Resolving pelvic floor pain-A case report

It’s been a little over a year since I began practicing biofeedback and visualization strategies to overcome vulvodynia. Today, I feel whole, healed, and hopeful. I learned that through controlled and conscious breathing, I could unleash the potential to heal myself from chronic pain. Overcoming pain did not happen overnight; but rather, it was a process where I had to create and maintain healthy lifestyle habits and meditation. Not only am I thankful for having learned strategies to overcome chronic pain, but for acquiring skills that will improve my health for the rest of my life. –-24 year old woman who successfully resolved vulvodynia

Pelvic floor pain can be debilitating, and it is surprisingly common, affecting 10 to 25% of American women. Pelvic floor pain has numerous causes and names. It can be labeled as vulvar vestibulitis, an inflammation of vulvar tissue, interstitial cystitis (chronic pain or tenderness in the bladder), or even lingering or episodic hip, back, or abdominal pain. Chronic pain concentrated at the entrance to the vagina (vulva), is known as vulvodynia. It is commonly under-diagnosed, often inadequately treated, and can go on for months and years (Reed et al., 2007; Mayo Clinic, 2014). The discomfort can be so severe that sitting is uncomfortable and intercourse is impossible because of the extreme pain. The pain can be overwhelming and destructive of the patient’s life. As the participant reported,

I visited a vulvar specialist and he gave me drugs, which did not ease the discomfort. He mentioned surgical removal of the affected tissue as the most effective cure (vestibulectomy). I cried immediately upon leaving the physician’s office. Even though he is an expert on the subject, I felt like I had no psychological support. I was on Gabapentin to reduce pain, and it made me very depressed. I thought to myself: Is my life, as I know it, over?

Physically, I was in pain every single day. Sometimes it was a raging burning sensation, while other times it was more of an uncomfortable sensation. I could not wear my skinny jeans anymore or ride a bike. I became very depressed. I cried most days because I felt old and hopeless instead of feeling like a vibrant 23-year-old woman. The physical pain, combined with my negative feelings, affected my relationship with my boyfriend. We were unable to have sex at all, and because of my depressed status, we could not engage in any kind of fun. (For more details, read the published case report,Vulvodynia treated successfully with breathing biofeedback and integrated stress reduction: A case report).

The four-session holistic biofeedback interventions to successfully resolved vulvodynia included teaching diaphragmatic breathing to transform shallow thoracic breathing into slower diaphragmatic breathing, transforming feelings of powerlessness and hopelessness to empowerment and transforming her beliefs that she could reduce her symptoms and optimize her health. The interventions also incorporated self-healing imagery and posture-changing exercises. The posture changes consisted of developing awareness of the onset of moving into a collapsed posture and use this awareness to shift to an erect/empowered postures (Carney, Cuddy, & Yap, 2010; Peper, 2014; Peper, Booiman, Lin, & Harvey, in press). Finally, this case report build upon the seminal of electromyographic feedback protocol developed by Dr. Howard Glazer (Glazer & Hacad, 2015) and the integrated relaxation protocol developed Dr. David Wise (Wise & Anderson, 2007).

Through initial biofeedback monitoring of the lower abdominal muscle activity, chest, and abdomen breathing patterns, the participant observed that when she felt discomfort or was fearful, her lower abdomen muscles tended to tighten. After learning how to sense this tightness, she was able to remind herself to breathe lower and slower, relax the abdominal wall during inhalation and sit or stand in an erect power posture.

The self-mastery approach for healing is based upon a functional as compared to a structural perspective. The structural perspective implies that the problem can only be fixed by changing the physical structure such as with surgery or medications. The functional perspective assumes that if you can learn to change your dysfunctional psychophysiological patterns the disorder may disappear.

The functional approach assumed that an irritation of the vestibular area might have caused the participant to tighten her lower abdomen and pelvic floor muscles reflexively in a covert defense reaction. In addition, ongoing worry and catastrophic thinking (“I must have surgery, it will never go away, I can never have sex again, my boyfriend will leave me”) also triggered the defense reaction—further tightening of her lower abdomen and pelvic area, shallow breathing, and concurrent increases in sympathetic nervous activation—which together activated the trigger points that lead to increased chronic pain (Banks et al, 1998).

