TechStress: Building Healthier Computer Habits
Posted: August 30, 2023 Filed under: ADHD, behavior, biofeedback, Breathing/respiration, cognitive behavior therapy, computer, digital devices, education, emotions, ergonomics, Evolutionary perspective, Exercise/movement, health, laptops, Neck and shoulder discomfort, Pain/discomfort, posture, screen fatigue, stress management, Uncategorized, vision, zoom fatigue | Tags: cellphone, fatigue, gaming, mobile devices, screens 6 CommentsBy Erik Peper, PhD, BCB, Richard Harvey, PhD, and Nancy Faass, MSW, MPH
Adapted by the Well Being Journal, 32(4), 30-35. from the book, TechStress: How Technology is Hijacking Our Lives, Strategies for Coping, and Pragmatic Ergonomics by Erik Peper, Richard Harvey, and Nancy Faass.
Every year, millions of office workers in the United States develop occupational injuries from poor computer habits—from carpal tunnel syndrome and tension headaches to repetitive strain injury, such as “mouse shoulder.” You’d think that an office job would be safer than factory work, but the truth is that many of these conditions are associated with a deskbound workstyle.
Back problems are not simply an issue for workers doing physical labor. Currently, the people at greatest risk of injury are those with a desk job earning over $70,000 annually. Globally, computer-related disorders continue to be on the rise. These conditions can affect people of all ages who spend long hours at a computer and digital devices.
In a large survey of high school students, eighty-five percent experienced tension or pain in their neck, shoulders, back, or wrists after working at the computer. We’re just not designed to sit at a computer all day.
Field of Ergonomics
For the past twenty years, teams of researchers all over the world have been evaluating workplace stress and computer injuries—and how to prevent them. As researchers in the fields of holistic health and ergonomics, we observe how people interact with technology. What makes our work unique is that we assess employees not only by interviewing them and observing behaviors, but also by monitoring physical responses.
Specifically, we measure muscle tension and breathing, in the moment, in real-time, while they work. To record shoulder pain, for example, we place small sensors over different muscles and painlessly measure the muscle tension using an EMG (electromyograph)—a device that is employed by physicians, physical therapists, and researchers. Using this device, we can also keep a record of their responses and compare their reactions over time to determine progress.
What we’ve learned is that people get into trouble if their muscles are held in tension for too long. Working at a computer, especially at a stationary desk, most people maintain low-level chronic tension for much of the day. Shallow, rapid breathing is also typical of fine motor tasks that require concentration, like data entry.
Muscle tension and breathing rate usually increase during data entry or typing without our awareness.
When these patterns are paired with psychological pressure due to office politics or job insecurity, the level of tension and the risk of fatigue, inflammation, pain, or injury increase. In most cases, people are totally unaware of the role that tension plays in injury. Of note, the absolute level of tension does not predict injury—rather, it is the absence of periodic rest breaks throughout the day that seems to correlate with future injuries.
Restbreaks
All of life is the alternation between movement and rest, inhaling and exhaling, sleeping and waking. Performing alternating tasks or different types of activities and movement is one way to interrupt the couch potato syndrome—honoring our evolutionary background.
Our research has confirmed what others have observed: that it’s important to be physically active, at least periodically, throughout the day. Alternating activity and rest recreate the pattern of our ancestors’ daily lives. When we alternate sedentary tasks with physical activity, and follow work with relaxation, we function much more efficiently. In short, move your body more.
Better Computer Habits: Alternate Periods of Rest and Activity
As mentioned earlier, our workstyle puts us out of sync with our genetic heritage. Whether hunting and gathering or building and harvesting, our ancestors alternated periods of inactivity with physical tasks that required walking, running, jumping, climbing, digging, lifting, and carrying, to name a few activities. In contrast, today many of us have a workstyle that is so immobile we may not even leave our desk for lunch.
As health researchers, we have had the chance to study workstyles all over the world. Back pain and strain injuries now affect a large proportion of office workers in the US and in high-tech firms worldwide. The vast majority of these jobs are sedentary, so one focus of the research is on how to achieve a more balanced way of working.
A recent study on exercise looked at blood flow to the brain. Researchers Carter and colleagues found that if people sit for four hours on the job, there’s a significant decrease in blood flow to the brain. However, if every thirty or forty minutes they get up and move around for just two minutes, then brain blood flow remains steady. The more often you interrupt sitting with movement, the better.
It may seem obvious that to stay healthy, it’s important to take breaks and be physically active from time to time throughout the day. Alternating activity and rest recreate the pattern of our ancestors’ daily lives. The goal is to alternate sedentary tasks with physical activity and follow work with relaxation. When we keep this type of balance going, most people find that they have more energy, are more productive, and can be more effective.
Genetics: We’re Hardwired Like Ancient Hunters
Despite a modern appearance, we carry the genes of our forebearers—for better and for worse. (Art courtesy of Peter Sis). Reproduced from Peper, E., Harvey, R., & Faass (2020). TechStress: How Technology is Hijacking Our Lives, Strategies for Coping, and Pragmatic Ergonomics. Berkeley: North Atlantic Books.
In the modern workplace, most of us find ourselves working indoors, in small office spaces, often sitting at a computer for hours at a time. In fact, the average Westerner spends more than nine hours per day sitting indoors, yet we’re still genetically programmed to be physically active and spend time outside in the sunlight most of the day, like the nomadic hunters and gatherers of forty thousand years ago.
Undeniably, we inherently conserve energy in order to heal and regenerate. This aspect of our genetic makeup also helps burn fewer calories when food is scarce. Hence the propensity for lack of movement and sedentary lifestyle (sitting disease).
In times of famine, the habit of sitting was essential because it reduced calorie expenditure, so it enabled our ancestors to survive. In a prehistoric world with a limited food supply, less movement meant fewer calories burned. Early humans became active when they needed to search for food or shelter. Today, in a world where food and shelter are abundant for most Westerners, there is no intrinsic drive to initiate movement.
It is also true that we have survived as a species by staying active. Chronic sitting is the opposite of our evolutionary pattern in which our ancestors alternated frequent movement while hunting or gathering food with periods of rest. Whether they were hunters or farmers, movement has always been an integral aspect of daily life. In contrast, working at the computer—maintaining static posture for hours on end—can increase fatigue, muscle tension, back strain, and poor circulation, putting us at risk of injury.
Quit a Sedentary Workstyle
Almost everyone is surprised by how quickly tension can build up in a muscle, and how painful it can become. For example, we tend to hover our hands over the keyboard without providing a chance for them to relax. Similarly, we may tighten some of the big muscles of our body, such as bracing or crossing our legs.
What’s needed is a chance to move a little every few minutes—we can achieve this right where we sit by developing the habit of microbreaks. Without regular movement, our muscles can become stiff and uncomfortable. When we don’t take breaks from static muscle tension, our muscles don’t have a chance to regenerate and circulate oxygen and necessary nutrients.
Build a variety of breaks into your workday:
- Vary work tasks
- Take microbreaks (brief breaks of less than thirty seconds)
- Take one-minute stretch breaks
- Fit in a moving break
Varying Work Tasks
You can boost physical activity at work by intentionally leaving your phone on the other side of the desk, situating the printer across the room, or using a sit-stand desk for part of the day. Even a few minutes away from the desk makes a difference, whether you are hand delivering documents, taking the long way to the bathroom, or pacing the room while on a call.
When you alternate the types of tasks and movement you do, using a different set of muscles, this interrupts the contractions of muscle fibers and allows them to relax and regenerate. Try any of these strategies:
- Alternate computer work with other activities, such as offering to do a coffee run
- Schedule walking meetings with coworkers
- Vary keyboarding and hand movements
Ultimately, vary your activities and movements as much as possible. By changing your posture and making sure you move, you’ll find that your circulation and your energy improve, and you’ll experience fewer aches and pains. In a short time, it usually becomes second nature to vary your activities throughout the day.
Experience It: “Mouse Shoulder” Test
You can test this simple mousing exercise at the computer or as a simulation. If you’re at the computer, sit erect with your hand on the mouse next to the keyboard. To simulate the exercise, sit with erect posture as if you were in front of your computer and hold a small object you can use to imitate mousing.
With the mouse (or a sham mouse), simulate drawing the letters of your name and your street address, right to left. Be sure each letter is very small (less than half an inch in height). After drawing each letter, click the mouse.
As part of the exercise, draw the letters and numbers as quickly as possible for ten to fifteen seconds. What did you observe? In almost all cases, you may note that you tightened your mousing shoulder and your neck, stiffened your trunk, and held your breath. All this occurred without awareness while performing the task. Over time, this type of muscle tension can contribute to discomfort, soreness, pain, or eventual injury.
Microbreaks
If you’ve developed an injury—or have chronic aches and pains—you’ll probably find split-second microbreaks invaluable. A microbreak means taking brief periods of time that last just a few seconds to relax the tension in your wrists, shoulders, and neck.
For example, when typing, simply letting your wrists drop to your lap for a few seconds will allow the circulation to return fully to help regenerate the muscles. The goal is to develop a habit that is part of your routine and becomes automatic, like driving a car. To make the habit of microbreaks practical, think about how you can build the breaks into your workstyle. That could mean a brief pause after you’ve completed a task, entered a column of data, or before starting typing out an assignment.
For frequent microbreaks, you don’t even need to get up—just drop your hands in your lap or shake them out, move your shoulders, and then resume work. Any type of shaking or wiggling movement is good for your circulation and kind of fun.
In general, a microbreak may be defined as lasting one to thirty seconds. A minibreak may last roughly thirty seconds to a few minutes, and longer large-movement breaks are usually greater than a few minutes. Popular microbreaks:
- Take a few deep breaths
- Pause to take a sip of water
- Rest your hands in your lap
- Stretch
- Let your arms drop to your sides
- Shake out your hands (wrists and fingers)
- Perform a quick shoulder or neck roll
Often, we don’t realize how much tension we’ve been carrying until we become more mindful of it. We can raise our awareness of excess tension—this is a learned skill—and train ourselves to let go of excess muscle tension. As we increase our awareness, we’re able to develop a new, more dynamic workstyle that better fits our goals and schedule.
One-Minute Stretch Breaks
We all benefit from a brief break, even with the best of posture (left). One approach is to totally release your muscles (middle). That release can be paired with a series of brief stretches (right). Reproduced from Peper, E., Harvey, R., & Faass (2020). TechStress: How Technology is Hijacking Our Lives, Strategies for Coping, and Pragmatic Ergonomics. Berkeley: North Atlantic Books.
The typical mini-stretch break lasts from thirty seconds to a few minutes, and ideally you want to take them several times per hour. Similar to microbreaks, mini-stretch breaks are especially important for people with an injury or those at risk of injury. Taking breaks is vital, especially if you have symptoms related to computer stress or whenever you’re working long hours at a sedentary job. To take a stretch break:
Begin with a big stretch, for example, by reaching high over your head then drop your hands in your lap or to your sides.
Look away from the monitor, staring at near and far objects, and blink several times. Straighten your back and stretch your entire backbone by lifting your head and neck gently, as if there were an invisible string attached to the crown of your head.
Stretch your mind and body. Sitting with your back straight and both feet flat on the floor, close your eyes and listen to the sounds around you, including the fan on the computer, footsteps in the hallway, or the sounds in the street.
Breathe in and out over ten seconds (breathe in for four or five seconds and breathe out for five or six seconds), making the exhale slightly longer than the inhale. Feel your jaw, mouth, and tongue muscles relax. Feel the back and bottom of the chair as your body breathes all around you. Envision someone in your mind’s eye who is kind and reassuring, who makes you feel safe and loved, and who can bring a smile to your face inwardly or outwardly.
