Healing chronic back pain

Erik Peper, PhD, BCB, Jillian Cosby, and Monica Almendras

In at the beginning of 2021, I broke my L3 vertebra during a motor cycle accident and underwent two surgeries in which surgeons replaced my shattered L3 with a metal “cage” (looks like a spring) and fused this cage to the L4 and L2 vertebrae with bars. I also broke both sides of my jaw and fractured my left shoulder. I felt so overwhelmed and totally discouraged by the ongoing pain. A year later, after doing the self-healing project as part of the university class assignment, I feel so much better all the time, stopped taking all prescription pain medications and eliminated the sharp pains in my back. This project has taught me that I have the skill set needed to be whole and healthy. –J.C., 28-year-old college student

Chronic pain is defined as a pain that persist or recurs for more than 3 months (Treede et al., 2019). It is exhausting and often associated with reduced quality of life and increased medical costs (Yong, Mullins, & Bhattacharyya, 2022).  Pain and depression co-exacerbate physical and psychological symptoms and can lead to hopelessness (IsHak, 2018; Von Korff & Simon, 1996). To go to bed with pain and anticipate that pain is waiting for you as you wake up is often debilitating. One in five American adults experience chronic pain most frequently in back, hip, knee or foot (Yong, Mullins, & Bhattacharyya, 2022). Patients are often prescribed analgesic medications (“pain killers”) to reduce pain. Although, the analgesic medications can be effective in the short term to reduce pain, the efficacy is marginal for relieving chronic pain (Eriksen et al., 2006; Tan, & Jensen, 2007). Recent research by Parisien and colleagues (2022) reported that anti-inflammatory drugs were associated with increased risk of persistent pain. This suggest that anti-inflammatory treatments might have negative effects on pain duration. In addition, the long-term medication use is a major contributor to opioid epidemic and increased pain sensitivity (NIH NIDA, 2022; Higgins, Smith, & Matthews, 2019; Koop, 2020). Pain can often be successfully treated with a multidisciplinary approach that incorporates non-pharmacologic approaches. These include exercise, acceptance and commitment therapy, as well as hypnosis (Warraich, 2022). This paper reports how self-healing strategies as taught as part of an undergraduate university class can be an effective approach to reduce the experience of chronic pain and improve health.

Each semester, about 100 to 150 junior and senior college students at San Francisco State University enroll in a holistic health class that focused on ‘whole-person’ Holistic Health curriculum. The class includes an assessment of complementary medicine and holistic health. It is based upon the premise that mind/emotions affect body and body affect mind/emotions that Green, Green & Walters (1970) called the psychophysiological principle.

“Every change in the physiological state is accompanied by an appropriate change in the mental emotional state, conscious or unconscious, and conversely, every change in the mental emotional state, conscious or unconscious, is accompanied by an appropriate change in the physiological state.”

The didactic components of the class includes the psychobiology of stress, the role of posture, psychophysiology of respiration, lifestyle and other health factors,  reframing internal language, guided and self-healing imagery. Students in the class are assigned self-healing projects using techniques that focus on awareness of stress, dynamic regeneration, stress reduction imagery for healing, and other behavioral change techniques adapted from the book, Make Health Happen (Peper, Gibney, & Holt, 2002).

The self-practices during the last six weeks of the class focus on identifying, developing and implementing a self-healing project to optimize their personal health.  The self-healing project can range from simple life style changes to reducing chronic pain. Each student identifies their project such as increasing physical activity, eating a healthy diet and reducing sugar and junk food,  stopping vaping/smoking, reducing anxiety or depression, stopping hair pulling, reducing headaches, decreasing ezema, or back pain, etc.  At the end of the semester, 80% or more of the students report significant reduction in symptoms (Peper, Sato-Perry, & Gibney, 2003; Peper, Lin, Harvey, Gilbert, Gubbala, Ratkovich, & Fletcher, 2014; Peper, Miceli, & Harvey, 2016; Peper, Harvey, Cuellar, & Membrila, 2022).  During the last five semesters, 13 percent of the students focused reducing pain (e.g., migraines, neck and shoulder pain, upper or lower back pain, knee pain, wrist pain, and abdominal pain).   The students successfully improved their symptoms an average of 8.8 on a scale from 0 (No benefit) to 10 (total benefit/improvement). The success for improving their symptoms correlates 0.63 with their commitment and persistence to the project (Peper, Amendras, Heinz, & Harvey, in prep).  

The purposes of this paper is to describe a case example how a student with severe back pain reduced her symptoms and eliminated medication by implementing an integrated self-healing process as part of a class assignment and offer recommendations how this could be useful for others.

Participant: A 28-year-old female student (J.C.) who on January 28, 2021 broke her L3 vertebra in a motor cycle accident. She underwent two surgeries in which surgeons replaced her shattered L3 with a metal “cage” (which she describes as looking like a spring) and fused this cage to the L2 and L4 vertebrae with bars. She also broke both sides of her jaw and fractured her left shoulder. More than a year later, at the beginning of the self-healing project, she continue to take 5-10 mgs of Baclofen and 300 mgs of Gabapentin three times a day to reduce pain.

Goal of the self-healing project: To decrease the sharp pain/discomfort in her lower back that resulted from the motor cycle accident and, although not explicitly listed, to decrease the pain medications.

Self-healing process

During the last six weeks of the 2022 Spring semester, the student implemented her self-healing practices for her personal project which consisted of the following steps. 

1. To create a self-healing plan that included exploring the advantage and disadvantage of her illness.

2. To create a step-by-step plan with specific goals to relief her tension and pain in her lower back. This practice allowed her to quantify her problem and the solutions. Like so many people with chronic pain, she focused on the problem and feelings (physical and emotional) associated with the pain. As a result, she often feel hopeless and worried that it would not change.

3. To observe and evaluate when her pain sensations changed. She recognized that she automatically anticipated and focused on the pain and anxiety whenever she needed to bend down into a squat. She realized that she had been anticipating pain even before she began to squat. This showed that she needed to focus on healing the movement of this area of her body.

Through her detailed observations, she realized that her previous general rating of back pain could be separated into muscle tightness/stiffness and pain. With this realization, she changed the way she was recording her pain level. She changed it from “pain level” into into two categories: tightness and sharp pains.

4. To ask questions of her unconscious through a guided practice of accessing an inner guide through imagery (For detailed instructions, see Peper, Gibney, & Holt, 2002, pages 197-206). In this self-guided imagery the person relaxes and imagines being in a special healing place where you felt calm, safe and secure. Then as you relaxed, you become aware of another being (wise one or guide) approaching you (the being can be a person, animal, light, spirit, etc.). The being is wise and knows you well. In your mind, you ask this being or guide questions such as, “What do I need to do to assist in my own healing?”  Then you wait and listen for an answer.  The answer may take many forms such as in words, a pictures, a sense of knowing, or it may come later in dreams or in other forms.  When students are assigned this practice for a week, almost all report experiencing some form of guide and many find the answers meaningful for their self-healing project.

Through this imagery of the inner guide script, she connected with her higher self and  the wise one told her to “Wait.”  This connecting with the wise one was key in accepting that the project was not as daunting as she initially thought.  She realized that pain was not going to be forever in her future. She also interpreted that as reminder to have patience with herself. Change takes practice, time and practice such as she previously experienced while correcting her posture to manage her emotions and edit her negative thoughts into positive ones (Peper, Harvey, Cuellar, & Membrila, 2022). Whenever she would have pain or feel discouraged because of external circumstances, she would remind herself of three things:

A. I need to have patience with myself.

B. I have all the healing tools inside me and I am learning to use them.

C. If I do not make time for my wellness, I’ll be forced to make time for my illness.

5. To practice self-healing imagery as described by Peper, Gibney, & Holt (2002) and adapted from the work by Dr. Martin Rossman (Rossman, 2000). Imagery can be the communication channel between the conscious/voluntary and the unconscious/autonomic/involuntary nervous system (Bressler, 2005; Hadjibalassi et al, 2018; Rossman, 2019). It appears to act as the template and post-hypnotic suggestion to implement behavior change and may offer insight and ways to mobilize the self-healing potential (Battino, 2020). Imagery is dynamic and changeable.

The process of self-healing imagery consists of three parts.

  1. To inspect the problem and create a graphic illustration of the problem as it is experienced at that moment of time.
  2. To illustrate graphically how that area/problem would look when being completely well/whole or disappeared.
  3. To create a self-healing process by which the problem would become transformed into health (Peper, Gibney & Holt, 2002, pp. 217-236). the process focuses on what the person can do for themselves; namely, each time they became aware of, anticipated, or felt the problem, they would focus on the self-healing process. It provideshope; since, the person now focuses on the healing of the problem and becoming well.  

The drawings of inspection of the pain and problem she experienced at that moment of time are shown in Figure 1.

Figure 1. Illustration of the problem of the pain. Thorns dug deep, muscles tight, and frozen vertebrates grinding.

The resolution of the problem and being well/whole are illustrated in Figure 2.

Figure 2. Resolution of the problem in which her muscles are warm, full of blood, free of thorns, relaxed and flexible and being whole happy and healthy in which her spine is warm, her muscles are warm, her back is flexible and full of movement.

Although she utilized the first image of the muscles warm, full of blood, free of thorns and the muscles relaxed and flexible, her second image of her fully being healed was inspired through a religious statue of Yemaya that she had in her room (Yemaya is a major water spirit from the Yoruba religion Santeria and Orisha of the seas and protector of women).  Each time she saw the statue, she thought of the image of herself fully healed and embodying the spirit Orisha. Therefore, this image remained important to her all the time.

Her healing imagery process by which she transforms the image of inspecting of the problem to being totally well are illustrated in Figure 3.

Figure 3. The healing process: The sun’s warm fingers thaw my muscles, lubricate my vertebra, thorns fall out, and blood returns.

For five weeks as she implemented her self-healing project by creating a self-healing plan, asking questions of her unconscious, drawing her self-healing imagery. She also incorporated previously learned skills from the first part of the semester such diaphragmatic breathing, hand warming, shifting slouching to upright posture, and changing language. Initially she paired hand warming with the self-healing imagery and she could feel an increase in body warmth each time she practiced the imagery.  She practiced the self-healing imagery as an in-depth daily practice and throughout the day when she became aware of her back as described in one of her log entries. 

I repeated the same steps as the day prior today. I did my practice in the early morning but focused on the details of the slowed down movements of the sun’s hands. I saw them as they stretched out to my back, passed through my skin, wrapped around my muscles, and began to warm them. I focused on this image and tried to see, in realistic detail, my muscles with a little ice still on them, feeling hard through and through, the sun’s glowing yellow-orange fingers wrapped around my muscles. I imaged the thorns still in my muscles, though far fewer than when I started, and then I imaged the yellow-orange glow start to seep out from the sun’s palms and fingers and spread over my muscles. I imaged the tendons developing as the muscle tissue thawed and relaxed, the red of the muscle brightened, the ice on and within my muscles started to melt, and the condensation formed as it ran down into collected droplets at the bottom of my muscles. I imaged the thorns lose their grip and fall out, one at a time, in tandem with the droplets falling. I continued this process and imaged my muscles expanding with warmth and relaxation as they stayed engulfed in the warmth of the sun.

At the end of my practice, I did a small stretch session. I felt extremely refreshed and ready for yet another extremely busy day between internship, graduation, and school. I would say I felt warm and relaxed all the way into the afternoon, about 6 hours after my practice. This was by far the most detailed and impactful imagery practice I have had.

The self-healing imagery practice provided me with the ability to conceptualize more than my problem as it showed me the tools to (and the importance of) conceptualizing my solution, both the tool and end result.

Results

Pain and tightness decreased and she stopped her medication by the third week as shown in Figure 4.  

Figure 4. Self-rating of sharp pains and tightness during the self-healing project.

At the 14-week follow-up, she has continued to improve, experiences minimal discomfort, and no longer takes medication. As she stated, I was so incredibly shocked how early on [in the project] I was able to stop taking pain medications that I had already taken every day for over a year.

Discussion

This individual case example provides hope that health can be improved when shifting the focus from pain and discomfort to focusing on actively participating in the self-healing process.  As she wrote, The lesson was self- empowerment in regard to my health. I brought comfort to my back. There is metal in my back for the rest of my life and this is something I have accepted. I used to look at that as a horrible thing to have to handle forever. I now look at it as a beautiful contraption that has allowed me to walk across a graduation stage despite having literally shattered a vertebra. I am reintegrating these traumatized parts of my body back into a whole health state of mind and body. Doctors did not do this, surgeries did not, PT didn’t and neither did pain medications. MY body and MY mind did it. I did this.

Besides the self-healing imagery and acting upon the information she received from the asking questions from the unconscious there were many other factors contributed to her healing.  These included the semester long self-practices and  mastery of different stress management techniques, learning how stress impacts health and what can the person can do to self-regulate, as well as being introduced to  the many case examples and research studies that suggested healing could be possible even in cases where it seemed impossible.

The other foundational components that was part of the class teachings included attending the weekly classes session and completing the assign homework practices. These covered discussion about placebo/nocebo, possibilities and examples of self-healing with visualization, the role of nutrition, psychophysiology of stress and factors are associated with healthy aging across cultures. The asynchronous assignments investigated factors that promoted or inhibited health and the role of hope. The discussions pointed out that not everyone may return to health; however, they can always be whole.  For example, if a person loses a limb, the limb will not regrow. The healing process includes acceptance and creating new goals to achieve and live a meaningful life. 

The possibility that students could benefit by implementing the different skills and concepts taught in the class were illustrated by sharing previous students’ successes in reversing disorders such as hair pulling, anxiety, psoriasis, and pain. In addition, students were assigned to watch and comment on videos of people who had overcome serious illness. These included Janine Shepherd’s  2012 TED talk, A broken body isn’t a broken person, and  Dr. Terry Wahl’s 2011 TEDxIowaCity talk, Minding your mitochondria.  Janine Shepard shared how she recovered from a very serious accident in which she became paralyzed to becoming an aecrobatic pilot instructor while Dr. Terry Wahl shares how she he used diet to cure her MS and get out of her wheelchair (Shepherd, 2012; Wahl, 2011).  Other assignments included watching Madhu Anziani’s presentation, Healing from paralysis-Music (toning) to activate health, in which he discussed his recovery from being a quadriplegic to becoming an inspirational musician (Anziani, & Peper, 2021). The students as read and  commented on  student case examples of reversing acid reflux, irritable bowel and chronic headaches (Peper, Mason, & Huey, 2017a; Peper, Mason, & Huey, 2017b; Peper, 2018; Peper et al., 2020; Peper, Covell, & Matzembacker, 2021; Peper, 2022).

Although self-healing imagery appears to be the major component that facilitated the healing, it cannot be separated from the many other concepts and practices that may have contributed. For example, the previous practices of learning slow diaphragmatic breathing and hand warming may have allowed the imagery to become a real kinesthetic experience. In addition, by seeing how other students overcame chronic disorders, the class provided a framework to mobilize one’s health.

Lessons extracted from this case example that others may be able use to mobilize health.

