Steven D. Pratscher, PhD1,2, , Lloyd Lalande, PhD3, Mark A. Lumley, PhD4, , Irene M. Estores, MD5, Adam W. Hanley, PhD6, Kimberly T. Sibille, PhD2,5, Roger B. Fillingim, PhD2,7
Chronic low back pain (cLBP) is the most common type of chronic pain and a leading cause of years lived with disability.1 Although psychosocial interventions can improve pain and related symptoms, average treatment effects are typically modest.2 Breathwork, or the conscious control of breathing, holds significant promise for managing chronic pain, because respiration is bidirectionally linked with bio-psychosocial processes that influence the pain experience, including stress, emotions, and nervous system functioning.3,4
Breathwork encompasses a wide range of practices, from basic self-directed techniques used for self-regulation to more intensive facilitator-guided integrative breathwork interventions.5 Guided Respiration Mindfulness Therapy (GRMT) is a manualized integrative breathwork intervention designed for clinical practice and rigorous research.6 As a novel therapy for chronic pain, GRMT warrants systematic evaluation consistent with goals of intervention development.7 Therefore, the primary objective of the pre- sent study was to investigate whether an individually delivered, 8- session version of GRMT was feasible and acceptable to adults with cLBP. We hypothesized good feasibility, with >80% of participants completing post-intervention assessments, attending at least 5 of 8 sessions, and reporting average acceptability ratings of at least 3 on a 4-point scale. We also expected to observe clinically meaningful improvements in pain intensity and pain interference, providing proof-of-concept for future efficacy testing.
Methods
This single-arm study investigated an 8-session breathwork intervention for adults with cLBP. The study was approved by the University of Florida Institutional Review Board and preregistered
(ClinicalTrials.gov NCT06546956). Participants were recruited from a research registry and via flyers distributed in the community. Inclusion criteria were consistent with National Institutes of Health recommendations for cLBP.8 Those with epilepsy, neurological disease, and moderate-to-severe respiratory, cardiovascular, and psychiatric disorders were excluded. Participants completed a phone screening to determine eligibility, provided informed consent, and attended a baseline assessment visit.
GRMT was developed by Dr. Lalande and delivered individually and in person by 1 of 4 trained facilitators. Sessions lasted 1hour and were scheduled weekly for 8 intervention visits. Each session had the same content and structure, in which the facilitator guided participants to engage in 3 core components: (1) respiratory regulation—maintaining deep, conscious connected breathing into the chest with no pause between inhale and exhale, with the exhale totally relaxed; (2) mindfulness— focusing attention on and accepting the dominant somatic sensation moment to moment, while letting go of thoughts; and (3) relaxation—releasing physical tension and remaining still. Participants were instructed to return to their normal breathing pattern during the final 5 minutes of the session before debrief- ing with the facilitator. There was no homework to practice the intervention between sessions.
Assessments occurred at baseline (pre-intervention), before and after each breathwork session, after the final intervention session (post-intervention), and at 1-month follow-up. Feasibility was determined by quantifying rates of participant retention and adherence. Treatment acceptability was assessed after the intervention with the Client Satisfaction Questionnaire-8 (CSQ-8), and session acceptability was assessed after each breathwork session through face-valid items. The Pain, Enjoyment, and General Activity Scale (PEG-3) was used to assess pain intensity and
interference with 3 items rated from 0 to 10, where higher scores represent worse pain severity and interference. Proof- of-concept was evaluated by changes in PEG-3 scores from baseline to the post-intervention assessment and to 1-month follow-up, with a ≥2-point improvement considered clinically meaningful.9 Secondary outcomes were selected to characterize changes across multiple domains relevant to chronic pain, including patient-reported symptoms, physical function, and pain processing. These were assessed with validated questionnaires, functional tasks, and quantitative sensory testing (QST). Descriptive statistics were calculated to summarize participant baseline characteristics, assess feasibility and acceptability, and characterize changes in outcomes over time. As this was an intervention development study, analyses focused on estimating within-person improvement with effect sizes rather than statistical significance.
Results
Nineteen participants with cLBP enrolled in the study (58% fe- male, age = 19–69years) from October 2024 through October 2025. Table 1 describes the clinical and demographic characteristics of the sample. Pre-specified feasibility benchmarks were met, with 17 of 19 participants retained for post-intervention assessments (89.5%; 95% CI: 68.6% to 97.1%) and 15 of 19 for 1- month follow-up (78.9%; 95% CI: 56.7% to 91.5%). Intervention adherence benchmarks were also met, with 16 of 19 participants attending at least 5 of 8 intervention sessions (84.2%; 95% CI: 62.4% to 94.5%). There were no serious adverse events or concerns about intervention safety.
The intervention was rated as highly acceptable (mean = 8.4, SD = 2.3) and satisfying (mean = 8.1, SD = 2.2), with 15 of 17 participants (88%; 95% CI: 65.7% to 96.7%) exceeding the prespecified acceptability threshold on the CSQ-8 (mean = 3.43, SD = 0.56). Across the 124 intervention sessions, more than 90% of participant ratings characterized the breathwork experience as positive, likable, and satisfying, while 100% indicated satisfaction with the facilitator. Improvements in pain intensity/interference (PEG-3) were observed from baseline to the post-intervention assessment and to 1-month follow-up. Clinically meaningful improvement in PEG-3 scores was achieved by 8 of 17 participants (47.1%; 95% CI: 26.2% to 69.0%) at the post-intervention assessment and by 5 of 15 participants (33.3%; 95% CI: 15.2% to 58.3%) at follow-up. Secondary outcomes showed small-to-large effect sizes for within-person improvement, whereas task-based pain measures of movement-evoked pain and QST showed more variable effects.