Do a wiggling movement. When you take a one-minute break, wiggling exercises are fast and easy, and especially good for muscle tension or wrist pain. Wiggle all over—it feels good, and it’s also a great way to improve circulation.
Building Exercise and Movement into Every Day
Studies show that you get more benefit from exercising ten to twenty minutes, three times a day, than from exercising for thirty to sixty minutes once a day. The implication is that doing physical activities for even a few minutes can make a big difference.
Dunstan and colleagues have found that standing up three times an hour and then walking for just two minutes reduced blood sugar and insulin spikes by twenty-five percent.Fit in a Moving Break
Fit in a Moving Break
Once we become conscious of muscle tension, we may be able to reverse it simply by stepping away from the desk for a few minutes, and also by taking brief breaks more often. Explore ways to walk in the morning, during lunch break, or right after work. Ideally, you also want to get up and move around for about five minutes every hour.
Ultimately, research makes it clear that intermittent movement, such as brief, frequent stretching throughout the day or using the stairs rather than elevator, is more beneficial than cramming in a couple of hours at the gym on the weekend. This explains why small changes can have a big impact—it’s simply a matter of reminding yourself that it’s worth the effort.
Workstation Tips
Your ability to see the display and read the screen is key to reducing neck and eye strain. Here are a few strategic factors to remember:
Monitor height: Adjust the height of your monitor so the top is at eyebrow level, so you can look straight ahead at the screen.
Keyboard height: The keyboard height should be set so that your upper arms hang straight down while your elbows are bent at a 90-degree angle (like the letter L) with your forearms and wrists held horizontally.
Typeface and font size: For email, word processing, or web content, consider using a sans serif typeface. Fonts that have fewer curved lines and flourishes (serifs) tend to be more readable on screen.
Checking your vision: Many adults benefit from computer glasses to see the screen more clearly. Generally, we do not recommend reading glasses, bifocals, trifocals, and progressive lenses as they tend to allow clear vision at only one focal length. To see through the near-distance correction of the lens requires you to tilt your head back. Although progressive lenses allow you to see both close up and at a distance, the segment of the lens for each focal length is usually too narrow for working at the computer.
Wearing progressive lenses requires you to hold your head in a fixed position to be in focus. Yet you may be totally unaware that you are adapting your eye and head movements to sustain your focus. When that is the case, most people find that special computer glasses are a good solution.
Consider computer glasses if you must either bring your nose to the screen to read the text, wear reading glasses and find that their focal length is inappropriate for the monitor distance, wear bi- or trifocal glasses, or are older than forty.
Computer glasses correct for the appropriate focal distance to the computer. Typically, monitor distance is about twenty-three to twenty-eight inches, whereas reading glasses correct for a focal length of about fifteen inches. To determine your individual, specific focal length, ask a coworker to measure the distance from the monitor to your eyes. Provide this personal focal distance at the eye exam with your optometrist or ophthalmologist and request that your computer glasses be optimized for that distance.
Remembering to blink: As we focus on the screen, our blinking rate is significantly reduced. Develop the habit of blinking periodically: at the end of a paragraph, for example, or when sending an email.
Resting your eyes: Throughout the day, pause and focus on the far distance to relax your eyes. When looking at the screen, your eyes converge, which can cause eyestrain. Each time you look away and refocus, that allows your eyes to relax. It’s especially soothing to look at green objects such as a tree that can be seen through a window.
Minimizing glare: If the room is lit with artificial light, there may be glare from your light source if the light is right in front of you or right behind you, causing reflection on your screen. Reflection problems are minimized when light sources are at a 90-degree angle to the monitor (with the light coming from the side). The worst situations occur when the light source is either behind or in front of you.
An easy test is to turn off your monitor and look for reflections on the screen. Everything that you see on the monitor when it’s turned off is there when you’re working at the monitor. If there are bright reflections, they will interfere with your vision. Once you’ve identified the source of the glare, change the location of the reflected objects or light sources, or change the location of the monitor.
Contrast: Adjust the light contrast in the room so that it is neither too bright nor too dark. If the room is dark, turn on the lights. If it is too bright, close the blinds or turn off the lights. It is exhausting for your eyes to have to adapt from bright outdoor light to the lighting of your computer screen. You want the light intensity of the screen to be somewhat similar to that in the room where you’re working. You also do not want to look from your screen to a window lit by intense sunlight.
Don’t look down at phone: According to Kenneth Hansraj, MD, chief of spine surgery at New York Spine Surgery and Rehabilitation Medicine, pressure on the spine increases from about ten pounds when you are holding your head erect, to sixty pounds of pressure when you are looking down. Bending forward to look at your phone, your head moves out of the line of gravity and is no longer balanced above your neck and spine. As the angle of the face-forward position increases, this intensifies strain on the neck muscles, nerves, and bones (the vertebrae).
The more you bend your neck, the greater the stress since the muscles must stretch farther and work harder to hold your head up against gravity. This same collapsed head-forward position when you are seated and using the phone repeats the neck and shoulder strain. Muscle strain, tension headaches, or neck pain can result from awkward posture with texting, craning over a tablet (sometimes referred to as the iPad neck), or spending long hours on a laptop.
A face-forward position puts as much as sixty pounds of pressure on the neck muscles and spine.
Repetitive strain of neck vertebrae (the cervical spine), in combination with poor posture, can trigger a neuromuscular syndrome sometimes diagnosed as thoracic outlet syndrome. According to researchers Sharan and colleagues, this syndrome can also result in chronic neck pain, depression, and anxiety.
When you notice negative changes in your mood or energy, or tension in your neck and shoulders, use that as a cue to arch your back and look upward. Think of a positive memory, take a mindful breath, wiggle, or shake out your shoulders if you’d like, and return to the task at hand.
Strengthen your core: If you find it difficult to maintain good posture, you may need to strengthen your core muscles. Fitness and sports that are beneficial for core strength include walking, sprinting, yoga, plank, swimming, and rowing. The most effective way to strengthen your core is through activities that you enjoy.
Final Thoughts
If these ideas resonate with you, consider lifestyle as the first step. We need to build dynamic physical activity into our lives, as well as the lives of our children. Being outside is usually an uplift, so choose to move your body in natural settings whenever possible, whatever form that takes. Being outside is the factor that adds an energetic dimension. Finally, share what you learn, and help others learn and grow from your experiences.
If you spend time in front of a computeror using a mobile device, read the book, TechStress: How Technology is Hijacking Our Lives, Strategies for Coping, and Pragmatic Ergonomics. It provides practical, easy-to-use solutions for combating the stress and pain many of us experience due to technology use and overuse. The book offers extremely helpful tips for ergonomic use of technology, it
goes way beyond that, offering simple suggestions for improving muscle health that seem obvious once you read them, but would not have thought of yourself: “Why didn’t I think of that?” You will learn about the connection between posture and mood, reasons for and importance of movement breaks, specific movements you can easily perform at your desk, as well as healthier ways to utilize technology in your everyday life.
See the book, TechStress-How Technology is Hijacking our Lives, Strategies for Coping and Pragmatic Ergonomics by Erik Peper, Richard Harvey and Nancy Faass. Available from: https://www.amazon.com/Beyond-Ergonomics-Prevent-Fatigue-Burnout/dp/158394768X/
Additional resources
Healing a Shoulder/Chest Injury
Posted: August 14, 2023 Filed under: behavior, biofeedback, Breathing/respiration, emotions, Exercise/movement, healing, Neck and shoulder discomfort, Pain/discomfort, relaxation, self-healing, Uncategorized | Tags: electromyograph, guided imagery, shoulder pain Leave a commentAdapted from Peper, E. & Fuhs, M. (2004). Applied psychophysiology for therapeutic use: Healing a shoulder injury, Biofeedback, 32(2), 11-18.
“It has been an occurrence of the third dimension for me! How come my pain — that lasted for more than 10 days and was still so strong that I really had difficulties in breathing, couldn’t laugh without pain nor move my arm not even to fulfil my daily routines such as dressing and eating — disappeared within one single session of 20 minutes? And not only that, I was able to freely rotate my arm as if it had never been injured before.” —23 year old woman
The participant T., aged 23, was a psychology student who participated in an educational workshop for Healthy Computing. She volunteered to be a subject for a surface electromyographic (SEMG) monitoring and feedback demonstration. Ten days prior to this workshop, she had a severe skiing accident. She described the accident as follows:
I went skiing and may be I had too much snow in my ski-binding and while turning, I slipped out of my binding and fell head first down into the hill. As I fell, I landed on my ski pole which hit my left upper chest and breast area. Afterwards, my head was humming and I assumed that I had a light concussion. I stopped skiing and stayed in bed for a while. The next day it started hurting and I couldn’t turn my head or put my shoulders back (they were rotated forward). Also, I couldn’t ski as I was not able to look down to my feet–my muscles were too contracted and I felt searing pain whenever I moved. I hoped that it would go away however, the pain and left forward shoulder rotation stayed.
Assessment
Observation and Palpation
T.´s left shoulder was rolled forward (adducted and in internal rotation). She was not able to breathe or laugh without pain or move her arm freely. All movements in vertical and horizontal directions and rotations were restricted by at least 50 % as compared to her right arm (limitations in shoulder extension, flexion and external rotation). Also, her hands were ice-cold and she breathed very shallowly and rapidly in her chest. She was not able to stand in an upright position or sit in a comfortable position without maintaining her left upper extremity in a protected position. Her left shoulder blade (scapula) was winging.
After visually observing her, the instructor placed his left hand on her left shoulder and pectoralis muscles and his right hand on the back of her shoulder. Using palpation and anchoring her back with his leg so that she could not rotate her trunk, he explored the existing range of shoulder movement. He also attempted to rotate the left shoulder outward and back–not by forcing or pulling—but by very gentle traction. No change in mobility was observed and the pectoralis muscle felt tight (SEMG monitoring is helpful to the therapist during such a diagnostic assessment by helping to identify the person’s reactivity and avoiding to evoke and condition even more bracing). T. reported afterwards that she was very scared by this assessment because there was one point in the back which was highly reactive to touch. T. appeared to tighten automatically out of fear and trigger a general flexor contraction pattern—a process that commonly occurs if a person is guarding an area.
Often a traumatic injury first induces a general shock that triggers an automatic freeze and fear reaction. Therefore, an intervention needed to be developed that did not trigger vigilance or fear and thereby allowed the muscle to relax. If pain is experienced or increased, it is another negative reinforcement for generalizing guarding and bracing and tightening the muscles. This guarding decreases mobility – a common reaction that may occur when health professionals in the process of assessment increase the client’s discomfort. T.’s vigilance was also “telegraphed” to the therapist by her ice-cold hands and very shallow chest breathing. Therefore, it was important to increase her comfort level and to not induce any further pain. We hypothesized that only if she felt safe it would be possible for her muscle tension to decrease and thereby increase her mobility.
Underlying concept: The very cold hands and shallow breathing probably indicated excessive vigilance and arousal—a possible indicator of a catabolic state that could limit regeneration. The chronic cold hands most likely implied that she was very sensitive to other people’s emotions and continuously searches/scans the environment for threats. In addition, she indicated that she liked to do/perform her best which induced more anxiety and fear of judgement.
Single Channel Surface Electromyographic (SEMG)Assessment
The triode electrode with sensor was placed over the left pectoralis muscle area as shown in Figure 1. The equipment was a MyoTrac™ produced by Thought Technology Ltd. which is a small portable SEMG with the preamplifiers at the triode sensor to eliminate electrode lead and movement artefacts (Peper & Gibney, 2006). Such a device is an inexpensive option for people who may use biofeedback for demonstrating and teaching awareness and control over muscle tension from a single electrode location.