  • Take action to shifts from being hopeless and powerless to becoming empowered and active agent in the healing process.
  • Change personal beliefs through experiential practices and storytelling that provides a framework that healing and improvement are possible.
    • Teach the person self-regulation skills such as slower breathing, muscle relaxation, cognitive internal language changes, hand warming by which the person experiences changes.
    • Provide believable role models who shared their struggle in overcoming traumatic injury, watch inspirational talks, and share previous clients or students’ self-reports who had previously improved.
  • Transform the problem from global description into behavioral specific parts. For example, being depressed is a global statement and too big to work on. Breaking the global concept into specific behaviors such as, my energy is too low to do exercise or I have negative thoughts, would provide specific interventions to work on such as, increasing exercise or changing thoughts. In JC’s case, she changed the general rating of pain into ratings of muscle tightness and sharp pains. This provided the bases for strategies to relax and warm her muscles.
  • Focus on what you can do at that moment versus focusing on the past, what happened, who caused it, or blaming yourself and others.  Explore and ask what you now can do now to support your healing process and reframe the problem as a new opportunity for growth and development.
  • Practice, practice, and practice with a childlike exploratory attitude.  Focus on the small positive benefits that occur as a result of the practices.  It is not mindless practice; it is practice while being present and being gentle with yourself. Do not discard very small changes.  The benefits accrue as you practice more and more, just many people have experienced when learning to play a musical instrument or mastering a sport.  Even though many participants think that practicing 15 minutes a day is enough, it usually takes much more time.  Reflect on how a baby learns to walk or climb. The toddler practices day-long and takes naps to regenerate and grow. When the toddler is not yet successful in walking or climbing, it does not give up or interpret it as failure or blaming himself that he cannot do it, it just means more practice.
  • Have external reminders to evoke the self-healing practices.  In JC’s case, the small statue of Yemaya in her room was the reminder. It reminded her to thinks of the image of herself fully healed each time she saw it.
  • Guide yourself through the wise one imagery, ask yourself a question and listen and act on the intuitional answers.
  • Develop a self-healing imagery process that transforms the dysfunction to health or wholeness.  Often the person only perceives the limitations and focusses on describing the problem. Instead, acknowledge, accept what was and is, and focus on developing a process to promote healing. What many people do not realize that if they think/imagine how their injury/illness was caused, it may reactivate and recreate the initial trauma. This can be illustrated through imagery. When we think or imagine something, it changes our physiology. For example, when one imagines eating a lemon, many people will salivate. The image affects physiology. Thus, focus on processes that support healing.
  • While practicing the imagery, experience it as if it is real and feel it happening inside yourself.  Many people initially find this challenging as they see it outside themselves.  One way to increase the “felt sense” is to incorporate more body involvement such as acting out the imagery with hand and body movements.
  • When having a relapse, remind yourself to keep going. Every morning  is the beginning of a new day, do each practices anew. In addition, reflect of something that was challenging in the past but that you successfully overcame. Focus on that success. As JC wrote, I was also successful in that I gave myself slack and reminded myself that relapses will happen and what matters more is the steps I take to move forward.
  • Make your healing a priority that means doing it often during the day. Allow the self-healing imagery and process to run in the back of the head all the time just as a worry can be present in the background. So often people practice for a few minutes (which is great and better than not practicing at all); however, at other times during the day they are captured by their worry, negative thoughts or focus on the limitations of the disorder. When a person focuses on the limitations, it may interrupt the self-healing process.  The analogy we often use is that the healing process is similar to healing from a small cut in the skin. Initially a scab forms and eventually the scab falls off and the skin is healed. On the other hand, if you keep moving the skin or pick on the scab, healing is much slower. By focusing on the limitations and past visualization of the injury, self-healing is reduced. This is similar to removing the scab before the skin has healed.   As JC stated, “If you don’t make time for your wellness, you’ll be forced to make time for your illness” was 100% a motivating factor in my success.
  • Explore resources for providers and people living with pain. See Dr. Rachel Zoffness website which provides a trove of high quality articles, books, videos, apps, and podcasts. https://www.zoffness.com/resources

In summary, we do not know the limits of self-healing; however, this case example illustrates that by implementing self-healing strategies health and recovery occurred. As JC wrote:

To have broken a vertebra in my back and experience all the injuries that came with the accident when I already did not have the strongest mind-body connection was incredibly intense and really heartbreaking and discouraging in my life. And, that made things difficult because I was not able to 100% focus on my healing because I felt so overwhelmed by the feeling of discouragement that I felt. Experiencing this self-healing project, seeing the imagery that helped me not just feel so much better all the time but be able to stop taking all prescription pain medications and eliminate the sharp pains in my back has taught me that I have the skill set needed to be whole and healthy.

Watch the interview will Jillian Cosby inwhich she describes her self-healing process.

References

Anziani, M. & Peper, E. (2021). Healing from paralysis-Music (toning) to activate health. The peperperspective.  https://peperperspective.com/2021/11/22/healing-from-paralysis-music-toning-to-activate-health/

Battino, R. (2020). Using Guided Imagery and Hypnosis in Brief Therapy and Palliative Care. New York: Routledge.

Bresler, D. (2005).Physiological Consequences of Guided Imagery. Pract Pain Manag, 5(6). https://www.practicalpainmanagement.com/treatments/complementary/biobehavioral/physiological-consequences-guided-imagery

Eriksen, J., Sjøgren, P., Bruera, E., et al. (2006). Critical issues on opioids in chronic non-cancer pain: An epidemiologic study. Pain, 125,172–179. https://doi.org/10.1016/j.pain.2006.06.009

Green, E. E., Green, A. M., & Walters, E. D. (1970). Voluntary control of internal states: Psychological and physiological. The Journal of Transpersonal Psychology2(1), 1. https://atpweb.org/jtparchive/trps-02-70-01-001.pdf

Hadjibalassi, M., Lambrinou, E.., Papastavrou,E., & Papathanassoglou, E. (2018). The effect of guided imagery on physiological and psychological outcomes of adult ICU patients: A systematic literature review and methodological implications, Australian Critical Care, 31(2), 73-86. https://doi.org/10.1016/j.aucc.2017.03.001

Higgins, C, Smith, B.H., & Matthews, K. (2019). Evidence of opioid-induced hyperalgesia in clinical populations after chronic opioid exposure: a systematic review and meta-analysis, British Journal of Anaesthesia, 122(6), e114-e126. https://doi.org/10.1016/j.bja.2018.09.019

IsHak, W.W., Wen, R.Y., Naghdechi, L., Vanle, B., Dang, J., Knosp, M., Dascal, J., Lobsang, Gohar, Y.,; Eskander, L., Yadegar, J.,   Hanna, S., Sadek, A., Aguilar-Hernandez, L.,  Danovitch, I.,  Louy, C. (2018).  Pain and Depression: A Systematic Review, Harvard Review of Psychiatry, 11/12, 26(6), 352-363. https://doi.org/10.1097/HRP.0000000000000198

Koob, G.F. (2020). Neurobiology of Opioid Addiction: Opponent Process, Hyperkatifeia, and Negative Reinforcement, Biological Psychiatry, 87(1), 44-53.

https://doi.org/10.1016/j.biopsych.2019.05.023

Mullins, P.M., & Bhattacharyya, N. (2022). Prevalence of chronic pain among adults in the United States, Pain, 163(2), e328-e332.  https://doi.org/10.1097/j.pain.0000000000002291NIH

NIDA (2022). Opioid Overdose Crisis. Downloaded June 30, 2022. https://nida.nih.gov/research-topics/opioids/opioid-overdose-crisis

Parisien, M., Lima, L.V., Dagostino, C., El-Hachem, N., Drury, G.L., Grant, A.V., Huising, J., Verma, V…. .(2022). Acute inflammatory response via neutrophil activation protects against the development of chronic pain. Science Translational Medicine, 14(644). https://doi.org/10.1126/scitranslmed.abj99

Peper, E. (2018). Breathing reduces acid reflux and dysmenorrhea discomfort. the peperperspective. https://peperperspective.com/2018/10/04/breathing-reduces-acid-reflux-and-dysmenorrhea-discomfort/

Peper, E. (2022). Resolving a chronic headache with posture feedback and breathing. the peperperspective.https://peperperspective.com/2022/01/04/resolving-a-chronic-headache-with-posture-feedback-and-breathing/

Peper, E., Almedras, M., Heinz, N. & Harvey, R. (in prep). How attending a Holistic Health class reduced symptoms.

Peper, E., Covell, A., & Matzembacker, N. (2021). How a chronic headache condition became resolved with one session of breathing and posture coaching. NeuroRegulation, 8(4), 194–197. https://doi.org/10.15540/nr.8.4.194

Peper, E., Gibney, K.H. & Holt. C. (2002).  Make Health Happen: Training Yourself to Create Wellness.  Dubuque, IA: Kendall-Hunt.ISBN: 978-0787293314 https://he.kendallhunt.com/make-health-happen

Peper, E., Harvey, R., Cuellar, Y., & Membrila, C. (2022). Reduce anxiety. NeuroRegulation, 9(2), 91–97. https://doi.org/10.15540/nr.9.2.91  https://www.neuroregulation.org/article/view/22815/14575

Peper, E., Lin, I-M., Harvey, r., Gilbert, M.  Gubbala, P, Ratkovich, A., & Fletcher, L. (2014). Transforming Chained Behaviors: Case Studies of Overcoming Smoking, Eczema, and Hair Pulling (Trichotillomania), Biofeedback, 42 (4), 154–160. https://doi.org/10.5298/1081-5937-42.4.06

Peper, E., Mason, L, & Huey, C. (2017a). Healing irritable bowel syndrome with diaphragmatic breathing. the peperperspective. https://peperperspective.com/2017/06/23/healing-irritable-bowel-syndrome-with-diaphragmatic-breathing/

Peper, E., Mason, L., Huey, C. (2017b).  Healing irritable bowel syndrome with diaphragmatic breathing. Biofeedback. (45-4). https://doi.org/10.5298/1081-5937-45.4.04

Peper, E., Mason, L., Harvey, R., Wolski, L, & Torres, J. (2020). Can acid reflux be reduced by breathing? Townsend Letters-The Examiner of Alternative Medicine, 445/446, 44-47. https://www.townsendletter.com/article/445-6-acid-reflux-reduced-by-breathing/

Peper, E., Miceli, B., & Harvey, R. (2016). Educational Model for Self-healing: Eliminating a Chronic Migraine with Electromyography, Autogenic Training, Posture, and Mindfulness. Biofeedback, 44(3), 130–137.  https://doi.org/10.5298/1081-5937-44.3.03

Peper, E., Sato-Perry, K & Gibney, K. H. (2003). Achieving Health: A 14-Session Structured Stress Management Program—Eczema as a Case Illustration. 34rd Annual Meeting of the Association for Applied Psychophysiology and Biofeedback. Abstract in: Applied Psychophysiology and Biofeedback, 28(4), 308. https://biofeedbackhealth.files.wordpress.com/2013/12/2003-aapb-poster-peper-keiko-long1.pdf

Peper, E., Lin, I-M, Harvey, R., Gilbert, M., Gubbala, P., Ratkovich, A., & Fletcher, F. (2014). Transforming chained behaviors: Case studies of overcoming smoking, eczema and hair pulling (trichotillomania). Biofeedback, 42(4), 154-160. https://doi.org/10.5298/1081-5937-42.4.06

Rossman, M. L.(2000). Guided imagery for self-healing. New York: New World Library. https://www.amazon.com/Guided-Imagery-Self-Healing-Martin-Rossman/dp/091581188X/ref=sr_1_3?crid=3M8I1Y1NV3A5N&keywords=martin+rossman&qid=1657649675&s=books&sprefix=rossman%2C+M%2Cstripbooks%2C131&sr=1-3

Rossman, M. L. (2019). Imagine health! Imagery in medical self-care. InSheikh, A.A. (ed).  Imagination and healing (pp. 231-258). Routledge. https://www.amazon.com/Imagination-Healing-Imagery-Human-Development-ebook/dp/B07QB4RGSW/ref=sr_1_9?crid=3C7V3E5ZN92R&keywords=Imagination+and+healing&qid=1657818303&s=books&sprefix=imagination+and+healing+%2Cstripbooks%2C105&sr=1-9

Sheng, J., Liu, S., Wang, Y., Cui, R., & Zhang, X. (2017). The link between depression and chronic pain: Neural mechanisms in the brain. Neural Plasticity, 2017, Article 9724371. https://doi.org/10.1155/2017/9724371

Shepherd, Janine. (2012). A broken body isn’t a broken person. TEDxKC. https://www.ted.com/talks/janine_shepherd_a_broken_body_isn_t_a_broken_person

Tan, G., & Jensen, M. P. (2007). Integrating complementary and alternative medicine into multidisciplinary chronic pain treatment. In Chronic Pain Management (pp. 75-99). CRC Press. https://www.taylorfrancis.com/chapters/edit/10.3109/9781420045130-6/integrating-complementary-alternative-medicine-multidisciplinary-chronic-pain-treatment-gabriel-tan-mark-jensen

Treede, R-D.,  Rief, W.,  Barke, A.,  Aziz, Q., Bennett, M.I.,  Benoliel, R.,  Cohen, M.,  Evers, S.,  Finnerup, N.B.,  First, M.B.,  Giamberardino, M.A.,  Kaasa, S.,  Korwisi, B., Kosek, E.,  Lavand’homme, P., ; Nicholas, M.,  Perrot, S.,  Scholz, J.,  Schug, S.,  Smith, B.H., ; Svensson, P.,  Vlaeyen, J.S., & Wang, S-J. (2019). Chronic pain as a symptom or a disease: the IASP Classification of Chronic Pain for the International Classification of Diseases (ICD-11), Pain, 160(1), 19-27.  https://do.org/10.1097/j.pain.0000000000001384

Von Korff, M. & Simon, G. (1996). The relationship between pain and depression. British Journal of Psychiatry, 168(S30), 101-108. https://doi.org/10.1192/S0007125000298474

Wahl, T. (2011). Minding your mitochondria. TEDzIowaCity. https://www.youtube.com/watch?v=KLjgBLwH3Wc

Warraich, H. (2022). Medicine has failed chronic pain patients. Here’s what they need. Pscyhe, Aeon, https://psyche.co/ideas/medicine-has-failed-chronic-pain-patients-heres-what-they-need

Yong, R. J., Mullins, P. M., & Bhattacharyya, N. (2022). Prevalence of chronic pain among adults in the United States. Pain163(2), e328-e332. https://doi.org/10.1097/j.pain.0000000000002291



Freedom of movement with the Alexander Technique

Erik Peper and Elyse Shafarman

After taking Alexander Technique lessons I felt lighter and stood taller and I have learned how to direct myself differently.  I am much more aware of my body, so that while I am working at the computer, I notice when I am slouching and contracting. Even better, I know what to do so that I have no pain at the end of the day. It’s as though I’ve learned to allow my body to move freely.

The Alexander Technique is one of the somatic techniques that optimize health and performance (Murphy, 1993). Many people report that after taking Alexander lessons, many organic and functional disorders disappear. Others report that their music or dance performances improve. The Alexander Technique has been shown to improve back pain, neck pain, knee pain walking gait, and balance (Alexander technique, 2022; Hamel, et al, 2016; MacPherson et al., 2015; Preece, et al., 2016). Benefits are not just  physical. Studying the technique decreases performance anxiety in musicians and reduces depression associated with Parkinson’s disease (Klein, et al, 2014; Stallibrass et al., 2002).

Background

The Alexander Technique was developed in the late 19th century by the Australian actor, Frederick Matthias Alexander (Alexander, 2001).  It is an educational method that teaches students to align, relax and free themselves from limiting tension habits (Alexander, 2001; Alexander technique, 2022).  F.M Alexander developed this technique to resolve his own problem of becoming hoarse and losing his voice when speaking on stage.

