Short-term slow-paced breathing improves processing speed and fluid cognition in young healthy adults

Short-term slow-paced breathing improves processing speed and fluid cognition in young healthy adults | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Short-term slow-paced breathing improves processing speed and fluid cognition in young healthy adults Kairavi Bimalkumar Unarkat, Vatsal Ashish Batra, Manpreet Kaur, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9385088/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 4 You are reading this latest preprint version Abstract Slow-paced breathing (SPB) has shown to promote parasympathetic dominance, and cognitive enhancement. This longitudinal interventional study aimed to explore the effects of a 10-session SPB protocol on cognitive function in healthy young adults. 30 healthy participants, aged 18-35 years (15 intervention group and 15 controls) were recruited. The intervention group performed daily 17-minute SPB session (5 min block of 4.5s inhalation/5.5s exhalation with 1 min rest interval) for 10 days. Cognitive function was assessed at baseline and post-intervention using the NIH Toolbox® V3, measuring cognitive flexibility and attention span (DCCS), attention and inhibitory control (FICA), working memory (LSWM), processing speed (PCPS), episodic memory (PSM), and fluid cognition (FCS). The primary metric was the Change Sensitive Score (CSS), supported by age-adjusted standard scores (ASS) and national percentile score (NAPS). The PCPS showed significant post-intervention improvements in the SPB group, with a high effect size in CSS (p=0.0003; Hedges' g=0.726 [0.006–1.447]) and ASS (p=0.0055; g=0.728 [0.008–1.448]). The FCS also showed improvement in CSS (p=0.0067; g=0.609 [0.104–1.322]), ASS (p=0.0058; g=0.625 [0.089–1.339]), and NAPS (p=0.0127; g=0.951 [0.214–1.688]) in the SPB group. No significant changes were observed in the DCCS, FICA, LSWM, or PSM, except for a small shift in the NAPS in the DCCS after the SPB session. Control group showed no significant changes in the cognitive function. The 10-session short-term SPB protocol significantly enhanced processing speed and global fluid cognition in healthy young adults. The SPB could potentially represent a simple, non-invasive technique for augmenting cognitive health. Slow-paced breathing (SPB) Cognitive function Fluid cognition Executive function Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction The slow-paced breathing (SPB) protocol is a respiratory maneuver in which the breathing rate is altered to a slower pace of approximately 6 cycles per minute with controlled inhalation and exhalation times. Voluntary slowing of the respiratory frequency to six breaths per minute has been linked to vagus afferent stimulation (Gerritsen & Band, 2018 ; You et al., 2021 ). According to the polyvagal theory and neuro-visceral integration theory (Porges, 2025 ; Smith et al., 2017 ), this stimulation of the afferent vagal nerve is associated with more positive attributes of calmness, compassion, improved cardiovascular autonomic flexibility, and better cognitive responses (Magnon et al., 2021 ; Xiong et al., 2025 ). It has been shown to improve the cardiovascular-respiratory function, reduce the inflammatory milieu, and improve executive functions in many clinical conditions (Herhaus et al., 2023 ; Laborde et al., 2022 ; Turankar et al., 2013 ). Studies have indicated that acute SPB leads to significant improvements in executive functioning and processing speed (Bonomini et al., 2020 ; Laborde et al., 2022 ). This improvement may be attributed to the respiratory modulation of neural circuits related to attention and cognition control, as well as the cardiovascular feedback circuit that supports brain network synchronization (Bonomini et al., 2020 ). Few studies have shown that SPB protocol is positively correlated with enhanced executive functioning, such as working memory and cognitive inhibition. Bonomini et al. 2020 demonstrated that SPB improves the accuracy of executive functions as assessed by working memory task and improves the processing speed as assessed by multitasking test (Bonomini et al., 2020 ). Similarly, Laborde et al. ( 2022 ) showed that an acute single-session of a 17- min SPB protocol improved executive functioning in healthy adults as compared to control group (Laborde et al., 2022 ). Single SPB in middle-aged women also showed improvement in simple and congruent reaction time (RT), and incongruent reaction accuracy was also improved in the experimental group compared to the control group (Masmoudi et al., 2025 ). Few studies have explored the effect of multi-session SPB on cognitive function. Minjoz et al. demonstrated that SPB for five min, three times a day, for 24 days showed improve decision-making performance in brain-damaged (stroke and traumatic brain injury) patients by reducing negative affectivity and enhancing emotional states (Minjoz et al., 2025 ). Similarly, Schoonjans et al. demonstrated that the combination of 3 sessions of 5-minute SPB after a bout of physical activity reduces worry and cardiovascular reactivity to emotional stimuli, as measured by inter-beat interval (IBI) (Schoonjans et al., 2025 ). However, they did not find any difference in their psychophysiological indices of stress as compared to control group. Importantly, these multi-session protocols have largely been investigated in clinical or combined intervention contexts rather than in healthy populations and have limited assessment of cognitive function. Although, there is a growing interest in the role of breathing-based interventions as adjunct for cognitive enhancement. There is a paucity of studies on the sustained effect of slow-paced breathing on cognitive function in healthy young adults over a short period of time. Most current research has concentrated on singular acute exposures, resulting in ambiguity about the potential cognitive benefits of repeated SPB sessions within a brief timeframe. Evaluating these effects may facilitate the establishment of SPB as a simple, non-pharmacological approach for cognitive improvement and the optimization of mental performance. Therefore, the present study aimed to examine the effects of ten sessions of slow-paced breathing on cognitive function in healthy young adults. We hypothesized that SPB would lead to improvements in cognitive performance, particularly in executive functioning, cognitive flexibility and processing speed domains. Methods Study Design The present study was a longitudinal interventional study with a pre-post design. Setting This study was conducted in the Department of Vardhman Mahavir Medical College and Safdarjung Hospital (VMMC & SJH), New Delhi, India, a tertiary care teaching hospital Ethical approval was obtained from the Institutional Ethics Committee of VMMC & Safdarjung Hospital (Approval No.: IEC/VMMC/SJH/Cert/Sept-2024/101). Written informed consent was obtained from all participants prior to enrolment. Participants Thirty healthy adults (15 in the slow-paced breathing intervention group and 15 in the control group) were recruited using convenience sampling. The health status of the participants was assessed using a structured health questionnaire and physical examination. The study population consisted primarily of healthy undergraduate medical students. This population was selected due to accessibility and homogeneity in age and educational background. While the inclusion of medical students could introduce expectancy bias due to prior knowledge of physiological mechanisms, the participants were first-year students with minimal formal training, thus mitigating the potential for significant bias. The inclusion criteria for both cases and controls were a) age between 18–35 years, b) able to read and write, and c) right-handed subject to reduced variability of hemispheric dominance. The exclusion criteria for both groups were a) subjects on any medications, b) acute or chronic diseases, and c) smoking. Intervention The participants in slow-paced breathing (SPB) group were asked to perform 10 sessions of slow-paced breathing once per day. Each session consisted of guided breathing, with an inspiration duration of 4.5 seconds and expiration duration of 5.5 seconds. The protocol had three 5-minute breathing blocks separated by 1-minute rest interval (Total duration of 17 minutes) using a pre-recorded audio-visual guide (Fig. 1 ). The audio-visual signal had pairing of visual cues with auditory voice instructions to guide for inhalation, exhalation and rest phase. During the protocol, the participants were instructed to sit comfortably with back supported, maintain nasal breathing, avoid holding of breath and perform SPB preferably at the same time each day. Compliance was assured by daily telephonic conversation to the SPB intervention group to ensure adherence and record completion status. Noninvasive cognitive function was assessed before and after the 10 intervention sessions. The control group was just observed before and after 10 days to decipher the temporal effect of time on the cognitive function in healthy young adults. The control group were not contacted daily by telephonic calls which is acknowledged as a social- interaction confound. Assessment of cognitive function The National Institutes of Health (NIH) Toolbox® V3 cognition testing software was used to assess the cognitive function (Akshoomoff et al., 2013 ). The NIH toolbox (NIHTB) is a validated (Ott et al., 2022 ) multidimensional set of brief measures to assess cognitive, motor, emotional, and sensory function in the 3–85-year-old age group. In this study selected tests of cognitive domain were administered using a 9th generation iPad (operating system 17.4) (Apple CA, USA Inc., Cupertino). Table 1 summarizes the cognitive battery of tests administered to each participant. The total administration time was approximately 25 min. Table 1 Summarizes the cognitive battery of tests administered NIHTB test name Cognitive Domains Brief Description of the test Equivalent test in Traditional neuropsychological tests (Weintraub et al., 2014 ) Dimensional Change Card Sort Test (DCCS) Executive function, cognitive flexibility and attention span Participant was asked to match a series of picture pairs to a target picture. Trail Making Test Part B Flanker Inhibitory Control and Attention Test (FICA) Attention, inhibition control and executive function Participant was asked to focus on a particular stimulus while inhibiting attention to the stimulus, flanking it. Comalli Stroop Interference List Sorting Working Memory Test (LSWM) Working memory (WM) Participant was asked to recall and sequence different stimuli that are presented visually and via audio. WAIS-IIIb Letter-Number Sequencing WAIS-IIIb Digit Span, Forwards and Backwards Pattern Comparison Processing Speed Test (PCPS) Processing speed (PS) Participants were asked to quickly determine whether two stimuli are the same or not the same. WAIS-IIIb Digit Symbol Coding Trail Making Test Part A Picture Sequence Memory Test (PSM) Episodic memory Participants were shown a few activities and then asked to reproduce the sequence of pictures in the order it was presented to them. WMS-IIIa Logical Memory I WMS-IIIa Logical Memory II The scores of the cognitive battery tests were quantified using multiple metrics, such as the change-sensitive score (CSS), age-adjusted standard score (ASS), and nationally age-adjusted percentile score (NAPS). Additionally, the Fluid Composite Score (FCS) was calculated using the software. FCS represents an individual’s ability to think flexibly and solve new problems. It serves as a robust indicator of fluid cognition (r = 0.95, test-retest reliability) (Akshoomoff et al., 2013 ) compared to crystalloid cognition. It is derived by standardizing the mean of the constituent age-adjusted scores to reflect the participant's overall capacity for new learning and problem-solving. The CSS is an Item Response Theory (IRT)-based metric specifically designed to monitor longitudinal changes. The CSS is derived directly from the examinee’s raw score and is independent of the examinee’s age group. Therefore, CSS provides a more precise measurement of absolute changes over time and was used a primary parameter for this study. On the NIHTB cognitive measures, a CSS of 500 is indexed to the median ability of 10-year-olds in the normative sample. The ASS reflects an individual's performance relative to the NIHTB nationally representative normative sample of the same age, with 100 representing the mean performance with an SD of 15. The NAPS is the transformation of the standardized age-adjusted performance score into a rank-based metric. This represents the percentage of people nationally in the participant’s age band who ranked below the participant’s score, signifying their position relative to the national average. These adjusted metrics were analyzed as secondary supportive outcomes of this study. Statistical analysis Data analysis was performed using GraphPad Prism version 9 (GraphPad Software, USA). After normality test analysis, the data were expressed as mean and standard deviation or as median and interquartile range [IQR] based on the Gaussian or non-Gaussian distribution of the data, respectively. Analytic pre-post comparison was performed using the paired t-test (Gaussian distribution) or Wilcoxon matched pairs signed-rank test (non-Gaussian distribution). The magnitude of the intervention effect was calculated using Hedges’ g (Lakens, 2013 ) for small sample size and are reported with their corresponding 95% confidence intervals (CI) to indicate the precision of the estimates. Results The demographic details of the participants are presented in Table 2 . The baseline demographic profile of the slow-paced breathing (SPB) intervention and control groups were comparable as represented in Table 2 . Table 2 Demographic details of case and control Male: Female Cases (n = 15) Control (n = 15) P-value 7:8 7:8 --- Age (in years) 19.53 ± 0.51 19.93 ± 0.70 0.086 Height (in cm) 167.02 ± 9.34 167.57 ± 7.78 0.860 Weight (in kg) 64.93 ± 7.78 62.33 ± 8.86 0.394 BMI (in kg/m 2 ) 23.25 ± 2.19 22.16 ± 2.76 0.240 Socioeconomic Status Medium Medium --- Educational status Undergraduate Undergraduate --- Values are in Mean ± SD Table 3 shows the pre-post comparison of cognitive function in SPB intervention and control group. Change-sensitive score (CSS) and age-adjusted standard score (ASS) of the Dimensional Card Change Sort (DCCS) test did not differ between the two groups. However, the pre-post nationally age-adjusted percentile score (NAPS) was significantly higher post-intervention in the SPB group (p = 0.0305) with a moderate size effect (g = 0.453, CI = 0.251–1.159). Table 3 Pre-post comparison of cognitive score for Cases and Controls Cases Pre (n = 15) Cases Post (n = 15) Control Pre (n = 15) Control Post (n = 15) P-value Hedges' g (95% CI) DCCS CSS 531 [520–547] 540 [532–572] 542.7 ± 20.46 562.5 ± 42.47 --- --- ASS 96 [92–103] 97 [87–100] 101.50 ± 8.60 109.9 ± 18.61 --- --- NAPS 46.73 ± 25.18 58.47 ± 25.15 * 49 [38–74] 60 [37–95] *p = 0.0305 vs Pre 0.453 (0.251–1.159) FICA CSS 525.7 ± 18.6 530.7 ± 20.65 527.1 ± 16.69 532.9 ± 21.33 --- --- ASS 103.00 ± 13.84 106.9 ± 15.51 104.00 ± 12.73 108.4 ± 16.19 --- --- NAPS 44 [28–86] 66 [40–90] 59.4 ± 26.76 64.13 ± 31.09 --- --- LSWM CSS 526.8 ± 15.4 530.8 ± 16.18 526 [513–532] 526 [519–539] --- --- ASS 106.20 ± 12.20 109.3 ± 12.7 103.70 ± 10.84 108.0 ± 7.60 --- --- NAPS 63.07 ± 25.32 68.20 ± 25.28 61.40 ± 19.86 68.40 ± 15.82 --- --- PCPS CSS 537.8 ± 31.65 561.0 ± 22.71 *** 549 [525–580] 565 [558–588] ***p = 0.0003 vs Pre 0.726 (0.006–1.447) ASS 95.67 ± 16.08 106.0 ± 11.05 ** 102 [89–117] 117 [107–120] **p = 0.0055 vs Pre 0.728 (0.008–1.448) NAPS 43.13 ± 33.37 62.47 ± 23.95 55 [22–87] 87 [68–91] --- --- PSM CSS 516 [507–545] 545 [531–545] 528 [518–531] 545 [523–545] --- --- ASS 102 [97–120] 120 [111–120] 109.5 [103–112] 120 [106.5–120] --- --- NAPS 54 [42–91] 91 [77–91] 73 [59–80] 91 [66.5–91] --- --- FCS CSS 530.9 ± 19.84 541.7 ± 14.2 ** 532 [528–547] 545 [529–559] **p = 0.0067 vs Pre 0.609 (0.104–1.322) ASS 103.50 ± 17.83 113.5 ± 12.91 ** 105 [97.25–118.3] 114.5 [105-125.3] **p = 0.0058 vs Pre 0.625 (0.089–1.339) NAPS 54.2 ± 23 74.67 ± 18.65 * 62 [43.25–88.5] 83 [63.75–95.5] *p = 0.0127 vs Pre 0.951 (0.214–1.688) Values are presented as mean ± SD for parametric tests and median with interquartile range [IQR] for non-parametric tests. CI: Confidence Interval; CSS: change-sensitive score; ASS: age-adjusted standard score; NAPS: nationally age-adjusted percentile score; FCS: Fluid Composite Score; DCCS: Dimensional Card Change Sort; FICA: Flanker Inhibitory Control and Attention Test; LSWM: List-Sorting Working Memory; PCPS: Pattern Comparison Processing Speed; PSM: Picture Sequence Memory. *p ≤ 0.05; **p ≤ 0.01; ***p ≤ 0.001. The CSS, ASS, and NAPS did not differ between the pre- and post-intervention periods for the SPB group and controls in the Flanker Inhibitory Control and Attention Test (FICA), List-Sorting Working Memory (LSWM), and Picture Sequence Memory (PSM) tests. In contrast, the Pattern Comparison Processing Speed (PCPS) scores demonstrated statistically significant improvement post-intervention in the CSS (p = 0.0003) and ASS (p = 0.0055), with a high effect size [Hedges' g of 0.726 (0.006–1.447) and ASS 0.728 (0.008–1.448), respectively] (Fig. 2). However, no such differences were observed in the control group (Table 3). As both the groups showed a pattern of rise in post scores in PCPS, thus, to ensure that the significant increase in SPB group was really relevant we additionally calculated the delta change in PCPS in the two groups and compared them. We found that the delta PCPS score in the SPB group (26.67 ± 19.55) was statistically significantly higher than the control group (12.53 ± 17.67) (Figure 3). The software-derived overall Fluid Composite Score (FCS) showed significant increase post intervention in CSS (p=0.0067) (Figure 4), ASS (p=0.0058), and NAPS (p=0.0127) with high effect sizes [Hedges' g of CSS 0.609 (0.104–1.322), ASS 0.625 (0.089–1.339) and NAPS 0.951 (0.214–1.688)], whereas the control group scores showed no statistically significant difference on pre-post comparison (Table 3). Discussion In the present study, we assessed the short-term effect of 10 sessions of slow-paced breathing (SPB) on the cognitive function of healthy young adults in comparison to an age- and sex-matched control group. The SPB group showed a selective significant improvement in their processing speed and fluid cognition after 10 sessions, while exerting minimal effects on executive function and working memory. The results support our initial hypothesis that the voluntary modulation of respiratory rhythm in the form of SPB improves cognition in healthy young adults. The study participants (both cases and controls) were young medical undergraduates with a mean age of 19 years and belonging to middle-class socioeconomic status. The most statistically significant difference was observed in the PCPS, indicating an improvement in processing speed after SPB sessions in the case group. The SPB group showed significant improvement in CSS and ASS scores, with a high effect size in the PCPS. Processing speed reflects the efficiency of perceptual encoding, attentional deployment, and rapid sensorimotor integration. It is highly sensitive to global arousal regulation and neuromodulatory balance. Unlike higher-order cognitive domains, processing speed relies less on task-specific strategies, rendering it particularly responsive to interventions that enhance autonomic flexibility and cortical–subcortical coupling such as SPB. These findings were consistent with those of Bonomini et al. ( 2020 ), who reported improved processing speed after SPB in healthy young adults; however, the improvement was not reported while the participants were breathing at 12 breaths per minute. The mean age of the participants was 34.4 ± 7.2 years (Bonomini et al., 2020 ). The DCCS showed a significant improvement in NAPS, while the changes in the CSS and ASS were statistically insignificant. This suggests that, although there was a shift in performance relative to the national average, the absolute change in executive functioning or cognitive flexibility was less pronounced than the change in processing speed, as shown by the PCPS. However, studies by Bonomini et al. ( 2020 ) and Laborde et al. ( 2022 ) reported that after a single session of SPB there is enhancement in executive functioning and cognitive flexibility (Bonomini et al., 2020 ; Laborde et al., 2022 ). Interestingly, no significant changes were noted in working memory (WM) and episodic memory, as shown by the performance in the LSWM and PSM test scores, respectively. These findings may suggest that 10-sessions SPB may be sufficient to augment speed-based tasks, but longer sessions may be required to augment the memory-influencing pathway. However, contrary to our findings, Bonomini et al. ( 2020 ) and Laborde et al. ( 2022 ) reported that SBP improved WM after a single session of SPB (Bonomini et al., 2020 ; Laborde et al., 2022 ). The results of these studies might differ as single-session paradigms predominantly