Figure 1. Location of the Triode electrode placement on the left pectoralis muscle area of another participant.
The MyoTrac was placed on a table within view, so that the therapist and the subject could simultaneously see the visual feedback signal and observe what was going on as well as demonstrate expected changes. The feedback was used for T. as a tool to see if she could reduce her SEMG activity. It was also used by the therapist to guide his interventions: To keep the SEMG activity low and to stop any intervention that would increase the SEMG activity as this would prevent bracing as a possible reaction to, or anticipation of, pain.
1. Assessment of Muscle Reactivity. After the electrode was attached on her pectoralis muscle and with her arm resting on her lap, she was asked to roll her left shoulder slightly more forward, hold the tension for the count of 10 and then let go and relax. Even with feedback, the muscle activity stayed high and did not relax and return to a lower level of activity as shown in Figure 2. This lack of return to baseline is often a diagnostic indicator of muscle irritability or injury (Sella, 1998; Sella, 2006). If the muscle does not relax immediately after contraction, movement or exercise should not be prescribed, since it may aggravate the injury. Instead, the person first needs to learn how to relax and then learn how to relax between activation and tensing of the muscle. The general observation of T. was that at the initiation of any movement (active or passive) muscle tension increased and did not return to baseline for more than two minutes.
Figure 2. Simulation of the effect on the pectoralis sEMG (this is a recording from another subject who showed a similar response pattern that was visually observed from T. with the Myotrac). After the muscle is contracted it takes a long time to return to baseline level
2. Exploration. Self-exploration with feedback was encouraged. T. was instructed to let go of muscle tension in her left shoulder girdle. In addition the therapist tried to induce her letting go by gently and passively rocking her left arm. The increased SEMG activity and the protective bracing in her shoulder showed that she couldn’t reduce the muscle tension. Each time her arm was moved, however slightly, she helped with the movement and kept control. In addition, T. was asked to reduce the muscle tension using the biofeedback signal; again she was not able to reduce her muscle tension with feedback.
3. Passive Stretch and Movements. The next step was to passively stretch the pectoralis muscle by holding the shoulder between both hands and very gently externally rotate the shoulder — a process derived from the Alexander technique (Barlow, 1991). Each time the instructor attempted to rotate her shoulder, the SEMG increased and T. reported an increased fear of pain. T.’s SEMG response most likely consisted of the following components:
- Movement induced pain
- Increased splinting and guarding
- Increased arousal/vigilance to perform well
These three assessment and self-regulation procedures were unsuccessful in reducing muscle tension or increasing shoulder movement. This suggested that another therapeutic intervention would need to be developed to allow the left pectoralis area to relax. The SEMG could be used as an indicator whether the intervention was successful as indicated by a reduction in SEMG activity. Finally, the inability to relax after tightening (bracing and splinting) probably aggravated her discomfort.
Multiple levels of injury: The obvious injury and discomfort was due to her left chest wall being hit by the ski pole. She then guarded the area by bracing the muscles to protect it which limited movement. The guarding tightened the muscles and limited blood circulation and lymphatic flow which increased local ischemia, irritation and pain. This led to a self-perpetuating cycle: Pain triggers guarding and guarding increases pain and impedes self-healing.
As the SEMG and passive stretching assessment were performed, the therapist concurrently discussed the pain process. Namely, from this perspective, there were at least two types of pains:
- Pain caused by the physiological injury
- Pain as the result of guarding
The pain from the guarding is similar to having exercised for a long time after not having exercised. The next day you feel sore. However, if you feel sore, you know that it was due to the exercise therefore it is defined as a good pain. In T.’s case, the pain indicated that something was wrong and did not heal and therefore she would need to protect it. We discussed this process as a way to use cognitive reframing to change her attitude toward guarding and pain.
Rationale: The intention was to interrupt her negative image of pain that acted as a post hypnotic suggestion. The objective was to change her image and thoughts from “pain indicates the muscle is damaged” to “pain indicates the muscle has worked too hard and long and needs time to regenerate.”
Treatment interventions
The initial intervention focused upon shifting shallow thoracic breathing to diaphragmatic breathing. Generally, when people breathe rapidly and predominantly in their chest, they usually tighten their neck and shoulder muscles during inhalation. One of the reasons T. breathed in her chest was that her clothing–very tight jeans–constricted her waist (MacHose & Peper, 1991; Peper et al., 2015). This breathing pattern probably contributed to sub-clinical hyperventilation and was part of a fear or flexor response pattern. When she loosened the upper buttons of her jeans and allowed her stomach to expand her pectoralis muscle relaxed as she breathed as shown in Figure 3. As she began to breathe in this pattern, each time she exhaled her pectoralis muscle tension decreased.
Figure 3. Illustration of the effect of loosening tight waist constriction (eliminating designer’s jean syndrome) on blood flow and pectoralis sEMG. Abdominal breathing became possible and finger temerature increased (this recording is from another subject whose physiological responses were similar to that was observed with the Myotrac from T.)
Following the demonstration that breathing significantly lowered her chest muscle tension, the discussion focussed on the importance of effortless diaphragmatic breathing for health and reduction of vigilance. Being awkward and uncomfortable at loosening her pants, she struggled with allowing her abdomen to expand and her pants to be looser because she thought that she looked much more attractive in tight clothing. Yet, she agreed that her boy friend would love her regardless whether she wore loose or tight clothing. To encourage an acceptance for wearing looser clothing and thereby permit diaphragmatic breathing during the day, an informal discussion focused on “designer jeans syndrome” (chest breathing induced by tight clothing) with humorous examples such as discussing the name of the room that is located on top of the stairs in the Victorian houses in San Francisco. It is called the fainting room–in the 19th century women who wore corsets and had to climb the stairs would have to breathe rapidly and then would faint when they reached the top of the stairs (Peper, 1990).
Rationale: Rapid shallow chest breathing can induce a catabolic state that inhibits healing while diaphragmatic breathing may induce an anabolic state that promotes regeneration. Moreover, effortless diaphragmatic breathing would increase respiratory sinus arhythmia (RSA)–heart rate variability linked to breathing– and thereby facilitate sympathetic-parasympathetic balance that would promote self-healing.
The discussion included the use of the YES set which meant asking a person questions in such a way that she/he answers the question with YES. When a person answers YES at least three times in a row rapport is often facilitated (Erikson, 1983, pp. 237-238). Questions were framed in such a way that the client would answer with YES. For example, if the therapist thought the person did not do their homework, a yes question could be framed as, “It must have been difficult to find time to do the homework this week?” In T.’s case, the therapist said, “I see, you would rather wear tight clothing than allow your shoulder to heal.” She answered, “Yes.” This was the expected answer, however, the question was framed in an intuitive guess on the therapist’s part. Nevertheless, the strategy would have been successful either way because if she had answered “No,” it would have broken the “Yes: set, but she would then be committed to change her clothing.
Throughout this discussion, the therapist placed his left hand on her abdomen over her belly button and overtly and covertly guided her breathing movement. As she exhaled, he pressed gently on her abdomen; as she inhaled he drew his hand away–as if her abdomen was like a balloon that inflated during inhalation and deflated during exhalation. To enhance learning diaphragmatic breathing and slower exhalation, the therapist covertly breathed at the same rhythm and gently exhaled as she exhaled while allowing the breathing movement to be mainly in his abdomen. In this process, learning occurred without demand for performance and she could imitate the breathing process that was covertly modelled by the therapist.
The Change
The central observation was that each time she tried to relax or do something, she would slight brace which increased her pectoralis SEMG activity. The chronic tension from guarding probably induced localized ischemia, inhibited lymphatic flow and drainage, and reduced blood circulation which would increase tissue irritation. Whenever the therapist began to move her arm, she would anticipate and try to help with the movement. Overall she was vigilant (also indicated by her very cold hands) and wanted to perform very well (a possible need for approval). Her muscle bracing and helping with movement was reframed as a combined activity that consisted of guarding to prevent further injury and as a compliment that she would like to perform well.
Labelling her activity as a “compliment” was part of a continuing YES set approach. The therapist was deliberately framing whatever happened as adaptive behaviour, with positive intent. Further, if one tries and does something with too much effort while being vigilant, the arousal would probably induce hand cooling. If the activity can be performed with passive attention, then increased blood flow and warmth may occur. The therapeutic challenge was how to reduce vigilance, perfectionism and guarding so that the muscles that were guarding the traumatized area would relax.
Therapeutic concept: If a direct approach does not work, an indirect approach needs to be employed. Through an indirect approach, the person experiences a change without trying to focus on doing or achieving it. Underlying this approach is the guideline: If something does not work, try it once more and then if it does not work, do something completely different. This is analogous to sexual arousal: If you demand from a male to have an erection: The more performance you demand the less likely will there be success. On the other hand, if you remove the demand for performance and allow the person to become interested and thereby feel an erotic experience an erection may occur without effort.
The shift to an indirect intervention was done through active somatic visualization. T. was encouraged to visualize and remember a positive image or memory from her past. She chose a memory of a time when she was in Paris with her grandmother. While T. visualized being with her grandmother, the therapist asked another older women participant to help and hold T’s right hand in a grandmother-like way as if she was her grandmother. The “grandmother” then moved T.’s hand in a playful way as if dancing with T.’s right arm. Through this kinesthetic experience, T. became more and more absorbed in her memory experience. At the same time, T´s left hand was being held and gently rocked by the therapist. During this gentle rocking, the SEMG activity decreased completely in her left pectoralis area. The therapist used the SEMG feedback to guide him in the gentle rocking motion of T.’s left arm and very slowly increased the range of her arm and shoulder motion. Gentle movement was done only as long as the SEMG activity did not increase. It allowed the muscle to stay relaxed and facilitated the experience of trust. The following is T. report two days later of what happened.
“Initially it was very difficult for me to let go of control because I found this idea somewhat strange and I was puzzled. I expected the therapist to intervene and I felt frightened. The therapist’s soft and gentle touch and his very soft voice in this kind of meditation helped me to let go of control and I was surprised about my own courage to give myself into the process without knowing what would happen next.”
Rationale: Every corresponding thought and emotion has an associated body response and every body response has an associated mental/emotional response (Green & Green, 1977; Green, 1999). Therefore, an image and experience of a happy and safe past memory will allow the body to evoke the same state and vigilance can be abated. The intensity of the experience is increased when multi-sensory cues are included such as actual handholding. The more senses are involved, the more the experience can become real. In addition, the tactile sensation of feeling the grandmother’s hand diverted her attention away from her shoulder into her hand and thereby reduced her active efforts of trying to relax the shoulder and pectoralis area. Doing something she did not expect to happen also helped her loose control – an implicit confusion approach.
SEMG feedback was used as the guide for controlling the movement. The therapist gently increased the range of the movements in abduction and external rotation directions while continuously rocking her arm until her injured arm was able to move unrestricted in full range of motion. The arm and shoulder relaxation and continuous subtle movement without evoking any SEMG activation facilitated blood flow and lymphatic drainage which probably reduced congestion. After a few minutes, the therapist gently dropped her arm on her lap. After her arm was resting on her lap, she reported that it felt very heavy and relaxed and that she didn’t feel any pain. However, she initially didn’t really realize that her mobility had increased dramatically.
Rationale: When previous movements that had been associated with pain are linked to an experience of pleasure, the movement is often easier. The conditioned muscle bracing patterns associated with anticipation of pain and/or concern for improvement/results are reduced.