Initially he went to doctors for treatment but nothing worked except rest. After resting, his voice was great again; however, it quickly became hoarse when speaking.  He recognized that it must be how he was using himself while speaking that caused the hoarseness.  He understood that “use” was not just a physical pattern, but a mental and emotional way of being. “Use” included beliefs, expectations and feelings. After working on himself, he developed the educational process known as the Alexander Technique that helps people improve the way they move, breathe and react to the situations of life.

The benefits of this approach has been documented in a large randomized controlled trial of one-on-one Alexander Technique lessons which showed that it significantly reduced chronic low back pain and the benefits persisted a year after treatment (Little, et al, 2008).  Back pain as well as shoulder and neck pain often is often related to stress and how we misuse ourselves.  When experiencing discomfort, we quickly tend to blame our physical structure and assume that the back pain is due to identifiable structural pathology identified by X-ray or MRI assessments. However, similar structural pathologies are often present in people who do not experience pain and the MRI findings correlate poorly with the experience of discomfort (Deyo & Weinstein, 2001; Svanbergsson et al., 2017). More likely, the causes and solutions involve how we use ourselves (e.g., how we stand, move, or respond to stress). A functional approach may include teaching awareness of the triggers that precede neck and back tension, skills to prevent the tensing of those muscles not needed for task performance,  resolving psychosocial stress and improving the ergonomic factors that contribute to working in a stressed position (Peper, Harvey & Faass, 2020). Conceptually, how we are use ourselves (thoughts, emotions, and body) affects and transforms our physical structure and then our physical structure constrains how we use ourselves.

Watch the video with Alexander Teacher, Elyse Shafarman, who describes the Alexander Technique and guides you through practices that you can use immediately to optimize your health while sitting and moving.

See also the following posts:

References

Alexander, F.M. (2001). The Use of the Self. London: Orion Publishing. https://www.amazon.com/Use-Self-F-M-Alexander/dp/0752843915

Alexander technique. (2022). National Health Service. Retrieved 19 April, 2022/.  https://www.nhs.uk/conditions/alexander-technique/

Deyo, R.A. & Weinstein, J.N. (2001). Low back pain. N Engl J Med., 344(5),363-70. https://doi.org/10.1056/NEJM200102013440508

Hamel, K.A., Ross, C., Schultz, B., O’Neill, M., & Anderson, D.I. (2016). Older adult Alexander Technique practitioners walk differently than healthy age-matched controls. J Body Mov Ther. 20(4), 751-760. https://doi.org/10.1016/j.jbmt.2016.04.009

Klein, S. D., Bayard, C., & Wolf, U. (2014). The Alexander Technique and musicians: a systematic review of controlled trials. BMC complementary and alternative medicine14, 414. https://doi.org/10.1186/1472-6882-14-414

Little, P.  Lewith, W G., Webley, F.,  Evans, M., …(2008). Randomised controlled trial of Alexander technique lessons, exercise, and massage (ATEAM) for chronic and recurrent back pain. BMJ, 337:a884. https://doi.org/10.1136/bmj.a884

MacPherson, H., Tilbrook, H., Richmond, S., Woodman, J., Ballard, K., Atkin, K., Bland, M., et al. (2015). Alexander Technique Lessons or Acupuncture Sessions for Persons With Chronic Neck Pain: A Randomized Trial. Ann Intern Med, 163(9), 653-62. https://doi.org/10.7326/M15-0667

Murphy, M. (1993). The Future of the Body. New York: Jeremy P. Tarcher/Perigee.

Peper, E., Harvey, R. & Faass, N. (2020). TechStress: How Technology is Hijacking Our Lives, Strategies for Coping, and Pragmatic Ergonomics. Berkeley: North Atlantic Books.

Preece, S.J., Jones, R.K., Brown, C.A. et al.  (2016). Reductions in co-contraction following neuromuscular re-education in people with knee osteoarthritis. BMC Musculoskelet Disord 17372.  https://doi.org/10.1186/s12891-016-1209-2

Stallibrass, C., Sissons, P., & Chalmers. C. (2002). Randomized controlled trial of the Alexander technique for idiopathic Parkinson’s disease. Clin Rehabil, 16(7), 695-708. https://doi.org/10.1191/0269215502cr544oa

Svanbergsson, G., Ingvarsson, T., & Arnardóttir RH. (2017). [MRI for diagnosis of low back pain: Usability, association with symptoms and influence on treatment]. Laeknabladid, 103(1):17-22. Icelandic. https://doi.org/10.17992/lbl.2017.01.116

Tuomilehto, J., Lindström, J., Eriksson, J.G., Valle, T.T., Hämäläinen, H., Ilanne-Parikka, P., Keinänen-Kiukaanniemi, S., Laakso, M., Louheranta, A., Rastas, M., et al. (2001). Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. N. Engl. J. Med., 344, 1343–1350. https://doi.org/10.1056/NEJM200105033441801

Uusitupa, Mm, Khan, T.A., Viguiliouk, E., Kahleova, H., Rivellese, A.A., Hermansen, K., Pfeiffer, A., Thanopoulou, A., Salas-Salvadó, J., Schwab, U., & Sievenpiper. J.L. (2019). Prevention of Type 2 Diabetes by Lifestyle Changes: A Systematic Review and Meta-Analysis. Nutrients, 11(11)2611. https://doi.org/10.3390/nu11112611


Reduce anxiety

The purpose of this blog is to describe how a university class that incorporated structured self-experience practices reduced self-reported anxiety symptoms (Peper, Harvey, Cuellar, & Membrila, 2022). This approach is different from a clinical treatment approach as it focused on empowerment and mastery learning (Peper, Miceli, & Harvey, 2016). 

As a result of my practice, I felt my anxiety and my menstrual cramps decrease. — College senior

When I changed back to slower diaphragmatic breathin, I was more aware of my negative emotions and I was able to reduce the stress and anxiety I was feeling with the deep diaphragmatic breathing.– College junior

Background

More than half of college students now report anxiety (Coakley et al., 2021). In our recent survey during the first day of the spring semester class, 59% of the students reported feeling tired, dreading their day, being distracted, lacking mental clarity and had difficulty concentrating.

Before the COVID pandemic nearly one-third of students had or developed moderate or severe anxiety or depression while being at college (Adams et al., 2021. The pandemic accelerated a trend of increasing anxiety that was already occurring.  “The prevalence of major depressive disorder among graduate and professional students is two times higher in 2020 compared to 2019 and the prevalence of generalized anxiety disorder is 1.5 times higher than in 2019” As reported by Chirikov et al (2020) from the UC Berkeley SERU Consortium Reports.

This increase in anxiety has both short and long term performance and health consequences. Severe anxiety reduces cognitive functioning and is a risk factor for early dementia (Bierman et al., 2005; Richmond-Rakerd et al, 2022). It also increases the risk for asthma, arthritis, back/neck problems, chronic headache, diabetes, heart disease, hypertension, pain, obesity and ulcer (Bhattacharya et al., 2014; Kang et al, 2017).

The most commonly used treatment for anxiety are pharmaceutical and cognitive behavior therapy (CBT) (Kaczkurkin & Foa, 2015).  The anti-anxiety drugs are usually benzodiazepines (e.g., alprazolam (Xanax), clonazepam (Klonopin), chlordiazepoxide (Librium), diazepam (Valium) and lorazepam (Ativan).  Although these drugs they may reduce anxiety, they have numerous side effects such as drowsiness, irritability, dizziness, memory and attention problems, and physical dependence (Shri, 2012; Crane, 2013).

Cognitive behavior therapy techniques based upon the assumption that anxiety is primarily a disorder in thinking which then causes the symptoms and behaviors associated with anxiety. Thus, the primary treatment intervention focuses on changing thoughts.

Given the significant increase in anxiety and the potential long term negative health risks, there is need to provide educational strategies to empower students to prevent and reduce their anxiety.  A holistic approach is one that assumes that body and mind are one and that soma/body, emotions and thoughts interchangeably affect the development of anxiety. Initially in our research, Peper, Lin, Harvey & Perez (2017) reported that it was easier to access hopeless, helpless, powerless and defeated memories in a slouched position than an upright position and it was easier to access empowering positive memories in an upright position than a slouched position. Our research on transforming hopeless, helpless, depressive thought to empowering thoughts, Peper, Harvey & Hamiel (2019) found that it was much more effective if the person first shifts to an upright posture, then begins slow diaphragmatic breathing and finally reframes their negative to empowering/positive thoughts. Participants were able to reframe stressful memories much more easily when in an upright posture compared to a slouched posture and reported a significant reduction in negative thoughts, anxiety (they also reported a significant decrease in negative thoughts, anxiety and tension as compared to those attempting to just change their thoughts).

The strategies to reduce anxiety focus on breathing and posture change. At the same time there are many other factors that may contribute the onset or maintenance of anxiety such as social isolation, economic insecurity, etc. In addition, low glucose levels can increase irritability and may lower the threshold of experiencing anxiety or impulsive behavior (Barr, Peper, & Swatzyna, 2019; Brad et al, 2014). This is often labeled as being “hangry” (MacCormack & Lindquist, 2019). Thus, by changing a high glycemic diet to a low glycemic diet may reduce the somatic discomfort (which can be interpreted as anxiety) triggered by low glucose levels.  In addition, people are also sitting more and more in front of screens.  In this position, they tend to breathe quicker and more shallowly in their chest. 

Shallow rapid breathing tends to reduce pCO2 and contributes to subclinical hyperventilation which could be experienced as anxiety (Lum, 1981; Wilhelm et al., 2001; Du Pasquier et al, 2020).  Experimentally, the feeling of anxiety can rapidly be evoked by instructing a person to sequentially exhale about 70 % of the inhaled air continuously for 30 seconds. After 30 seconds, most participants reported a significant increase in anxiety (Peper & MacHose, 1993).  Thus, the combination of sitting, shallow breathing and increased stress from the pandemic are all cofactors that may contribute to the self-reported increase in anxiety.

To reduce anxiety and discomfort, McGrady and Moss (2013) suggested that self-regulation and stress management approaches be offered as the initial treatment/teaching strategy in health care instead of medication. One of the useful approaches to reduce sympathetic arousal and optimize health is breathing awareness and retraining (Gilbert, 2003).  

Stress management as part of a university holistic health class

Every semester since 1976, up to 180 undergraduates have enrolled in a three-unit Holistic Health class on stress management and self-healing (Klein & Peper, 2013).  Students in the class are assigned self-healing projects using techniques that focus on awareness of stress, dynamic regeneration, stress reduction imagery for healing, and other behavioral change techniques adapted from the book, Make Health Happen (Peper, Gibney & Holt, 2002).

82% of students self-reported that they were ‘mostly successful’ in achieving their self-healing goals. Students have consistently reported achieving positive benefits such as increasing physical fitness, changing diets, reducing depression, anxiety, and pain, eliminating eczema, and even reducing substance abuse (Peper et al., 2003; Bier et al., 2005; Peper et al., 2014).

This assessment reports how students’ anxiety decreased after five weeks of daily practice. The students filled out an anonymous survey in which they rated the change in their discomfort after practicing effortless diaphragmatic breathing. More than 70% of the students reported a decrease in anxiety. In addition, they reported decreases in symptoms of stress, neck and shoulder pain as shown in Figure 1.

Figure 1. Self-report of decrease in symptoms after practice diaphragmatic breathing for a week.

In comparing the self-reported responses of the students in the holistic health class to those of the control group (N=12), the students in the holistic health class reported a significant decrease in symptoms since the beginning of the semester as compared to the control group as shown in Figure 2.

Figure 2. Change in self-reported symptoms after 6 weeks of practice the integrated holistic health skills as compared to the control group who did not practice these skills.

Changes in symptoms Most students also reported an increase in mental clarity and concentration that improved their study habits. As one student noted: Now that I breathe properly, I have less mental fog and feel less overwhelmed and more relaxed. My shoulders don’t feel tense, and my muscles are not as achy at the end of the day.

The teaching components for the first five weeks included a focus on the psychobiology of stress, the role of posture, and psychophysiology of respiration. The class included didactic presentations and daily self-practice

Lecture content

  1. Diadactic presentation on the physiology of stress and how posture impacts health.
  2. Self-observation of stress reactions; energy drain/energy gain and learning dynamic relaxation.
  3. Short experiential practices so that the student can experience how slouched posture allows easier access to helpless, hopeless, powerless and defeated memories.
  4. Short experiential breathing practices to show how breathing holding occurs and how 70% exhalation within 30 seconds increases anxiety.
  5. Didactic presentation on the physiology of breathing and how a constricted waist tends to have the person breathe high in their chest (the cause of neurasthemia) and how the fight/flight response triggers chest breathing, breath holding and/or shallow breathing.
  6. Explanation and practice of diaphragmatic breathing.

Daily self-practice

Students were assigned weekly daily self-practices which included both skill mastery by practicing for 20 minutes as well and implementing the skill during their daily life.  They then recorded their experiences after the practice. At the end of the week, they reviewed their own log of week and summarized their observations (benefits, difficulties) and then met in small groups to discuss their experiences and extract common themes. These daily practices consisted of:

  1. Awareness of stress.  Monitoring how they reacted to daily stressor
  2. Practicing dynamic relaxation. Students practiced for 20 minutes a modified progressive relaxation exercise and observed and inhibit bracing pattern
  3. Changing energy drain and energy gains. Students observed what events reduced or increased their subjective energy and implemented changes in their behavior to decrease events that reduced their energy and increased behaviors that increase their enery
  4. Creating a memory of wholeness practice
  5. Practicing effortless breathing. Students practiced slowly diaphragmatic abdominal breathing for 20 minutes per day and each time they become aware of dysfunctional breathing (breath holding, shallow chest breathing, gasping) during the day, they would shift to slower diaphragmatic breathing.

Discussion

Almost all students were surprised how beneficial these practices were to reduce their anxiety and symptoms. Generally, the more the students would interrupt their personal stress responses during the day by shifting to diaphragmatic breathing the more did they experience success. We hypothesize that some of the following factors contributed to the students’ improvement.

  • Learning through self-mastery as an education approach versus clinical treatment.
  • Generalizing the skills into daily life and activities. Practicing the skills during the day in which the cue of a stress reaction triggered the person to breathe slowly. The breathing would reduce the sympathetic activation.
  • Interrupting escalating sympathetic arousal. Responding with an intervention reduced the sense of being overwhelmed and unable to cope by the participant by taking charge and performing an active task.
  • Redirecting attention and thoughts away from the anxiety triggers to a positive task.
  • Increasing heart rate variability. Through slow breathing heart rate variability increased which enhanced sympathetic parasympathetic balance.
  • Reducing subclinical hyperventilation by breathing slower and thereby increasing pC02.
  • Increasing social support by meeting in small groups.  The class discussion group normalized the anxiety experiences.
  • Providing hope. The class lectures, assigned readings and videos provide hope; since,  it included reports how other students had reversed their chronic  disorders such as irritable bowel disease, acid reflux, psoriasis with behavioral interventions.

Although the study lacked a control group and is only based upon self-report, it offers an economical non-pharmaceutical approach to reduce anxiety. These stress management strategies may not resolve anxiety for everyone. Nevertheless, we recommend that schools implement this approach as the first education intervention to improve health in which students are taught about stress management, learn and practice relaxation and diaphragmatic breathing and then practice these skills during the day  whenever they experience stress or dysfunctional breathing.

I noticed that breathing helped tremendously with my anxiety. I was able to feel okay without having that dreadful feeling stay in my chest and I felt it escape in my exhales. I also felt that I was able to breathe deeper and relax better altogether. It was therapeutic, I felt more present, aware, and energized.