capture state-dependent modulation driven by momentary shifts in arousal, attention allocation, and expectancy. These effects may be inherently labile and thus, may not reflect consolidated cognitive change. Contrary to this, repeated SPB sessions are more likely to facilitate cumulative autonomic and central adaptations. The FCS, which reflects the ability to solve new problems and think flexibly, also showed significant improvement in the SPB group compared to the control group, with a large effect size. This signifies the global impact of SPB on an individual’s overall fluid intelligence. Fluid cognitive ability is independent of prior knowledge and represents how quickly and efficiently one can solve novel problems (Khammash et al., 2023 ). An earlier study showed that fluid cognitive ability was inversely associated with stressor-related increases in negative mood, allowing for greater emotional resilience (Stawski et al., 2010 ). As the Fluid Composite Score represents an integrated measure of multiple cognitive domains, its significant improvement suggests a trend toward global cognitive enhancement, despite the absence of statistically significant changes in individual domain-specific outcomes except processing speed. The typical respiratory maneuver in SPB, performed at approximately six cycles per minute with controlled inhalation and longer exhalation, stimulates the parasympathetic system (Strauss-Blasche et al., 2000 ). Parasympathetic dominance is conveyed to the central nervous system (CNS) through the nucleus tractus solitarius to the thalamus and the nucleus parabrachial to the limbic system (Brown et al., 2013 ; Streeter et al., 2012 ). Additionally, SPB may influence the top-down components of cognition, such as attention, WM, and executive monitoring. A voluntary shift of attention towards breath monitoring during SPB may influence this top-down process. Various studies have supported this notion by demonstrating increased activity in the anterior prefrontal cortex, parietal cortex, and other subcortical areas, such as the periaqueductal gray and the hypothalamus, during the SPB (Critchley et al., 2015 ; Yu et al., 2011 ). The dorsolateral prefrontal, posterior parietal, and fronto-parietal areas of the brain are part of the central executive network, which is crucial for managing higher levels of cognition, such as attention, WM, and executive functions (Bigliassi et al., 2025 ). Additionally, SPB through the nostrils mechanically stimulates the olfactory epithelium, which may influence the fine control of the thalamus and cortex through the olfactory bulb. Supporting this, a study by Piarulli et al. (2018) demonstrated that ultra-slow mechanical stimulation of the olfactory epithelium enhanced cortical delta-theta EEG activity in the limbic system (Pilcher et al., 2025 ). Therefore, SBP influences cognitive function via multiple mechanisms. The selective enhancement of processing speed has important physiological and clinical implications. Processing speed is a sensitive marker of neural efficiency and cognitive reserve and is often among the earliest domains affected in cognitive aging and stress-related disorders. Thus, improvements observed in young healthy adults may reflect optimized central–autonomic integration, positioning SPB as a low-cost, non-invasive strategy for enhancing cognitive efficiency and resilience. Conclusion Short-term 10 session slow-paced breathing protocol augments the processing speed in young healthy adults. Limitation A major drawback of this study is its limited sample size (n = 30) and the employment of a convenience sampling method, which may restrict the generalisability of the results. Other possible sources of bias are the way medical students were chosen, the fact that the control group didn't have daily phone contact, and the fact that there wasn't an active control condition. Nonetheless, various factors diminish the probability that these limitations significantly impacted the primary outcomes. First, the participants were first-year medical students with limited prior exposure to physiological research concepts, thereby mitigating expectancy or performance bias associated with awareness of study hypotheses. Second, the groups had similar baseline demographic and cognitive traits, which means that they were similar at first and that selection bias was kept to a minimum. Third, standardized computerized cognitive assessments (NIH Toolbox® Cognitive Battery) were utilized, mitigating assessor bias and minimizing subjective impact on outcome measurement. Furthermore, improvements were domain-specific rather than generalized across all cognitive tests, supporting the possibility of intervention-related effects rather than nonspecific practice or social interaction effects. Nonetheless, the current investigation was structured as an exploratory pilot study aimed at producing initial evidence concerning the short-term effects of multi-session, slow-paced breathing on cognition. The research did not evaluate the long-term retention of cognitive improvements after the termination of the intervention. Subsequent research ought to investigate the dose–response relationship of slow-paced breathing, incorporate active control conditions, and assess the durability of cognitive enhancements in larger and more heterogeneous populations. Declarations Clinical Trial Registration: Nil. Ethics approval and consent to participate: The protocol was approved by the “Institutional Ethical Committee” (No: IEC/VMMC/SJH/Cert/Sept-2024/101) before starting any work related to the study, and written informed consent was obtained from each participant in accordance with the principles of the Declaration of Helsinki. Consent for publication: All authors consented to publication. Competing interests: The authors declare no perceived or potential conflicts of interest, financial, or otherwise. Funding/grant None Author Contribution KBU: Conception of the work, acquisition, analysis, or interpretation of data, drafting the work, final approval of the version to be published, and agreed to be accountable for all aspects of the work.VAB: Conception of the work, acquisition, analysis, or interpretation of data, drafting the work, final approval of the version to be published, and agreed to be accountable for all aspects of the work. MK: Conception of the work, interpretation of data, revising the draft critically for important intellectual content, final approval of the version to be published, and agreed to be accountable for all aspects of the work.SM: Conception of the work, acquisition, analysis, or interpretation of data, drafting the work, final approval of the version to be published, and agreed to be accountable for all aspects of the work.HA: Conception of the work, revising the draft critically for important intellectual content, final approval of the version to be published, and agreed to be accountable for all aspects of the work. Acknowledgement We thank all the participants who devoted their time to our study. We also thank all the residents, doctors, and staff of the department of physiology, VMMC and Safdarjung hospital, New Delhi, India, for their help during subject recruitment. Data Availability All data are available upon request from the corresponding author. 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Neuropsychology , 36 (5), 468–481. https://doi.org/10.1037/neu0000813 Pilcher, J. J., Byrne, K. A., Weiskittel, S. E., Clark, E. C., Brancato, M. G., Rosinski, M. L., & Spinelli, M. R. (2025). Brief slow-paced breathing improves working memory, mood, and stress in college students. Anxiety Stress And Coping , 38 (5), 528–543. https://doi.org/10.1080/10615806.2025.2505897 Porges, S. W. (2025). Polyvagal Theory: Current Status, Clinical Applications, and Future Directions. Clin Neuropsychiatry , 22 (3), 169–184. https://doi.org/10.36131/cnfioritieditore20250301 Schoonjans, E., Li, Z., Allaert, J., Wezenbeek, E., Van den Berghe, P., Helleputte, S., De Smet, S., De Raedt, R., & Vanderhasselt, M. A. (2025). The combination of physical exercise and slow-paced breathing on psychophysiological indices of emotion reactivity, psychosocial stress reactivity and recovery: A multimodal investigation. Behaviour Research And Therapy , 194 , 104852. https://doi.org/10.1016/j.brat.2025.104852 Smith, R., Thayer, J. F., Khalsa, S. S., & Lane, R. D. (2017). The hierarchical basis of neurovisceral integration. Neuroscience And Biobehavioral Reviews , 75 , 274–296. https://doi.org/10.1016/j.neubiorev.2017.02.003 Stawski, R. S., Almeida, D. M., Lachman, M. E., Tun, P. A., & Rosnick, C. B. (2010). Fluid cognitive ability is associated with greater exposure and smaller reactions to daily stressors. Psychology And Aging , 25 (2), 330–342. https://doi.org/10.1037/a0018246 Strauss-Blasche, G., Moser, M., Voica, M., McLeod, D. R., Klammer, N., & Marktl, W. (2000). Relative timing of inspiration and expiration affects respiratory sinus arrhythmia. Clinical And Experimental Pharmacology And Physiology , 27 (8), 601–606. https://doi.org/10.1046/j.1440-1681.2000.03306.x Streeter, C. C., Gerbarg, P. L., Saper, R. B., Ciraulo, D. A., & Brown, R. P. (2012). Effects of yoga on the autonomic nervous system, gamma-aminobutyric-acid, and allostasis in epilepsy, depression, and post-traumatic stress disorder. Medical Hypotheses , 78 (5), 571–579. https://doi.org/10.1016/j.mehy.2012.01.021 Turankar, A. V., Jain, S., Patel, S. B., Sinha, S. R., Joshi, A. D., Vallish, B. N., Mane, P. R., & Turankar, S. A. (2013). Effects of slow breathing exercise on cardiovascular functions, pulmonary functions & galvanic skin resistance in healthy human volunteers - a pilot study. Indian Journal Of Medical Research , 137 (5), 916–921. Weintraub, S., Dikmen, S. S., Heaton, R. K., Tulsky, D. S., Zelazo, P. D., Slotkin, J., Carlozzi, N. E., Bauer, P. J., Wallner-Allen, K., Fox, N., Havlik, R., Beaumont, J. L., Mungas, D., Manly, J. J., Moy, C., Conway, K., Edwards, E., Nowinski, C. J., & Gershon, R. (2014). The cognition battery of the NIH toolbox for assessment of neurological and behavioral function: validation in an adult sample. Journal Of The International Neuropsychological Society , 20 (6), 567–578. https://doi.org/10.1017/S1355617714000320 Xiong, S., Peng, M., Zhao, W., Ren, J., Yao, D., Qin, Y., & Liu, T. (2025). Slow-paced breathing enhancing emotional control accompanied with the change of the ∼0.1 Hz heartbeat evoked EEG. International Journal of Clinical and Health Psychology , 25 (2), 100571. https://doi.org/https://doi.org/10.1016/j.ijchp.2025.100571 You, M., Laborde, S., Zammit, N., Iskra, M., Borges, U., & Dosseville, F. (2021). Single