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Year : 2020  |  Volume : 28  |  Issue : 1  |  Page : 74-78

The effect of rhythmic deep breathing on pain and anxiety in patients with burns

Department of Physiotherapy, Sancheti Institute College of Physiotherapy, Pune, Maharashtra, India

Date of Submission28-Apr-2020
Date of Decision10-Aug-2020
Date of Acceptance22-Aug-2020
Date of Web Publication21-May-2021

Correspondence Address:
Dr. Suroshree Mitra
Sancheti Institute College of Physiotherapy, Thube Park, Shivajinagar, Pune - 411 005, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijb.ijb_5_20

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Context: Patients with burns suffer from physical (pain) and psychosocial (anxiety) sequelae due to the burns wounds and mobilization activities. Deep breathing is a simple intervention to manage pain and anxiety in various conditions. Data concerning the effect of breathing on burns patients are limited. In order to add to this information, this study was undertaken on burns patients.
Aims and Objectives: The aim was to study the effect of rhythmic deep breathing on pain and anxiety in patients with burns.
Methods: This study followed an experimental, pretest–posttest design. A single group of twenty patients in the age group of 5–70 years who had suffered various types of burns to some or all parts of the body were recruited from a tertiary care center in Pune, India. With institutional approval and written consent, deep breathing technique was taught to the patients. Pretest and posttest scores of pain visual analog scale (VAS), anxiety (VAS), and anticipatory anxiety pain anxiety symptom scale were collected in the period from October 2019 to November 2019.
Results: Significant change (P = 0.00) was observed in the mean pain, anxiety, and anticipatory anxiety scores over time.
Conclusion: Rhythmic deep breathing can significantly help to decrease pain and anxiety in patients with burns.

Keywords: Anxiety, breathing, burn, pain, psychosocial, symptom

How to cite this article:
Iyer AR, Mitra S, Dabadghav R. The effect of rhythmic deep breathing on pain and anxiety in patients with burns. Indian J Burns 2020;28:74-8

How to cite this URL:
Iyer AR, Mitra S, Dabadghav R. The effect of rhythmic deep breathing on pain and anxiety in patients with burns. Indian J Burns [serial online] 2020 [cited 2022 Jun 25];28:74-8. Available from: https://www.ijburns.com/text.asp?2020/28/1/74/316580

  Introduction Top

Burns patients suffer from background burn pain throughout the day. There is evidence of “procedural pain” or pain which increases with wound cleaning and debridement, self-care activities, and mobilization. It affects the sleep, thinking, and daily personal and social activities.[1] Anticipatory anxiety has also been found to be highly prevalent in burns patients, even more than background pain and procedural pain levels.[2] It is the anxiety experienced while thinking about a painful event in the future. It manifests in the form of fear, avoidance of activities, inability to concentrate, and physiological symptoms such as sweating, trembling, dizziness, and palpitations. These psychosocial symptoms lead to patients being very depressed and unable to come out of the trauma and apprehension of the hospital stay.[3]

There is also evidence that pain and anxiety are interrelated. Increase in anxiety levels during an activity can increase the pain levels and vice versa. Patients get trapped in this pain-anxiety loop during the acute stage of hospital stay. Hence, there need to be some special treatment measures undertaken in order to manage these pain symptoms. Only if this is managed effectively, can the patient cooperate in mobilization and range of motion exercises.

Pharmacological intervention in the form of drugs is standard in most health-care centers to manage pain in burns. Despite this, most patients still complain of pain. Pain-relieving drugs are also associated with adverse effects such as tolerance, dependence, and affection of the kidney and liver.[4] Hence, nonpharmacological measures or behavioral practices are more important in pain management. Pain is not entirely physical, it is an emotional and cognitive experience (Melzack and Wall, gate control theory).

Studies examining the effect of breathing on pain and anxiety in burns patients using valid and reliable tools are limited. Previous studies have not evaluated the anxiety aspect in detail apart from visual analog scale (VAS) ratings. Hence, the objective of the study was to evaluate the effect of breathing on pain and anxiety using the VAS and pain anxiety symptom scale (PASS).[5],[6]

  Methods Top

The study was approved by the Ethical Committee of the Institutional Review Board. Moreover, the study followed all the ethical standards as per the Helsinki Declaration of 1975. The study was an experimental, pretest–posttest comparison group design involving a single group of twenty patients.