Process to deepen and generalize the relaxation and breathing. She was asked to imagine breathing the air down and through her arms and legs–a strategy that she could then do at home with her boyfriend. We wanted to involve another person because it is often difficult to do homework practices without striving and concern for results and focussing on the area of discomfort. Her response to asking if her boyfriend would help was an automatic “naturally” (the continuation of the YES set). With her agreement, we role played how her boyfriend was to encourage diaphragmatic breathing. He was to gently stroke down her legs as she exhaled. She could then just focus on the sensations and allow the air to flow down her legs. Then, while she continued to breathe effortlessly, he would gently rock and move her arm.
To be sure that she knew how to give the instructions, the therapist role played her boyfriend and then asked her to rock his arm so that she would know how to teach her boy friend how to move her arm. The therapist sat on her left side, and, as she now held his right arm and gently rocked it with her left arm, the therapist gently moved backwards. This meant that she externally rotated her left arm and shoulder more and more. He moved in such a way that in the process of rocking his arm, she moved her “previously injured shoulder” in all directions (up, down, forward and backwards) and was unaware that she could move her arm and shoulder as she did not experience any discomfort. Afterwards, we shared our observations and she was asked to move her arm and shoulder. She moved it without any restrictions or discomfort.
Rationale: By focusing outside herself and not being concerned about herself, she did not think of herself or of trying to move her arm and shoulder. Hence, she did not evoke the anticipatory guarding and thus significantly increased her flexibility.
Process of acceptance. Often after an injury, we are frustrated with our bodies. This frustration may interfere with healing. Therefore, the session concluded by asking her to be appreciative of her shoulder and arm. She was asked to think of all the positive things her shoulder, chest and arm have done for her in the past instead of the many limitations and pains caused by the injury. Instead of being angry at her shoulder that it had not healed or restricted her movement, we suggested that she should appreciate her shoulder and pectoralis area for all it had done without her awareness such as: How the shoulder moved her arm during love-making, how without complaining her shoulder moved during walking, writing, skiing, eating, etc., and how many times in the past she had abused her shoulder without giving it proper respect and appreciation. This process reframes the way one symbolically relates to the injured area. Every thought of discomfort or negative judgement becomes the trigger and is transformed into breathing lower and slower and evokes an appreciation of the positive nice things her shoulder has done for her in the past.
Rationale: When injured we often evoke negative mental and emotional images which become post- hypnotic suggestions. Those negative thoughts, images and emotions interfere with healing while positive thoughts, images and emotions tend to promote healing. A possible energetic process that occurs when injured is that we withdraw awareness/ consciousness from the injured area which reduces blood and lymph circulation. Caring and positive feelings about an area tends to increase blood flow and warmth (a heart-warming experience) and promotes healing.
RESULTS
She left the initial session without any pain and with total range of motion. At the two week follow-up she reported continued pain relief and complete range of motion. T.s reflection of the experience was:
“I really was not aware that I could move my arm freely like before the accident, I was just feeling a kind of trance and was happy to not feel any pain and to feel much more upright than before. Then I watched the faces of the two other therapists who sat there with big eyes and a grin on their face and then become aware of my own arms position which was rotated backwards and up, a movement that was impossible to do before. I remember this evening that I left with this feeling of trance and that I often tried to go back to my collapsed posture but this was not possible anymore and I felt very tall and straight. Now two weeks later I still feel like that and know that I had an amazing experience which I will store in my brain!
My father who is an orthopedic surgeon tested me and found out, that I had hurt my rib. He said that I have a contusion and it will go away in a few weeks. Before this experience, I would say that he was not open to Biofeedback. However he was so captivated by my experiences that he spontaneously promised me to pay for my own biofeedback equipment and to support me with my educational program and even offered me a job in his practice to do this work!”
Psychophysiological Follow-up: 3 Weeks Later
The physiological assessment included monitoring thoracic and abdominal breathing patterns, blood volume pulse, heart rate and SEMG from her left pectoralis muscle while she was asked to roll her left shoulder forward (adducted and internally rotated) for the count of 10 and then relax. The physiological recording showed that she breathed more diaphragmatically and that her pectoralis muscle relaxed and returned directly to baseline after rotation as shown in Fig. 4.
Figure 4. Physiological profile during the rolling left shoulder forward (tense) and relaxing at thethree week follow-up. Note that the pectoralis sEMG activity returned rapidly to baseline after contracting and her breathing pattern is abdomninal and slower.
Summary
This case example demonstrates the usefulness of a simple one-channel SEMG biofeedback device to guide the interventions during assessment and treatment. It suggests that the therapist and client can use the SEMG activity as an indicator of guarding–a visual representation of the subjective experience of fear, pain and range of mobility–that can be evoked during assessment and therapeutic interventions. The anticipation of increased pain commonly occurs during diagnosis and treatment and often becomes an obstacle for healing because increased pain may increase anticipation of pain and trigger even more bracing. To avoid triggering this vicious circle of guarding/fear, the feedback signal allows the therapist and the client to explore strategies that reduce muscle activity by indirect interventions.
By using an indirect approach that the client may not expect, the interventions shift the focus of attention and striving and may allow increased freedom and relaxation. The biofeedback signal may guide the therapeutic process to reduce the patterns of fear, panic, and bracing that are commonly associated with injury and illnesses. Once this excessive sympathetic activity is reduced, the actual pathophysiology may become obvious (in most cases is much less then before) and the healing process may be accelerated. This case description may offer an approach in diagnosis and treatment for many therapists and open a door for a gentle, painless and yet successful way of treatment and encourage therapists to be creative and use both experience/technique and intuition.
For additional intervention approaches see the following two blogs.
References
Barlow, W. (1991). The Alexander technique: How to use your body without stress. Rochester, VT: Healing Arts Press https://www.amazon.com/Alexander-Technique-Your-without-Stress/dp/0892813857#:~:text=Barlow%2C%20the%20foremost%20exponent%20and,and%20movement%20in%20everyday%20activities.
Erikson, M. H. (1983). Healing in hypnosis, volume 1 (Edited by E. L. Rossi, M. O. Ryan, M. & F. A. Sharp). New York: Irvington Publishers, Inc.. https://www.amazon.com/Hypnosis-Seminars-Workshops-Lectures-Erickson/dp/0829007393/ref=sr_1_1?keywords=9780829007398&linkCode=qs&qid=1692038804&s=books&sr=1-1
Green, E. (1999). Psychophysical Principal. Accessed August 14, 2023 https://www.elmergreenfoundation.org/psychophysiological-principal/
Green, E., & Green, A. (1977). Beyond biofeedback. New York:
Delacorte Press/Seymour. https://elmergreenfoundation.org/wp-content/uploads/2019/02/Beyond-Biofeedback-Green-Green-Searchable.pdf
MacHose, M., & Peper, E. (1991). The effect of clothing on inhalation volume. Biofeedback and Self-Regulation. 16(3), 261-265. https://doi.org/10.1007/BF01000020
Peper, E. (1990). Breathing for health. Montreal: Thought Technology Ltd.
Peper, E. & Gibney, K.H. (2006). Muscle biofeedback at the computer-A manual to prevent repetitive strain injury (RSI) by taking the guesswwork out of assessment, monitoring and training. Biofeedback Foundation of Europe. https://thoughttechnology.com/muscle-biofeedback-at-the-computer-book-t2245/
Peper, E., Gilbert, C.D., Harvey, R. & Lin, I-M. (2015). Did you ask about abdominal surgery or injury? A learned disuse risk factor for breathing dysfunction. Biofeedback. 34(4), 173-179. https://doi.org/10.5298/1081-5937-43.4.06
Sella, G. E. (2006). SEMG: Objective methodology in muscular dysfunction investigation and rehabilitation. Weiner’s pain management: A practical guide for clinicians, CRC Press, 645-662. https://www.taylorfrancis.com/chapters/edit/10.1201/b14253-45/semg-objective-methodology-muscular-dysfunction-investigation-rehabilitation-gabriel-sella
Sella, G. E. (1998). Towards an Integrated Approach of sEMG Utilization: Quantative Protocols of Assessment and Biofeedback. Electromyography: Applications in Physical Medicine. Thought Technology, 13. https://www.bfe.org/protocol/pro13eng.htm
[1] We thank Theresa Stockinger for her significant contribution and Candy Frobish for her helpful comments.
Healing from vulvodynia
Posted: May 4, 2023 Filed under: behavior, biofeedback, Breathing/respiration, emotions, healing, health, Pain/discomfort, relaxation, self-healing, Uncategorized | Tags: muscle tension, pelvic floor pain, therapeutic relationship, triggers for illness, vulvodynia 1 CommentPamela Jertberg and Erik Peper
Adapted from: Jertberg, P. & Peper, E. (2023). The healing of vulvodynia from the client’s perspective. Biofeedback, 51 (1), 18–21. https://doi.org/10.5298/1081-5937-51.01.02
This introspective report describes how a young woman who experienced a year-long struggle with vulvodynia, or vulvar vestibulitis, regained her health through biofeedback training and continues to be symptom-free 7 years after the intervention. This perspective may offer insight into factors that promote health and healing and provide an approach to reduce symptoms and promote health. The methodology of this case was described previously by Peper et al. (2015).
The Client’s Experience
I have been a healthy young woman my whole life. Growing up in a loving, dedicated family, I always ate home-cooked meals, went to bed at a reasonable time, and got plenty of exercise by playing with my family members and friends. I never once thought that at age 23 I might be at risk of undergoing vulvar surgery. There are many factors that contributed to the genesis of my vulvar pain, and many other factors that worsened this pain. Traditional medicine did not help me, and I did not find relief until I met my biofeedback practitioner, who taught me biofeedback. Through the many strategies I learned, such as visualization, diaphragmatic breathing techniques, diet tips, and skills to reframe my thoughts, I finally began to feel relief and hope. Practicing all these elements every day helped me overcome my physical pain and enjoy a normal life once again. Today, I do not have any vulvar discomfort. I am so grateful to my biofeedback practitioner for the many skills he taught me. I can enjoy my daily activities once again without experiencing pain. I have been given a second chance at loving life, and now I have learned the techniques that will help me sustain a more balanced path for the rest of my life. Seven years later, I am healthy and have no symptoms.
Triggers for Illness
Not Having a Positive Relationship with the Doctor
The first factor that aggravated my pain was having a doctor with whom I did not have a good relationship. Although the vulvar specialist I was referred to had treated hundreds of women with vulvar vestibulitis, his methods were very traditional: medicine, low oxalate diet, ointments, and surgery. Whenever I left his office, I would cry and feel like surgery was the only option. Vaginal surgery at 23 was one of the scariest and most unexpected thoughts my brain had ever considered. The doctor never thought of the impact that his words and treatment would have on my mental state.
Depression
Being depressed also triggered more pain. Whenever I would have feelings of hopelessness and create irrational beliefs in my mind (“I will never get better,” “I will never have sex again,” “I am not a woman anymore”), my physical pain would increase. Having depression only triggered more depression and pain, and this became a vicious cycle. The depression deeply affected my relationships with my boyfriend, friends, and family and my performance in my college classes.
Being Sedentary
Being sedentary and not exercising also increased my pain. At first, I believed that the mere act of sitting down hurt me due to the direct pressure on the area, but after a few months I came to realize that it was inactivity itself that triggered pain. Whenever I would sit for too long writing a paper or I would stay home all day because of my depression, my pain would increase, perhaps because I was inhibiting circulation. Still, when I am inactive most of the day, I feel lethargic and bloated. When I exercise, the pain goes away 100%. Exercise is almost magical.