Slow-Paced Breathing Session at Six Cycles per Minute: Investigation of Dose-Response Relationship on Cardiac Vagal Activity. International Journal Of Environmental Research And Public Health , 18 (23). https://doi.org/10.3390/ijerph182312478 Yu, X., Fumoto, M., Nakatani, Y., Sekiyama, T., Kikuchi, H., Seki, Y., Sato-Suzuki, I., & Arita, H. (2011). Activation of the anterior prefrontal cortex and serotonergic system is associated with improvements in mood and EEG changes induced by Zen meditation practice in novices. International Journal Of Psychophysiology , 80 (2), 103–111. https://doi.org/10.1016/j.ijpsycho.2011.02.004 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers invited by journal 15 Apr, 2026 Editor assigned by journal 15 Apr, 2026 Submission checks completed at journal 15 Apr, 2026 First submitted to journal 11 Apr, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9385088","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":624304933,"identity":"737ef925-974d-47ae-b1e6-2fbb0e8360ee","order_by":0,"name":"Kairavi Bimalkumar Unarkat","email":"","orcid":"","institution":"Vardhman Mahavir Medical College and Safdarjung Hospital","correspondingAuthor":false,"prefix":"","firstName":"Kairavi","middleName":"Bimalkumar","lastName":"Unarkat","suffix":""},{"id":624304934,"identity":"abbc25d3-365f-4224-89ac-51328c2b1252","order_by":1,"name":"Vatsal Ashish Batra","email":"","orcid":"","institution":"Vardhman Mahavir Medical College and Safdarjung Hospital","correspondingAuthor":false,"prefix":"","firstName":"Vatsal","middleName":"Ashish","lastName":"Batra","suffix":""},{"id":624304935,"identity":"244285eb-3b20-47f7-a338-df13a0deeced","order_by":2,"name":"Manpreet Kaur","email":"data:image/png;base64,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","orcid":"","institution":"Vardhman Mahavir Medical College and Safdarjung Hospital","correspondingAuthor":true,"prefix":"","firstName":"Manpreet","middleName":"","lastName":"Kaur","suffix":""},{"id":624304938,"identity":"8e05d6e7-e041-46f7-ae03-a93ae0fc9662","order_by":3,"name":"Soumen Manna","email":"","orcid":"","institution":"Vardhman Mahavir Medical College and Safdarjung Hospital","correspondingAuthor":false,"prefix":"","firstName":"Soumen","middleName":"","lastName":"Manna","suffix":""},{"id":624304939,"identity":"271f554d-9e92-4b30-a3ed-021870696ca2","order_by":4,"name":"Himani Ahluwalia","email":"","orcid":"","institution":"Vardhman Mahavir Medical College and Safdarjung Hospital","correspondingAuthor":false,"prefix":"","firstName":"Himani","middleName":"","lastName":"Ahluwalia","suffix":""}],"badges":[],"createdAt":"2026-04-11 06:24:09","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9385088/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9385088/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":107675671,"identity":"66e9f8cf-0298-4761-958d-7588d23d9d43","added_by":"auto","created_at":"2026-04-24 00:45:36","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":12198,"visible":true,"origin":"","legend":"\u003cp\u003eSlow-paced breathing protocol used in the study. Participants underwent 10 daily SPB sessions described above.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-9385088/v1/e3f286a1f1557399fac0a4c3.png"},{"id":107707649,"identity":"5ccdba7a-06e0-4788-87c1-7a835c0d2f59","added_by":"auto","created_at":"2026-04-24 09:20:50","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":20449,"visible":true,"origin":"","legend":"\u003cp\u003eComparison of the pre and post change sensitive score (CSS) in Pattern Comparison Processing Speed (PCPS) test in the cases. The post CSS was statistically significantly higher than the pre-CSS in cases.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-9385088/v1/1db2e84d34d9c2a2cc3814f6.png"},{"id":107675673,"identity":"e68a382c-7b92-4e8a-b371-89d18b3bc617","added_by":"auto","created_at":"2026-04-24 00:45:37","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":19333,"visible":true,"origin":"","legend":"\u003cp\u003eComparison of the delta changes in change sensitive score (CSS) in Pattern Comparison Processing Speed (PCPS) test in case and control groups. The delta changes in CSS were statistically significantly higher in the case group as compared to control group.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-9385088/v1/7b9ee8763ef873853e610b14.png"},{"id":107675674,"identity":"76ec6c34-8f18-4ea1-866b-fc3f495b3a0a","added_by":"auto","created_at":"2026-04-24 00:45:37","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":24786,"visible":true,"origin":"","legend":"\u003cp\u003eComparison of the pre and post change sensitive score (CSS) in Fluid Composite Score in the cases. The post CSS was statistically significantly higher than the pre-CSS in cases.\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-9385088/v1/9807dd4ec768c3d882a35bf9.png"},{"id":107709257,"identity":"991d9416-9322-46df-95d8-d3dfb49af6e5","added_by":"auto","created_at":"2026-04-24 09:35:10","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":425354,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9385088/v1/fb0f8336-9cf2-45c4-9227-d64b301bfd05.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Short-term slow-paced breathing improves processing speed and fluid cognition in young healthy adults","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe slow-paced breathing (SPB) protocol is a respiratory maneuver in which the breathing rate is altered to a slower pace of approximately 6 cycles per minute with controlled inhalation and exhalation times. Voluntary slowing of the respiratory frequency to six breaths per minute has been linked to vagus afferent stimulation (Gerritsen \u0026amp; Band, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; You et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). According to the polyvagal theory and neuro-visceral integration theory (Porges, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2025\u003c/span\u003e; Smith et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2017\u003c/span\u003e), this stimulation of the afferent vagal nerve is associated with more positive attributes of calmness, compassion, improved cardiovascular autonomic flexibility, and better cognitive responses (Magnon et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Xiong et al., \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). It has been shown to improve the cardiovascular-respiratory function, reduce the inflammatory milieu, and improve executive functions in many clinical conditions (Herhaus et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Laborde et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Turankar et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2013\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eStudies have indicated that acute SPB leads to significant improvements in executive functioning and processing speed (Bonomini et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Laborde et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). This improvement may be attributed to the respiratory modulation of neural circuits related to attention and cognition control, as well as the cardiovascular feedback circuit that supports brain network synchronization (Bonomini et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2020\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFew studies have shown that SPB protocol is positively correlated with enhanced executive functioning, such as working memory and cognitive inhibition. Bonomini et al. \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2020\u003c/span\u003e demonstrated that SPB improves the accuracy of executive functions as assessed by working memory task and improves the processing speed as assessed by multitasking test (Bonomini et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Similarly, Laborde et al. (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) showed that an acute single-session of a 17- min SPB protocol improved executive functioning in healthy adults as compared to control group (Laborde et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Single SPB in middle-aged women also showed improvement in simple and congruent reaction time (RT), and incongruent reaction accuracy was also improved in the experimental group compared to the control group (Masmoudi et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2025\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFew studies have explored the effect of multi-session SPB on cognitive function. Minjoz et al. demonstrated that SPB for five min, three times a day, for 24 days showed improve decision-making performance in brain-damaged (stroke and traumatic brain injury) patients by reducing negative affectivity and enhancing emotional states (Minjoz et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). Similarly, Schoonjans et al. demonstrated that the combination of 3 sessions of 5-minute SPB after a bout of physical activity reduces worry and cardiovascular reactivity to emotional stimuli, as measured by inter-beat interval (IBI) (Schoonjans et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). However, they did not find any difference in their psychophysiological indices of stress as compared to control group. Importantly, these multi-session protocols have largely been investigated in clinical or combined intervention contexts rather than in healthy populations and have limited assessment of cognitive function.\u003c/p\u003e \u003cp\u003eAlthough, there is a growing interest in the role of breathing-based interventions as adjunct for cognitive enhancement. There is a paucity of studies on the sustained effect of slow-paced breathing on cognitive function in healthy young adults over a short period of time. Most current research has concentrated on singular acute exposures, resulting in ambiguity about the potential cognitive benefits of repeated SPB sessions within a brief timeframe. Evaluating these effects may facilitate the establishment of SPB as a simple, non-pharmacological approach for cognitive improvement and the optimization of mental performance.\u003c/p\u003e \u003cp\u003eTherefore, the present study aimed to examine the effects of ten sessions of slow-paced breathing on cognitive function in healthy young adults. We hypothesized that SPB would lead to improvements in cognitive performance, particularly in executive functioning, cognitive flexibility and processing speed domains.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design\u003c/h2\u003e \u003cp\u003eThe present study was a longitudinal interventional study with a pre-post design.