The influence of breathing techniques and exposure to cold on inflammation during human endotoxemia, an explorative study

Inflammatory cytokines play a pivotal role in rheumatoid arthritis (RA) and
innovative non-pharmacological therapies aimed at limiting cytokine production
are highly warranted. Recently, our group showed that healthy volunteers
trained in an intervention developed by *Iceman* Wim Hof were able to
voluntarily attenuate the pro-inflammatory response during experimental human
endotoxemia (a model of systemic inflammation elicited by administration of
lipopolysaccharide [LPS] in healthy volunteers). Subjects trained in the
intervention exhibited profound increases in plasma adrenaline levels, a rapid
increase of an anti-inflammatory cytokine and subsequent attenuation of the
pro-inflammatory response. This intervention could therefore represent a
treatment modality that would empower RA patients to exert self-control over
their disease.
The intervention consists of three elements, namely meditation, exposure to
cold and breathing techniques. 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. Exposure to cold and the
subsequent rewarming to normal body temperature may influence the inflammatory
response through the release of immunomodulatory molecules like HSP-70. Also,
exposure to cold can induce an ischemia-reperfusion-like state in the skin and
peripheral tissue that is known to be involved in the downregulation of
pro-inflammatory cytokines and upregulation of anti-inflammatory cytokines. We
anticipate that the third element, breathing techniques, is the major
contributor to the anti-inflammatory effects of the intervention previously
observed. Subjects and Hof practiced two types of breathing techniques. In our
latest study (yet unpublished data, CMO 2014-1374), we investigated the effects
of these two breathing techniques in the absence of cold exposure (or
meditation) on plasma adrenaline levels, which we found to be strongly
correlated with the anti-inflammatory effects previously found. The present
study aims to explore the effects of two of those elements of the intervention
developed by Hof, namely the breathing technique (*strength ventilation*) and
the exposure to cold, on the immune response during human endotoxemia.

The primary objective of the present study is to determine the effects of the
`strength ventilation` breathing technique and exposure to cold, both
separately and in combination, on the inflammatory response during human
endotoxemia. To this end, we will employ a 2 by 2 design. Additionally, we want
to evaluate the influence of the cold exposure and breathing technique on pain
thresholds and oxygen tension in the mitochondria.

A parallel randomized controlled explorative study in healthy male volunteers
during experimental endotoxemia.

a cold exposure course and training in *Strength Ventilation* breathing
technique in various modalities:
1. `Cold Exposure` group. A group of subjects (n=12) that will receive an
extensive cold exposure course.
2. ` Strength Ventilation` group. A group of subjects (n=12) that will be
trained in the Strength Ventilation breathing technique.
3. `Cold Exposure and Strength Ventilation` group. A group of subjects (n=12)
that will receive both the cold exposure and the training in the *Strength
Ventilation* breathing technique .
4. `Control` group. A group of subjects (n=12) that will only participate in
the endotoxemia experiment.

The burden of the study procedures consist of the time investment related to
the training procedures and a maximum of three visits to the hospital. All
subjects will visit the hospital for a 60-minute screening visit (medical
interview, physical examination, venapuncture, pain threshold measurement) and
a 45 minute baseline visit. Subjects participating in the cold exposure course
will visit the training facility four days in a row and subsequently expose
themselves to daily cold showers. Subjects participating in the *Strength
Ventilation* breathing training visit the training facility once for 2 hours.
For the endotoxemia experiment day, all subjects will be admitted to the
research intensive care unit for 10 hours.

The training methods developed by Hof have been applied to hundreds of
volunteers in the past. These include not only healthy persons, but also more
than 100 patients with varying illnesses. No problems or emergencies have ever
arisen in healthy persons or patients. The training will be given by the study
team by an MD from the Radboudumc department of Intensive Care Medicine. The
study team is medically responsible for the subjects during the training and
will supervise every part of the training. Importantly, during the training,
subjects will not be forced in any way to expose themselves to cold any longer
than they wish to. The training is specifically targeted at moving a person`s
boundaries within his own capabilities.

On the endotoxemia experiment day, subjects will be admitted to the research
intensive care unit for 10 hours. An arterial catheter (under local
anesthesia), and a intravenous catheter will be placed. The administration of
LPS induces flu-like symptoms for approximately 4-6 hrs. This model of systemic
inflammation has been applied for more than 10 years in our department and
thousands of subjects worldwide have participated in endotoxemia trials. During
the endotoxemia experiment day, subjects will be under constant supervision of
an experienced intensivist with continuous monitoring of blood pressure and
heart rate. The endotoxemia protocol and associated risks are identical to
earlier endotoxemia studies performed in our institute. In total, a maximum of
400 ml blood will be drawn during the study, which is comparable to previous
studies and never resulted in adverse events. Subjects will not benefit
directly from participation to the study. A subject fee is provided.