The Influence of Breathing Techniques and Exposure to Cold on Inflammation During Human Endotoxemia, an Explorative Study'

Auto-immune diseases are characterized by an inappropriate inflammatory response against tissues in the body. These diseases, of which rheumatoid arthritis (RA) is the most well-known, represent a major health care burden. Pro-inflammatory cytokines such as TNF-α, IL-6 and IL-1β are central in the pathogenesis of RA and many other auto-immune diseases. Biologics that antagonize inflammatory cytokines or their receptors, e.g. anti-TNF-α, soluble TNF-α-receptor, anti-IL-6 receptor, and IL-1 receptor antagonist, are very effective treatments. However, they are very expensive and can have serious side effects. Furthermore, the consequences of RA are currently completely beyond the patients' sphere of influence. Therefore, innovative therapies aimed at limiting inflammation in RA patients are warranted.

Recently, a study into the effects of an intervention developed by 'The Iceman' Wim Hof revealed that it is possible to voluntarily attenuate the pro-inflammatory response during experimental human endotoxemia (a standardized, controlled, and reproducible model of systemic inflammation elicited by administration of lipopolysaccharide (LPS) in healthy volunteers). The intervention developed by Hof consists of several elements, namely meditation, exposure to cold and breathing techniques. Subjects trained in this intervention exhibited profound increases in plasma adrenaline levels, a rapid increase of the anti-inflammatory cytokine IL-10, and subsequent attenuation of the pro-inflammatory response (e.g. plasma levels of TNF-α, IL-6, and IL-8) during experimental human endotoxemia. This intervention could therefore represent a treatment modality that would empower RA patients to exert self-control over their disease.

Based on these data, investigating the effectiveness of the intervention in RA patients is highly warranted. The study described in this protocol is part of a larger project in which the investigators ultimately strive to translate the intervention to clinical practice for RA patients. However, there are important issues that need to be addressed first. For example, feasibility and safety would be substantially improved if patients would only have to learn or practice one of the three elements of the intervention. The meditation element is not likely to be involved. It was a very minor part of the training program and was not practiced during the endotoxemia experiments. Also, there is no objective manner to measure this element and there is no hypothesis for a possible mechanism. Concerning the second element, exposure to cold, it would especially be of value to determine whether this element has additional value, because it is very demanding and might not be suitable for RA patients at all. The investigators anticipate that the third element, breathing techniques, is the major contributor to the anti-inflammatory effects of the intervention previously observed for reasons outlined below.

Breathing techniques First, although the healthy volunteers were trained in all three elements, subjects only practiced breathing techniques during the endotoxemia experiment. Second, the breathing techniques were characterized by cyclic hyperventilation, which has been shown before to result in increased adrenaline levels. Subjects practiced two types of breathing techniques during the endotoxemia experiment in our previous endotoxemia study. Both of these breathing techniques were characterized by cycles of hyperventilation. In one of the techniques (hyper/hypoventilation), subjects held their breath for up to several minutes after each hyperventilation period, while in the other technique (strength ventilation), subjects held their breath for only 10 seconds during which all muscles were tightened after each hyperventilation period.

Yet unpublished data (CMO 2014-1374) showed the effects of these two breathing techniques in the absence of cold exposure (or meditation) on plasma adrenaline levels. The investigators found these to be strongly correlated with the anti-inflammatory effects previously found. Both breathing techniques resulted in comparable increases in plasma adrenaline levels. Furthermore, adrenaline levels in subjects trained by Hof were comparable to those that were trained by an independent trainer previously not familiar with the intervention developed by Hof. Finally, adrenaline levels in subjects trained for 4 days were similar to those who were trained for only 2 hours.