The participants were recruited by convenient sampling from the burns ward of a single tertiary care center based on certain inclusion criteria – Patients of both sexes; patients of all age groups except infants; burns affecting some or all parts of the body such as the face, hands, feet, back, abdomen, and chest; superficial to full-thickness burns; burns percentage of 5–70; and anticipatory anxiety >30 on PASS. The ages of the participants ranged from 5 to 70 years (mean = 31.75 and standard deviation [SD] = 17.82). The total number of females was 7, and males were 13.

The patients were excluded from the criteria: (1) He/she suffered inhalation burns (2) Self-inflicted burns.


Patients were approached as soon as possible after admission, the earliest being a few hours postadmission (day 0) and the latest being the day 1 postadmission. After this, written informed consent was obtained from each participant. Then, demographic data and information regarding the cause, extent, and type of burns were collected.

Rhythmic deep breathing program

The participants were explained the breathing technique verbally in brief, after which it was demonstrated. This was repeated twice until the patient felt prepared to replicate.

Duration of breathing technique: 1 session lasting 15 min per day for 7 days.[7],[8]

The patient was asked to sit comfortably with shoulders and neck relaxed. The patient's hand was placed on the abdomen for feedback of the depth of respiration. He/she was asked to breathe in slowly and deeply through the nose and breathe out in the same manner. This was repeated for sets of 5–6 cycles for 15 min under supervision. Throughout this intervention and training, the investigator responsible for teaching the technique and supervision of the same was discrete from the one responsible for measuring and interpreting the results, to avoid bias in the study.[9]


Pretest scores

Pretest scores (day 0) of pain, anxiety, and anticipatory anxiety were measured on the same day using the VAS and PASS, respectively.

Posttest scores

Immediate or early effect (day 1) was measured on pain and anxiety only using VAS. Long-term effect (day 7) on pain, anxiety, and anticipatory anxiety was measured using VAS and PASS. The point in time during the day at which the measurements were taken was kept consistent throughout the intervention period.

PASS is a 20-item questionnaire that assesses pain-related anxiety on four aspects – cognition, fear, physiological symptoms, and avoidance of activities. Each aspect has five questions dedicated to it. The patient was asked to rate his/her experience for each aspect on a scale of 0 (never) to 5 (always). This was done by interviewing each patient verbally and marking the appropriate option on the scale according to the patient's answer. The questions were originally in English and were translated to Marathi and Hindi. The translated versions underwent face validity from experts known to have sufficient knowledge, fluency, and capability in the respective languages before they were used.

Data analysis

Data were analyzed using the SPSS version 26 (Windows XP, SPSS Inc., Chicago, IL, USA) software. Descriptive data analysis was done for calculating the mean and SD. Pretest–posttest pain and anxiety scores' comparison was done using Friedman's and Wilcoxon signed-rank test.

  Results Top

The authors found that the most common cause of burns among the sample population was thermal (14 out of 20 patients), followed by electric burns and scalds (3 out of 20). The degree of burns ranged from superficial (9 out of 20 patients) to full thickness (7 out of 20). The most common parts affected were the chest (13 out of 20), followed by abdomen, face, and extremities. [Table 1], [Table 2], [Table 3] show a significant change in pain and anxiety scores over time.
Table 1: Mean pain scores (visual analog scale) over time

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Table 2: Mean anxiety scores (visual analog scale) over time

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Table 3: Mean anticipatory anxiety (pain anxiety symptom scale) scores over time

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Anticipatory anxiety was found to be manifested in the patients highest in the form of avoiding activities. Next, it was found that patients experienced problems governing cognition, which may be frequent or constant thoughts related to pain and inability to concentrate. Fear and physiological anxiety (sweating, palpitations, and light-headedness) scored least among the patients [Figure 1].
Figure 1: Comparison of anticipatory anxiety scores between day 0 and day 7. The greatest effect was found on the cognition aspect of anxiety, followed by physiological symptoms, fear, and lastly, avoidance of activities

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  Discussion Top

The authors found that rhythmic deep breathing significantly reduces pain and anxiety in burns patients, which is consistent with findings in similar studies by Park et al. and Bozorg-Nejad et al. who evaluated the effect of relaxation breathing on burns pain using VAS ratings.[10],[11] More importantly, it was found that the breathing technique had a significant effect on each of these aspects and the overall anxiety experienced by these patients.