Stress
Stress is the worst trigger for pain. Throughout my life, I always strived to be perfect in every way, meaning I was stressed about the way I looked, performed in school, drove, etc. Through the sessions with my biofeedback practitioner, I learned that my body was in a state of perpetual stress and tightness, which induced pain in certain areas. My body’s way of releasing such tension was to send pain signals to my vulvar area, perhaps because of a yeast infection a couple of months back. Still, if I become very stressed, I will feel pain or tightness in certain parts of my body, but now I have strategies for performing proper stress-relieving techniques.
Processed Foods
Junk food affects me instantly. When I eat processed foods for a week straight, I feel groggy, bloated, lethargic, and in pain. Processed sugar, white flour, and salt are a few of the foods that make the pain increase. I used to love sugar, so I would enjoy the occasional milkshake and cheeseburger and feel mostly okay. However, in times of stress it became crucial for me to learn to refrain from any junk food, because it would worsen my vulvar pain and increase my overall stress levels.
Menstruation
Menstruation is unavoidable, and unfortunately it would always worsen my vulvar pain. Right about the time of my period, my sensitivity and pain would massively increase. Sometimes as my pain would increase incredibly, I would question myself: “What am I doing wrong?” Then, I would remember: “Oh yes, I am getting my period in a few days.” The whole area became very sensitive and would get irritated easily. It became imperative to listen to my body and nurture myself especially around that time of the month.
Triggers for Healing
A Good Doctor
Just as I learned which factors triggered the pain, I also learned how to reduce it. The most important factor that helped me find true relief was meeting a good health professional (which could be a healer, nurse, or professor). The first time I met my biofeedback practitioner and told him about my issues, he really listened, gave me positive feedback, and even made jokes with me. To this day we still have a friendship, which has really aided me in getting better. In contrast to the vulvar specialist, I would leave the biofeedback practitioner’s office feeling powerful, able to defeat vulvodynia, and truly happy. Just having this support from a professional (or a friend, boyfriend, or relative) can make all the difference in the world. I don’t know where I would be right now if I hadn’t worked with him.
Positive Thoughts and Beliefs
Along with having a good support group, having positive thoughts and believing in a positive result helped me greatly. When I actually set my mind to feel “happy” and to believe that I was getting better, I began to really heal. After months of being depressed and feeling incomplete, when I began to practice mantras such as “I am healing,” “I am healthy,” and “I am happy,” my pain began to go away, and I was able to reclaim my life.
Journaling
One of the ways in which “happiness” became easier to achieve was to journal every day. I would write everything: from my secrets to what I ate, my pain levels, my goals for the day, and my symptoms. Writing down everything and knowing that no one would ever read it but me gave me relief, and my journal became my confidante. I still journal every day, and if I forget to write, the next day I will write twice as much. Now that writing has become a habit and a hobby, it is hard to imagine my life without that level of introspection.
Meditation
Although I would do yoga often, I would never sit and meditate. I began to use Dr. Peper’s guided meditations and Dr. Kabat-Zinn’s CD (Kabat-Zinn, 2006; Peper et al., 2002). The combination of these meditation techniques, whether on different days or on the same day, helped me focus on my breathing and relax my muscles and mind. Today, I meditate at least 20 min each day, and I feel that it helps me see life through a more willing and patient perspective. In addition, through meditation and deep breathing I have learned to control my pain levels, concentration, and awareness.
Imagery and Visualization
Imagery is a powerful tool that allowed me to heal faster. My biofeedback practitioner instructed me to visualize how I wanted to feel and look. In addition, he suggested that I draw and color how I was feeling at any given moment, my imagined healing process, and how I would look and feel after the healing process had traveled throughout my body (Peper et al., 2022). It is still amazing to me how much imagery helped me. Even visualizing here and there throughout the day helped. Now I envision how I want to feel as a healthy woman, I take a deep breath, and as a I breathe out I let my imagined healing process go through my body into all my tight areas along with the exhalation.
Biofeedback
Biofeedback is the single strategy that helped me the most. During my first session with my biofeedback practitioner, he pointed out that my muscles were always contracted and stressed and that I was not breathing diaphragmatically. As I learned how to take deep belly breaths, I began to feel the tight areas in my body loosen up. I started to practice controlled breathing 20 min every day. Through biofeedback, my body and muscles became more relaxed, promoting circulation and ultimately reducing the vulvar pain.
Regular Exercise and Yoga
Exercising daily decreased my pain and improved the quality of my life greatly. When I first started experiencing significant vulvar pain, I stopped exercising because I felt that movement would aggravate the pain. To my surprise, the opposite was true. Being sedentary increased the feelings of discomfort, whereas exercising released the tension. The exercise I found most helpful was yoga because it is meditation in movement. I became so focused on my breathing and the poses that my brain did not have time to think about anything else. After attending every yoga class, I felt like I could take on anything. Swimming, Pilates, and gentle cardiovascular exercises have also helped me greatly in reducing stress and feeling great.
Sex
Although sex was impossible for almost a year due to the pain, it became possible and even enjoyable after implementing other relaxation strategies. When I first reintroduced sex back into my life, my partner at the time and I would go gently and stop if it hurt my vulvar area at all. Today, sex again is joyful. Being able to engage in intercourse has boosted my self-esteem and helped me feel sexy again, which empowers me to keep practicing the relaxation techniques.
Listening to the Mind-Body Connection
The mind-body connection is present in all of us, but I am fortunate to have a very strong connection. My thoughts influence my body almost instantly, which is why when I would get depressed my pain would increase, and when I would see my biofeedback practitioner or believe in a good outcome, my pain would decrease. Being aware of this connection is crucial because it can help me or hurt me greatly. After a few months of practicing the relaxation strategies, I saw a different gynecologist and one dermatologist. Both professionals said that there was nothing wrong with my vulvar area—that maybe I just felt some irritation due to the medicines I had previously taken and my current stress. They said that there was no way I needed surgery. When I heard these opinions, I began to feel instantly better—thus proving that my thoughts (and even others’ thoughts) affect my body in significant ways.
Although today I am 100% better, I still experience pain and tightness in my body when I experience the “illness factors” I mentioned above. I still have to remember that feeling healthy and good is a process, not a result, and that even if I feel better one day that does not mean I can stop all my new healthy habits. To completely cure vulvodynia, I needed to change my life habits, perspective, and attitude toward the illness and life. I needed to make significant changes, and now my biggest challenge is to stick to those changes. Biofeedback, imagery, meditation, good food, and exercise are not just treatments that I begin and end on a certain day, but rather they have become essential components of my life forever.
My life with vulvodynia was ultimately a journey of introspection, decision making, and life-changing habits. I struggled with vulvar pain for over a year, and during that year I experienced severe symptoms, depression, and the loss of several friendships and relationships. I felt old, hopeless, useless, and powerless. When I began to incorporate biofeedback, relaxation techniques, journaling, visualization, a proper diet, and regular exercise, life took a turn for the better. Not only did my vulvar pain begin to decrease, but the quality of my overall life improved and I regained the self-confidence I had lost. I became happy, hopeful, and proactive. Even though I practiced the relaxation strategies every day, the pain did not go away in a day or even a month. It took me several months of diligent practice to truly heal my vulvar pain. Even today, such practices have carried on to all areas of my life, and now there is not a day when I do not meditate, even for 5 min.
As paradoxical as it may seem, vulvodynia was a blessing in disguise. I believe that vulvodynia was my body’s way of signaling to me that many areas of my life were in perpetual stress: my pelvic floor, my thoracic breathing, my romantic relationship at the time, etc. When I learned to let go and truly embrace my life, I began to feel relief. I became less irritable and more patient and understanding, with both my body and the outside world. The best advice I can give a woman with vulvar symptoms or any person with otherwise inexplicable chronic pain is to apply the strategies that work for you and stick to them every day—even on the days when you want to go astray. When I started to focus on what my body needed to be nurtured and to live my life and do the things I truly wanted to do, I became free. Today, I live in a way that allows me to find peace, serenity, pride, and fun. I live exactly the way I want to, and I find the time to follow my passions. Vulvodynia, or any kind of chronic pain, does not define who we are. We define who we are.
Conclusion
This introspective account of the client’s personal experience with biofeedback suggests that healing is multidimensional. We suggest that practitioners use a holistic approach, which can provide hope and relief to clients who suffer from vulvodynia or other disorders that are often misunderstood and underreported.
Useful blogs
References
Kabat-Zinn, J. (2006). Coming to our senses: Healing ourselves and the world through mindfulness. Hachette Books
Peper, E., Cosby, J. & Almendras, M. (2022). Healing chronic back pain. NeuroRegulation, 9(3), 164–172. https://doi.org/10.15540/nr.9.3.164
Peper, E., Gibney, K.H, & Holt, C.F. (2002. Make health happen: Training yourself to create wellness. Kendall/Hunt.
Peper, E. Martinex, Aranda, P. & Moss, D. (2015). Vulvodynia treated successfully with breathing biofeedback and integrated stress reduction: A case report. Biofeedback, 43(2), 103–109. https://doi.org/10.5298/1081-5937-43.2.04
Hope for menstrual cramps (dysmenorrhea) with breathing
Posted: April 22, 2023 Filed under: behavior, biofeedback, Breathing/respiration, healing, health, meditation, Pain/discomfort, posture, relaxation, self-healing, stress management, Uncategorized | Tags: dysmenorrhea, Imagery, menstrual cramps, stroking, visualization 7 CommentsAdapted from: Peper, E., Chen, S., Heinz, N., & Harvey, R. (2023). Hope for menstrual cramps (dysmenorrhea) with breathing. Biofeedback, 51(2), 44–51. https://doi.org/10.5298/1081-5937-51.2.04; Republished in Townsend E-Letter – 18 November, 2023 https://www.townsendletter.com/e-letter-22-breath-affects-stress-and-menstrual-cramps/
“I have always had extremely painful periods. They would get so painful that I would have to call in sick and take some time off from school. I have been to many doctors and medical professionals, and they told me there is nothing I could do. I am currently on birth control, and I still get some relief from the menstrual pain, but it would mess up my moods. I tried to do the diaphragmatic breathing so that I would be able to continue my life as a normal woman. And to my surprise it worked. I was simply blown away with how well it works. I have almost no menstrual pain, and I wouldn’t bloat so much after the diaphragmatic breathing.” -22 year old student
Each semester numerous students report that their cramps and dysmenorrhea symptoms decrease or disappear during the semester when they implement the relaxation and breathing practices that are taught in the semester long Holistic Health class. Given that so many young women suffer from dysmenorrhea, many young women could benefit by using this integrated approach as the first self-care intervention before relying on pain reducing medications or hormones to reduce pain or inhibit menstruation. Another 28-year-old student reported:
“Historically, my menstrual cramps have always required ibuprofen to avoid becoming distracting. After this class, I started using diaphragmatic breath after pain started for some relief. True benefit came when I started breathing at the first sign of discomfort. I have not had to use any pain medication since incorporating diaphragmatic breath work.”
This report describes students practicing self-regulation and effortless breathing to reduce stress symptoms, explores possible mechanisms of action, and suggests a protocol for reducing symptoms of menstrual cramps. Watch the short video how diaphragmatic breathing eliminated recurrent severe dysmenorrhea (pain and discomfort associated with menstruation).
Background: What is dysmenorrhea?
Dysmenorrhea is one of the most common conditions experienced by women during menstruation and affects more than half of all women who menstruate (Armour et al., 2019). Most commonly dysmenorrhea is defined by painful cramps in the lower abdomen often accompanied by pelvic pain that starts either a couple days before or at the start of menses. Symptoms also increase with stress (Wang et al., 2003) with pain symptoms usually decreasing in severity as women get older and, after pregnancy.
