and 2,485 patients, heart rate variability biofeedback (HRVB) and slow breathing improve a wide range of behavioral and physiological outcomes.

  • These methods provide a simple, safe, and effective complementary therapy that could be useful in a wide variety of settings.

  • Slow breathing (without biofeedback) is likely to be enough, requiring little more than a cellphone application to get started.

The Breathing Diabetic Summary

A hallmark of slow breathing is that it increases heart rate variability (HRV). It does this by increasing respiratory sinus arrhythmia (RSA), which synchronizes your heart rate with your breathing. When they match, your heart rate increases while you inhale and it decreases while you exhale.

Thus, RSA enhances the “peaks and troughs” of heart rate with each breath, which increases HRV. Because HRV is a robust indicator of overall health and wellness, this is one way in which slow breathing is so powerful. So much so, in fact, that HRV biofeedback (or HRVB) has become extremely popular to help with a variety of problems. 

With HRVB, a person’s “perfect” breathing rate is determined—that is, one that maximizes HRV. And because increases in RSA and HRV are driven by increases in the calming parasympathetic branch of the nervous system, this can reduce negative stress and increase overall resiliency. This has wide-reaching positive benefits.

We’ve covered many of them before. But here are some of the general benefits:

  • Reduced blood pressure.

  • Reduced stress and anxiety.

  • Improved emotional control.

  • Enhanced cognitive function.

  • Better cardio-autonomic function.

  • Improved gas exchange in the lungs.

In this meta-analysis, the authors performed an extensive literature review to examine these benefits of HRVB from a broader statistical perspective. They included papers spanning a wide range of settings, measuring a wide range of outcomes.

Note that, although HRVB sounds fancy (and it can be), many of the benefits are achieved by simply breathing at a rate of about 5-6 breaths per minute.

Therefore, this meta-analysis also included studies that used 6 breaths per minute because:

it is possible that simply doing paced breathing at about six breaths per minute would have the same salutary effects as breathing more exactly at resonance frequency. […] This can easily be taught by following a computer-generated pacing signal or a clock.

From a practical perspective, this might be the most important aspect of this meta-analysis.

After starting with more than 1,500 papers, they ended up with 58 studies having a total of 2,485 patients.

Their statistical analysis of all these studies revealed that HRVB and slow breathing both significantly improve many aspects of health and wellness.

The greatest benefits were for:

  • Athletic performance

  • Artistic performance

  • Depression

  • Gastrointestinal problems

  • Anxiety and anger

  • Respiratory disorders

  • Systolic blood pressure

  • Pain

Smaller, but still meaningful, benefits were found for:

  • Self-reported stress

  • Quality of life

  • Diastolic blood pressure

  • PTSD

  • General energy

  • Sleep

Interestingly, I would have expected several items on the second list to be on the first. But that’s why meta-analyses like this are so important : ) Also, note that measures like “self-reported stress” are harder to quantify. The authors even mention that these results might be the result of how the questionnaires were given.

In any case, the overall results of this meta-analysis are quite exceptional: HRVB and slow breathing both have wide-ranging benefits for overall health and wellness.

These two sentences from the paper sum it up better than I ever could:

These results suggest that HRVB might be a useful addition to the skill sets of clinicians working in a variety of settings, including mental health, behavioral medicine, sports psychology, and education. The method is easy to learn and can easily be used along with other forms of intervention, with rare side effects.

Abstract

We performed a systematic and meta analytic review of heart rate variability biofeedback (HRVB) for various symptoms and human functioning. We analyzed all problems addressed by HRVB and all outcome measures in all studies, whether or not relevant to the studied population, among randomly controlled studies. Targets included various biological and psychological problems and issues with athletic, cognitive, and artistic performance. Our initial review yielded 1868 papers, from which 58 met inclusion criteria. A significant small to moderate effect size was found favoring HRVB, which does not differ from that of other effective treatments. With a small number of studies for each, HRVB has the largest effect sizes for anxiety, depression, anger and athletic/artistic performance and the smallest effect sizes on PTSD, sleep and quality of life. We found no significant differences for number of treatment sessions or weeks between pretest and post-test, whether the outcome measure was targeted to the population, or year of publication. Effect sizes are larger in comparison to inactive than active control conditions although significant for both. HRVB improves symptoms and functioning in many areas, both in the normal and pathological ranges. It appears useful as a complementary treatment. Further research is needed to confirm its efficacy for particular applications.