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSetting\u003c/h3\u003e\n\u003cp\u003eThis study was conducted in the Department of Vardhman Mahavir Medical College and Safdarjung Hospital (VMMC \u0026amp; SJH), New Delhi, India, a tertiary care teaching hospital Ethical approval was obtained from the Institutional Ethics Committee of VMMC \u0026amp; Safdarjung Hospital (Approval No.: IEC/VMMC/SJH/Cert/Sept-2024/101). Written informed consent was obtained from all participants prior to enrolment.\u003c/p\u003e\n\u003ch3\u003eParticipants\u003c/h3\u003e\n\u003cp\u003eThirty healthy adults (15 in the slow-paced breathing intervention group and 15 in the control group) were recruited using convenience sampling. The health status of the participants was assessed using a structured health questionnaire and physical examination. The study population consisted primarily of healthy undergraduate medical students. This population was selected due to accessibility and homogeneity in age and educational background. While the inclusion of medical students could introduce expectancy bias due to prior knowledge of physiological mechanisms, the participants were first-year students with minimal formal training, thus mitigating the potential for significant bias.\u003c/p\u003e \u003cp\u003eThe inclusion criteria for both cases and controls were a) age between 18\u0026ndash;35 years, b) able to read and write, and c) right-handed subject to reduced variability of hemispheric dominance. The exclusion criteria for both groups were a) subjects on any medications, b) acute or chronic diseases, and c) smoking.\u003c/p\u003e\n\u003ch3\u003eIntervention\u003c/h3\u003e\n\u003cp\u003e The participants in slow-paced breathing (SPB) group were asked to perform 10 sessions of slow-paced breathing once per day. Each session consisted of guided breathing, with an inspiration duration of 4.5 seconds and expiration duration of 5.5 seconds. The protocol had three 5-minute breathing blocks separated by 1-minute rest interval (Total duration of 17 minutes) using a pre-recorded audio-visual guide (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The audio-visual signal had pairing of visual cues with auditory voice instructions to guide for inhalation, exhalation and rest phase. During the protocol, the participants were instructed to sit comfortably with back supported, maintain nasal breathing, avoid holding of breath and perform SPB preferably at the same time each day. Compliance was assured by daily telephonic conversation to the SPB intervention group to ensure adherence and record completion status. Noninvasive cognitive function was assessed before and after the 10 intervention sessions.\u003c/p\u003e \u003cp\u003eThe control group was just observed before and after 10 days to decipher the temporal effect of time on the cognitive function in healthy young adults. The control group were not contacted daily by telephonic calls which is acknowledged as a social- interaction confound.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eAssessment of cognitive function\u003c/b\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThe National Institutes of Health (NIH) Toolbox\u0026reg; V3 cognition testing software was used to assess the cognitive function (Akshoomoff et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2013\u003c/span\u003e). The NIH toolbox (NIHTB) is a validated (Ott et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) multidimensional set of brief measures to assess cognitive, motor, emotional, and sensory function in the 3\u0026ndash;85-year-old age group. In this study selected tests of cognitive domain were administered using a 9th generation iPad (operating system 17.4) (Apple CA, USA Inc., Cupertino).\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e summarizes the cognitive battery of tests administered to each participant. The total administration time was approximately 25 min.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSummarizes the cognitive battery of tests administered\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNIHTB test name\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCognitive Domains\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBrief Description of the test\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEquivalent test in Traditional neuropsychological tests (Weintraub et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2014\u003c/span\u003e)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDimensional Change Card Sort Test (DCCS)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExecutive function, cognitive flexibility and attention span\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eParticipant was asked to match a series of picture pairs to a target picture.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTrail Making Test Part B\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFlanker Inhibitory Control and Attention Test (FICA)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAttention, inhibition control and executive function\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eParticipant was asked to focus on a particular stimulus while inhibiting attention to the stimulus, flanking it.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eComalli Stroop Interference\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eList Sorting Working Memory Test (LSWM)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWorking memory (WM)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eParticipant was asked to recall and sequence different stimuli that are presented visually and via audio.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWAIS-IIIb Letter-Number Sequencing\u003c/p\u003e \u003cp\u003eWAIS-IIIb Digit Span, Forwards and Backwards\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePattern Comparison Processing Speed Test (PCPS)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eProcessing speed (PS)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eParticipants were asked to quickly determine whether two stimuli are the same or not the same.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWAIS-IIIb Digit Symbol Coding\u003c/p\u003e \u003cp\u003eTrail Making Test Part A\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePicture Sequence Memory Test (PSM)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEpisodic memory\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eParticipants were shown a few activities and then asked to reproduce the sequence of pictures in the order it was presented to them.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWMS-IIIa Logical Memory I\u003c/p\u003e \u003cp\u003eWMS-IIIa Logical Memory II\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThe scores of the cognitive battery tests were quantified using multiple metrics, such as the change-sensitive score (CSS), age-adjusted standard score (ASS), and nationally age-adjusted percentile score (NAPS). Additionally, the \u003cem\u003eFluid Composite Score (FCS)\u003c/em\u003e was calculated using the software. FCS represents an individual\u0026rsquo;s ability to think flexibly and solve new problems. It serves as a robust indicator of fluid cognition (r\u0026thinsp;=\u0026thinsp;0.95, test-retest reliability) (Akshoomoff et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2013\u003c/span\u003e) compared to crystalloid cognition. It is derived by standardizing the mean of the constituent age-adjusted scores to reflect the participant's overall capacity for new learning and problem-solving.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe \u003cem\u003eCSS\u003c/em\u003e is an Item Response Theory (IRT)-based metric specifically designed to monitor longitudinal changes. The CSS is derived directly from the examinee\u0026rsquo;s raw score and is independent of the examinee\u0026rsquo;s age group. Therefore, CSS provides a more precise measurement of absolute changes over time and was used a primary parameter for this study. On the NIHTB cognitive measures, a CSS of 500 is indexed to the median ability of 10-year-olds in the normative sample.\u003c/p\u003e \u003cp\u003eThe ASS reflects an individual's performance relative to the NIHTB nationally representative normative sample of the same age, with 100 representing the mean performance with an SD of 15. The NAPS is the transformation of the standardized age-adjusted performance score into a rank-based metric. This represents the percentage of people nationally in the participant\u0026rsquo;s age band who ranked below the participant\u0026rsquo;s score, signifying their position relative to the national average. These adjusted metrics were analyzed as secondary supportive outcomes of this study.\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eData analysis was performed using GraphPad Prism version 9 (GraphPad Software, USA). After normality test analysis, the data were expressed as mean and standard deviation or as median and interquartile range [IQR] based on the Gaussian or non-Gaussian distribution of the data, respectively. Analytic pre-post comparison was performed using the paired t-test (Gaussian distribution) or Wilcoxon matched pairs signed-rank test (non-Gaussian distribution).\u003c/p\u003e \u003cp\u003eThe magnitude of the intervention effect was calculated using Hedges\u0026rsquo; g (Lakens, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2013\u003c/span\u003e) for small sample size and are reported with their corresponding 95% confidence intervals (CI) to indicate the precision of the estimates.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe demographic details of the participants are presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. The baseline demographic profile of the slow-paced breathing (SPB) intervention and control groups were comparable as represented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic details of case and control\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eMale: Female\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCases (n\u0026thinsp;=\u0026thinsp;15)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl (n\u0026thinsp;=\u0026thinsp;15)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7:8\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7:8\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (in years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19.53\u0026thinsp;\u0026plusmn;\u0026thinsp;0.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19.93\u0026thinsp;\u0026plusmn;\u0026thinsp;0.