See the following blogs for detailed breathing instructions

References

Adams. K.L., Saunders KE, Keown-Stoneman CDG, et al. (2021). Mental health trajectories in undergraduate students over the first year of university: a longitudinal cohort study. BMJ Open 2021; 11:e047393. https://doi.org/10.1136/bmjopen-2020-047393

Barr, E. A., Peper, E. & Swatzyna, R.J. (2019).  Slouched Posture, Sleep Deprivation, and Mood Disorders: Interconnection and Modulation by Theta Brain Waves. Neuroregulation, 6(4), 181–189 https://doi.org/10.15540/nr.6.41.181

Bhattacharya, R., Shen, C. & Sambamoorthi, U. (2014). Excess risk of chronic physical conditions associated with depression and anxiety. BMC Psychiatry 14, 10 (2014). https://doi.org/10.1186/1471-244X-14-10

Bier, M., Peper, E., & Burke, A. (2005). Integrated stress management with ‘Make Health Happen: Measuring the impact through a 5-month follow-up. Poster presentation at the 36th Annual Meeting of the Association for Applied Psychophysiology and Biofeedback. Abstract published in: Applied Psychophysiology and Biofeedback, 30(4), 400. https://biofeedbackhealth.files.wordpress.com/2013/12/2005-aapb-make-health-happen-bier-peper-burke-gibney3-12-05-rev.pdf

Bierman, E.J.M., Comijs, H.C. , Jonker, C. & Beekman, A.T.F.  (2005). Effects of Anxiety Versus Depression on Cognition in Later Life. The American Journal of Geriatric Psychiatry,13(8),  686-693, https://doi.org/10.1097/00019442-200508000-00007.

Brad, J., Bushman, C., DeWall, N., Pond, R.S., &. Hanus, M.D. (2014).. Low glucose relates to greater aggression in married couplesPNAS, April 14, 2014.  https://doi.org/10.1073/pnas.1400619111

Chirikov, I., Soria, K. M, Horgos, B., & Jones-White, D. (2020). Undergraduate and Graduate Students’ Mental Health During the COVID-19 Pandemic. UC Berkeley: Center for Studies in Higher Education. Retrieved from https://escholarship.org/uc/item/80k5d5hw

Coakley, K.E., Le, H., Silva, S.R. et al. Anxiety is associated with appetitive traits in university students during the COVID-19 pandemic. Nutr J 20, 45 (2021). https://doi.org/10.1186/s12937-021-00701-9

Crane,E.H. (2013).Highlights of the 2011 Drug Abuse Warning Network (DAWN) Findings on Drug-Related Emergency Department Visits. 2013 Feb 22. In: The CBHSQ Report. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2013-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK384680/

Du Pasquier, D., Fellrath, J.M., & Sauty, A. (2020). Hyperventilation syndrome and dysfunctional breathing: update. Revue Medicale Suisse, 16(698), 1243-1249. https://europepmc.org/article/med/32558453

Gilbert C. Clinical Applications of Breathing Regulation: Beyond Anxiety Management. Behavior Modification. 2003;27(5):692-709. https://doi.org/10.1177/0145445503256322

Kaczkurkin, A.N. & Foa, E.B. (2015). Cognitive-behavioral therapy for anxiety disorders: an update on the empirical evidence. Dialogues Clin Neurosci. 17(3):337-46.  https://doi.org/10.31887/DCNS.2015.17.3/akaczkurkin

Kang, H. J., Bae, K. Y., Kim, S. W., Shin, H. Y., Shin, I. S., Yoon, J. S., & Kim, J. M. (2017). Impact of Anxiety and Depression on Physical Health Condition and Disability in an Elderly Korean Population. Psychiatry investigation14(3), 240–248. https://doi.org/10.4306/pi.2017.14.3.240

Klein, A. & Peper, W. (2013). There is Hope: Autogenic Biofeedback Training for the Treatment of Psoriasis. Biofeedback, 41(4), 194–201. https://doi.org/10.5298/1081-5937-41.4.01

Lum, L. C. (1981). Hyperventilation and anxiety state. Journal of the Royal Society of Medicine74(1), 1-4. https://journals.sagepub.com/doi/pdf/10.1177/014107688107400101

MacCormack, J. K., & Lindquist, K. A. (2019). Feeling hangry? When hunger is conceptualized as emotion. Emotion, 19(2), 301–319. https://doi.org/10.1037/emo0000422

McGrady, A. & Moss, D. (2013). Pathways to illness, pathways to health. New York: Springer. https://link.springer.com/book/10.1007/978-1-4419-1379-1

Peper, E., Gibney, K.H., & Holt, C.F. (2002). Make health happen: Training yourself to create wellness. Dubuque, IA: Kendall/Hunt Publishing Company. https://he.kendallhunt.com/make-health-happen

Peper, E., Harvey, R., Cuellar, Y., & Membrila, C. (2022). Reduce anxiety. NeuroRegulation, 9(2), 91–97. https://doi.org/10.15540/nr.9.2.91  https://www.neuroregulation.org/article/view/22815/14575

Peper, E., Harvey, R., & Hamiel, D. (2019). Transforming thoughts with postural awareness to increase therapeutic and teaching efficacy.  NeuroRegulation, 6(3),153-169.  doi:10.15540/nr.6.3.1533-1   https://www.neuroregulation.org/article/view/19455/13261

Peper, E., Lin, I-M., Harvey, R., & Perez, J. (2017). How posture affects memory recall and mood.  Biofeedback.45 (2), 36-41. https://doi.org/10.5298/1081-5937-45.2.01

Peper, E., Lin, I-M, Harvey, R., Gilbert, M., Gubbala, P., Ratkovich, A., & Fletcher, F. (2014). Transforming chained behaviors: Case studies of overcoming smoking, eczema and hair pulling (trichotillomania). Biofeedback, 42(4), 154-160. https://doi.org/10.5298/1081-5937-42.4.06

Peper, E., MacHose, M. (1993). Symptom prescription: Inducing anxiety by 70% exhalation. Biofeedback and Self-Regulation 18, 133–139). https://doi.org/10.1007/BF00999790

Peper, E., Miceli, B., & Harvey, R. (2016). Educational Model for Self-healing: Eliminating a Chronic Migraine with Electromyography, Autogenic Training, Posture, and Mindfulness. Biofeedback, 44(3), 130–137.  https://doi.org/10.5298/1081-5937-44.3.03

Peper, E., Sato-Perry, K & Gibney, K. H. (2003). Achieving Health: A 14-Session Structured Stress Management Program—Eczema as a Case Illustration. 34rd Annual Meeting of the Association for Applied Psychophysiology and Biofeedback. Abstract in: Applied Psychophysiology and Biofeedback, 28(4), 308. Proceeding in:  http://www.aapb.org/membersonly/articles/P39peper.pdf

Richmond-Rakerd, L.S., D’Souza, S, Milne, B.J, Caspi, A., & Moffitt, T.E. (2022). Longitudinal Associations of Mental Disorders with Dementia: 30-Year Analysis of 1.7 Million New Zealand Citizens. JAMA Psychiatry. Published online February 16, 2022. https://doi.org/10.1001/jamapsychiatry.2021.4377

Shri, R. (2012). Anxiety: Causes and Management. The Journal of Behavioral Science5(1), 100–118. Retrieved from https://so06.tci-thaijo.org/index.php/IJBS/article/view/2205

Wilhelm, F.H., Gevirtz, R., & Roth, W.T. (2001). Respiratory dysregulation in anxiety, functional cardiac, and pain disorders. Assessment, phenomenology, and treatment. Behav Modif, 25(4), 513-45. https://doi.org/10.1177/0145445501254003


Addicted to your phone?  How to separate from your phone for a healthy lifestyle[1]

Erik Peper, PhD[2] and Monica Almendras

Our evolutionary traps with technology

Maintaining and optimizing health at the computer means re-envisioning our relationship with technology—and reclaiming health, happiness, and sanity in a plugged-in world.  We have the ability to control everything from our mobile phones without needing to get up from our seat. Work, social life and online learning all involve the mobile phone or some type of smart devices.

A convenient little device that is supposed to simplify our lives has actually trapped us into a vicious cycle of relying on it for every single thing we must do.  We spend most of our day being exposed to digital displays on our smartphones, computers, gaming consoles, and other digital devices, immersing ourselves in the content we are viewing. From work related emails or tasks, to spending our free time looking at the screen for texting, playing games, and updating social media sites on a play-by-play of what we are eating, wearing, and doing. We click on one hyperlink after the other and create a vicious cycle trapped for hours until we realize we need to move. We are unaware how much time has frittered away without actually doing anything productive and then, we realize we have wasted another day. Below are some recent estimates of ‘daily active user’ minutes per day that uses a screen.

  • Facebook about an hour per day
  • Instagram just under an hour per day
  • Texting about 45 minutes per day
  • Internet browsing, about 45 minutes per day
  • Snapchat, about 30 minutes per day
  • Twitter, about 25 minutes per day

Adolescents and college students interact with media for over 40 hours per week, or around 6 hours per day. That is a lot of hours spent on staring at the screen, which it is almost impossible not to be distracted by the digital screen. In time, we rehearse a variety of physical body postures as well as a variety of cognitive and behavioral states that impact our physical, mental, emotional, and social health. The powerful audiovisual formats override our desires to do something different, that some of us become enslaved to streaming videos, playing virtual games, or texting. We then tell ourselves that the task that needs to be done, will be finished later. That later becomes never by the end of the day, since the ongoing visual and auditory notifications from our apps interrupt and/or capture our attention. This difficulty to turn away from visual or auditory stimuli roots in our survival instincts.

Each time visual or auditory stimuli occur, we automatically check it out and see if it is a friend or foe, safety or danger. It is such an automatic response that we are unaware are reacting. The good news is that we all have experienced this compelling effect. Even when we are waiting for a response and the notifications has not arrived, we may anticipate or project that there may be new information on our social media accounts, and sometimes we become disappointed when the interval between notification is long. As one student said, “Don’t worry, they’ll respond. It’s only been 30 seconds”. Anticipating responses from the media can interrupt what we are otherwise doing. Rather than finishing our work or task, we continuously check for updates on social media, even though we probably know that there are no new important messages to which we would have to respond right away.

Unfortunately, some forms of social media interactions also lead to a form of social isolation, loneliness–sometimes called phoneliness (Christodoulou, G., Majmundar, A., Chou, C-P, & Pentz, M.A., 2020Kardaras, 2017). Digital content requires the individual to respond to the digital stimuli, without being aware of the many verbal and nonverbal communication cues (facial expressions, gestures, tone of voice, eye contact, body language, posture, touch, etc.) that are part of social communication (Remland, 2016). It is no wonder that more and more adolescents experience anxiety, depression, loneliness, and attention deficit disorders with a constant ‘digital diet’ that some have suggested that include not only media, but junk food as well.

In my class survey of 99 college students, 85% reported experiencing anxiety, 48% neck and should tension, and 41% abdominal discomfort.

We are not saying to avoid the beneficial parts of the digital age. Instead, it should be used in moderation and to be aware of how some material and digital platforms prey upon our evolutionary survival mechanisms. Unfortunately, most people -especially children- have not evolved skills to counter the negative impacts of some types of media exposure. Parental control and societal policies may be needed to mitigate the damage and enhance the benefits of the digital age.

Zoom Fatigue- How to reduce it and configure your brain for better learning

Zoom became the preferred platform for academic teaching and learning for synchronous education during the pandemic. Thus, students and faculty have been sitting and looking at the screen for hours end. While looking at the screen, the viewers were often distracted by events in their environment, notifications from their mobile phones, social media triggers, and emails; which promoted multitasking (Solis, 2019). These digital distractions cause people to respond to twice as many devices with half of our attention- a process labeled semi-tasking’ -meaning getting twice as much done and half as well.

We now check our phones an average of 96 times a day – that is once every 10 minutes and an increase of 20% as compared to two years ago (Asurion Research, 2019). Those who do media multitasking such as texting while doing a task perform significantly worse on memory tasks than those who are not multitasking (Madore et al., 2020).  Multitasking is negatively correlated with school performance (Giunchiglia et al, 2018). The best way to reduce multitasking is to turn off all notifications (e.g., email, texts, and social media) and let people know that you will look at the notifications and then respond in a predetermined time, so that you will not be interrupted while working or studying.

When students from San Francisco State University in the United States chose to implement a behavior change to monitor mobile phone and media use and reduce the addictive behavior during a five-week self-healing project, many reported a significant improvement of health and performance. For example one student reported that when she reduced her mobile phone use, her stress level equally decreased as shown in Fig 1 (Peper et al, 2021).

Figure 1. Example of student changing mobile phone use and corresponding decrease in subjective stress level. Reproduced by permission from Peper et al. (2021).

During this class project, many students observed that the continuous responding to notifications and social media affected their health and productivity. As one student reported,

The discovery of the time I wasted giving into distractions was increasing my anxiety, increasing my depression and making me feel completely inadequate. In the five-week period, I cut my cell phone usage by over half, from 32.5 hours to exactly 15 hours and used some of the time to do an early morning run in the park. Rediscovering this time makes me feel like my possibilities are endless. I can go to work full time, take online night courses reaching towards my goal of a higher degree, plus complete all my homework, take care of the house and chores, cook all my meals, and add reading a book for fun! –22-year-old College Student

Numerous students reported that it was much easier to be distracted and multitask, check social media accounts or respond to emails and texts than during face-to-face classroom sessions as illustrated by two student comments from San Francisco State University.

“Now that we are forced to stay at home, it’s hard to find time by myself, for myself, time to study, and or time to get away. It’s easy to get distracted and go a bit stir-crazy.”

“I find that online learning is more difficult for me because it’s harder for me to stay concentrated all day just looking at the screen.” 

Students often reported that they had more difficulty remembering the material presented during synchronous presentations. Most likely, the passivity while watching Zoom presentations affected the encoding and consolidation of new material into retrievable long-term memory. The presented material was rapidly forgotten when the next screen image or advertisement appeared and competed with the course instructor for the student’s attention. We hypothesize that the many hours of watching TV and streaming videos have conditioned people to sit and take in information passively, while discouraging them to respond or initiate action (Mander, 1978Mărchidan, 2019).

To reduce the deleterious impact of media use, China has placed time limits on cellphone use, gaming, and social media use for children. On February 2021 Chinese children were banned from taking their mobile phones into school, on August 2021 Children under 18 were banned from playing video games during the week and their play was restricted to just one hour on Fridays, weekends and holidays, and beginning on September 20, 2021 children under 14 who have been authenticated using their real name can access Douyin, the Chinese version of Tik Tok, for maximum of 40 minutes a day between the hours of 6:00 and 22:00.

Ways to avoid Zoom

Say goodnight to your phone

It is common for people to use their mobile phone before going to bed, and then end up having difficult falling asleep. The screen emits blue light that sends a signal to your brain that says it is daytime instead of night. This causes your body to suppress the production of the melatonin hormone, which tells your body that it is time to sleep. Reading or watching content also contributes, since it stimulates your mind and emotions and thereby promote wakefulness (Bravo, 2020). Implement sleep hygiene and stop using your phone or watching screens 30-minutes before going to bed for a better night’s sleep.

Maintaining a healthy vision

We increase near visual stress and the risk of developing myopia when we predominantly look at nearby surfaces. We do not realize that eyes muscles can only relax when looking at the far distance. For young children, the constant near vision remodels the shape of eye and the child will likely develop near sightedness. The solutions are remarkably simple. Respect your evolutionary background and allow your eyes to spontaneously alternate between looking at near and far objects while being upright (Schneider, 2016Peper, 2021Peper, Harvey & Faass, 2020).