 

 

Journal Reference:

Lehrer, P., Kaur, K., Sharma, A., Shah, K., Huseby, R., Bhavsar, J., & Zhang, Y. (2020). Heart Rate Variability Biofeedback Improves Emotional and Physical Health and Performance: A Systematic Review and Meta Analysis. Applied Psychophysiology and Biofeedback, 45(3), 109–129. https://doi.org/10.1007/s10484-020-09466-z

 

How Breathing Regulates the Cardiovascular System and Improves Chemosensitivity

Bernardi_et_al-2001_modulatory_WTG.png
 

Key Points

  • Breathing modulates the cardiovascular system through respiratory sinus arrhythmia

  • Slow breathing reduces chemosensitivity to high carbon dioxide and low oxygen

  • Controlled breathing could be a beneficial intervention in different pathological states

The Breathing Diabetic Summary

How does breathing affect us physiologically?  Well, the answer to that is complex.  Breathing is felt by various receptors throughout the body, affecting cardiovascular and autonomic variability on many levels. This review study examined these different modulatory effects of breathing through a comprehensive analysis of the peer-reviewed literature.

 

Breathing and the Cardiovascular System

The cardiovascular system is sensitive to external stimuli. Just picture something scary (like giving a presentation), and your heart rate will likely increase. Consequently, your breathing will also change to match your metabolic needs.

But this is a two-way street. Controlled, rather than reactive, breathing also has profound impacts on the cardiovascular system. This can be temporary, for example, breathing rapidly for one minute, or permanent, for example, developing the behavior/habit of chronic over-breathing.

Knowing that breathing has "direct access" to the cardiovascular system, let's look at how this occurs and how controlled breathing might be beneficial in different pathological states.

 

Respiratory Sinus Arrhythmia

One way in which breathing permeates the cardiovascular system is through respiratory sinus arrhythmia (RSA). RSA is a measurement of how breathing, heart rate, and blood pressure all interact. In simple terms, RSA refers to the increase in heart rate as you inhale and decrease in your heart rate as you exhale. RSA is thought to be an index of vagal activity and direct measurement of heart rate variability.  

When we breathe so that the length of our inhale matches seamlessly with our heart rate increase and our exhale with our heart rate decrease, we maximize RSA. Typically, this occurs when breathing at around 6 breaths per minute. This coherence among respiration and heart rate leads to the maximization of heart rate variability, improving cardiovascular efficiency.

 

Breathing and Chemoreflexes

Slow breathing can reduce breathlessness and improve exercise performance in patients with chronic heart failure. These results suggest that slow breathing could be modifying the chemoreflexes, allowing one to tolerate higher concentrations of carbon dioxide and lower concentrations of oxygen.

To test this hypothesis, a study was conducted with yoga trainees and non-yoga trained participants. Both groups performed different breathing protocols to test their response to high carbon dioxide (hypercapnia) and low oxygen (hypoxia). Although none of these participants had heart problems, the goal was to see if slow breathing could reduce chemoreflexes in the controls to the levels seen in yoga practitioners.

As we might expect, the chemoreflexes of the yoga practitioners at baseline were much lower than the non-trained participants.  This means their breathing did not increase as much when exposed to hypercapnia or hypoxia. Interestingly, the chemoreflexes of the controls decreased to levels similar to the yogis when breathing at 6 breaths per minute.  Therefore, the simple act of slow breathing reduced chemosensitivity to carbon dioxide and hypoxia, regardless of previous training.

These results indicate that breathing could represent another way to better coordinate the breathing muscles, improve chemoreflexes, and improve exercise performance in patients with cardiovascular problems. Slow breathing could, therefore, be a practical alternative when other rehabilitation programs are not available.

 

Breathing Modulates Cardiovascular and Autonomic Control

To summarize, breathing is a potent modulator of cardiovascular and autonomic systems.  Deliberate practice of different breathing patterns (for example, slow breathing) could be beneficial for increasing heart rate variability, improving breathing efficiency, improving chemosensitivity, and enhancing cardio-autonomic control.

 

Abstract

Respiration is a powerful modulator of heart rate variability, and of baro- and chemoreflex sensitivity. Abnormal respiratory modulation of heart rate is often an early sign of autonomic dysfunction in a number of diseases. In addition, increase in venous return due to respiration may help in maintaining blood pressure during standing in critical situations. This review examines the possibility that manipulation of breathing pattern may provide beneficial effects in terms not only of ventilatory efficiency, but also of cardiovascular and respiratory control in physiologic and pathologic conditions, such as chronic heart failure. This opens a new area of future research in the better management of patients with cardiovascular autonomic dysfunction.

 

Journal Reference:

L Bernardi, C Porta, A Gabutti, L Spicuzza, P Sleight.  Modulatory Effects of Respiration.  Auton Neurosci. 2001;90(1-2):47-56. doi: 10.1016/S1566-0702(01)00267-3.