Economic cost of dysmenorrhea
Dysmenorrhea can significantly interfere with a women’s ability to be productive in their occupation and/or their education. It is “one of the leading causes of absenteeism from school or work, translating to a loss of 600 million hours per year, with an annual loss of $2 billion in the United States” (Itani et al, 2022). For students, dysmenorrhea has a substantial detrimental influence on academic achievement in high school and college (Thakur & Pathania, 2022). Despite the frequent occurrence and negative impact in women’s lives, many young women struggle without seeking or having access to medical advice or, without exploring non-pharmacological self-care approaches (Itani et al, 2022).
Treatment
The most common pharmacological treatments for dysmenorrhea are nonsteroidal anti-inflammatory drugs (NSAIDs) (e.g., Ibuprofen, Aspirin, and Naproxen Sodium) along with hormonal contraceptives. NSAIDs act by preventing the action of cyclooxygenase which prevents the production of prostaglandins. Itani et al (2022) suggested that prostaglandin production mechanisms may be responsible for the disorder. Hormonal contraceptives also prevent the production of prostaglandins by suppressing ovulation and endometrial proliferation.
The pharmacological approach is predominantly based upon the model that increased discomfort appears to be due to an increase in intrauterine secretion of prostaglandins F2α and E2 that may be responsible for the pain that defines this condition (Itani et al, 2022). Pharmaceuticals which influence the presence of prostaglandins do not cure the cause but mainly treat the symptoms.
Treatment with medications has drawbacks. For example, NSAIDs are associated with adverse gastrointestinal and neurological effects and also are not effective in preventing pain in everyone (Vonkeman & van de Laar, 2010). Hormonal contraceptives also have the possibility of adverse side effects (ASPH, 2023). Acetaminophen is another commonly used treatment; however, it is less effective than other NSAID treatments.
Self-regulation strategies to reduce stress and influence dysmenorrhea
Common non-pharmacological treatments include topical heat application and exercise. Both non-medication approaches can be effective in reducing the severity of pain. According to Itani et al. (2022), the success of integrative holistic health treatments can be attributed to “several mechanisms, including increasing pelvic blood supply, inhibiting uterine contractions, stimulating the release of endorphins and serotonin, and altering the ability to receive and perceive pain signals.”
Although less commonly used, self-regulation strategies can significantly reduce stress levels associated menstrual discomfort as well as reduce symptoms. More importantly, they do not have adverse side effects, but the effectiveness of the intervention varies depending on the individual.
- Autogenic Training (AT), is a hundred year old treatment approach developed by the German psychiatrist Johannes Heinrich Schultz that involves three 15 minute daily practice of sessions, resulted in a 40 to 70 percent decrease of symptoms in patient suffering from primary and secondary dysmenorrhea (Luthe & Schultz, 1969). In a well- controlled PhD dissertation, Heczey (1978) compared autogenic training taught individually, autogenic training taught in a group, autogenic training plus vaginal temperature training and a no treatment control in a randomized controlled study. All treatment groups except the control group reported a decrease in symptoms and the most success was with the combined autogenic training and vaginal temperature training in which the subjects’ vaginal temperature increased by .27 F degrees.
- Progressive muscle relaxation developed by Edmund Jacobson in the 1920s and imagery are effective treatments for dysmenorrhea (Aldinda et al., 2022; Chesney & Tasto, 1975; Çelik, 2021; Jacobson, 1938; Proctor et al., 2007).
- Rhythmic abdominal massage as compared to non-treatment reduces dysmenorrhea symptoms (Suryantini, 2022; Vagedes et al., 2019):
- Biofeedback strategies such as frontalis electromyography feedback (EMG) and peripheral temperature training (Hart, Mathisen, & Prater, 1981); trapezius EMG training (Balick et al, 1982); lower abdominal EMG feedback training and relaxation (Bennink, Hulst, & Benthem, 1982); and integrated temperature feedback and autogenic training (Dietvorts & Osborne, 1978) all successfully reduced the symptoms of dysmenorrhea.
- Breathing relaxation for 5 to 30 minutes resulted in a decrease in pain or the pain totally disappeared in adolescents (Hidayatunnafiah et al., 2022). While slow deep breathing in combination with abdominal massage is more effective than applying hot compresses (Ariani et al., 2020). Slow pranayama (Nadi Shodhan) breathing the quality of life and pain scores improved as compared to fast pranayama (Kapalbhati) breathing and improved quality of life and reduces absenteeism and stress levels (Ganesh et al. 2015). When students are taught slow diaphragmatic breathing, many report a reduction in symptoms compared to the controls (Bier et al., 2005).
Observations from Integrated stress management program
This study reports on changes in dysmenorrhea symptoms by students enrolled in a University Holistic Health class that included homework assignment for practicing stress awareness, dynamic relaxation, and breathing with imagery.
Respondents: 32 college women, average age 24.0 years (S.D. 4.5 years)
Procedure: Students were enrolled in a three-unit class in which they were assigned daily home practices which changed each week as described in the book, Make Health Happen (Peper, Gibney & Holt, 2002). The first five weeks consisted of the following sequence: Week 1 focused on monitoring one’s reactions to stressor; week 2 consisted of daily practice for 30 minutes of a modified progressive relaxation and becoming aware of bracing and reducing the bracing during the day; Week 3 consisted of practicing slow diaphragmatic breathing for 30 minutes a day and during the day becoming aware of either breath holding or shallow chest breath and then use that awareness as cue to shift to lower slower diaphragmatic breathing; week 4 focused on evoking a memory of wholeness and relaxing; and week 5 focused on learning peripheral hand warming.
During the class, students observed lectures about stress and holistic health and met in small groups to discuss their self-regulation experiences. During the class discussion, some women discussed postures and practices that were beneficial when experiencing menstrual discomfort, such as breathing slowly while lying on their back, focusing on slow abdominal awareness in which their abdomen expanded during inhalation and contracted during exhalation. While exhaling they focused on imagining a flow of air initially going through their arms and then through their abdomen, down their legs and out their feet. This kinesthetic feeling was enhanced by first massaging down the arm while exhaling and then massaging down their abdomen and down their thighs when exhaling. In most cases, the women also experienced that their hands and feet warmed. In addition, they were asked to shift to slower diaphragmatic breathing whenever they observed themselves gasping, shallow breathing or holding their breath. After five weeks, the students filled out a short assessment questionnaire in which they rated the change in dysmenorrhea symptoms since the beginning of the class.
Results.
About two-thirds of all respondents reported a decrease in overall discomfort symptoms. In addition to any ‘treatment as usual’ (TAU) strategies already being used (e.g. medications or other treatments such as NSAIDs or birth control pills), 91% (20 out 22 women) who reported experiencing dysmenorrhea reported a decrease in symptoms when they practiced the self-regulation and diaphragmatic breathing techniques as shown in Figure 1.
Figure 1. Self-report in dysmenorrhea symptoms after 5 weeks.
Discussion
Many students reported that their symptoms were significantly reduced and they could be more productive. Generally, the more they practiced the relaxation and breathing self-regulation skills, the more they experienced a decrease in symptoms. The limitation of this report is that it is an observational study; however, the findings are similar to those reported by earlier self-care and biofeedback approaches. This suggests that women should be taught the following simple self-regulation strategies as the first intervention to prevent and when they experience dysmenorrhea symptoms.
Why would breathing reduce dysmenorrhea?
Many women respond by ‘curling up’ a natural protective defense response when they experience symptoms. This protective posture increases abdominal and pelvic muscle tension, inhibits lymph and blood flow circulation, increases shallow breathing rate, and decreases heart rate variability. Intentionally relaxing the abdomen with slow lower breathing when lying down with the legs extended is often the first step in reducing discomfort.
By focusing on diaphragmatic breathing with relaxing imagery, it is possible to restore abdominal expansion during inhalation and slight constriction during exhalation. This dynamic breathing while lying supine would enhance abdominal blood and lymph circulation as well as muscle relaxation (Peper et al., 2016). While practicing, participants were asked to wear looser clothing that did not constrict the waist to allow their abdomen to expand during inhalation; since, waist constriction by clothing (designer jean syndrome) interferes with abdominal expansion. Allowing the abdomen to fully extend also increased acceptance of self, that it was okay to let the abdomen expand instead of holding it in protectively. The symptoms were reduced most likley by a combination of the following factors.
- Abdominal movement is facilitated during the breathing cycle. This means reducing the factors that prevent the abdomen expanding during inhalation or constricting during exhalation (Peper et al., 2016).
- Eliminate‘Designer jean syndrome’ (the modern girdle). Increase the expansion of your abdomen by loosening the waist belt, tight pants or slimming underwear (MacHose & Peper, 1991).
- Accept yourself as you are. Allow your stomach to expand without pulling it in.
- Free up learned disuse: Allow the abdomen to expand and constrict instead of inhibiting movement to avoid pain that occurred following a prior abdominal injury/surgery (e.g., hernia surgery, appendectomy, or cesarean operation), abdominal pain (e.g., irritable bowel syndrome, recurrent abdominal pain, ulcers, or acid reflux), pelvic floor pain (e.g., pelvic floor pain, pelvic girdle pain, vulvodynia, or sexual abuse).
- The ‘defense response’ is reduced. Many students described that they often would curl up in a protective defense posture when experiencing menstrual cramps. This protective defense posture would maintain pelvic floor muscle contractions and inhibit blood and lymph flow in the abdomen, increase shallow rapid thoracic breathing and decrease pCO2 which would increase vasoconstriction and muscle constriction (Peper et al., 2015; Peper et al., 2016). By having the participant lie relaxed in a supine position with their legs extended while practicing slow abdominal breathing, the pelvic floor and abdominal wall muscles can relax and thereby increase abdominal blood and lymph circulation and parasympathetic activity. The posture of lying down implies feeling safe which is a state that facilitates healing.
- The pain/fear cycle is interrupted. The dysmenorrhea symptoms may trigger more symptoms because the person anticipates and reacts to the discomfort. The breathing and especially the kinesthetic imagery where the attention goes from the abdomen and area of discomfort to down the legs and out the feet acts as a distraction technique (not focusing on the discomfort).
- Support sympathetic-parasympathetic balance. The slow breathing and kinesthetic imagery usually increases heart rate variability and hand and feet temperature and supports sympathetic parasympathetic balance.
- Interrupt the classical conditioned response of the defense reaction. For some young girls, the first menstruation occurred unexpectedly. All of a sudden, they bled from down below without any understanding of what is going on which could be traumatic. For some this could be a defense reaction and a single trial condition response (somatic cues of the beginning of menstruation triggers the defense reaction). Thus, when the girl later experiences the initial sensations of menstruation, the automatic conditioned response causes her to tense and curl up which would amplify the discomfort. Informal interviews with women suggests that those who experienced their first menstruation experience as shameful, unexpected, or traumatic (“I thought I was dying”) thereafter framed their menstruation negatively. They also tended to report significantly more symptoms than those women who reported experiencing their first menstruation positively as a conformation that they have now entered womanhood.
How to integrate self-care to reduce dysmenorrhea
Be sure to consult your healthcare provider to rule out treatable underlying conditions before implementing learning effortless diaphragmatic breathing.
- Allow the abdomen to expand during inhalation and become smaller during exhalation. This often means, loosen belt and waist constriction, acceptance of allowing the stomach to be larger and reversing learned disuse and protective response caused by stress.
- Master diaphragmatic breathing (see: Peper & Tibbetts, 1994 and the blogs listed at the end of the article).
- Practice slow effortless diaphragmatic breathing lying down with warm water bottle on stomach in a place that feels safe.