Interrupt sitting disease

We sit for the majority of the day while looking at screens that is a significant risk factor for diabetes, cardiovascular disease, depression and anxiety (Matthews et al., 2012; Smith et al., 2020). Interrupt sitting by getting up every 30 minutes and do a few stretches. You will tend to feel less sleepy, less discomfort and more productive. As one of our participants reported that when he got up, moved and exercised every 30 minutes at the end of the day he felt less tired.  As he stated, “There is life after five”, which meant he had energy to do other activities after working at the computer the whole day. While working time flies and it is challenging to get up every 30 minutes.  Thus, install a free app on your computer that reminds you to get up and move such as StretchBreak (www.stretchbreak.com).

Use slouching as a cue to change

Posture affects thoughts and emotions as well as, vice versa. When stressed or worried (e.g., school performance, job security, family conflict, undefined symptoms, or financial insecurity), our bodies tend to respond by slightly collapsing and shifting into a protective position. When we collapse/slouch, we are more at risk to:

When stressed, anxious or depressed, it is challenging to change. The negative feelings, thoughts and worries continue to undermine the practice of reframing the experience more positively. Our recent study found that a simple technique, that integrates posture with breathing and reframing, rapidly reduces anxiety, stress, and negative self-talk (Peper, Harvey, Hamiel, 2019). When you are captured by helpless defeated thoughts and slouch, use the thought or posture as the trigger to take change.  The moment you are aware of the thoughts or slouched posture, sit up straight, look up, take a slow large diaphragmatic breath and only then think about reframing the problem positively (Peper, Harvey, Hamiel, 2019).

When we are upright and look up, we are more likely to:

The challenge is that we are usually unaware we have begun to slouch. A very useful solution is to use a posture feedback device to remind us, such as the UpRight Go (https://www.uprightpose.com/). This simple device and app signals you when you slouch. The device attaches to your neck and connects with blue tooth to your cellphone.  After calibrating, it provides vibrational feedback on your neck each time you slouch. When participants use the vibration feedback to become aware of what is going on and interrupt their slouch by stretching and sitting up, they report a significant decrease in symptoms and an increase in productivity. As one student reported: “Having immediate feedback on my posture helped me to be more aware of my body and helped me to link my posture to my emotions. Before using the tracker, doing this was very difficult for me. It not only helped my posture but my awareness of my mental state as well.”


[1] Adapted from the book by Erik Peper, Richard Harvey and Nancy Faass, TechStress-How Technology is Hijacking our Lives, Strategies for Coping and Pragmatic Ergonomics, North Atlantic Press.  https://www.penguinrandomhouse.com/books/232119/tech-stress-by-erik-peper-phd/ 

[2] Correspondence should be addressed to:

Erik Peper, Ph.D., Institute for Holistic Healing Studies/Department of Recreation, Parks, Tourism and Holistic Health, San Francisco State University, 1600 Holloway Avenue, San Francisco, CA 94132   COVID-19 mailing address:  2236 Derby Street, Berkeley, CA 94705   Email: epeper@sfsu.edu  web: www.biofeedbackhealth.org  blog: www.peperperspective.com


Improve learning with peak performance techniques

Erik Peper, PhD and Vietta Wilson, PhD

Adapted from: Peper, E. & Wilson, V. (2021). Optimize the learning state: techniques and habits. Biofeedback, 9(2), 46-49. https://doi.org/10.5298/1081-5937-49-2-04

Long after the COVID-19 pandemic is over, online learning will continue to increase as better methodologies and strategies are developed to implement and integrate it into our lives. This post provides suggestions on how to enhance the learner’s ability to engage while online with the use of pre-performance routines or habits.

Facilitating online learning requires coordination of the teacher, technology, student, environment and the topic. Teachers can enhance engagement (Shoepe et al., 2020) online through different types of prompts: intellectual (associated with instructor interaction, academic challenge, active learning), organizational (associated with enriching academic experiences by directing students, selecting topics and summarizing or redirecting), and social (associated with supportive campus environments by encouraging social interaction, using informal language and affirming student comments).

The student can enhance the satisfaction and quality of the online experience by having a good self-regulated learning style. Learning is impacted by motivation (beliefs about themselves or the task, perceived value, etc.), and metacognition (ability to plan, set goals, monitor and regulate their behavior and evaluate their performance) (Greene & Azevedo, 2010; Mega et al., 2014). While critical for learning, it does not provide information on how students can maintain their optimized performance long term, which is increasingly necessary during the pandemic but will possibly be the model of education and therapy of the future.

Habit can enhance performance across a life span.

Habit is a behavioral tendency tied to a specific context, such as learning to brush one’s teeth while young and continuing through life (Fiorella, 2020). Habits are related to self-control processes that are associated with higher achievement (Hagger, 2019). Sport performance extensively values habit, typically called pre-performance routine, in creating an ongoing optimized state of performance (Lautenbach et al., 2015; Lidor & Mayan, 2005; Mesagno et al., 2015). Habits or pre-performance routines are formed by repeating a behavior tied to a specific context and with continued repetition, wherein the mental association between the context and the response are strengthened. This shifts from conscious awareness to subconscious behavior that is then cued by the environment. The majority of one’s daily actions and behaviors are the results of these habits.

Failure to create a self-regulated learning habit impedes long-term success of students. It does take significant time and reinforcement to create the automaticity of a real-life habit. Lally et al. (2010) tracked real world activities (physical activity, eating, drinking water) and found habit formation varied from 18-254 days with a mean of 66 days. There was wide variability in the creation of the habit and some individuals never reached the stage of automaticity. Interestingly, those who performed the behavior with greater consistency were more likely to develop a habit.

The COVID pandemic resulted in many people working at home, which interrupted many of the covert habit patterns by which they automatically performed their tasks. A number of students reported that everything is the same and that they are more easily distracted from doing the tasks. As one student reported:

After a while, it all seems the same. Sitting and looking at the screen while working, taking classes, entertaining, streaming videos and socializing. The longer I sit and watch screens, the more I tend to feel drained and passive, and the more challenging it is to be present, productive and pay attention.

By having rituals and habits trigger behavior, it is easier to initiate and perform tasks. Students can use the strategies developed for peak performance in sports to optimize their performances so that they can achieve their personal best (Wilson & Peper, 2011; Peper et al., 2021). These strategies include environmental cueing and personal cueing.

Environmental cueing

By taking charge of your environment and creating a unique environment for each task, it is possible to optimize performance specific for each task. After a while, we do not have to think to configure ourselves for the task. It is no different than the sequence before going to sleep: you brush your teeth and if you forget, it feels funny and you probably will get up to brush your teeth.

Previously, many people, without awareness, would configure and reinforce themselves for work by specific tasks such as commuting to go work, being at a specific worksite to perform the work, wearing specific clothing, etc. (Peper et al., 2021). Now there are few or no specific cues tied to working; it tends to be all the same and it is no wonder that people feel less energized and focused.

Many people forget that learning and recall are state-dependent to where the information was acquired. The Zoom environment where we work or attend class is the same environment where we socialize, game, watch videos, message, surf the net and participate in social media. For most, there has been no habit developed for the new reality of in-home learning. To do this, the environment must be set up so the habit state (focused, engaged) is consistently paired with environmental, emotional, social and kinesthetic cues. The environment needs to be reproducible in many locations, situations, and mental states as possible. As illustrated by one student’s report.

To cue myself to get ready for learning, I make my cappuccino play the same short piece of music, wear the same sweater, place my inspiring poster behind my screen, turn off all software notifications and place the cell phone out of visual range.

A similar concept is used in the treatment of insomnia by making the bedroom the only room to be associated with sleep or intimacy (Irish et al., 2017; Suni, 2021). All other activities, arguing with your partner, eating, watching television, checking email, texting, or social media are done at other locations. Given enough time, the cues in the bedroom become the conditioned triggers for sleep and pleasure.

Create different environments that are unique to each category of Zoom involvement (studying, working, socializing, entertaining).

Pre COVID, we usually wore different clothing for different events (work versus party) or visited different environments for different tasks (religious locations for worship; a bar, coffee shop, or restaurant for social gathering). The specific tasks in a specified location had conscious and subconscious cues that included people, lighting, odors, sound or even drinks and food. These stimuli become the classically conditioned cues to evoke the appropriate response associated with the task, just as Pavlov conditioned dogs to salivate when the bell sound was paired with the presentation of meat. Taking charge of the conditioning process at home may help many people to focus on their task as so many people now use their bedroom, kitchen or living room for Zoom work that is not always associated with learning or work. The following are suggestions to create working/learning environments.

  • Wear task-specific clothing just as you would have done going to work or school. When you plan to study or work, put on your work shirt. In time, the moment you put on the work shirt, you are cueing yourself to focus on studying/working. When finishing with working/studying, change your clothing.
  • If possible, maintain a specific location for learning/working. When attending classes or working, sit at your desk with the computer on top of the desk. For games or communication tasks, move to another location.
  • If you can’t change locations, arrange task-specific backgrounds for each category of Zoom tasks. Place a different background such as a poster or wall hanging behind the computer screen—one for studying/working, and another for entertainment. When finished with the specific Zoom event, take down the poster and change the background.
  • Keep the sound appropriate to the workstation area. Try to duplicate what is your best learning/working sound scape.

Personal Cueing

Learning to become aware of and in control of one’s personal self is equally or more important than setting up the environment with cues that foster attention and learning. Practicing getting the body/mind into the learning state can become a habit that will be available in many different learning situations across one’s lifespan.

  • Perform a specific ritual or pre-performance routine before beginning your task to create the learning/performing state. The ritual is a choreographed sequence of actions that gets you ready to perform. For example, some people like to relax before learning and find playing a specific song or doing some stretching before the session is helpful.  Others sit at the desk, turn off all notifications, take a deep breath then look up and state to themselves: “I am now looking forward to working/studying and learning,” “focus” (whatever it may be). For some, their energy level is low and doing quick arm and hand movements, slapping their thighs or face, or small fast jumps may bring them to a more optimal state. For many people smell and taste are the most powerful conditioners, and coffee improves their attention level. Test out an assortment of activities that get your body and mind at the performance level. Practice and modify as necessary.

Just as in sport, the most reliable method is to set up oneself for the learning/performance state, because a person has less control over the environment. For example, when I observed the Romanian rhythmic gymnasts team members practice their routine during the warmup before the international competition, they would act as if it was the actual competition. They stood at the mat preparing their body/mind state, then they would bow to the imaginary judge, wait for a signal to begin, and then perform their routine. On the other hand, most of the American rhythmic gymnasts would just do their practice routine. For the Romanian athletes, the competition was the same as their rehearsal practice. No wonder, the Romanian athletes were much more consistent in their performance. Additionally, ritual helps buffer against uncertainty and anxiety (Hobson et al., 2017).

  • Develop awareness of the body-mind state associated with optimum performance. This can be done by creating a ritual and an environment that evoke the optimum mental and emotional state for learning. As you configure yourself and your environment, explore how you physically feel when you are most focused and engaged. Identify what your posture, muscle tension, and body position feel like during these times, and identify what you are paying attention to. If your attention wanders, observe how you bring your attention back to the task. Does it help focus you to write summary notes or doodle? Do you flag important statements in your head and then visibly nod your head when you understand the concept? Or do you repeat an important cue word?  Find what you do when you are optimally functioning. Then try to reproduce that same state that can be triggered by a key word that tells you what to focus on (e.g., listen to teacher, look at slide, etc.).

In summary, by becoming aware of and controlling one’s environment and personal states that are associated with productive learning, and then practicing them until they become a routine or habit, one can maximize all learning opportunities. This blog presented a few tips, techniques and cues that may help one to maximize attention and increase performance and learning while online.

I noticed when I took the time to prepare and ready myself to be focused and be present during the class, I no longer had to actively work to resist distractions; I was focused in the moment and not worried about emails, other assignments, what to make for dinner, etc…

References

Findlay-Thompson, S. and Mombourquette, P. (2014). Evaluation of a Flipped Classroom in an Undergraduate Business Course. Business Education & Accreditation, v. 6 (1), 63-71.https://papers.ssrn.com/sol3/papers.cfm?abstract_id=2331035

Fiorella, L. (2020). The science of habit and its implications for student learning and ell-being. Educational Psychology Review, 32,603–625. https://doi.org/10.1007/s10648-020-09525-1

Greene, J. A., & Azevedo, R. (2010). The measurement of learners’ self-regulated cognitive and metacognitive processes while using computer-based learning environments. Educational Psychologist, 45(4), 203–209. https://doi.org/10.1080/00461520.2010.515935

Hagger, M. S. (2019). Habit and physical activity: Theoretical advances, practical implications, and agenda. Psychology of Sport and Exercise, 42, 118–129. https://doi.org/10.1016/j.psychsport.2018.12.007

Hobson, N. M., Bonk, D., & Inzlicht, M. (2017). Rituals decrease the neural response to performance failure. PeerJ5, e3363. https://doi.org/10.7717/peerj.3363

Irish, L. A., Kline, C. E., Gunn, H. E., Buysse, D. J., & Hall, M. H. (2015). The role of sleep hygiene in promoting public health: A review of empirical evidence. Sleep medicine reviews, 22, 23–36. https://doi.org/10.1016/j.smrv.2014.10.001

Lally, P., VanJaarsveld, C. H., Potts, H. W., & Wardle, J. (2010). How habits are formed: Modelling habit formation the real world. European Journal of Social Psychology, 40, 998–1009. https://doi.org/10.1002/ejsp.674

Lautenbach, F., Laborder, S. I., Lobinger, B. H., Mesagno, C. Achtzehn, S., & Arimond, F. (2015). Non automated pre-performance routine in tennis: An intervention study. Journal of Applied Sport Psychology, 27(2), 123-131. https://doi.org/10.1080/10413200.2014.957364

Lidor, R. & Mayan, Z. (2005). Can beginning learners benefit, from pre-performance routines when serving in volleyball? The Sport Psychologist 19(4), 243–263. https://doi.org/10.1123/tsp.19.4.343

Mega, C., Ronconi, L., & De Beni, R. (2014). What makes a good student? How emotions, self-regulated learning, and motivation contribute to academic achievement. Journal of Educational Psychology, 106(1), 121–131. https://doi.org/10.1037/a0033546

Mesagno, C., Hill, D. M., & Larkin, P. (2015). Examining the accuracy and in game performance effects between pre- and post-performance routines: A mixed methods study. Psychology of Sort and Exercise, 19, 85–94. https://doi.org/10.1016/j.psychsport.2015.03.005

Peper, E., Wilson, V., Martin, M., Rosegard, E., & Harvey, R. (2021). Avoid Zoom fatigue, be present and learn. NeuroRegulation, 7(1).

Shoepe, T. C., McManus, J. F., August, S. E., Mattos, N. L., Vollucci, T. C. & Sparks, P. R. (2020). Instructor prompts and student engagement in synchronous online nutrition classes. American Journal of Distance Education, 34, 194–210. https://doi.org/10.1080/08923647.2020.1726166

Suni, E. (2021). Sleep Hygiene. https://www.sleepfoundation.org/sleep-hygiene.

Wilson, V. E. & Peper, E. (2011). Athletes are different: factors that differentiate biofeedback/neurofeedback for sport versus clinical practice. Biofeedback, 39(1), 27–30. https://doi.org/10.5298/1081-5937-39.1.01


Are you encouraging your child to get into accidents or even blind when growing up?