Stress and anxiety causes the muscles to tighten and remain in a constant state of tension. Relaxed breathing reduces sympathetic activity, thereby reducing muscle tension. This induces relaxation of the skin around the wound edges and leads to inhibition of the stretch reflex in the muscle spindles, breaking the spasm-pain cycle.[12] Moreover, stimuli to the pain nerve endings situated in the wound are decreased, thereby reducing pain.

The significant effect on pain can also be explained by the gate control theory. Breathing stimulates sensorimotor impulses carried by the large afferent fibers that stimulate the inhibitory interneuron which closes the “gate” by inhibiting the transmission cells and prevents pain stimuli carried by small afferent fibers from passing to the cortex, thereby reducing the pain.[13]

There is evidence that deep breathing increases the levels of “feel good” hormones, namely endorphins, serotonin, and dopamine by decreasing the activation of the sympathoadrenal system and hypothalamic–pituitary–adrenal axis. It also decreases the responsiveness of the sympathetic system to adrenaline and noradrenaline (”fight or flight” hormones).[14] Cortisol is a hormone that is elevated during prolonged stress and anxiety. Deep breathing for as low as 20 min a day produced a considerable decrease in the salivary cortisol levels in individuals facing stress at professional fronts.[15]

Studies of traditional Indian breathing techniques and exercises are many, of which Sudarshan Kriya Yoga incorporates breathing, Om chanting and yogic postures was found to be helpful in reducing anxiety and many more neuropsychological conditions such as stress, insomnia, and posttraumatic stress disorder. “Om” chanting is a form of controlled and prolonged exhalation with vibrations from the larynx. It brought a feeling of calm in the mind and decreased worrying thoughts that facilitated sleep.[16]

Diaphragmatic breathing is comparable to Pranayama (slow to fast breathing rates with a partially closed oropharynx). The latter, in a 3-month study, was found to induce relaxation through stimulation of the vagus nerve during slow breathing cycles.[17] Pursed lip breathing is a similar form of breathing that combines deep inhalation and prolonged exhalation through pursed lips. A 5 min session over 30 sessions was shown to help decrease labor pain, anxiety, as well as duration by Chang et al.[18] All this proves that rhythmic, controlled, and focused breathing, irrespective of the time, rate, duration, and cycle, holds a significant place in treating all forms of pain, negative emotion or mental states, and neuropsychological disorders spanning a large variety of pathological and nonpathological conditions.

Breathing exercise acts as a distraction (just like some soulful music would) garnering utmost attention and focus of the patient. Thereby, negative thoughts of fear and distress are not the focus of attention in the mind.[19] This finding is strongly supported by the effectiveness of cognitive behavioral therapy (CBT) seen in numerous studies for generalized anxiety disorders and depression. In CBT, strategies like thought diaries and attention-refocusing helped the patients to overcome fears and effectively perform tasks that were previously anxiety provoking.[20]

Progressive muscle relaxation involves actively tightening and relaxing group of muscles in a particular order to achieve overall relaxation of the body. It is based on concepts of “Shavasana” in Yoga technique. It has been found that this technique is rather lengthy (30 min) requiring repeated trainings, as compared to others. Moreover, tightening of the body parts may be pain inducing or even impossible in some cases of burns. Khanolkar et al. combined body relaxation and training calm, peaceful imagery in the form of photographs and videos to further enhance the effects and improve the cooperation of the patients.[21]

Jaw relaxation in comparison to deep breathing is much the same considering its simplicity and treatment duration. A 20 min session just before dressing changes significantly reduced pain anxiety in burns patients. Mohammadi et al. incorporated slow breathing (inhale-exhale-rest) and reinforced the concept of “no thoughts, not even words in the mind” while teaching jaw relaxation.[22]

Therefore, no matter the technique of relaxation, the effects achieved have been found to be more or less the same. A common theme in all these techniques would be correct and precise steps for patients' comprehension, repetition, retraining, focusing on the act of relaxation/breathing, emphasis on minimal thoughts, and a slow rhythm.


