The effect of breath-holding and Valsalva manoeuvre on pain: a systematic review and meta-analysis
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Abstract
Breath-holding and the Valsalva manoeuvre are simple, non-pharmacological techniques that may modulate pain through autonomic and cardiovascular mechanisms. However, their effects on pain have not been systematically synthesized. This systematic review and meta-analysis aimed to evaluate the effect of breath-holding and the Valsalva manoeuvre on pain intensity. Electronic searches were conducted in PubMed, ScienceDirect, Embase, Scopus, and the Cochrane Library for studies published between 1996 and 2025. Experimental and quasi-experimental studies investigating breath-holding, breath retention, or the Valsalva manoeuvre with pain intensity as the primary outcome were included. Two reviewers independently screened studies and assessed methodological quality using the Downs and Black checklist. A random-effects meta-analysis was performed. Of 8,266 records identified, four studies involving 102 healthy young adults met the inclusion criteria for qualitative synthesis, and three studies involving 64 healthy young adults were included in the metaanalysis. All studies were rated as fair methodological quality. Meta-analysis showed that breath-holding significantly reduced pain intensity compared with normal breathing, with a pooled effect size of −0.93 on a 10-point pain scale (95% CI: −1.06 to −0.80; p-value < 0.001; I² = 0.00%). However, the certainty of evidence was rated as very low (GRADE), and effect sizes did not reach established minimal clinically important differences. Pain reduction was observed across most experimental pain models, although findings were condition-specific in thermal pain. These preliminary findings suggest that breath-holding may reduce pain intensity in healthy young adults, potentially through baroreceptor activation and vagal modulation. Further high-quality randomised controlled trials in diverse clinical populations are required to establish clinical effectiveness, safety, and applicability.
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