 
 

Intermittent hypoxia is beneficial in sedentary, non-athletic, and clinical populations

Lizamore_and_Hamlin-2017_WTG.JPG

Key Points

  • Intermittent hypoxia improves cardio-autonomic function and exercise tolerance

  • There are several ways to achieve intermittent hypoxia and receive benefits, including prolonged hypoxic exposure, intermittent hypoxic exposure, and intermittent hypoxic training

  • Intermittent hypoxia is beneficial in sedentary and clinical populations

The Breathing Diabetic Summary

I love review papers because they summarize the key findings from the scientific literature in an easy to follow manner. Therefore, anytime I find a review study on a subject of interest, I dive right in.

This one was unique because it looked at the effects of simulated altitude on non-athletic, sedentary, and clinical populations. Most studies on simulated altitude involve elite performers, so it was interesting seeing a review paper focusing on more “everyday” people.

Using different search criteria, they identified 26 studies that have looked at intermittent hypoxia in the abovementioned populations. Within those 26 studies, they then identified 3 different methods of achieving intermittent hypoxia:

  1. Prolonged hypoxic exposure (PHE): Continuous hypoxic interval, such as “live high, train low”.

  2. Intermittent hypoxic exposure (IHE): Short intervals (5-10 min) of hypoxic:normoxic exposure.

  3. Intermittent hypoxic training (IHT): Exercising in hypoxia.

For our purposes, IHE and IHT are the only practical methods for achieving hypoxia via breath holds. However, the results for PHE will also be included for completeness (and, maybe one day altitude tents will be affordable!).

Here, I’ll summarize the benefits they found for each method of hypoxia.

IHE:

  • Reduced systemic stress

  • Improved heart rate variability

  • Improved autonomic balance

  • Reduced blood pressure

  • Greater exercise tolerance

  • Longer time to exhaustion while exercising

  • Hematological results were mixed. Some studies showed increased red blood cells, others didn’t.

PHE:

  • Improved lung ventilation

  • Improved submaximal exercise performance

  • Improved blood lipid profile

  • Improved blood flow to the heart

IHT:

  • Increased aerobic capacity

  • Increased fat burning

  • Increased mitochondrial density

  • Improved autonomic balance

With respect to PHE, the research suggested that at least 1 hour of 12% O2 for 2 weeks would provide the greatest benefits without side effects. They did not provide recommendations for IHE or IHT.

However, a 2014 review study showed that 3-15 episodes of 9-16% O2 is the therapeutic range for IHE. This corresponds to blood O2 saturations of approximately 82-95%.

Also, from a practical perspective, we know that we can perform walking breath holds to achieve mild IHT. Essentially, we combine the IHE protocol with walking.

Overall, this paper suggests that intermittent hypoxia has many benefits in sedentary, non-athletic, and clinical populations, including improved cardiovascular and autonomic function and increased exercise capacity.

It also showed that there are several ways to achieve those benefits: Prolonged exposure, intermittent exposure, or exposure during exercise.

I recommend that you find a modality that fits you or your client’s lifestyle that can be practiced consistently.

Abstract from Paper

BACKGROUND: The reportedly beneficial improvements in an athlete's physical performance following altitude training may have merit for individuals struggling to meet physical activity guidelines.

AIM: To review the effectiveness of simulated altitude training methodologies at improving cardiovascular health in sedentary and clinical cohorts.

METHODS: Articles were selected from Science Direct, PubMed, and Google Scholar databases using a combination of the following search terms anywhere in the article: "intermittent hypoxia," "intermittent hypoxic," "normobaric hypoxia," or "altitude," and a participant descriptor including the following: "sedentary," "untrained," or "inactive."

RESULTS: 1015 articles were returned, of which 26 studies were accepted (4 clinical cohorts, 22 studies used sedentary participants). Simulated altitude methodologies included prolonged hypoxic exposure (PHE: continuous hypoxic interval), intermittent hypoxic exposure (IHE: 5-10 minutes hypoxic:normoxic intervals), and intermittent hypoxic training (IHT: exercising in hypoxia).

CONCLUSIONS: In a clinical cohort, PHE for 3-4 hours at 2700-4200 m for 2-3 weeks may improve blood lipid profile, myocardial perfusion, and exercise capacity, while 3 weeks of IHE treatment may improve baroreflex sensitivity and heart rate variability. In the sedentary population, IHE was most likely to improve submaximal exercise tolerance, time to exhaustion, and heart rate variability. Hematological adaptations were unclear. Typically, a 4-week intervention of 1-hour-long PHE intervals 5 days a week, at a fraction of inspired oxygen (FIO2) of 0.15, was beneficial for pulmonary ventilation, submaximal exercise, and maximum oxygen consumption ([Formula: see text]O2max), but an FIO2 of 0.12 reduced hyperemic response and antioxidative capacity. While IHT may be beneficial for increased lipid metabolism in the short term, it is unlikely to confer any additional advantage over normoxic exercise over the long term. IHT may improve vascular health and autonomic balance.

