Is mindfulness training old wine in new bottles?

Posted: January 11, 2024 | Author: | Filed under: attention, behavior, biofeedback, Breathing/respiration, CBT, cognitive behavior therapy, healing, health, meditation, mindfulness, self-healing, stress management | Tags: , , , , , , , , , | 2 Comments

Adapted from: Peper, E., Harvey, R., & Lin, I-M. (2019).  Mindfulness training has themes common to other technique. Biofeedback. 47(3), 50-57.  https://doi.org/10.5298/1081-5937-47.3.02

This extensive blog discusses the benefits of mindfulness-based meditation (MM) techniques and explores how similar beneficial outcomes occur with other mind-centered practices such as transcendental meditation, and body-centered practices such as progressive muscle relaxation (PMR), autogenic training (AT), and yoga. For example, many standardized mind-body techniques such as mindfulness-based stress reduction and mindfulness-based cognitive therapy (a) are associated with a reduction in symptoms of symptoms such as anxiety, pain and depression. This article explores the efficacy of mindfulness based techniques to that of other self-regulation techniques and identifies components shared between mindfulness based techniques and several previous self-regulation techniques, including PMR, AT, and transcendental meditation. The authors conclude that most of the commonly used self-regulation strategies have comparable efficacy and share many elements.

Mindfulness-based strategies are based in ancient Buddhist practices and have found acceptance as one of the major contemporary behavioral medicine techniques (Hilton et al, 2016; Khazan, 2013).  Throughout this blog the term mindfulness will refer broadly to a mental state of paying total attention to the present moment, with a non-judgmental awareness of the inner and/ or outer experiences (Baer et al., 2004; Kabat-Zinn, 1994).

In 1979, Jon Kabat-Zinn introduced a manual for a standardized Mindfulness-Based Stress Reduction (MBSR) program at the University of Massachusetts Medical Center (Kabat-Zinn, 1994, 2003).  The eight-week program combined mindfulness as a form of insight meditation with specific types of yoga breathing and movements exercises designed to focus on awareness of the mind and body, as well as thoughts, feelings, and behaviors. 

There is a substantial body of evidence that mindfulness-based cognitive therapy (MBCT); Teasdale et al., 1995) and mindfulness-based stress reduction (MBSR) (Kabat-Zinn, 1994, 2003) have combined with skills of cognitive therapy for ameliorating stress symptoms such as negative thinking, anxiety and depression.  For example, MBSR and MBCT has been confirmed to be clinical beneficial in alleviating a variety of mental and physical conditions, for people dealing with anxiety, depression, cancer-related pain and anxiety, pain disorder, or high blood pressure (The following are only a few of the hundred studies published: Andersen et al., 2013; Carlson et al., 2003; Fjorback et al., 2011; Greeson, & Eisenlohr-Moul, 2014; Hoffman et al., 2012; Marchand, 2012; Baer, 2015; Demarzo et al., 2015; Khoury et al, 2013; Khoury et al, 2015; Chapin et al., 2014; Witek Janusek et al., 2019).  Currently, MBSR and MBCT techniques that are more standardized are widely applied in schools, hospitals, companies, prisons, and other environments. 

The Relationship Between Mindfulness and Other Self-Regulation Techniques

This section addresses two questions: First, how do mindfulness-based interventions compare in efficacy to older self-regulation techniques? Second, and perhaps more basically, how new and different are mindfulness-based therapies from other self-regulation-oriented practices and therapies?

Is mindfulness more effective than other mind/body body/mind approaches?

Although mindfulness-based meditation (MM) techniques are effective, it does not mean that is is more effective than other traditional meditation or self-regulation approaches.  To be able to conclude that MM is superior, it needs to be compared to equivalent well-coached control groups where the participants were taught other approaches such as progressive relaxation, autogenic training, transcendental meditation, or biofeedback training. In these control groups, the participants would be taught by practitioners who were self-experienced and had mastered the skills and not merely received training from a short audio or video clip (Cherkin et al, 2016). The most recent assessment by the National Centere for Complementary and Integrative Health, National Institutes of Health (NCCIH-NIH, 2024) concluded that generally “the effects of mindfulness meditation approaches were no different than those of evidence-based treatments such as cognitive behavioral therapy and exercise especially when they include how to generalize the skills during the day” (NCCIH, 2024). Generalizing the learned skills into daily life contributes to the  successful outcome of Autogenic Training, Progressive Relaxation, integrated biofeedback stress management training, or the Quieting Response (Luthe, 1979; Davis et al., 2019; Wilson et al., 2023; Stroebel, 1982).