When the participant experienced a sensation or thought/worried about the pain, her body responded in a defense reaction by breathing in her chest and tightening the lower abdominal area as monitored with biofeedback. Anticipation of being monitored increased her shoulder tension, recalling the stressful memory increased lower abdominal muscle tension (pulling in the abdomen for protection), and the breathing became shallow and rapid as shown in Figure 1.

Fig 3 biofeedback relax memory relax

Figure 1. Physiological recording of pre-stressor relaxation, the recall of a fearful driving experience, and a post-stressor relaxation. The scalene to trapezius SEMG increased in anticipation while she recalled the experience, and then initially did not relax (from Peper, Martinez Aranda, & Moss, 2015).

This defense pattern became a conditioned response—initiating intercourse or being touched in the affected area caused the participant to tense and freeze up. She was unaware of these automatic protective patterns, which only worsened her chronic pain.

During the four sessions of training, the participant learned to reverse and interrupt the habitual defense reaction. For example, as she became aware of her breathing patterns she reported,

It was amazing to see on the computer screen the difference between my regular breathing pattern and my diaphragmatic breathing pattern. I could not believe I had been breathing that horribly my whole life, or at least, for who knows how long. My first instinct was to feel sorry for myself. Then, rather than practicing negative patterns and thoughts, I felt happy because I was learning how to breathe properly. My pain decreased from an 8 to alternating between a 0 and 3.

The mastery of slower and lower abdominal breathing within a holistic perspective resulted in the successful resolution of her vulvodynia. An essential component of the training included allowing the participant to feel safe, and creating hope by enabling her to experience a decrease in discomfort while doing a specific practice, and assisting her to master skills to promote self-healing. Instead of feeling powerless and believing that the only resolution was the removal of the affected area (vestibulectomy). The integrated biofeedback protocol offered skill mastery training, to promote self-healing through diaphragmatic breathing, somatic postural changes, reframing internal language, and healing imagery as part of a common sense holistic health approach.

For more details about the case report, download the published study,  Peper, E., Martinez Aranda, P., & Moss, E. (2015). Vulvodynia treated successfully with breathing biofeedback and integrated stress reduction: A case report. Biofeedback. 43(2), 103-109.

The participant also wrote up her subjective experience of the integrated biofeedback process in the paper, Martinez Aranda & Peper (2015). Healing of vulvodynia from the client perspective.  In this paper she articulated her understanding and experiences in resolving vulvodynia which sheds light on the internal processes that are so often skipped over in published reports.


Banks, S. L., Jacobs, D. W., Gevirtz, R., & Hubbard, D. R. (1998). Effects of autogenic relaxation training on electromyographic activity in active myofascial trigger points. Journal of Musculoskeletal Pain, 6(4), 23-32.

Carney, D. R., Cuddy, A. J., & Yap, A. J. (2010). Power posing brief nonverbal displays affect neuroendocrine levels and risk tolerance. Psychological Science, 21(10), 1363-1368. Available from:

Glazer, H. & Hacad, C.R. (2015). The Glazer Protocol: Evidence-Based Medicine Pelvic Floor Muscle (PFM) Surface Electromyography (SEMG). Biofeedback, 40(2), 75-79.

Martinez Aranda, P. & Peper, E. (2015). Healing of vulvodynia from the client perspective. Available from:

Mayo Clinic (2014). Diseases and conditions: Vulvodynia. Available at

Peper, E. (2014). Increasing strength and mood by changing posture and sitting habits. Western Edition, pp.10, 12. Available from:

Peper, E., Booiman, A., Lin, I, M.,& Harvey, R. (in press). Increase strength and mood with posture. Biofeedback.

Peper, E., Martinez Aranda, P., & Moss, E. (2015). Vulvodynia treated successfully with breathing biofeedback and integrated stress reduction: A case report. Biofeedback. 43(2), 103-109. Available from:

Reed, B. D., Haefner, H. K., Sen, A., & Gorenflo, D. W. (2008). Vulvodynia incidence and remission rates among adult women: a 2-year follow-up study. Obstetrics & Gynecology, 112(2, Part 1), 231-237.

Wise, D., & Anderson, R. U. (2006). A headache in the pelvis: A new understanding and treatment for prostatitis and chronic pelvic pain syndromes. Occidental, CA: National Center for Pelvic Pain Research.