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.086\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHeight (in cm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e167.02\u0026thinsp;\u0026plusmn;\u0026thinsp;9.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e167.57\u0026thinsp;\u0026plusmn;\u0026thinsp;7.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.860\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWeight (in kg)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e64.93\u0026thinsp;\u0026plusmn;\u0026thinsp;7.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e62.33\u0026thinsp;\u0026plusmn;\u0026thinsp;8.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.394\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI (in kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23.25\u0026thinsp;\u0026plusmn;\u0026thinsp;2.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22.16\u0026thinsp;\u0026plusmn;\u0026thinsp;2.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.240\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSocioeconomic Status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMedium\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMedium\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducational status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUndergraduate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUndergraduate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eValues are in Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e shows the pre-post comparison of cognitive function in SPB intervention and control group. Change-sensitive score (CSS) and age-adjusted standard score (ASS) of the Dimensional Card Change Sort (DCCS) test did not differ between the two groups. However, the pre-post nationally age-adjusted percentile score (NAPS) was significantly higher post-intervention in the SPB group (p\u0026thinsp;=\u0026thinsp;0.0305) with a moderate size effect (g\u0026thinsp;=\u0026thinsp;0.453, CI\u0026thinsp;=\u0026thinsp;0.251\u0026ndash;1.159).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePre-post comparison of cognitive score for Cases and Controls\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCases Pre\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;15)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCases Post\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;15)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eControl Pre\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;15)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eControl Post\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;15)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eHedges' g\u003c/p\u003e \u003cp\u003e(95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"1\" nameend=\"c8\" namest=\"c8\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"8\" nameend=\"c8\" namest=\"c1\"\u003e \u003cp\u003eDCCS\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCSS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e531 [520\u0026ndash;547]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e540 [532\u0026ndash;572]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e542.7\u0026thinsp;\u0026plusmn;\u0026thinsp;20.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e562.5\u0026thinsp;\u0026plusmn;\u0026thinsp;42.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c8\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eASS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e96 [92\u0026ndash;103]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e97 [87\u0026ndash;100]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e101.50\u0026thinsp;\u0026plusmn;\u0026thinsp;8.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e109.9\u0026thinsp;\u0026plusmn;\u0026thinsp;18.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c8\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNAPS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46.73\u0026thinsp;\u0026plusmn;\u0026thinsp;25.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e58.47\u0026thinsp;\u0026plusmn;\u0026thinsp;25.15 *\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e49 [38\u0026ndash;74]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e60 [37\u0026ndash;95]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e*p\u0026thinsp;=\u0026thinsp;0.0305 vs Pre\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.453\u003c/p\u003e \u003cp\u003e(0.251\u0026ndash;1.159)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c8\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFICA\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c8\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCSS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e525.7\u0026thinsp;\u0026plusmn;\u0026thinsp;18.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e530.7\u0026thinsp;\u0026plusmn;\u0026thinsp;20.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e527.1\u0026thinsp;\u0026plusmn;\u0026thinsp;16.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e532.9\u0026thinsp;\u0026plusmn;\u0026thinsp;21.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c8\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eASS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e103.00\u0026thinsp;\u0026plusmn;\u0026thinsp;13.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e106.9\u0026thinsp;\u0026plusmn;\u0026thinsp;15.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e104.00\u0026thinsp;\u0026plusmn;\u0026thinsp;12.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e108.4\u0026thinsp;\u0026plusmn;\u0026thinsp;16.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c8\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNAPS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44 [28\u0026ndash;86]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e66 [40\u0026ndash;90]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e59.4\u0026thinsp;\u0026plusmn;\u0026thinsp;26.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e64.13\u0026thinsp;\u0026plusmn;\u0026thinsp;31.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c8\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLSWM\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c8\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCSS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e526.8\u0026thinsp;\u0026plusmn;\u0026thinsp;15.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e530.8\u0026thinsp;\u0026plusmn;\u0026thinsp;16.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e526 [513\u0026ndash;532]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e526 [519\u0026ndash;539]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c8\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eASS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e106.20\u0026thinsp;\u0026plusmn;\u0026thinsp;12.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e109.3\u0026thinsp;\u0026plusmn;\u0026thinsp;12.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e103.70\u0026thinsp;\u0026plusmn;\u0026thinsp;10.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e108.0\u0026thinsp;\u0026plusmn;\u0026thinsp;7.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c8\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNAPS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e63.07\u0026thinsp;\u0026plusmn;\u0026thinsp;25.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e68.20\u0026thinsp;\u0026plusmn;\u0026thinsp;25.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e61.40\u0026thinsp;\u0026plusmn;\u0026thinsp;19.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e68.40\u0026thinsp;\u0026plusmn;\u0026thinsp;15.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c8\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePCPS\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c8\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCSS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e537.8\u0026thinsp;\u0026plusmn;\u0026thinsp;31.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e561.0\u0026thinsp;\u0026plusmn;\u0026thinsp;22.71 ***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e549 [525\u0026ndash;580]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e565 [558\u0026ndash;588]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e***p\u0026thinsp;=\u0026thinsp;0.0003 vs Pre\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.726\u003c/p\u003e \u003cp\u003e(0.006\u0026ndash;1.447)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c8\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eASS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e95.67\u0026thinsp;\u0026plusmn;\u0026thinsp;16.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e106.0\u0026thinsp;\u0026plusmn;\u0026thinsp;11.05 **\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e102 [89\u0026ndash;117]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e117 [107\u0026ndash;120]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e**p\u0026thinsp;=\u0026thinsp;0.0055 vs Pre\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.728\u003c/p\u003e \u003cp\u003e(0.008\u0026ndash;1.448)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c8\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNAPS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e43.13\u0026thinsp;\u0026plusmn;\u0026thinsp;33.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e62.47\u0026thinsp;\u0026plusmn;\u0026thinsp;23.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e55 [22\u0026ndash;87]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e87 [68\u0026ndash;91]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c8\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePSM\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c8\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCSS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e516 [507\u0026ndash;545]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e545 [531\u0026ndash;545]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e528 [518\u0026ndash;531]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e545 [523\u0026ndash;545]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c8\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eASS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e102 [97\u0026ndash;120]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e120 [111\u0026ndash;120]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e109.5 [103\u0026ndash;112]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e120 [106.5\u0026ndash;120]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c8\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNAPS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e54 [42\u0026ndash;91]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e91 [77\u0026ndash;91]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e73 [59\u0026ndash;80]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e91 [66.5\u0026ndash;91]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c8\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFCS\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c8\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCSS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e530.9\u0026thinsp;\u0026plusmn;\u0026thinsp;19.