Discussion
This study found that a novel 8-week integrative breathwork intervention was feasible, safe, and highly acceptable among adults with cLBP. Feasibility and acceptability outcomes exceeded prespecified benchmarks, which suggests that the intervention and study procedures are suitable for further testing. There were large within-person changes in pain intensity and pain interference, providing preliminary proof-of-concept that GRMT could improve the primary outcome in a future efficacy trial. Although the study was not powered to evaluate efficacy, medium-to-large within-person improvements were observed in several secondary outcomes, including sleep disturbance, fatigue, and physical function, as well as non–self-report assess- ments of functional performance and movement-evoked pain. In a previous study, we showed that a 1-session group-format GRMT was also feasible, acceptable, and potentially helpful to adults with chronic musculoskeletal pain.10 Future research is needed to examine dose–response relationships of GRMT, predictors of treatment response, and the relative benefits of individual versus group delivery formats. As existing psychosocial interventions often include elements of breathing, mindfulness, and relaxation, future comparative testing is also needed to determine whether integrative breathwork might produce greater benefits through its distinct combination of these components. Following frameworks for behavioral intervention development,7 these findings support progression to a pilot randomized controlled trial in anticipation of a fully powered efficacy study.
References
01. Wu A, March L, Zheng X, et al. Global low back pain prevalence and years lived with disability from 1990 to 2017: estimates from the Global Burden of Disease Study 2017. Ann Transl Med. 2020;8:299. https://doi.org/10.21037/atm.2020. 02.175
02. Williams ACC, Fisher E, Hearn L, Eccleston C. Psychological therapies for the management of chronic pain (excluding headache) in adults. Cochrane Database Syst Rev. 2020;8: CD007407. https://doi.org/10.1002/14651858.CD007407.pub4
03. Jafari H, Courtois I, Van den Bergh O, Vlaeyen JWS, Van Diest I. Pain and respiration: a systematic review. Pain. 2017;158: 995-1006. https://doi.org/10.1097/j.pain.0000000000000865
04. Jerath R, Beveridge C. Respiratory rhythm, autonomic modulation, and the spectrum of emotions: the future of emotion recognition and modulation. Front Psychol. 2020;11: 1980. https://doi.org/10.3389/fpsyg.2020.01980
05. Fincham GW, Kartar A, Uthaug MV, et al. High ventilation breathwork practices: an overview of their effects, mechanisms, and considerations for clinical applications. Neurosci Biobehav Rev. 2023;155:105453. https://doi.org/10.1016/j. neubiorev.2023.105453
06. Lalande L, King R, Bambling M, Schweitzer RD. Guided respiration mindfulness therapy: development and evaluation of a brief therapist training program. J Contemp Psychother. 2016;46:107-116. https://doi.org/10.1007/s10879-015-9320-5
07. Czajkowski SM, Hunter CM. From ideas to interventions: a re- view and comparison of frameworks used in early phase behavioral translation research. Health Psychol. 2021;40: 829-844. https://doi.org/10.1037/hea0001095
08. Deyo RA, Dworkin SF, Amtmann D, et al. Report of the NIH task force on research standards for chronic low back pain. J Pain. 2014;15:569-585. https://doi.org/10.1016/j.jpain.2014.03.005
09. ReedDE,2nd,StumpTE,MonahanPO,KroenkeK.Comparable minimally important differences and responsiveness of brief pain inventory and PEG pain scales across 6 trials. J Pain. 2024; 25:142-152. https://doi.org/10.1016/j.jpain.2023.07.028
10. Pratscher SD, Lalande L, Davis A, Hanley AW. Single-session group breathwork intervention for chronic pain: a proof-of- concept study of guided respiration mindfulness therapy. J Integr Complement Med. 2026;32:465-474. https://doi.org/ 10.1177/27683605251406218
1Division of Palliative Medicine, Department of Internal Medicine, The Ohio State University, Columbus, OH, United States 2Pain Research and Intervention Center of Excellence, University of Florida, Gainesville, FL, United States
3Institute for Guided Respiration Mindfulness Therapy, Far North, New Zealand
4Department of Psychology, Wayne State University, Detroit, MI, United States
5Department of Physical Medicine and Rehabilitation, University of Florida, Gainesville, FL, United States
6Complementary Health Innovation Lab, College of Nursing, Florida State University, Tallahassee, FL, United States
7Department of Community Dentistry and Behavioral Science, College of Dentistry, University of Florida, Gainesville, FL, United States
*Corresponding author: Division of Palliative Medicine, Department of Internal Medicine, The Ohio State University, 3650 Olentangy River Rd, Columbus, OH 43214, United States. Email: Steven.Pratscher@osumc.edu.
Keywords; respiration, pain