Doctor Mike Evans: What’s the Best Diet? Healthy Eating 101

A healthy diet is much more than just focusing on a single food. People focus so often on adding one type of food or eliminating another such as, “Don’t eat ice cream!”, “Eat chia seeds.” “No red meat.” In almost all cases, it is not just one thing, instead a healthy diet is embedded in awareness and healthy life style choices. Watch the superb common sense white board video presentation by Doctor Mike Evans, What’s the Best Diet? Healthy Eating 101. In this short presentation, he summarizes the best practices known. Implement his approach and your health will significantly improve.

Gut understanding-From salivating to pooping and all that is in between

Eighty percent of all your cells in your body are bacteria and not human cells. Or is it that human beings are this mixture of beneficial bacteria and human cells? The majority of the bacteria live in our large intestines and contribute to our health and well-being. One of the hottest area in medicine and biology is the study of the human microbiome–understanding the role of the bacteria that co-habitate with us. The dynamic mixture of healthy and harmful bacteria can create illness or health and change our moods.

Ever wondered how food is digested, what foods do for you, what is a stomach ache, diarrhea or how defecation occurs? To understand our digestive tract from the mouth to the anus, from the first morsel of food entering our mouth to pooping is explained in superb readable book, Gut-The Inside Story of Our Body’s Most Underrated Oran, written by the German writer and scientist. Giulia Enders. It is a must read for anyone concerned about impact of cesarean birth, food allergies, eczema, ulcers, effect of antibiotics, constipation, farting, bloating, etc.For a fun summary, see Steve Palkin’s interview with Giulia Enders on YouTube.


Understanding marketing to doctors, food waste and sugar consumption through humor

The Last Week Tonight Show with John Oliver is a superb presentation of the problems and solutions about our health and food systems. Using humor, John William Oliver hosts the weekly HBO program on Sundays at 11pm and provides superb documentation of the corruption and marketing strategies that often negatively affect our health, diet and budget.
For evidence based–yet humorous–reporting watch the following episodes;
Marketing to Doctors (HBO). Pharmaceutical companies spend billions of dollars marketing drugs to doctors (published on Feb 8, 2015).

Food Waste (HBO). Producers, sellers, and consumers waste tons of food. John Oliver discusses the shocking amount of food we don’t eat (published on Jul 19, 2015).

Sugar (HBO). Sugar. It’s in everything!
Is it good for us? Well, the sugar industry thinks so (published on Oct 26, 2014).

For additional information, see the following blogs:

What the food companies forgot to tell you: For the sake of profits we promote metabolic syndrome, obesity and diabetes

Be aware of evolutionary/environmental traps

Over diagnosed: Should I have more tests?

Drug to smart phone addiction-A need for a new perspective

The federal and state governments have spent more than $1 trillion during the last 40 years on the  war on drugs. A war that has been so unsuccessful that more than half a million people are in prison for drug law violations–a tenfold increase since 1980. Once released from prison with the stigma of a criminal record, the people face a very difficult future.

Clearly, the present drug policies are not working.  There is a need to rethink the basis and treatment of addiction. Watch British journalist Johann Hari’s 2015 Ted talk in which he offers surprising and hopeful ways of thinking about an age-old problem.

Giving a voice to the agony of rape and justice system

Krakauer book cover

19% of women and 6.1% of men have been victims of at least one completed or attempted sexual assault since entering college (Krebs et al, 2007). These numbers are probably lower than the actual rate because many rape and other sexual assault victims do not report their attacks to law enforcement (Kruttschnitt et al, 2014). Rape or attempted rape victims sometimes blame themselves for the assault especially when they “did not resist/fight the aggressor”. The rape experience can even be more devastating when it is done by an acquaintance rape and 84% of the victims knew their attacker beforehand (Kuersten, 2003)–it is an experience of total betrayal. The horrifying experience and the challenges to achieve justice is sensitively described in the superb book by Jon Krakauer, Missoula Rape and the justice system in a college town.

It is a MUST book to read for every therapist, educator or anyone interested in understanding the human suffering of rape. The book describes the intimate and long lasting emotional impacts of rape with the challenges of achieving justice. It complements my previous post, Porges and Peper Propose Physiological Basis for Paralysis as Reaction to Date Rape, which explains that paralysis and not fighting the aggressor is not the result of agreeing to further sexual activity but  the activation of the reptilian stress response of death fainting and withdrawal. A survival response by which the person cannot respond (Porges & Peper, 2015)..