Erik Peper and Meir Schneider

Adapted in part from: TechStress-How Technology is Hijacking our Lives, Strategies for Coping and Pragmatic Ergonomics by Erik Peper, Richard Harvey and Nancy Faass   

As a young child I laid on the couch and I read one book after the other.  Hours would pass as I was drawn into the stories. By the age of 12 I was so nearsighted that I had to wear glasses.  When my son started to learn to read, I asked him to look away at the far distance after reading a page. Even today at age 34, he continues this habit of looking away for a moment at the distance after reading or writing a page.  He is a voracious reader and a novelist of speculative fiction. His vision is perfect. –Erik Peper

How come people in preliterate, hunting and gatherer, and agricultural societies tend to have better vision and very low rates of nearsightedness (Cordain et al, 2003)? The same appear true for people today who spent much of their childhood outdoors as compared to those who predominantly stay indoors. On the other hand, how come 85% of teenagers in Singapore are myopic (neasighted) and how come in the United States myopia rate have increased for children from 25% in the 1970s to 42% in 2000s (Bressler, 2020; Min, 2019)? 

Why should you worry that your child may become nearsighted since it is easy correct with contacts or glasses?   Sadly, in numerous cases, children with compromised vision and who have difficulty reading the blackboard may be labeled disruptive or having learning disability. The vision problems can only be corrected if the parents are aware of the vision problem (see https://www.covd.org/page/symptoms for symptoms that may be related to vision problems). In addition, glasses may be stigmatizing and  children may not want to wear glasses because of vanity or the fear of being bullied.

The recent epidemic of near sightedness is paritally a result of disrespecting our evolutionary survival patterns that allowed us to survive and thrive. Throughout human history, people continuously alternated by looking nearby and at the distance.  When looking up close, the extraocular muscles contract to converge the eyes and the ciliary muscles around the lens contract to increase the curvature of the lens so that the scene is in focus on the retina — this muscle tension creates near visual stress.

The shift from alternating between far and near vision to predominantly near vision and immobility

Figure 2. The traditional culture of Hdzabe men in Tanzania returning from a hunt. Notice how upright they walk and look at the far distance as compared to young people today who slouch and look predominantly  at nearby screens.

Experience the effect of near visual stress. 

Bring your arm in front of you and point your thumb up.  Look at your thumb on the stretched out arm.  Keep focusing on the thumb and slow bring the thumb four inches from your nose.  Keep focusing on the thumb for a half minute.  Drop the arm to the side, and look outside at the far distance.

What did you experience? Almost everyone reports feeling tension in the eyes and a sense of pressure inside around and behind their eyes.  When looking at the distance, the tension slowly dissipates.  For some the tension is released immediately while for others it may take many minutes before the tension disappears especially if one is older. Many adults experience that after working at the computer, their distant vision is more fuzzy and that it takes a while to return to normal clarity.

When the eyes focus at the distance, the ciliary muscles around lens relaxes so that the lens can flatten and the extra ocular muscles relax so that the eyes can diverge and objects in the distance are in focus.  Healthy vision is the alternation between near and far focus– an automatic process by which the muscles of the eyes tightening and relax/regenerate.

Use develops structure and structure limits use

If we predominantly look at nearby surfaces, we increase near visual stress and the risk of developing myopia. As children grow, the use of their eyes will change the shape of the eyeball so that the muscles will have to contract less to keep the visual object into focus.  If the eyes predominantly look at near objects, books, cellphones, tablets, toys, and walls in a room where there is little opportunity to look at the far distance, the eye ball will elongate and the child will more likely become near sighted. Over the last thirty year and escalated during COVID’s reside-in-place policies, children spent more and more time indoors while looking at screens and nearby walls in their rooms. Predominantly focusing on nearby objects starts even earlier as parents provide screens to baby and toddlers to distract and entertain them. The constant near vision remodels the shape of eye and the child will  likely develop near sightedness.  

Health risks of sightedness and focusing predominantly upon nearby objects

  • Increased risk of get into an accident as we have reduced peripheral vision.  In earlier times if you were walking in jungle, you would not survive without being aware of your peripheral vision. Any small visual change could indicate the possible presence food or predator, friend or foe.  Now we focus predominantly centrally and are less aware of our periphery. Observe how your peripheral awareness decreases when you bring your nose to the screen to see more clearly.  When outside and focusing close up the risk of accidents (tripping, being hit by cars, bumping into people and objects) significantly increases as shown in figure 3 and illustrated in the video clip.

Pedestrian accidents (head forward with loss of peripheral vision)

Figure 3. Injuries caused by cell phone use per year since the introduction of the smartphone (graphic from Peper, Harvey and Faass,2020; data source: Povolatskly et al., 2020).

Source: https://media.giphy.com/media/308cQ2vXnA5X8Ou3jo/giphy.mp4
  • Myopia increases the risk of eye disorder. The risk for glaucoma, one the leading causes of blindness, is doubled (Susanna, De Moraes, Cioffi, & Ritch, R. 2015). The excessive tension around the eyes and ciliary muscles around the lens can interfere with the outflow of the excess fluids of the aqueous humour through the schlemm canal and may compromise the production of the aqueous humour fluid. These canals are complex vascular structures that maintains fluid pressure balance within the anterior segment of the eye. When the normal outflow is hindered it would contribute to elevated intraocular pressure and create high tension glaucoma (Andrés-Guerrero, García-Feijoo,  & Konstas, 2017).  Myopia also increases the risk for retinal detachment and tears, macular degeneration and cataract. (Williams & Hammond, 2019).

By learning to relax the muscles around the lens, eye and face and sensing a feeling of soft eyes, the restriction around the schlemm canals is reduced and the fluids can drain out easier and is one possible approach to reverse glaucoma (Dada et al., 2018; Peper, Pelletier & Tandy, 1979).

WHAT CAN YOU DO?

The solutions are remarkable simple. Respect your evolutionary background and allow your eyes to spontaneously alternate between looking at near and far objects while being upright (Schneider, 2016; Peper, 2021; Peper, Harvey & Faass, 2020).

For yourself and your child

  • Let children play outside so that they automatically look far and near.
  • When teaching children to read have them look at the distance at the end of every paragraph or page to relax the eyes.
  • Limit screen time and alternate with outdoor activities
  • Every 15 to 20 minutes take a vision break when reading or watching screens.  Get up, wiggle around, move your neck and shoulders, and look out the window at the far distance.
  • When looking at digital screens, look away every few minutes. As you look away, close your eyes for a moment and as you  are exhaling gently open your eyes.
  • Practice palming and relaxing the eyes. For detailed guidance and instruction see the YouTube video by Meir Schneider.

Create healthy eye programs in schools and work

  • Arrange 30 minute lesson plans and in between each lesson plan take a vision and movement breaks. Have children get up from their desks and move around.  If possible have them look out the window or go outside and describe the furthest object they can see such as the shape of clouds, roof line or details of the top of trees.
  • Teach young children as they are learning reading and math to look away at the distance after reading a paragraph or finishing a math problem.
  • Teach palming for children.
  • During recess have students play games that integrate coordination with vision such as ball games.
  • Episodically, have students close their eyes, breathe diaphragmatically and then as they exhale slowly open their eyes and look for a moment at the world with sleepy/dreamy eyes.
  • Whenever using screen use every opportunity to look away at the distance and for a moment close your eyes and relax your neck and shoulders.

BOOKS TO OPTIMIZE VISION AND TRANSFORM TECHSTRESS INTO TECHHEALTH

Vision for Life, Revised Edition: Ten Steps to Natural Eyesight Improvement by Meir Schneider.

TechStress-How Technology is Hijacking our Lives, Strategies for Coping and Pragmatic Ergonomics by Erik Peper, Richard Harvey and Nancy Faass   

YOUTUBE PRESENTATION, Transforming Tech Stress into Tech Health.

ADDITIONAL BLOGS THAT FOCUS ON RESOLVING EYES STREAN AND TECHSTRESS

REFERENCES

Andrés-Guerrero, V., García-Feijoo, J., & Konstas, A.G. (2017). Targeting Schlemm’s Canal in the Medical Therapy of Glaucoma: Current and Future Considerations. Adv Ther, 34(5), 1049-1069.

Bressler, N.M. (2020). Reducing the Progression of Myopia. JAMA, 324(6), 558–559.

Chen, S. J., Lu, P., Zhang, W. F., & Lu, J. H. (2012). High myopia as a risk factor in primary open angle glaucoma. International journal of ophthalmology5(6), 750–753.

Cordain, L.,  Eaton, S.B., Miller, J. B., Lindeberg, S., & Jensen, C. (2003). An evolutionary analysis of the aetiology and pathogenesis of juvenile‐onset myopia. Acta Ophthalmologica Scandinavica, 80(2), 125-135.

Dada, T., Mittal, D., Mohanty, K., Faiq, M.A., Bhat, M.A., Yadav, R.K., Sihota, R., Sidhu, T,, Velpandian, T., Kalaivani, M., Pandey, R.M., Gao, Y., Sabel, B,A., & Dada, R. (2018). Mindfulness Meditation Reduces Intraocular Pressure, Lowers Stress Biomarkers and Modulates Gene Expression in Glaucoma: A Randomized Controlled Trial. J Glaucoma, 27(12), 1061-1067.

Hansraj, K. K. (2014). Assessment of stresses in the cervical spine caused by posture and position of the head. Surgical Technology International, 25, 277–279.

Harvey, R., Peper, E., Booiman, A., Heredia Cedillo, A., & Villagomez, E. (2018). The effect of head and neck position on head rotation, cervical muscle tension and symptoms. Biofeedback. 46(3), 65–71.

Min, L.P. (2019). Speech by Dr. Lam Pin Min, Senior Minister of State for Health, Singapore, at the opening of the Sangapore National Eye Centre’s Myopia Center, 16 August, 2019.

Peper, E. (2021). Resolve eyestrain and screen fatigue. Well Being Journal, 30(1), 24-28.

Peper, E., Booiman, A., Lin, I.M., & Harvey, R. (2016). Increase strength and mood with posture. Biofeedback. 44(2), 66–72.

Peper, E., Harvey, R. & Faass, N. (2020). TechStress: How Technology is Hijacking Our Lives, Strategies for Coping, and Pragmatic Ergonomics. Berkeley: North Atlantic Books.

Peper, E., Lin, I-M., Harvey, R., & Perez, J. (2017). How posture affects memory recall and mood.  Biofeedback.45 (2), 36-41.

Peper E., Pelletier K.R., Tandy B. (1979) Biofeedback Training: Holistic and Transpersonal Frontiers. In: Peper E., Ancoli S., Quinn M. (eds) Mind/Body Integration. Springer, Boston, MA.

Povolotskiy, R., Gupta, N., Leverant, A. B., Kandinov, A., & Paskhover, B. (2020). Head and Neck Injuries Associated With Cell Phone Use. JAMA Otolaryngology–Head & Neck Surgery, 146(2), 122-127.

Schneider, M. (2016). Vision for Life, Revised Edition: Ten Steps to Natural Eyesight Improvement. Berkeley, CA: North Atlantic Books.

Schneider, M. (2019). YouTube video Free Webinar by Meir Schneider: May 6, 2019.

Susanna, R., Jr, De Moraes, C. G., Cioffi, G. A., & Ritch, R. (2015). Why Do People (Still) Go Blind from Glaucoma?. Translational vision science & technology4(2), 1.

Williams, K., & Hammond, C. (2019). High myopia and its risks. Community eye health32(105), 5–6.


Why did the CDC mishandle the COVID-19 pandemic response?

The CDC (Centers for Disease Control and Prevention) located in Atlanta, George, with a stellar international reputation responded too late and incompetently to the COVID-19 pandemic in the United States.  Although many people blame the Trump administration for the failed response, a significant factor was the risk adverse and politicized CDC.. To understand what actually happened, listen to the superb New York Times podcast with Michael Lewis and read his just published book, The Premonition: A Pandemic Story.  The interview and his book should be the first requirement for anyone interested in Public Health careers, government service and public policy.

Listen to the New York Times book review podcast interview: and read the book.


Configure your brain to learn and avoid Zoom fatigue [1]

Adapted from: Peper, E., Wilson, V., Martin, M., Rosegard, E., & Harvey, R. (2021). Avoid Zoom fatigue, be present and learn. NeuroRegulation, 8(1), 47–56. https://doi.org/10.15540/nr.8.1.47

After a while, it all seems the same.  Sitting and looking at the screen while working, taking classes, entertaining, streaming videos and socializing.  The longer I sit and watch screens, the more I tend to feel drained and passive, and the more challenging it is to be present, productive and pay attention.

Overnight, the pandemic transformed college teaching from in-person to online education. Zoom[2] became the preferred academic teaching and learning platform for synchronous education. Students and faculty now sat and looked at the screen for hours. While looking at the screen, the viewers were often distracted by events in their environment, notifications from smartphones, social media and email, which promoted multitasking (Solis, 2019).  The digital distractions causing people to respond to twice as many devices with half of our attention—a process labeled ‘semi-tasking’- meaning getting twice as much done half as well.

For many students synchronous online learning was more challenging, especially after teaching was shifted to a Zoom environment without adapting the course materials to optimize online learning. During polling of 325 undergraduate university students at a metropolitan university who were all taking synchronous online Zoom classes, the vast majority reported that learning was somewhat to extremely difficult, with only the minority of students (approximately 6%) preferring online learning as shown in Figure 1. 

Figure 1.  Survey of 325 Undergraduates comparing Zoom online learning compared to the previous in person classes. Approximately 94% had moderate to considerable difficulty with on line learning.

The increased self-report on difficulty experienced in synchronous Zoom online learning may also affect academic achievement.  At the same time, many people have reported an increase in physical, behavioral and psycho-emotional problems  (e.g. backache, headache, stomachache, eye-strain, sore neck and shoulder pain, over or under eating, over or under sleeping, over or under exercising, ruminative thoughts related to categories of anxiety/fear, boredom/numbness, depression/sadness, anger/hostility, etc) (Fosslien & Duffy, 2020; Lee, 2020; Intolo, 2019; Leeb et al, 2020; McGinty et al, 2020; Peper & Harvey, 2018; Peper, Harvey and Faas, 2020). 

This post explores factors that contribute to zoom fatigue and offers practical suggestions to optimize learning during synchronous Zoom online education. The concepts are derived from our teaching athletes to sustain peak mental and physical performance, with the implication that the same concepts can help students towards sustaining on-topic attention during online learning (Wilson & Peper, 2011). In sports, the coach can help guide the athlete; however, the athlete needs to be present and motivated.  Faculty have a responsibility to support, encourage, and engage students while students have the responsibility to configure themselves into an optimum learning state.

Part 1: Factors that contribute to Zoom fatigue

Differences in communication between live and computer communication

Until the 20th century, almost all communication included non-verbal expressions. The speaker used verbal and nonverbal expressions while the respondent would immediately show a reaction to the speaker.  There was a continuous dynamic verbal and nonverbal exchange. The listener would respond to the speaker. If they agreed they nodded their head.  If they disagreed or were intimidated they would provide alternative body movements (e.g., shake their head) or facial expressions (look away or frown).  During normal conversations, both the speaker’s facial expression and body language are noticed and responded to, which are in turn, can be used as feedback by the other person. In large group sessions with many participants, the visual feedback is reduced and facial responses are difficult to distinguish especially the gallery view. 