Journal Reference:

Lizamore CA, Hamlin MJ.  The Use of Simulated Altitude Techniques for Beneficial Cardiovascular Health Outcomes in Nonathletic, Sedentary, and Clinical Populations: A Literature Review.  High Alt Med Biol.  2017;18(4):305-321.

Breathe slowly (and pause) to improve heart rate variability

Russell_et_al-2017_WTG.JPG

Key Points

  • Slow breathing at ~6 breaths/min increases heart rate variability (HRV)

  • Including a post-exhalation pause enhances relaxation and makes it easier to breathe slowly

  • A post-exhalation pause also enhances some HRV parameters more than continuous breathing

The Breathing Diabetic Summary

We don’t want our hearts to beat like a metronome, but to constantly be changing and adapting to the current conditions.  One way to measure this is through heart rate variability (HRV), which represents the changes in time between heartbeats.  HRV is a marker of overall health: Higher HRV is associated with better health. 

Many studies have shown that slow breathing can increase HRV.  Depending on the individual, it appears that breathing at a pace between 4 and 6 breaths/min maximizes HRV.  However, there are many ways to achieve a breathing rate of 4-6 breaths/min. 

For example, you can inhale for 5 sec, and exhale for 5 sec.  Inhale for 4 sec, exhale for 6 sec, etc.  But, these different methods might not necessarily be the best way to maximize HRV.  The current study set out to see if including a post-exhalation pause would increase HRV compared to continuous breathing with equal inhales and exhales.

Specifically, they tested two different methods for breathing at 5.5 breaths/min: 5-5 and 4-2-4.  The 5-5 protocol used a 5 sec inhale and 5 sec exhale.  The 4-2-4 protocol used a 4 sec inhale, 2 sec exhale, and 4 sec post-exhalation pause. 

Forty subjects performed the breathing protocols in a seated upright position.  They performed each breathing protocol for 6 min, followed by a 5 min rest period before starting the next one.  Along with measuring several different HRV parameters, the authors also evaluated which breathing protocol the subjects found more relaxing and easier to perform.

68% of the participants found the 4-2-4 cycle easier to follow and 63% found it more relaxing.  The authors suspect that this is a result of the shorter inhalation period, which caused less strain on the breathing muscles.  They also suspect that the post-exhalation rest period reduced the risk of hyperventilation.

There is no one single measurement for HRV.  There are high and low frequency bands, along with other parameters such as the standard deviation of the NN intervals.  In this study, they found that the 4-2-4 cycle significantly improved one aspect of HRV (high-frequency HRV), whereas the 5-5 cycle improved another (low-frequency HRV).  Thus, although the title of the paper suggests that the rest period is critical, it is important to note that both breathing protocols improved HRV in different ways.

Overall, this study shows that you can improve HRV by slowing down your breath.  Whether you adopt a post-exhalation rest or simply do slow continuous breathing is up to you. Either way, you can rest assurred you will be improving this critical indicator of overall health.

Let’s wrap up with a quote from the end of the paper that is one of my new favorites:

With breathing interventions being relatively rapid interventions to implement and also demonstrating a wide range of positive clinical outcomes, breathing interventions warrant closer consideration from healthcare professionals.

Abstract from Paper

Heart rate variability (HRV) is associated with positive physiological and psychological effects. HRV is affected by breathing parameters, yet debate remains regarding the best breathing interventions for strengthening HRV. The objective of the current study was to test whether the inclusion of a postexhalation rest period was effective at increasing HRV, while controlling for breathing rate. A within-subject crossover design was used with 40 participants who were assigned randomly to a breathing pattern including a postexhalation rest period or a breathing pattern that omitted the postexhalation rest period. Participants completed training on each breathing pattern, practiced for 6 min, and sat quietly during a 5-min washout period between practices. Participants were given instructions for diaphragmatic breathing at a pace of six breaths/minute with or without a postexhalation rest period. Recordings of heart rate, breathing rate, HF-HRV, RMSSD, LF-HRV, and SDNN were collected before and during each of the breathing trials. HRV indices were derived from Lead 1 ECG recordings. Pairwise contrasts showed that inclusion of a postexhalation rest period significantly decreased heart rate (p<.001) and increased HF-HRV (p<.05). No differences were found for breathing rates (p>.05), RMSSD (p>.05), and SDNN (p>.05). Results indicated that omission of the postexhalation rest period resulted in higher LF-HRV (p<.05). A postexhalation rest period improves HF-HRV, commonly associated with self-regulatory control, yet the importance of a postexhalation rest period requires further exploration.

Journal Reference:

Russell MEB, Scott AB, Boggero IA, Carlson CR. Inclusion of a rest period in diaphragmatic breathing increases high frequency heart rate variability: Implications for behavioral therapy. Psychophysiology, 2017;54:358 – 365.