- Include kinesthetic imagery as you breathe at about 6 breaths per minute (e.g. slowly inhale for 4 or 5 seconds and then exhale for 5 or 6 seconds, exhaling slightly longer than inhaling). Imaging that when you exhale you can sense healing energy flow through your abdomen, down the legs and out the feet.
- If possible, integrate actual touch with the exhalation can provide added benefit. Have a partner first stroke or massage down the arms from the shoulder to your fingertips as you exhale and, then on during next exhalation stroke gently from your abdomen down your legs and feet. Stroke in rhythm the exhalation.
- Exhale slowly and shift to slow and soft diaphragmatic breathing each time you become aware of neck and shoulder tension, breath holding, shallow breathing, or anticipating stressful situations. At the same time imagine /sense when exhaling a streaming going through the abdomen and out the feet when exhaling. Do this many times during the day.
- Practice and apply general stress reduction skills into daily life since stress can increase symptoms. Anticipate when stressful event could occur and implement stress reducing strategies.
- Be respectful of the biological changes that are part of the menstrual cycle. In some cases adjust your pace and slow down a bit during the week of the menstrual cycle; since, the body needs time to rest and regenerate. Be sure to get adequate amount of rest, hydration, and nutrition to optimize health.
- Use self-healing imagery and language to transform negative association with menstruation to positive associations (e.g., “curse” to confirmation “I am healthy”).
Conclusion
There are many ways to alleviate dysmenorrhea. Women can find ways to anticipate and empower themselves by practicing stress reduction, wearing more comfortable clothing, using heat compression, practicing daily diaphragmatic breathing techniques, visualizing relaxed muscles, and positive perception towards menstrual cycles to reduce the symptoms of dysmenorrhea. These self-regulation methods should be taught as a first level intervention to all young women starting in middle and junior high school so that they are better prepared for the changes that occur as they age.
“I have been practicing the breathing techniques for two weeks prior and I also noticed my muscles, in general, are more relaxed. Of course, I also avoided the skinny jeans that I like to wear and it definitely helped.
I have experienced a 90% improvement from my normal discomfort. I was still tired – and needed more rest and sleep but haven’t experienced any “terrible” physical discomfort. Still occasionally had some sharp pains or bloating but minor discomfort, unlike some days when I am bedridden and unable to move for half a day. – and this was a very positive experience for me “ — Singing Chen (Chen, 2023).
Listen to the expanded podcast created from this blogpost by Google Notebook LM.
Useful blogs to learn diaphragmatic breathing
References
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Biofeedback, posture and breath: Tools for health
Posted: December 1, 2022 Filed under: ADHD, behavior, biofeedback, Breathing/respiration, CBT, cognitive behavior therapy, computer, digital devices, education, emotions, ergonomics, Evolutionary perspective, Exercise/movement, healing, health, laptops, mindfulness, Neck and shoulder discomfort, Pain/discomfort, posture, relaxation, screen fatigue, self-healing, stress management, Uncategorized, vision, zoom fatigue 3 CommentsTwo recent presentations that that provide concepts and pragmatic skills to improve health and well being.
How changing your breathing and posture can change your life.
In-depth podcast in which Dr. Abby Metcalf, producer of Relationships made easy, interviews Dr. Erik Peper. He discusses how changing your posture and how you breathe may result in major improvement with issues such as anxiety, depression, ADHD, chronic pain, and even insomnia! In the presentation he explain how this works and shares practical tools to make the changes you want in your life.
How to cope with TechStress
A wide ranging discussing between Dr. Russel Jaffe and Dr Erik that explores the power of biofeedback, self-healing strategies and how to cope with tech-stress.
These concepts are also explored in the book, TechStress-How Technology is Hijacking our Lives, Strategies for Coping and Pragmatic Ergonomics. You may find this book useful as we spend so much time working online. The book describes the impacts personal technology on our physical and emotional well-being. More importantly, “Tech Stress” provides all of the basic tools to be able not only to survive in this new world but also thrive in it.
Additiona resources:
Gonzalez, D. (2022). Ways to improve your posture at home.
Hope for abdominal discomfort
Posted: June 21, 2022 Filed under: behavior, biofeedback, Breathing/respiration, emotions, Evolutionary perspective, healing, health, Pain/discomfort | Tags: functional abdominal pain, heart rate variability, HRV, IBS, irritable bowel syndrome, neurasthenia, Rap, recurrent abdominal pain, respiration 3 CommentsAdapted from: Peper, E. & Harvey, R. (2022). Nausea and GI discomfort: A biofeedback assessment model to create a rational for training. Biofeedback, 50(1), 24–32. https://doi.org/10.5298/1081-5937-50.1.05
Abdominal discomfort and pain such as functional abdominal pain, acid reflux or irritable bowel affects many people. Teaching slower biofeedback-assisted HRV breathing with biofeedback is a useful strategy by which the person may be able to reduce symptoms. This essay provides detailed instruction for a first session assessment for clients who have abdominal discomfort (functional abdominal pain). Descriptions include how the physiological recording can be used to understand a possible etiology of the illness, to create a biological/evolutionary based explanation that is readily understood by the client, and finally to offer self-regulation suggestions to improve health.
Background of abdominal discomfort (irritable bowel syndrome, acid reflux, functional abdominal pain, recurrent abdominal pain)
Irritable bowel syndrome (IBS) affects 7% to 21% of the general population in Western cultures with a global prevalence estimated at around 11% (Fairbrass, Costantino, Gracie, & Ford, 2020). The chronic symptoms (i.e., lasting more than 30 days) usually include abdominal cramping, discomfort or pain, bloating, loose or frequent stools and constipation, which can significantly reduce the quality of life (Chey et al., 2015). A precursor of IBS in children is called recurrent abdominal pain (RAP), which affects 0.3% to 19% of school children (Chitkara et al., 2005). Both IBS and RAP appear to be functional illnesses, as no organic causes have been identified to explain the symptoms. IBS and RAP are contrasted to various types of diseases such as Crohn’s disease, inflammatory bowel disease or ulcerative colitis.
Multiple factors may contribute to IBS, such as genetics, food allergies, previous treatment with antibiotics, infections, psychological status and stress. More recently, dietary factors contributing to changes in the intestinal and colonic microbiome resulting in small intestine bacterial overgrowth have been suggested as another risk factor (Dupont, 2014). Generally, standard medical treatments (reassurance, dietary manipulation and of pharmacological therapy) are often ineffective in reducing IBS symptoms (Chey et al., 2015). On the other hand, complementary and alternative approaches such as biofeedback-assisted relaxation techniques (Davidoff & Whitehead, 1996; Goldenberg et al., 2019; Stern et al. 2014), autogenic training (Luthe & Schultz, 1969) and cognitive therapy are more effective than traditional medical treatment (Vlieger et al., 2008).
Biofeedback-assisted relaxation training typically moderates IBS or RAP symptoms by restoring balance in the nervous system (sympathetic/parasympathetic autonomic balance), such as through heart rate variability (HRV) breathing training. For example, Sowder et al. (2010) as well as Sun et al. (2016) demonstrated that functional abdominal pain can be reduced with HRV feedback training. In most cases, increased vagal tone was achieved by breathing at about six breaths per minute. While Taneja et al. (2004) reported that yogic breathing decreased diarrhea-predominant irritable bowel syndrome symptoms significantly more than conventional treatment in a randomized control study.Sympathetic/parasympathetic balance can be enhanced by increasing HRV, which occurs when a person breathes at their resonant frequency, which is usually 5–7 breaths per minute. For most people, the HRV training means breathing at much slower rate. A benefit of slow abdominal breathing appears to be a self-control strategy that can reduce symptoms of IBS, RAP and similar functional abdominal pain symptoms.
Mastery of effortless diaphragmatic breathing can be affected by injury, surgery or similar insults to the abdominal area (Peper et al., 2015). In addition, dysregulation of diaphragm, which is enervated by the phrenic nerve and the vagus nerve, along with dysregulation of other abdominal muscles appears to be associated with irritable bowel syndrome (Bordoni & Morabito, 2018). It is likely that slower biofeedback-assisted HRV breathing training restores abdominal muscles and diaphragmatic movement, theoretically by tonic and phasic regulation of the phrenic and vagal nerve activity (cf. Marchenko et al., 2015; Streeter et al., 2012). The theory, simply stated, is that HRV breathing training at an individual’s resonant frequency produces increases in regulatory neurotransmitters, particularly gamma amino butyric acid (GABA). Many of our students who complain of abdominal discomfort report reductions of symptoms following HRV breathing training.
Consistently for more than 40 years, we have taught undergraduate students a semester-long integrated stress management program that includes modified progressive relaxation, slow diaphragmatic breathing and changing internal language as outlined in the book, Make Health Happen, by Peper, Gibney & Holt (2002). At the end of each semester, numerous students report that their anxiety, gastrointestinal distress and other symptoms related to self-described IBS or RAP have decreased or disappeared (Peper et al., 2014; Peper, Miceli, & Harvey, 2016; Peper, Mason, Huey, 2017; Peper et al., 2020). Abdominal discomfort is prevalent experience of distress by college students. In our recent survey of 99 undergraduate students, 41% self-reported abdominal discomfort (25% irritable bowel or acid reflux), 86% self-reported anxiety, 70% neck and shoulder tension and 48% headaches. After practicing slower breathing (i.e., typically directing them to breath abdominally at a rate of about six breaths a minute) and focus on slower exhalation and allowing the air to flow in without effort as the abdominal wall expands, as a homework assignment for a week, many reported that their symptoms significantly decreased (Peper, Harvey, Cuellar, & Membrila, in press).
Case example illustrating how to use the physiological recording to guide the client discussion and provide motivation
A 16-year-old high school junior suffered from abdomen discomfort for years. The symptoms mainly consisted of frequent constipation, and when it occurred, great discomfort from nausea. After having been diagnosed and undergoing all the necessary tests by the gastroenterologist, there was no identifiable cause of the chief complaints. Biofeedback was suggested as an alternative to medications for symptom reduction. During the biofeedback assessment and training session, the client discussed what she would like to learn from the session. It was challenging for her to respond to those questions. Not being able to report what the client would like from a training session is also a very common experience when working with students. A useful strategy is to describe experiences of other students that the clients could relate to, and imply that their abdominal discomfort is somewhat commonplace in other students.
Discussed during the session was the link between being very sensitive and reactive to other people’s feeling and being concerned about what others think of her. The client nodded her head in agreement. When describing herself, she discussed being very perfectionistic using a scale from being lackadaisical/undemanding to being perfectionistic (i.e., self-oriented perfectionism, self-worth contingencies, concern over mistakes, doubts about actions, self-criticism, socially prescribed perfectionism, other-oriented perfectionism, hypercriticism; see Smith, Saklofske, Stoeber, & Sherry, 2016).
Furthermore, the client sat slouched in the chair. Possibly her slouched posture implied a state of powerlessness instead of empowerment, a state of being ready to react and protect (Carney, Cuddy, & Yap, 2010; Cuddy, 2012; Peper, Lin, & Harvey, 2017).
Working hypotheses. The client was very sensitive and continuously reacted to external and internal signals with sympathetic arousal, while masking her reactions. These ongoing flight/flight responses would decrease intestinal peristalsis and abdominal blood flow, which would result in nausea, constipation and abdominal distress. Namely, the body reacts to the stimuli as signals of danger and blood flow is shunted away from the abdomen into the large muscles to run and fight. To paraphrase Stanford University professor Robert Sapolsky (2004): Why should the body digest food and repair itself, if it is going to be the predator’s lunch? It is only when we are safe that we can digest and regenerate.