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e541.7\u0026thinsp;\u0026plusmn;\u0026thinsp;14.2 **\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e532 [528\u0026ndash;547]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e545 [529\u0026ndash;559]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e**p\u0026thinsp;=\u0026thinsp;0.0067 vs Pre\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.609\u003c/p\u003e \u003cp\u003e(0.104\u0026ndash;1.322)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c8\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eASS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e103.50\u0026thinsp;\u0026plusmn;\u0026thinsp;17.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e113.5\u0026thinsp;\u0026plusmn;\u0026thinsp;12.91 **\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e105 [97.25\u0026ndash;118.3]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e114.5 [105-125.3]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e**p\u0026thinsp;=\u0026thinsp;0.0058 vs Pre\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.625\u003c/p\u003e \u003cp\u003e(0.089\u0026ndash;1.339)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c8\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNAPS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e54.2\u0026thinsp;\u0026plusmn;\u0026thinsp;23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e74.67\u0026thinsp;\u0026plusmn;\u0026thinsp;18.65 *\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e62 [43.25\u0026ndash;88.5]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e83 [63.75\u0026ndash;95.5]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e*p\u0026thinsp;=\u0026thinsp;0.0127 vs Pre\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.951\u003c/p\u003e \u003cp\u003e(0.214\u0026ndash;1.688)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c8\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eValues are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD for parametric tests and median with interquartile range [IQR] for non-parametric tests. CI: Confidence Interval; CSS: change-sensitive score; ASS: age-adjusted standard score; NAPS: nationally age-adjusted percentile score; FCS: Fluid Composite Score; DCCS: Dimensional Card Change Sort; FICA: Flanker Inhibitory Control and Attention Test; LSWM: List-Sorting Working Memory; PCPS: Pattern Comparison Processing Speed; PSM: Picture Sequence Memory. *p\u0026thinsp;\u0026le;\u0026thinsp;0.05; **p\u0026thinsp;\u0026le;\u0026thinsp;0.01; ***p\u0026thinsp;\u0026le;\u0026thinsp;0.001.\u003c/p\u003e \u003cp\u003eThe CSS, ASS, and NAPS did not differ between the pre- and post-intervention periods for the SPB group and controls in the Flanker Inhibitory Control and Attention Test (FICA), List-Sorting Working Memory (LSWM), and Picture Sequence Memory (PSM) tests. In contrast, the Pattern Comparison Processing Speed (PCPS) scores demonstrated statistically significant improvement post-intervention in the CSS (p\u0026thinsp;=\u0026thinsp;0.0003) and ASS (p\u0026thinsp;=\u0026thinsp;0.0055), with a high effect size [Hedges' g of 0.726 (0.006\u0026ndash;1.447) and ASS 0.728 (0.008\u0026ndash;1.448), respectively] (Fig.\u0026nbsp;2).\u003c/p\u003e \u003cp\u003eHowever, no such differences were observed in the control group (Table 3). As both the groups showed a pattern of rise in post scores in PCPS, thus, to ensure that the significant increase in SPB group was really relevant we additionally calculated the delta change in PCPS in the two groups and compared them. We found that the delta PCPS score in the SPB group (26.67 \u0026plusmn; 19.55) was statistically significantly higher than the control group (12.53 \u0026plusmn; 17.67) (Figure 3). The software-derived overall Fluid Composite Score (FCS) showed significant increase post intervention in CSS (p=0.0067) (Figure 4), ASS (p=0.0058), and NAPS (p=0.0127) with high effect sizes [Hedges\u0026apos; g of CSS 0.609 (0.104\u0026ndash;1.322), ASS 0.625 (0.089\u0026ndash;1.339) and NAPS 0.951 (0.214\u0026ndash;1.688)], whereas the control group scores showed no statistically significant difference on pre-post comparison (Table 3).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn the present study, we assessed the short-term effect of 10 sessions of slow-paced breathing (SPB) on the cognitive function of healthy young adults in comparison to an age- and sex-matched control group. The SPB group showed a selective significant improvement in their processing speed and fluid cognition after 10 sessions, while exerting minimal effects on executive function and working memory. The results support our initial hypothesis that the voluntary modulation of respiratory rhythm in the form of SPB improves cognition in healthy young adults. The study participants (both cases and controls) were young medical undergraduates with a mean age of 19 years and belonging to middle-class socioeconomic status.\u003c/p\u003e \u003cp\u003eThe most statistically significant difference was observed in the PCPS, indicating an improvement in processing speed after SPB sessions in the case group. The SPB group showed significant improvement in CSS and ASS scores, with a high effect size in the PCPS. Processing speed reflects the efficiency of perceptual encoding, attentional deployment, and rapid sensorimotor integration. It is highly sensitive to global arousal regulation and neuromodulatory balance. Unlike higher-order cognitive domains, processing speed relies less on task-specific strategies, rendering it particularly responsive to interventions that enhance autonomic flexibility and cortical\u0026ndash;subcortical coupling such as SPB.\u003c/p\u003e \u003cp\u003eThese findings were consistent with those of Bonomini et al. (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2020\u003c/span\u003e), who reported improved processing speed after SPB in healthy young adults; however, the improvement was not reported while the participants were breathing at 12 breaths per minute. The mean age of the participants was 34.4\u0026thinsp;\u0026plusmn;\u0026thinsp;7.2 years (Bonomini et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2020\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe DCCS showed a significant improvement in NAPS, while the changes in the CSS and ASS were statistically insignificant. This suggests that, although there was a shift in performance relative to the national average, the absolute change in executive functioning or cognitive flexibility was less pronounced than the change in processing speed, as shown by the PCPS. However, studies by Bonomini et al. (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) and Laborde et al. (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) reported that after a single session of SPB there is enhancement in executive functioning and cognitive flexibility (Bonomini et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Laborde et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eInterestingly, no significant changes were noted in working memory (WM) and episodic memory, as shown by the performance in the LSWM and PSM test scores, respectively. These findings may suggest that 10-sessions SPB may be sufficient to augment speed-based tasks, but longer sessions may be required to augment the memory-influencing pathway. However, contrary to our findings, Bonomini et al. (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) and Laborde et al. (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) reported that SBP improved WM after a single session of SPB (Bonomini et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Laborde et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). The results of these studies might differ as single-session paradigms predominantly capture state-dependent modulation driven by momentary shifts in arousal, attention allocation, and expectancy. These effects may be inherently labile and thus, may not reflect consolidated cognitive change. Contrary to this, repeated SPB sessions are more likely to facilitate cumulative autonomic and central adaptations.\u003c/p\u003e \u003cp\u003eThe FCS, which reflects the ability to solve new problems and think flexibly, also showed significant improvement in the SPB group compared to the control group, with a large effect size. This signifies the global impact of SPB on an individual\u0026rsquo;s overall fluid intelligence. Fluid cognitive ability is independent of prior knowledge and represents how quickly and efficiently one can solve novel problems (Khammash et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). An earlier study showed that fluid cognitive ability was inversely associated with stressor-related increases in negative mood, allowing for greater emotional resilience (Stawski et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2010\u003c/span\u003e). As the Fluid Composite Score represents an integrated measure of multiple cognitive domains, its significant improvement suggests a trend toward global cognitive enhancement, despite the absence of statistically significant changes in individual domain-specific outcomes except processing speed.