Krakauer, J. (2015). Missoula-Rape and the justice system in a college town. New York: Doubleday.

Krebs, C.P., Lindquist, C.H., Warner, T.D., Fisher, B.S., & Martin, S.L. (2007). The Campus Sexual Assault (CSA) Study.

Kruttschnitt, Candace; Kalsbeek, William D.; House, Carol C. (2014). Estimating the Incidence of Rape and Sexual Assault. Washington, DC: The National Academies Press.

Kuersten, Ashlyn K. (2003). Women and the Law: Leaders, Cases, and Documents. ABC-CLIO. pp. 143–144.

Porges, S.W. & Peper, E. (2015). When Not Saying NO Does Not Mean Yes: Psychophysiological Factors Involved in Date Rape. Biofeedback. 43(1), 45-48.

Porges and Peper Propose Physiological Basis for Paralysis as Reaction to Date Rape

Paralysis Can Be a Natural Reaction to Date rape

This is the press release for my recently published article in the journal, Biofeedback, coauthored with Stephen Porges,

Stigma is often associated with inaction during a crisis. Those who freeze in the face of a life-threatening situation often experience feelings of shame and guilt, and they often feel that they are constantly being judged for their inaction. While others may confidently assert that they would have been more “heroic” in that situation, there is a far greater chance that their bodies would have reacted in exactly the same way, freezing as an innate part of self-preservation.

Stephen Porges and Erik Peper describe how immobilization is a natural neurobiological response to being attacked as can occur during date the article titled “When Not Saying NO Does Not Mean Yes: Psychophysiological Factors Involved in Date Rape,” published in the journal Biofeedback .

The article explains the immobilization response in light of the polyvagal theory, which Porges introduced about 20 years ago. According to this theory, the brain reacts to various risk situations in three ways: The situation is safe, the situation is dangerous, or the situation is life-threatening. After our brain identifies risk, our body reacts either with a fight-or-flight response or, especially in dire situations, can become completely immobilized. The likelihood of an immobilization response increases when the person is physically restrained or is in a confined environment. Immobilization is also often accompanied by a higher pain threshold and a tendency to disassociate.

In the case of rape, it is often assumed that the victim should simply have said No, should have fought back, or should have made it clear that the sexual attention was unwanted. However, the more we learn about the brain’s response to extreme threats, the more we realize that it may be difficult to recruit the neural circuits necessary to verbally express oneself or to fight or flee, especially when drugs or alcohol are involved. Instead, it is a natural response for victims to freeze, to feel so physically threatened that their own body will not allow them to fight or flee.

Porges and Peper note that polyvagal theory supports a law passed in California in September 2014. The new law requires the governing boards of the state’s colleges and universities to adopt policies and procedures that require students who engage in sexual activity to obtain “affirmative, unambiguous, and conscious decision by each participant.” In other words, simply not saying No will no longer be tolerated as an excuse for rape.

The article conclude that victims of date rape should not feel shame or guilt if they froze in that situation. The body’s natural defense reactions are not just flight or fight; sometimes it is complete immobilization.

The authors hope that recognizing this will help people deal with trauma and help those around them understand their experiences. After a lecture, one of the authors, Peper, had a profound experience when a student came up to him with tears in her eyes. She explained that the same immobilization process happened to her two weeks before when she was robbed and she had felt so guilty.` Just listening to her made the efforts of writing the article worthwhile.”

Full text of the article, “When Not Saying NO Does Not Mean Yes: Psychophysiological Factors Involved in Date Rape,” Biofeedback, Vol. 43, No. 1, 2015, is available at

About the journal Biofeedback

Biofeedback is published four times per year and distributed by the Association for Applied Psychophysiology and Biofeedback. The chief editor of Biofeedback is Donald Moss, Dean of Saybrook University’s School of Mind-Body Medicine. AAPB’s mission is to advance the development, dissemination, and utilization of knowledge about applied psychophysiology and biofeedback to improve health and the quality of life through research, education, and practice.

Media Contact:

Bridget Lamb
Allen Press, Inc.
800/627-0326 ext. 248


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