The session began by exploring how pressure on the abdomen could potentially affect experiences of nausea and abdominal distress. After explaining how the diaphragm descends and how abdominal content in the stomach can be displaced (spread out) during inhalation, we systematically changed her posture by placing and adjusting a small pillow behind her middle back so that she could sit tall. The tall posture resulted in an open feeling of empowerment not felt during slouching. She observed that breathing was slightly easier and felt there was more space in her abdomen. As she began to feel more comfortable during the training session, we discussed the impact of posture on the body. We also discussed the relationship between thoughts of perfectionism and abdominal discomfort. The discussion also included an exploration of why some people tend to curl-up and slouch in a protective posture (e.g., head down to protect the neck region and big bones of the arms and legs positioned to protect the core organs) when feeling self-consciousness or perfectionistic about body image.
Biofeedback monitoring for assessment
Psychophysiology was recorded with multichannel physiological system (Procomp Infinity System running Biograph Infinity software version 6.7.1, Thought Technology Ltd). Respiration was monitored with strain-gauge sensors placed around the abdomen and thoracic regions (for a discussion on sensor placement see Peper et al., 2016 and Chu et al., 2019). Blood volume pulse was recorded with the sensor placed on the left thumb. The thumb was used because the participant had small and cold fingers (for a discussion about blood volume pulse, see Peper et al, 2007 and Peper, Shafer, & Lin, 2010). Skin conductance was recorded with the sensor wrapped around the left index and middle fingers with the electrodes on the finger pads (for a discussion about skin conductance and normal values, see Khazan, 2019, and Shafer et al, 2016).
After sensors were attached and the signals explained, the client sat comfortably while looking at the screen. Unexpectedly the clinician clapped his hands and made a loud noise. The client reacted with a momentary startle and smile. The physiological response, showed an increase in skin conductance, decrease in pulse amplitude, decrease in abdominal diameter, and increase in heart rate, is shown in Figure 1.
Figure 1. Physiological response to a loud noise (clap) (1) increased skin conductance, (2) decrease in pulse amplitude, (3) decrease in decreased abdominal circumference, and (4) increased heart rate and decreased heart rate variability.
The client was aware that she reacted to the clap; however, she was totally unaware how much her body responded. The computer screen display of her physiological reaction made the invisible visible. It provided the opportunity to discuss how various body reactions related to heart rate, breathing, and skin conductance could contribute to experiences of abdominal discomfort.
She was unaware that skin conductance did not return to baseline levels for more than 20 minutes. An elevated skin conductance level may mean that the body’s reaction to the hand-clap noise triggered a defense reaction and maintained the increased sympathetic activity for more than 20 minutes. Having a sustained flight/fight reaction to external stimuli such as a hand-clap would most likely affect digestive and peristalsis processes, contributing to symptoms found in IBS and RAP. The observations made during biofeedback monitoring led to a discussion of how sympathetic activation affects the gastrointestinal track.
Blood volume pulse amplitude decreased, which indicated a decrease in blood flow through her hands, which would decrease hand temperature and again indicated a systemic sympathetic activation.
Abdominal circumference decreased, which indicated that she tightened her abdominal muscles as a protective response to the hand-clap. She was unaware of the abdominal muscles tightening; however, she stated that she was aware that her breathing had changed. The abdominal muscle, which pulled the abdomen in, took almost two minutes to relax. The sustained muscle constriction around the abdomen increased pressure around the core organs, which may contribute to ongoing abdominal discomfort. A fight-flight reaction includes body bracing (e.g. tightened muscles, head down to protect the neck, big bones of arms and legs curled to protect core organs), and she confirmed that she experienced neck and shoulder tensions.
The discussion of abdominal muscle tension led to another discussion of how holding your stomach in may relate to self-image. For example, tight clothing can contribute to constricted movement around the abdomen. Wearing corsets contributed to psychophysiological symptoms, mainly for women in the late 19th and early 20th centuries, during a time when women who wore very tight corsets were diagnosed with neurasthenia. Simply stated, neurasthenia was characterized as a condition of mental and/or physical fatigue with at least two of the following symptoms: dyspepsia, dizziness, muscular aches or pains, tension headaches, inability to relax, irritability and sleep disturbance.
“Dyspepsia” was the commonly reported symptom of neurasthenia, which included upset stomach, a gnawing or burning stomach pain, heartburn, bloating, and or burping, nausea, and vomiting. The constricted waist region that resulted from wearing a corset in the name of fashion compromises the functions of both digestion and breathing. When the person inhales, the abdomen cannot expand as the diaphragm is flattening and pushing downward. Thus, the person is forced to breathe more shallowly by lifting their ribs; this increases neck and shoulder tension as well as the risk of anxiety, heart palpitation, and fatigue (Cohen & White, 1947; Courtney, 2009).
It also can contribute to abdominal discomfort since the abdomen is being squeezed by the corset and forcing the abdominal organs upward. Even architects of the Victorian era recognized a need for a place to position a chair or chaise lounge, such as at the top of some stairs, because people wearing corsets could faint, pass out or otherwise experience breathlessness through the effort of climbing the stairs with restrictive clothing around their abdomen (Melissa, 2015). Many of these symptoms could be easily reduced by wearing looser clothing and learning slower diaphragmatic breathing. In modern times, a related phenomenon results when people wear items of clothing that are too tight around their waist or abdomen (e.g., tight jeans) in service to fashion trends often labeled as designer jean syndrome (MacHose & Peper, 1991; Stonehewer, 2009). Similarly, when people wear garments that are too tight around their chest or thoracic region (e.g., tight vests) in service to external protection (e.g., athletes, industrial workers, police or soldiers wearing heavy, restrictive gear), then restrictive ventilatory disorders can occur (Harty et al., 1999). Simply stated, when the muscles related to breathing are restricted from moving, respiration is affected.
The client’s heart rate increased and stayed high for more than 30 seconds. The first decrease in heart rate at about 20 seconds after the hand-clap was a long sigh of relief as breathing (i.e., oxygen/carbon dioxide exchange) started again. It took almost 90 seconds before breathing and heart rate returned to normal as reflected by measures of HRV. The computer screen showing increased heart rate was reviewed with the client to explain how her body reacted with a fight-flight response to the hand-clap, as well as how regulating breathing through biofeedback training could lower the heart rate and reduce the sympathetic activation and enhance the parasympathetic activation.
Body responds to cognitive stressful thoughts
After discussion about the psychophysiological response to the hand-clap (a physical external stressor) and how other external stressors (e.g., startling noise) or internal stressors (e.g., perfectionistic ruminations) could trigger a similar response of abdominal muscle tightening, the assessment was repeated by having her relax and then think about a mental stressor, as shown in Figure 2.
Figure 2. Physiological responses to thinking about a past stressor (1) increased skin conductance, (2) decreased pulse amplitude, (3) decreased abdominal circumference, and (4) increased heart rate and decreased HRV.
The physiological response pattern to thinking about a past stressor was similar to the bodily reaction to a loud noise. The skin conductance increased and blood volume pulse amplitude decreased immediately after hearing (e.g., anticipating) the task of evoking/thinking of a past stressor. Most likely, the initial response was triggered by performance anxiety, then 6 seconds later the heart rate increased and breathing changed as she began experiencing the somatic reaction evoked by the recall of a negative stressor. The recordings also showed that her pulse amplitude decreased. The decrease in pulse amplitude suggested that her hands would probably become colder, which was confirmed by her self-report that she often experienced cold hands and feet. She reported being aware of the feeling an emotional reaction, but mainly noticing the change of breathing in her chest, and she was unaware of the abdominal changes. The client was surprised by how her body reacted to emotional thoughts. The recording viewed on the computer screen demonstrated objectively that her thoughts (initial performance anxiety) had a physical effect on her body. Specifically, experiencing the emotions that were evoked by recalling the stressful memory had a direct effect on the body in the same way that a physical external threat leads to a fight-flight response.
Building a psychophysiological model
Using these recorded computer images reflecting physical reactions to the hand clap and emotional thoughts, the discussion focused on how abdominal discomfort could be the result of activating a normal biological survival response. Survival responses would occur hundreds of times throughout a day, especially when worrying. Each thought would evoke the response, and the awareness of body reaction would evoke another reaction. Similar to how awareness of blushing amplifies blushing.
The client shared that she was very sensitive and reactive especially when other people were upset. She reported feeling “cursed” by their sensitivity and reactivity. The linguistic metaphor that could be used to describe her reactions is “she could not stomach what was going on.”
The discussion about physiological reactions provided the client with a model how her disorder (IBS and RAP) could have developed and been maintained over the years. The model matched her subjective experience: when stressed, the discomfort often increased. The discussion shifted to reframing her internal labels. Instead of describing her sensitivity as a curse, the sensitivity was reframed and labeled a gift; namely, she could sense many people’s emotional reactions, to which they would react in a variety of ways. She just needed to learn how to manage this sensitivity. Once she learned to manage it, she would have many advantages in interpersonal relations at home and at work. She would be able to sense what other people are experiencing. By reframing her symptoms as a result of a survival physiological response pattern, it reduces self- blame and offers solutions about how to master and change reactions and thereby have more control in the world.
Training to demonstrate control is possible.
The discussion was followed by teaching her diaphragmatic breathing in sitting and lying down positions. As she had no history of abdominal injuries, similar to many of our students, she rapidly demonstrated slower diaphragmatic breathing as shown in Figures 3 and 4.
Figure 3. The client practiced a few slower diaphragmatic breaths in the sitting and reclining position, which increased heart rate variability, decreased skin conductance and increased blood volume pulse amplitude.
Figure 4. Practicing slower diaphragmatic breathing at about six breaths per minute in a reclining position increased HRV.
With tactile coaching, she demonstrated that she could breathe at about six breaths per minute with the heart rate increasing during inhalation and decreasing during exhalation. She reported feeling more relaxed and that the sensations of nausea had disappeared. Additionally, her hands felt warmer. This recording provided proof that there was hope and that she could do something about her body’s psychophysiological responses.
The discussion focused on how breathing affecting heart rate variability. Namely, if she allowed exhalation to occur without effort, her heart rate decreased (the vagal response of slowing the heart) and thereby increased the parasympathetic activation that would support digestion and gastrointestinal functioning. Often when people practice effortless diaphragmatic breathing, abdominal noises (borborygmus)– the gurgling, rumbling, or squeaking noise from the abdomen–occur and indicate that intestinal activity is being activated, and that food, liquids and digestive juice are moving through the intestines. It is usually a positive indicator that the person is relaxing and sympathetic activity has been reduced.
During the last part of session, we reviewed how posture affects physiology, emotions and cognitions, as well as how posture and breathing would be the first step in beginning to reduce symptoms and enhance health. To provide additional information using video and bibliotherapy/education, we suggested that she watches the embedded videos in the blogs listed at the end of the article.
Recommendations for future sessions and home practice
The recommended strategies for future sessions would focus on teaching the client to master slow diaphragmatic breathing and practicing that for 10–20 minutes per day. The teaching techniques would incorporate imagery to imagine air flowing down their arms and legs as she exhaled. . More importantly, the focus would shift to generalize the skill during the day; namely, whenever she would become aware of feeling stressed or observed herself holding her breath or breathing in her chest, she would use that as the cue to shift to slower abdominal breathing. Had the client continued training, future sessions would focus on mastering slower diaphragmatic breathing. The training would include relaxing the lower abdominal muscles during inhalation, increasing control of HRV, practicing imagining stress and use image to trigger slower breathing, and cognitive reframing practices to interrupt worrying and promote self-acceptance. The final goal is to generalize these skills into daily life as illustrated in the successful cases described in the following blogs
Blogs on posture:
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