Unfortunately, there are few studies that compare the effective of mindfulness meditation to other sitting mental techniques such as Autogenic Training, Transcendental Meditation or similar meditative practices that are used therapeutically.  When the few randomized control studies of MBSR versus autogenic training (AT) was done, no conclusions could be drawn as to the superior stress reduction technique among German medical students (Kuhlmann et al., 2016).

Interestingly, Tanner, et al (2009) in a waitlist study of students in Washington, D.C. area universities practicing TM used the concept of mindfulness, as measured by the Kentucky Inventory of Mindfulness Skills (KIM) (Baer et al, 2004)  as a dependent variable, where TM practice resulted in greater degrees of ‘mindfulness.’ More direct comparisons of MM with body-focused techniques, such as progressive relaxation, or Autogenic training mindfulness-based approaches, have not found superior benefit.  For example, Agee et al (2009) compared the stress management effects of a five-week Mindfulness Meditation (MM) to a five-week Progressive Muscle Relaxation (PMR) course and found no meaningful reports of superiority of one over the other program; both MM and PMR were effective in reducing symptoms of stress. 

In a persuasive meta-analysis comparing MBSR with other similar stress management techniques used among military service members, Crawford, et al (2013) described various multimodal programs for addressing post-traumatic stress disorder (PTSD) and other military or combat-related stress reactions.  Of note, Crawford, et al (2013) suggest that all of the multi-modal approaches that include Autogenic Training, Progressive Muscle Relaxation, movement practices including Yoga and Tai Chi, as well as Mindfulness Meditation, and various types of imagery, visualization and prayer-based contemplative practices ALL provide some benefit to service members experiencing PTSD. 

An important observation by Crawford et al (2013) pointed out that when military service members had more physical symptoms of stress, the meditative techniques appeared to work best, and when the chief complaints were about cognitive ruminations, the body techniques such as Yoga or Tai Chi worked best to reduce symptoms.  Whereas it may not be possible to say that mindfulness meditation practices are clearly superior to other mind-body techniques, it may be possible to raise questions about mechanisms that unite the mind-body approaches used in therapeutic settings.

Could there be negative side effects?

Another point to consider is the limited discussion of the possible absence of benefit or even harms that may be associated with mind-body therapies. For example, for some people, meditation does not promote prosocial behavior (Kreplin et al, 2018). For other people, meditation can evoke negative physical and/or psychological outcomes (Lindahl et al, 2017; Britton et al., 2021).  There are other struggles with mind-body techniques when people only find benefit in the presence of a skilled clinician, practitioner, or guru, suggesting a type of psychological dependency or transference, rather than the ability to generalize the benefits outside of a set of conditions (e.g. four to eight weeks of one to four hour trainings) or a particular setting (e.g. in a natural and/or quiet space). 

Whereas the detailed instructions for many mindfulness meditation trainings, along with many other types of mind-body practices (e.g. Transcendental Meditation, Autogenic Training, Progressive Muscle Relaxation, Yoga, Tai Chi…)  create conditions that are laudable because they are standardized, a question is raised as to ‘critical ingredients’, using the metaphor of baking.  The difference between a chocolate and a vanilla cake is not ingredients such as flour, or sugar, etc., which are common to all cakes, but rather the essential or critical ingredient of the chocolate or vanilla flavoring.  So what are the essential or critical ingredients in mind-body techniques?  Extending the metaphor, Crawford, et al (2013, p. 20) might say the critical ingredient common to the mind-body techniques they studied was that people “can change the way their body and mind react to stress by changing their thoughts, emotions, and behaviors…” with techniques that, relatively speaking, “involve minimal cost and training time.”

The skeptical view suggested here is that MM techniques share similar strategies with other mind-body approaches that encouraging learners to ‘pay attention and shift intention.’ This strategy is part of the instructions when learning Progressive Relaxation, Autogenic Training, Transcendental Meditation, movement meditation of Yoga and Tai Chi and, with instrumented self-regulation techniques such as bio/neurofeedback.  In this sense, MM training repackages techniques that have been available for millennia and thus becomes ‘old wine sold in new bottles.’

We wonder if a control group for compassionate mindfulness training would report more benefits if they were asked not only to meditate on compassionate acts, but actually performed compassionate tasks such as taking care of person in pain, helping a homeless person, or actually writing and delivering a letter of gratitude to a person who has helped them in the past?  The suggestion is to titrate the effects of MM techniques, moving from a more basic level of benefit to a more fully actualized level of benefit, generalizing their skill beyond a training setting, as measured by the Baer et al (2004) Kentucky Inventory of Mindfulness Skills.