In a Zoom environment, both the sender and receiver are watching the computer screen without awareness that nonverbal cues are essential for the purpose of understanding not only what is being said but also for the implied meaning and its importance. These non-verbal cues are usually processed without awareness in live person-to-person exchange. While sending and receiving are usually simultaneous, there can exist a disconnect between the attached meanings of the encoded information and that of the decoded information due to the inconsistent existence of important nonverbal components.  In a Zoom environment, the end-result could mean multiple images of receivers providing the sender with little or no non-verbal cues with which to interpret the meaning they have attached to your message.  The person may appear to look at you; however, you do not know whether they are attending to you, have a neurological disorder and cannot respond, are reading their emails, watching YouTube videos, or texting on their phone. Additionally, the nonverbal cues they are sending may not be related to your message but to their reaction to other media, people or distractions not seen by the presenter. 

This mode of communication is different from communication patterns that evolved through natural selection and allowed the human species to thrive and survive. For the first time in human history we learn, teach, work, socialize, and entertain in front of the same screen.  In many cases, communication in the era of smartphones has been reduced to texting, writing digital responses or reacting to media content on any screen.  Over the past few decades, it is possible for people to communicate through more disembodied, off-topic and external modes of interaction. So many types of learning activities vie for our attention and can occur without leaving our chairs, thus, it may be difficult to stay on-topic online Zoom classes (Keller, Davidesco, & Tanner, 2020).

Normal communication typically involves whole body movements (face, head, arms and hands) which tends to energize or sometimes distract the speaker or listener (Kendon, 2004). When communicating with friends-we often move our bodies dynamically and responsively during the discussion.  With synchronous large online lectures, students tend to be passive and just sit and watch.[3] This state of sitting and just watching the screen is similar to watching video entertainment where we sit for a long time and are covertly conditioned not to act. 

Unknowingly, we have trained ourselves not to initiate action since the screen does not provide feedback to our responses- a process so different from talking and responding spontaneously in groups of participants.

When communication is safe, people interact, respond and chime in.  In large groups, just like large lectures, Zoom tends to inhibit this process because it delays social feedback since most people mute their microphone to avoid extraneous noise. This is usually the rule for large groups although for small groups, people often unmute themselves. The physical act of unmuting is an additional barrier to spontaneous verbal responses. This shift of attention induces a delay before responding.  From a communication perspective, a delay before responding reduces the spontaneity and is may be interpreted more negatively by the listener (Roberts, Margutti, & Takano, 2011).

Facial Expressions and Auditory Processing

Facial expressions are a critical part of non- verbal feedback and signals to the other person that they are being listened to and provide cues that the interaction is safe.  We unknowingly react to facial expressions–processed unconsciously through neuroception (Porges, 2017)–to indicate whether the person is signaling safety or danger.  Usually when the person is facially responsive and shows expression, it signals safety and allows communication and intimacy to be developed. If the person shows no facial expressions (a still/flat face), we unconsciously interpret this as a signal of danger (Porges, 2017). The importance of responsive feedback is illustrated in the study by Tronick et al (1975) where mothers were instructed not to respond with facial and body cues to their infant. The babies rapidly became highly disturbed when the mother stayed nonresponsive as dramatically illustrated in the YouTube video, Still Face Experiment: Dr. Edward Tronick (Tronick, 2007).  In adults lack of verbal and nonverbal feedback during social evaluations is extremely stressful (Gruenewald, Kemeny, Aziz, & Fahey, 2004; Birkett, 2011).

The absence of social facial and body feedback often makes teaching and learning more challenging.  Namely, are the receivers–the invisible, (only their picture or name is shown), partially visible (facial features are indistinct due to backlighting) or ghosting (those whose picture and name are shown but are physically absent from the session)–understanding the information the way the sender intended? 

Unlike traditional classroom settings where one has the benefit of seeing/sensing nonverbal cues, the Zoom gallery view often, the speaker may not know what how the audience is responding and this contributes to Zoom fatigue. In addition, the communication bond is often reduced when the speaker does not look at audience and the listener does not respond to the speaker with facial expressions.  Zoom fatigue can also be reduced when online teaching tools are used appropriately by involving active feedback responses through polls, chat, etc. as well as asking specific participants to speak and give feedback.

What is unique to the synchronous online environment is that the speakers and participants view themselves. This is the first time in human history that people are seeing themselves while speaking[4].   For some people, seeing themselves may increase anxiety and negative self-judgement- a process that is even more prevalent in teens.  Some are self-conscious and some have social anxiety and do not want their face to be shown (Degges-White, 2020).  In the past, most of us had no idea how we looked when others or ourselves are communicating—it is totally novel experience to see yourself while talking and communicating.

Reduced physical activity and increased near vision stress.

 Before sheltering in place, I would walk from my house to the BART station, take the train to Daly City station and then walk to the university.  At the university, I would climb stairs to go to my office, meet with other faculty and walk to the classroom.  At the end of the day, I would walk back to the Bart station and eventually walk home. Without any thinking or trying to do any exercise, I usually would do 12,000 steps and about 25 stairs.  Now, I am lucky if I do 3000 unless will myself to do more exercise.  –Erik Peper

The move to a Zoom environment and sheltering in place meant that we sit more and more which tends to increase mortality, decrease subjective energy and contributes to an attitude of passive engagement, more as an observer than as a participant (Stamtakis et al, 2019; Patel et al, 2018; Oswald et. al., 2020; Yalçin, Özkurt, Özmaden & Yagmur, 2020). While sitting, we also tend to slouch as we look at the screen that may be a covert factor in the increasing rates of depression and anxiety. 

This slouching position tends to decrease access to positive memories and allow easier access to negative memories (Peper et al, 2017) as well as interfere with academic performance.  Peper et al (2018) found that students have more difficulty performing mental math in the slouched as compared to upright sitting position. To reduce the impact of sitting, Peper & Lin (2012) found that when student perform some physical activities (e.g., skipping in place) for just a minute they report a significantly increase subjective energy and attention levels.

When looking at the screen our eyes only focus on the screen, which is different from in-person communication where you look at the person and then look at behind or to the side of the person. Only looking at the screen means that to focus on the screen the muscles of the eyes tighten so that the eyes can converge and the ciliary muscles around the lens contract so that the lens curvature is increased which results in near visual stress. This continuous looking at a near object is different from normal eye function in which we alternately focus on nearby objects and then look far away which allows the muscles of the eyes to relax.

Student Issues

Numerous students reported that it was much easier to be distracted and multitask, check Instagram, facebook, TikTok, or respond to emails and texts than during face-to-face classroom sessions as illustrated by two students’ comments.

“Now that we are forced to stay at home, it’s hard to find time by myself, for myself, time to study, and or time to get away. It’s easy to get distracted and go a bit stir-crazy.”

“I find that online learning is more difficult for me because it’s harder for me to stay concentrated all day just looking at the screen.” 

Students often reported that they had more difficulty remembering the materials presented during synchronous presentations. Most likely, the passivity while watching Zoom presentation affected the encoding and consolidation of new material into retrievable long term memory. The presented material was rapidly forgotten when the next screen image or advertisement appeared and competed with the course instructor for the student’s attention. We hypothesize that the many hours of watching TV and streaming videos have conditioned people to sit and take in information passively, while discouraging them to respond or initiate action (Mander, 1978; Mărchidan, 2019). Learning requires engagement, which means a shifting from passively watching and listening to being an active, participant shareholder in synchronous online classes.  However, in most cases, students have not received information/education or training on HOW TO be a more active/engaged participant in a synchronous Zoom class.

Instructor Issues

Instructors also have many of the same issues when presenting classes online. They engage in multiple simultaneous roles: presenter, director, and producer.  While teaching, they need to engage students, monitor the chat for feedback and look at the screen for facial responses.  At the same time, they may face similar technical issues as those experienced by students such as internet connectivity, limited bandwidth, and mastering the technical features of synchronous online learning technology.  At times, instructors feel that students expect each presentation to be as captivating as a TED talk.  Thus, teaching has shifted from education to edutainment

Part 2: Practical suggestions to optimize learning

To optimize learning in the synchronous online environment, teachers have the responsibility to reconfigure their teaching so that it incorporates active student involvement and students have the responsibility to be present and engaged. The following practices may facilitate learning:

Be present to learn

Mastering media presence is becoming even more important for everyone. The skill implemented in attending an online learning class will also be useful for professional development.  Although the pandemic shifted personal interviews to online interviews, most likely, synchronous and asynchronous video interviews are part of the first automatic screening level to assess candidates for a job (Rubinstein, 2020).

Be visible for the other person looking at you to create a positive impression

Adjust your camera and lights so that your face is visible and you are looking at the person to whom you are talking. Your screen presence is representing you.  Does the camera show you engaged or distracted lying on bed?  Be aware that you and your background together create an impression. The concept that looking directly at the audience– looking directly at the camera–is not new. Everyone working in media (newscasters, politicians, actors) have been trained to make their faces visible and expressive.  This means arranging your webcam at eye level right in front of you and speaking to the camera as if it is the person.  Avoid looking down at the person on the screen since the viewer would see you looking look down and away. Be sure your face is illuminated and there are no bright light sources behind you (Purdy, 2020).  We recommend that in small group, participants unmute their microphones so that people can respond spontaneously to each other unless there is excessive background noise.

Be a responsive and interactive listener to configure your brain to be engaged

Shift from being a passive absorber to an active participant even if your camera is off or the speaker cannot see you. Imagine being physically with the speaker and activate yourself by increasing your face and body animation as you are attending a synchronous online class.  Thus, when you watch a presentation, act as if you are in a personal conversation with the presenter or the material. This means that if you agree, nod your head; if you disagree, shake your head (do this naturally without making it a work task). Do this for the whole session.  Our research has shown that when college students purposely implement animated facial and body responses during Zoom classes, they report a significant increase in energy level, attention and involvement as compared to just attending normally in class (Peper & Yang, in press). See Figure 2.

Figure 2.  Change in subjective energy, attention and involvement when the students significantly increase their facial and body animation by 123 % as compared to their normal non-expressive class behavior (Peper & Yang, 2021).

  “I never realized how my expressions affected my attention. Class was much more fun”

-22 year old woman student.

“I can see how paying attention and participation play a large role in learning material. After trying to give positive facial and body feedback I felt more focused and I was taking better notes and felt I was understanding the material a bit better.”-28 year old medical student

Configure your body to attend and perform

Sit upright and adapt a position of empowerment. When we sit upright and expanded it is easier to have positive thoughts and detach from negative hopeless thoughts (Peper, Lin, Harvey, & Perez, 2017; Peper, Harvey, Mason, & Lin, 2018). Students also performed better in mental math when they sat upright as compared to collapsed. When students are provided ongoing feedback when they begin to slouch by an app that uses the computer camera to monitor slouching, they reported a significant decrease in neck and back symptoms (Chetwynd et al, 2020). As one of many students reported:

“Before when I didn’t use the app, I had a lots of shoulder and neck pain. Now when I use it, the pain went way down as I kept changing posture to the feedback signal. I had more energy and I was more alert. I did notice that when I would get the alert to sit up straight.”

Optimize concentration and learning

In the online environment, the structure more likely depends upon the person unlike the externally created structure of going to work or to class. Thus, purposely creating a time structure and scheduled time-periods to perform different tasks as time management skills are associated with improved school and work performance (Macan et al., 1990).  Create an environment to promote concentration and reduce distractions.

  • Stay on task and reduce interruption and practice refocusing on task. On the average we now check our phones 96 times a day—that is once every 10 minutes and an increase of 20% as compared to two years ago (Asurion Research, 2019). Those who do media multitasking such as texting while doing a task perform significantly worse on memory tasks than those who are not multitasking (Madore et al., 2020). Multitasking is negatively correlated with school performance (Giunchiglia et al, 2018). When working or attending a class or meeting, turn off all notifications (e.g., email, texts and social media). Then block out specific times when you work on Zoom and when you respond to email, phone or social media (Newport, 2016). Let people know that you will look at the notifications and respond in a predetermined time so that you will not be interrupted while working or studying.  If you work where there are other people, arrange your workstation so that there are fewer distractions such as sitting with your back to other people. When students chose to implement a behavior change to monitor cellphone and media use and reduce the addictive behavior during a five-week self-healing project, many report a significant improvement of health and performance.  One student observed that when she reduced her cellphone use her stress level equally decreased as shown in Fig 3.

Figure 3. Example of a student changing cellphone use and corresponding decrease in subjective stress level.

During this class project, many students observed that the continuous responding to notifications and social media affect their health and productivity. As one student reported,

The discovery of the time I wasted giving into distractions was increasing my anxiety, increasing my depression and making me feel completely inadequate. In the five-week period, I cut my cell phone usage by over half, from 32.5 hours to exactly 15 hours and used some of the time to do an early morning run in the park. Rediscovering this time makes me feel like my possibilities are endless. I can go to work full time, take online night courses reaching towards my goal of a higher degree, plus complete all my homework, take care of the house and chores, cook all my meals, and add reading a book for fun! –22 year old College Student

  • Approached learning with a question. When you begin to study the material or attend a class, ask yourself questions that you would like to be answered. If possible, put your questions to the instructor. When you have a purpose, it is easier to stay emotionally present and remember the material (Osman, & Hannafin, 1994).
  • Take written notes while attending a Zoom meeting or class.  When participants take hand written notes versus on the computer they tend to integrate and remember the material much more than just watching passively (Mueller & Oppenheimer, 2014). Active note taking leads to focused attention and fewer distractions from social media content (Flanigan & Titsworth, 2020).
  • Review materials. At the end of the class, meet with your fellow students on ZOOM or social media and review the class materials.  As you discuss the materials, add comments to your notes and if possible, do a hierarchical outline to more easily remember the relationships among the ideas. 
  • Change your internal language. What we overtly or covertly say and believe is what we may become. When one says, “I am stupid”, “I can’t do math,” or “It is too difficult to learn,” one may become powerless which increases stress and inhibits cognitive function.  Instead, change the internal language so that it implies that you can master the materials such as, “I need more time to study and to practice the material,”  “Learning just takes time and at this moment it may take a bit longer than for someone else,” or “I need a better tutor.” 

Create an environment to trigger the appropriate mental and emotional state for learning.

Learning and recall are state dependent.  Without awareness, the learned content is covertly associated with environmental, emotional, social and kinesthetic cues.  Thus, when you study in bed, the material is more easily accessed while lying down. When you study with music, the music becomes a retrieval cue.  Without awareness, the materials are encoded with the cues of lying down or the music played in the background.  When you take your exam in a different setting then you have studied, none of the covert cues are there, thus, it is more difficult to recall the material. Study and review the materials under similar conditions, as you will be tested. 

To configure yourself to be ready to study, work, or socialize create different environments that are unique to each category of Zoom involvement (studying, working, socializing, entertaining). Pre COVID, we usually used different clothing for different events (work versus party) or different environments for different tasks (temple, churches, mosques, or synagogue for religious practice; bar or coffee shop to meet friends). Create a unique environment with each Zoom activity. The stimuli to be associated to the specific tasks can also include lighting, odors, sound or even drinks and food. These stimuli become the classically conditioned cues to evoke the appropriate response associated with the task just as Pavlov conditioned dogs to salivate by pairing a sound with the meat.  Taking charge of the conditioning process may help many people to focus on their task as so many students use their bedroom, kitchen or living room for Zoom work which is not always conducive for learning or work.

  • Wear task specific clothing just as you would have done going to work or school.  When you plan to study, put on your study T-shirt. In time, the moment you put on the study T-shirt, you are cueing yourself to focus on studying. When finishing with studying, change your clothing.
  • Arrange task specific backgrounds for each category of Zoom task. Place a different background such as a poster or wall hanging behind the computer screen-one for studying and another for entertainment. When finished with the specific Zoom event, take down the poster and change the background. 