This study could not evaluate the long-term carryover effect of deep breathing on pain and anxiety due to limitations in the span of hospital stay of burns patients.

  Conclusion Top

Rhythmic deep breathing is an effective technique for patients to manage pain and anxiety. Routine physiotherapy treatment should include this technique apart from routine mobilization and ambulation activities for better mental and physical well-being of patient.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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Byers JF, Bridges S, Kijek J, LaBorde P. Burn patients' pain and anxiety experiences. J Burn Care Rehabil 2001;22:144-9.  Back to cited text no. 2
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Salyers MP, Hudson C, Morse G, Rollins AL, Monroe-DeVita M, Wilson C, et al. BREATHE: A pilot study of a one-day retreat to reduce burnout among mental health professionals. Psychiatr Serv 2011;62:214-7.  Back to cited text no. 9
Park E, Oh H, Kim T. The effects of relaxation breathing on procedural pain and anxiety during burn care. Burns 2013;39:1101-6.  Back to cited text no. 10
Bozorg-Nejad M, Azizkhani H, Mohaddes Ardebili F, Mousavi SK, Manafi F, Hosseini AF. The effect of rhythmic breathing on pain of dressing change in patients with burns referred to Ayatollah Mousavi Hospital. World J Plast Surg 2018;7:51-7.  Back to cited text no. 11
Rafii F, Mohammadi-Fakhar F, Jamshidi Orak R. Effectiveness of jaw relaxation for burn dressing pain: randomized clinical trial. Pain Manag Nurs 2014;15:845-53.  Back to cited text no. 12
Melzack R, Katz J. The gate control theory: Reaching for the brain. Pain 2004;27:13-34.  Back to cited text no. 13
Jerath R, Crawford MW, Barnes VA, Harden K. Self-regulation of breathing as a primary treatment for anxiety. Appl Psychophysiol Biofeedback 2015;40:107-15.  Back to cited text no. 14
Ma X, Yue ZQ, Gong ZQ, Zhang H, Duan NY, Shi YT, et al. The effect of diaphragmatic breathing on attention, negative affect and stress in healthy adults. Front Psychol 2017;8:874.  Back to cited text no. 15
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Ganesh BR, Madhushree PD, Andrea RH. Comparative study on effect of slow and fast phased pranayama on quality of life and pain in physiotherapy girls with primary dysmenorrhoea: Randomized clinical trial. Int J Physiother Res 2015;3:928-37.  Back to cited text no. 17
Chang SB, Kim HS, Ko YH, Bae CH, An SE. Effects of abdominal breathing on anxiety, blood pressure, peripheral skin temperature and saturation oxygen of pregnant women in preterm labor. Korean J Women Health Nurs 2009;15:32-42.  Back to cited text no. 18
Najafi Ghezeljeh T, Mohades Ardebili F, Rafii F, Haghani H. The effects of music intervention on background pain and anxiety in burn patients: Randomized controlled clinical trial. J Burn Care Res 2016;37:226-34.  Back to cited text no. 19
Egan SJ, Wade TD, Shafran R, Antony MM. Cognitive-Behavioral Treatment of Perfectionism. New York: Guilford Publications; 2016.  Back to cited text no. 20
Khanolkar TS, Metgud S, Verma C. A study on combined effects of progressive muscle relaxation and visual imagery technique on perceived pain, levels of anxiety and depression in patients with burns. Indian J Physiother Occup Ther 2013;7:225.  Back to cited text no. 21
Mohammadi Fakhar F, Rafii F, Jamsidi Orak R. The effect of jaw relaxation on pain anxiety during burn dressings: Randomised clinical trial. Burns 2013;39:61-7.  Back to cited text no. 22


  [Figure 1]

  [Table 1], [Table 2], [Table 3]

This article has been cited by
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