Each generation of clinicians and educators rediscover principles without always recognizing that the similar principles were part of the previous clinical interventions. The analogies and language has changed; however, the underlying concepts may be the same.   Mindfulness interventions are now the new, current and popular approach. Some of the underlying ‘mindfulness’ concepts that are shared in common with successfully other mind-body and self-regulation approaches include: 

The practitioner must be self-experienced in mindfulness practice. This means that the practitioners do not merely believe the practice is effective; they know it is effective from self-experience.  Inner confidence conveyed to clients and patients enhances the healing/placebo effect. It is similar to having sympathy or empathy for clients and patients that occurs from have similar life experiences, such as when a clinician speaks to a patient.  For example, a male physician speaking to a female patient who has had a mastectomy may be compassionate; however, empathy occurs more easily when another mastectomy patient (who may also be a physician) shares how she struggled overcame her doubts and can still be loved by her partner.   

There may also be a continuum of strengthening beliefs about the benefits of mindfulness techniques that leads to increase benefits for the approach.  Knowing there are some kinds of benefits from initiating a practice of mindfulness increases empathy/compassion for others as they learn.  Proving that mindfulness techniques are causing benefits after systematically comparing their effectiveness with other approaches strengthens the belief in the mindfulness approaches.  Note that a similar process of strengthening one’s belief in an approach occurs gradually, over time as clients and patients progress through beginner, intermediate and advanced levels of mind-body practices.

Observing thoughts without being captured. Being a witness to the thoughts, emotions, and external events results in a type of covert global desensitization and skill mastery of NOT being captured by those thoughts and emotions. This same process of non-attachment and being a witness is one of the underpinnings of techniques that tacitly and sometime covertly support learning ways of controlling attention, such as with Autogenic Training; namely how to passively attend to a specific body part without judgment and, report on the subjective experience without comparison or judgment.

Ongoing daily practice. Participants take an active role in their own healing process as they learn to control and focus their attention. Participants are often asked to practice up to one hour a day and apply the practices during the day as mini-practices or awareness cues to interrupt the dysfunctional behavior.  For example in Autogenic training, trainees are taught to practice partial formula (such my “neck and shoulders are heavy”) during the day to bring the body/mind back to balance. While with Progressive Relaxation, the trainee learns to identify when they tighten inappropriate muscles (dysponesis) and then inhibit this observed tension.

Peer support by being in a group. Peer support is a major factor for success as people can share their challenges and successes.  Peer support tends to promote acceptance of self-and others and provides role modeling how to cope with stressors.  It is possible  that some peer support groups may counter the benefits of a mind-body technique, especially when the peers do not provide support or may in fact impede progress when they complain of the obstacles or difficulties in their process.

These concepts are not unique to Mindfulness Meditation (MM) training. Similar instructions have been part of the successful/educational intervention of Progressive Relaxation, Autogenic Training, Yogic practices, and Transcendental Meditation. These approaches have been most successful when the originators, and their initial students, taught their new and evolving techniques to clients and patients; however, they became less successful as later followers and practitioners used these approaches without learning an in-depth skill mastery. For example, Progressive relaxation as taught by Edmund Jacobson consisted of advanced skill mastery by developing subtle awareness of different muscle tension that was taught over 100 sessions (Mackereth & Tomlinson, 2010).  It was not simply listening once to a 20-minute audio recording about tightening and relaxing muscles.  Similarly, Autogenic training is very specific and teaches passive attention over a three to six-month time-period while the participant practices multiple times daily.  Stating the obvious, learning Autogenic Training, Mindfulness, Progressive Relaxation, Bio/Neurofeedback or any other mind-body technique is much more than listening to a 20-minute audio recording.

The same instructions are also part of many movement practices. For many participants focusing on the movement automatically evoked a shift in attention.  Their attention is with the task and they are instructed to be present in the movement.

Areas to explore.

Although Mindfulness training with clients and patients has resulted in remarkable beneficial outcomes for the participants, it is not clear whether mindfulness training is better than well taught PR, AT, TM or other mind/body or body/mind approaches.  There are also numerous question to explore such as: 1) Who drops out, 2) Is physical exercise to counter sitting disease and complete the alarm reaction more beneficial, and 3) Strategies to cope with wandering attention.

  • Who drops out?

We wonder if mindfulness is appropriate for all participants as sometimes participants drop out or experience negative abreactions. It not clear who those participants are. Interestingly, hints for whom the techniques may be challenging can be found in the observations of Autogenic Training that lists specific guidelines for contra-, relative- and non-indications (Luthe, 1970).