\u003c/p\u003e \u003cp\u003eThe typical respiratory maneuver in SPB, performed at approximately six cycles per minute with controlled inhalation and longer exhalation, stimulates the parasympathetic system (Strauss-Blasche et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2000\u003c/span\u003e). Parasympathetic dominance is conveyed to the central nervous system (CNS) through the nucleus tractus solitarius to the thalamus and the nucleus parabrachial to the limbic system (Brown et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2013\u003c/span\u003e; Streeter et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2012\u003c/span\u003e). Additionally, SPB may influence the top-down components of cognition, such as attention, WM, and executive monitoring. A voluntary shift of attention towards breath monitoring during SPB may influence this top-down process. Various studies have supported this notion by demonstrating increased activity in the anterior prefrontal cortex, parietal cortex, and other subcortical areas, such as the periaqueductal gray and the hypothalamus, during the SPB (Critchley et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2015\u003c/span\u003e; Yu et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2011\u003c/span\u003e). The dorsolateral prefrontal, posterior parietal, and fronto-parietal areas of the brain are part of the central executive network, which is crucial for managing higher levels of cognition, such as attention, WM, and executive functions (Bigliassi et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2025\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAdditionally, SPB through the nostrils mechanically stimulates the olfactory epithelium, which may influence the fine control of the thalamus and cortex through the olfactory bulb. Supporting this, a study by Piarulli et al. (2018) demonstrated that ultra-slow mechanical stimulation of the olfactory epithelium enhanced cortical delta-theta EEG activity in the limbic system (Pilcher et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). Therefore, SBP influences cognitive function via multiple mechanisms.\u003c/p\u003e \u003cp\u003eThe selective enhancement of processing speed has important physiological and clinical implications. Processing speed is a sensitive marker of neural efficiency and cognitive reserve and is often among the earliest domains affected in cognitive aging and stress-related disorders. Thus, improvements observed in young healthy adults may reflect optimized central\u0026ndash;autonomic integration, positioning SPB as a low-cost, non-invasive strategy for enhancing cognitive efficiency and resilience.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eShort-term 10 session slow-paced breathing protocol augments the processing speed in young healthy adults.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eLimitation\u003c/h2\u003e \u003cp\u003eA major drawback of this study is its limited sample size (n\u0026thinsp;=\u0026thinsp;30) and the employment of a convenience sampling method, which may restrict the generalisability of the results. Other possible sources of bias are the way medical students were chosen, the fact that the control group didn't have daily phone contact, and the fact that there wasn't an active control condition. Nonetheless, various factors diminish the probability that these limitations significantly impacted the primary outcomes. First, the participants were first-year medical students with limited prior exposure to physiological research concepts, thereby mitigating expectancy or performance bias associated with awareness of study hypotheses. Second, the groups had similar baseline demographic and cognitive traits, which means that they were similar at first and that selection bias was kept to a minimum. Third, standardized computerized cognitive assessments (NIH Toolbox\u0026reg; Cognitive Battery) were utilized, mitigating assessor bias and minimizing subjective impact on outcome measurement. Furthermore, improvements were domain-specific rather than generalized across all cognitive tests, supporting the possibility of intervention-related effects rather than nonspecific practice or social interaction effects.\u003c/p\u003e \u003cp\u003eNonetheless, the current investigation was structured as an exploratory pilot study aimed at producing initial evidence concerning the short-term effects of multi-session, slow-paced breathing on cognition. The research did not evaluate the long-term retention of cognitive improvements after the termination of the intervention. Subsequent research ought to investigate the dose\u0026ndash;response relationship of slow-paced breathing, incorporate active control conditions, and assess the durability of cognitive enhancements in larger and more heterogeneous populations.\u003c/p\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cb\u003eClinical Trial Registration:\u003c/b\u003e Nil.\u003c/p\u003e \u003ch2\u003eEthics approval and consent to participate:\u003c/h2\u003e \u003cp\u003e The protocol was approved by the \u0026ldquo;Institutional Ethical Committee\u0026rdquo; (No: IEC/VMMC/SJH/Cert/Sept-2024/101) before starting any work related to the study, and written informed consent was obtained from each participant in accordance with the principles of the Declaration of Helsinki.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication:\u003c/strong\u003e \u003cp\u003e All authors consented to publication.\u003c/p\u003e \u003ch2\u003eCompeting interests:\u003c/h2\u003e \u003cp\u003eThe authors declare no perceived or potential conflicts of interest, financial, or otherwise.\u003c/p\u003e\u003ch2\u003eFunding/grant\u003c/h2\u003e \u003cp\u003e \u003cb\u003e\u003c/b\u003e None\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eKBU: Conception of the work, acquisition, analysis, or interpretation of data, drafting the work, final approval of the version to be published, and agreed to be accountable for all aspects of the work.VAB: Conception of the work, acquisition, analysis, or interpretation of data, drafting the work, final approval of the version to be published, and agreed to be accountable for all aspects of the work. MK: Conception of the work, interpretation of data, revising the draft critically for important intellectual content, final approval of the version to be published, and agreed to be accountable for all aspects of the work.SM: Conception of the work, acquisition, analysis, or interpretation of data, drafting the work, final approval of the version to be published, and agreed to be accountable for all aspects of the work.HA: Conception of the work, revising the draft critically for important intellectual content, final approval of the version to be published, and agreed to be accountable for all aspects of the work.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWe thank all the participants who devoted their time to our study. 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Activation of the anterior prefrontal cortex and serotonergic system is associated with improvements in mood and EEG changes induced by Zen meditation practice in novices. \u003cem\u003eInternational Journal Of Psychophysiology\u003c/em\u003e, \u003cem\u003e80\u003c/em\u003e(2), 103\u0026ndash;111. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.ijpsycho.2011.02.004\u003c/span\u003e\u003cspan address=\"10.1016/j.ijpsycho.2011.02.004\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"applied-psychophysiology-and-biofeedback","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"apbi","sideBox":"Learn more about [Applied Psychophysiology and Biofeedback](http://link.springer.com/journal/10484)","snPcode":"10484","submissionUrl":"https://submission.nature.com/new-submission/10484/3","title":"Applied Psychophysiology and Biofeedback","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Slow-paced breathing (SPB), Cognitive function, Fluid cognition, Executive function","lastPublishedDoi":"10.21203/rs.3.rs-9385088/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9385088/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eSlow-paced breathing (SPB) has shown to promote parasympathetic dominance, and cognitive enhancement. This longitudinal interventional study aimed to explore the effects of a 10-session SPB protocol on cognitive function in healthy young adults.\u003c/p\u003e\n\u003cp\u003e30 healthy participants, aged 18-35 years (15 intervention group and 15 controls) were recruited. The intervention group performed daily 17-minute SPB session (5 min block of 4.5s inhalation/5.5s exhalation with 1 min rest interval) for 10 days. Cognitive function was assessed at baseline and post-intervention using the NIH Toolbox® V3, measuring cognitive flexibility and attention span (DCCS), attention and inhibitory control (FICA), working memory (LSWM), processing speed (PCPS), episodic memory (PSM), and fluid cognition (FCS). The primary metric was the Change Sensitive Score (CSS), supported by age-adjusted standard scores (ASS) and national percentile score (NAPS).\u003c/p\u003e\n\u003cp\u003eThe PCPS showed significant post-intervention improvements in the SPB group, with a high effect size in CSS (p=0.0003; Hedges' g=0.726 [0.006–1.447]) and ASS (p=0.0055; g=0.728 [0.008–1.448]). The FCS also showed improvement in CSS (p=0.0067; g=0.609 [0.104–1.322]), ASS (p=0.0058; g=0.625 [0.089–1.339]), and NAPS (p=0.0127; g=0.951 [0.214–1.688]) in the SPB group. No significant changes were observed in the DCCS, FICA, LSWM, or PSM, except for a small shift in the NAPS in the DCCS after the SPB session. Control group showed no significant changes in the cognitive function.\u003c/p\u003e\n\u003cp\u003eThe 10-session short-term SPB protocol significantly enhanced processing speed and global fluid cognition in healthy young adults. The SPB could potentially represent a simple, non-invasive technique for augmenting cognitive health.\u003c/p\u003e","manuscriptTitle":"Short-term slow-paced breathing improves processing speed and fluid cognition in young healthy adults","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-24 00:45:33","doi":"10.21203/rs.3.rs-9385088/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewersInvited","content":"","date":"2026-04-15T19:33:08+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-15T11:30:45+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-04-15T11:30:05+00:00","index":"","fulltext":""},{"type":"submitted","content":"Applied Psychophysiology and Biofeedback","date":"2026-04-11T06:13:51+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"applied-psychophysiology-and-biofeedback","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"apbi","sideBox":"Learn more about [Applied Psychophysiology and Biofeedback](http://link.springer.com/journal/10484)","snPcode":"10484","submissionUrl":"https://submission.nature.com/new-submission/10484/3","title":"Applied Psychophysiology and Biofeedback","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"40fd3010-58ba-4ce7-b212-296f6a66888c","owner":[],"postedDate":"April 24th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-24T00:45:33+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-24 00:45:33","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9385088","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9385088","identity":"rs-9385088","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}