Optimize arousal and regenerate vision

  • The longer we sit the more passive we tend to become. Teachers will benefit by interrupting the passive transfer of information by guiding students in fun short movements to increase arousal.  If instructors fail to put in movement breaks, students sitting in front of screens can remind themselves to move. The challenge is that we are usually unaware of how much time has passed as we are captured by the screen.  It is often helpful to use an app such as StretchBreak[5] to remind yourself to get up and move.
  • Get up and move every 30 minutes. After sitting for 30 minutes stretch, wiggle and move.  Do the movements with vigor or even dance, look up and reach up.  When you stand up and move your legs and feet, you tighten and relax your calf muscles that pump the venous blood and lymph fluids that have been pooling in your legs back to your heart. The calf muscle is often called the second heart because in facilitates venous blood return.
  • Regenerate vision. Our eyes tend to get tired and world looks blurry.  Interrupt the near vision stress by allowing the eyes to relax and regenerate.
  • Palming.  Bring your hands to your face and cup the hands so that there is no pressure on your eyeballs. Allow the base of the hands to touch the cheeks while the fingers are interlaced and resting your forehead. Then with your eyes closed imagine seeing black. Breathe slowly and diaphragmatically while feeling the warmth of the palm soothing the eyes. Feel your shoulders, head and eyes relaxing and do this for five minutes (Schneider, 2016; Peper, 2021).
  • Look at the distance.  Interrupt near visual stress (convergence of the eyes and tightening of the ciliary muscle around the lens allows us to focus on the screen) by looking away at the far distance.  Every so look at the clouds, top of trees or rooftops outside the window to relax the eyes.

Summary

By activating the evolutionary communication patterns that allowed us to survive and thrive and using known performance enhancement skills derived from peak performance training, we can enhance involvement and productivity. The instructor needs to stay current on methods that keep students attention. At the same time, students have a responsibility to configure themselves to optimize learning.   We recommend practices 1) to be present and learn, 2) optimize concentration and learning, 3) create an environment to trigger the appropriate mental and emotional state for learning, and 4) optimize arousal and regenerate vision.  By taking charge of your own teaching/learning process and configuring yourself to be present through active participation, learning is enhanced.

References

Asurion Research (November 19, 2019). Americans Check Their Phones 96 Times a Day. https://www.asurion.com/about/press-releases/americans-check-their-phones-96-times-a-day/#:~:text=Despite%20our%20attempts%20to%20curb,tech%20care%20company%20Asurion1.

Birkett M. A. (2011). The Trier Social Stress Test protocol for inducing psychological stress. Journal of visualized experiments: JoVE, (56), 3238. https://doi.org/10.3791/3238 

Chetwynd, J., Mason, L.A., Almendras, M., Peper, E., Harvey, R. (2020). Posture Awareness Training.  Poster presented for the 51th Annual Scientific online Meeting of the Association for Applied Psychophysiology and Biofeedback. (Dec 2, 3, 4, 9, 10, 11, 2020). https://doi.org/10.13140/RG.2.2.20194.76485

 Degges-White, S. (April 13, 2020). Dealing With Zoom Anxiety. Psychology Today. https://www.psychologytoday.com/us/blog/lifetime-connections/202004/dealing-zoom-anxiety

Flanigan, A.E. & Titsworth, S. (2020). The impact of digital distraction on lecture note taking and student learning. Instr Sci, 48495–524. https://doi.org/10.1007/s11251-020-09517-2

Fosslien, L. & Duffy, M. W. (2020). How to combat Zoom fatigue. Harvard Business Review. April 29, 2020. https://hbr.org/2020/04/how-to-combat-zoom-fatigue

Giunchiglia, F. Zeni, M.,  Gobbi, E., Bignotti,E., & Bison, I. (2018). Mobile social media usage and academic performance, Computers in Human Behavior, 82, 177-185. https://doi.org/10.1016/j.chb.2017.12.04

Gruenewald, T.L., Kemeny, M.E., Aziz, N., & Fahey. J.L. (2004). Acute threat to the social self: shame, social self-esteem, and cortisol activity. Psychosom. Med, 66, 915–924. https://doi.org/10.1097/01.psy.0000143639.61693.ef.

Intolo, P., Shalokhon, B.;, Wongwech, G., Wisiasut, P., Nathavanij, S., & Baxter, D.G. (2019). Analysis of neck and shoulder postures, and muscle activities relative to perceived pain during laptop computer use at a low-height table, sofa and bed. Work, 63(3), 361-367. https://doi.org/10.3233/WOR-192942

Jelaca, M., Anastasovski, I., & Velickovska, L.L.A. (2020). A report on the impacts of the coronovirus SARS-CO-2 “Shelter-in-place order” on fitness and well-being. Research in Physical Education, Sport and Health, 9(1), 13-18. https://doi.org/10.46733/PESH2090013j

Keller, A. S., Davidesco, I., & Tanner, K. D. (2020). Attention Matters: How Orchestrating Attention May Relate to Classroom Learning. CBE—Life Sciences Education19(3), fe5. https://doi.org/10.1187/cbe.20-05-0106

Kendon, A. (2004). Gesture: Visible Action as Utterance. Cambridge, England: Cambridge University Press. https://www.amazon.com/Gesture-Visible-Action-as-Utterance/dp/0521542936/ref=sr_1_2?dchild=1&keywords=Gesture%3A+Visible+Action+as+Utterance.&qid=1617248925&s=books&sr=1-2

Kuhfeld, M. Soland, J., Tarasawa, B., Johnson, Al., Ruzek, E., & Liu, J. (2020). Projecting the Potential Impact of COVID-19 School Closures on Academic Achievement. Educational Researcher, 49 (80, 549–565 https://doi.org/10.3102/0013189X20965918

Lee, J. (2020). A neuropsychological exploration of Zoom fatigue. Psychiatric Times.  November 17, 2020. Accessed December 26, 2020. https://www.psychiatrictimes.com/view/psychological-exploration-zoom-fatigue

Leeb, R.T., Bitsko, R,H,, Radhakrishnan. L., Martinez, P., Njai, R., & Holland, K.M. (2020). Mental Health–Related Emergency Department Visits Among Children Aged <18 Years During the COVID-19 Pandemic — United States, January 1–October 17, 2020. MMWR Morb Mortal Wkly Rep, 69,1675– https://doi.org/10.15585 /mmwr.mm6945a3

Lemay, D.J., Doleck, T.,& Bazedlais, P. (2019). Self-determination, loneliness, fear of missing out, and academic performance. Knowledge Management & E-Learning: An International Journal, 11(4). https://doi.org/10.34105/j.kmel2019.11.025

Macan, T. H., Shahani, C., Dipboye, R. L., & Phillips, A. P. (1990). College students’ time management: Correlations with academic performance and stress. Journal of Educational Psychology, 82(4), 760–768. https://doi.org/10.1037/0022-0663.82.4.760

Madore, K.P., Khazenzon, A.M., Backes, C.W. et al. (2020).Memory failure predicted by attention lapsing and media multitasking. Nature, 587, 87–91. https://doi.org/10.1038/s41586-020-2870-z

Mander, J. (1978).  Four Arguments for the Elimination of Television, New York: William Morrow Paperbacks.

Mărchidan, A., (2019). “More technologized is not more educated,” 2019 11th International Conference on Electronics, Computers and Artificial Intelligence (ECAI), Pitesti, Romania, 2019, pp. 1-4, https://doi.org/10.1109/ECAI46879.2019.9041993.

McGinty, E.E., Presskreischer, R., Anderson, K.E., Han, H., &Barry, C.L. (2020). Psychological distress and COVID-19–related stressors reported in a longitudinal cohort of US adults in April and July 2020. JAMA, 324(24), 2555-2557.  https://doi.org/10.1001/jama.2020.21231

Mueller, P.A. & Oppenheimer, D.M. (2014). The Pen Is Mightier Than the Keyboard: Advantages of Longhand Over Laptop Note Taking. Psychological Science, 25(6) 1159–1168. https://doi.org/10.1177/0956797614524581

Newport, C. (2016). Deep Work: Rules for Focused Success in a Distracted World. New York:Grand Central Publishing. https://www.amazon.com/Deep-Work-Focused-Success-Distracted/dp/1455586692/ref=sr_1_3?dchild=1&keywords=Deep+Work%3A+Rules+for+Focused+Success+in+a+Distracted+World&qid=1617249879&s=books&sr=1-3

Osman, M.E. & Hannafin, M.J. (1994). Effects of Advance Questioning and Prior Knowledge on Science Learning, The Journal of Education Research, 88(1), 5-13. https://doi.org/10.1080/00220671.1994.9944829

Oswald, T.K., Rumbold, A.R., Kedzior, S/G.E., & Moore, V.M. (2020) Psychological impacts of “screen time” and “green time” for children and adolescents: A systematic scoping review. PLoS ONE, 15(9), e0237725. https://doi.org/10.1371/journal.pone.0237725

Patel, A.V., Maliniak, M.L., Rees-Punia, E.R., Matthews, C.E., & Gapstur, S.M. (2018). Prolonged leisure time spent sitting in relation to cause-specific mortality in a large US cohort. American Journal of Epidemiology, 187(10), 2151–2158, https://doi.org/10.1093/aje/kwy125

Peper, E. (2021). Resolve Eyestrain and Screen Fatigue. Well Being Journal, 30, 24-28. https://www.researchgate.net/publication/345123096_Resolve_Eyestrain_and_Screen_Fatigue

Peper, E. & Harvey, R. (2018). Digital addiction: increased loneliness, depression, and anxiety. NeuroRegulation5(1),3–8 http://dx.doi.org/10.15540/nr.5.1.3

Peper, E., Harvey, R., & Faass, N. (2020). TechStress-How Technology is Hijacking our Lives, Strategies for Coping and Pragmatic Ergonomics.  Berkeley, CA: North Atlantic Books. https://www.penguinrandomhouse.com/books/232119/tech-stress-by-erik-peper-phd/ 

Peper, E., Harvey, R., Mason, L., & Lin, I.-M. (2018). Do better in math: How your body posture may change stereotype threat response. NeuroRegulation, 5(2), 67–74. http://dx.doi.org/10.15540/nr.5.2.67

Peper, E. & Lin, I-M. (2012). Increase or decrease depression-How body postures influence your energy level.  Biofeedback, 40 (3), 126-130. https://doi.org/10.5298/1081-5937-40.3.01

Peper, E., Lin, I-M., Harvey, R., & Perez, J. (2017). How posture affects memory recall and mood.  Biofeedback, 45 (2), 36-41. https://doi.org/10.5298/1081-5937-45.2.01

Peper, E. & Yang, A. (2021). Beyond Zoom Fatigue: Re-energize yourself and improve learning. Academia Letters. Adapted as a blog, Beyond zoom fatigue: Re-energize yourself and improve learning.

Porges, S.W. (2017). The pocket guide to the polyvagal theory: The transformative power of feeling safe. New York: W. W. Norton & Co. https://www.amazon.com/Pocket-Guide-Polyvagal-Theory-Transformative/dp/0393707873/ref=sr_1_2?dchild=1&keywords=The+pocket+guide+to+the+polyvagal+theory%3A+The+transformative+power+of+feeling+safe&qid=1617249068&s=books&sr=1-2

Purdy, K. (April 21, 2020).  How to Pull Off a Professional Video Call From Home. New York Times Wirecutter. https://www.nytimes.com/wirecutter/blog/professional-video-call-from-home/

Roberts F., Margutti P., Takano S. (2011). Judgments concerning the valence of inter-turn silence across speakers of American English, Italian, and Japanese. Discourse Process. 48,  331–354.  https://doi.org/10.1080/0163853X.2011.558002

Rubinstein, P. (2020). Asynchronous video interviews: The tools you need to succeed. 5th November 2020 https://www.bbc.com/worklife/article/20201102-asynchronous-video-interviews-the-tools-you-need-to-succeed

Schneider, M (2016). Vision for Life, Revised Edition: Ten Steps to Natural Eyesight Improvement. Berkeley, CA: North Atlantic Books. https://www.amazon.com/Vision-Life-Revised-Eyesight-Improvement/dp/1623170087/ref=sr_1_1?dchild=1&keywords=Vision+for+Life%2C+Revised+Edition%3A+Ten+Steps+to+Natural+Eyesight+Improvement&qid=1617250077&s=books&sr=1-1

Solis, B. (2019). How Managers Can Help Workers Tackle Digital Distractions. MIT Sloan Management Review, 60(4), 1-3. https://sloanreview.mit.edu/article/how-managers-can-help-workers-tackle-digital-distractions/?gclid=CjwKCAiA25v_BRBNEiwAZb4-ZRuImr0A9EtQgRLl9FXmmALLPdMAjaFDDVAJSpwo7ta8vEPLW147XRoCmO8QAvD_BwE

Stamatakis, E., Gale, J., Bauman, A., Ekelund, U., Hamer, M., & Ding, D. (2019). Sitting time, physical activity, and risk of mortality in adults. J Am Coll Cardio, 73(16), 2062-2072. https://doi.org/10.1016/j.jacc.2019.02.031

Tronick, E., Adamson, L.B., Als, H., & Brazelton, T.B. (1975, April). Infant emotions in normal and pertubated interactions. Paper presented at the biennial meeting of the Society for Research in Child Development, Denver, CO.

Tronick, E. (2007). Youtube video-Still Face Experiment: Dr. Edward Tronick. https://www.youtube.com/watch?v=apzXGEbZht0

Wilson, V.E. & Peper, E. (2011). Athletes Are Different: Factors That Differentiate Biofeedback/Neurofeedback for Sport Versus Clinical Practice. Biofeedback, 39(1), 27–30. https://doi.org/10.5298/1081-5937-39.1.01

Yalçin, I., Özkurt, B.,  Özmaden, M., & Yagmur, R. (2020). Effect of Smartphone Addiction on Loneliness Levels and Academic Achievement of Z Generation. International Journal of Psychology and Educational Studies, 7(1), 208-214. https://doi.org/10.17220/ijpes.2020.01.017


[1] We thank Professor Jackson Wilson for his incisive comments.

[2] In this paper will use Zoom as the example for synchronous online teaching although the concepts may apply equally to other platforms such Microsoft Teams and Google Meet.

[3] Zoom and other synchronous online platforms provide tools to indicate that you would like to speak (e.g., electronic hand raising); however, it is an issue of how the class session is designed (e.g., do you use breakout rooms, are there structured requests for interaction). 

[4] Zoom has a feature to hide yourself. Start or join a Zoom meeting. The meeting automatically begins in Speaker View and you can see your own video. Then, right-click your video to display the menu, then choose Hide Myself.


Timing affects health and productivity

Have you experienced that your attentions is more focused in the morning than late afternoon? 

Have you wondered what is the best time in the day to have a job interview?

Is it better to have an operation in the morning or in the afternoon?

These and many other questions are explored in the superb book by Daniel Pink, When-The scientific secrets of perfect timing. This book reviews the literature of chronobiology, psychology, and behavior economics and describes the effect of time of day on human behavior. For example, students do significantly better if they take math tests in the morning than late afternoon or parolees have a much higher chance of being paroled early morning or right after the judge has taken a break than before lunch or late afternoon.    Read Pink’s book or watch his JCCSF presentation and use the information to change your own timing patterns to optimize your health and performance.

Cover of When