  • Physical movement to counter sitting disease and complete the alarm reaction.

Although many mindfulness meditation practices may include yoga practices, most participants practice it in a sitting position.  It may be possible that for some people somatic movement practices such as a slow Zen walk may quiet the inner dialogue more quickly. In our experience, when participants are upset and highly stressed, it is much easier to let go of agitation by first completing the triggered fight/flight response with vigorous physical activity such as rapidly walking up and downs stairs while focusing on the burning sensations of the thigh muscles.  Once the physical stress reaction has been completed and the person feels physically calmer then the mind is quieter. Then have the person begin their meditative practice.  

  •  Strategies to cope with wandering attention.

Some participants have difficulty staying on task, become sleepy, worry, and/or are preoccupied. We observed that first beginning with physical movement practices or Progressive Relaxation appears to be a helpful strategy to reduce wandering thoughts.  If one has many active thoughts, progressive relaxation continuously pulls your attention to your body as you are directed to tighten and let go of muscle groups.  Being guided supports developing the passive focus of attention to bring awareness back to the task at hand. Once internally quieter, it is easier hold their attention while doing Autogenic Training, breathing or Mindfullness Meditation.

By integrating somatic components with the mindfulness such as done in Progressive Relaxation or yoga practices facilitates the person staying present.  Similarly, when teaching slower breathing, if a person has a weight on their abdomen while practicing breathing, it is easier to keep attending to the task: allow the weight to upward when inhaling and feeling the exhalation flowing out through the arms and legs.

Therapeutic and education strategies that implicitly incorporate mindfulness

Progressive relaxation

In the United States during the 1920 progressive relaxation (PR) was developed and taught by Edmund Jacobson (1938). This approach was clinically very successful for numerous illnesses ranging from hypertension, back pain, gastrointestinal discomfort, and anxiety; it included 50 year follow-ups. Patients were active participants and practiced the skills at home and at work and interrupt their dysfunctional patterns during the day such as becoming aware of unnecessary muscle tension (dyponetic activity) and then release the unnecessary muscle tension (Whatmore & Kohli, 1968).  This structured approach is totally different than providing an audio recording that guides clients and patients through a series of tightening and relaxing of their muscles.  The clinical outcome of PR when taught using the original specific procedures described by Jacobson (1938) was remarkable. The incorporation of Progressive Relaxation as the homework practice was an important cofactor in the successful outcome in the treatment of muscle tension headache using electromyography (EMG) biofeedback by Budzynski, Stoyva and Adler (1970).

Autogenic Training

In 1932 Johannes Schultz in Germany published a book about Autogenic Training describing the basic training procedure. The basic autogenic procedure, the standard exercises, were taught over a minimum period of three month in which the person practiced daily.  In this practice they directed theri passive attention to the following  cascading sequence: heaviness of their arms, warmth of their arms, heart beat calm and regular, breathing calm and regular or it breathes me, solar plexus is warm, forehead is cool, and I am at peace (Luthe, 1979). Three main principles of autonomic training mentioned by Luthe (1979) are: (1) mental repetition of topographically oriented verbal formulae for brief periods; (2) passive concentration; and (3) reduction of exteroceptive and proprioceptive afferent stimulation.  The underlying concepts of Autogenic Therapy include as described by Peper and Williams (1980):

The body has an innate capacity for self-healing and it is this capacity that is allowed to become operative in the autogenic state. Neither the trainer nor trainee has the wisdom necessary to direct the course of the self-balancing process; hence, the capacity is allowed to occur and not be directed.

  • Homeostatic self-regulation is encouraged.
  • Much of the learning is done by the trainee at home; hence, the responsibility for the training lies primarily with the trainee.
  • The trainer/teacher must be self-experience in the practice.
  • The attitude necessary for successful practice is one of passive attention; active striving and concern with results impedes the learning process. An attitude of acceptance is cultivated, letting be whatever comes up. This quality of attention is known as “mindfulness’ in meditative traditions.

The clinical outcome for autogenic therapy is very promising. The detailed guided self-awareness training and uncontrolled studies showed benefits across a wide variety of psychosomatic illness such as asthma, cancer, hypertension, anxiety, pain irritable bowel disease, depression (Luthe & Schultz, 1970a; Luthe & Schultz, 1970b). Autogenic training components have also been integrated in biofeedback training.  Elmer and Alice Green included the incorporation of autogenic training phrases with temperature biofeedback for the very successful treatment of migraines (Green & Green, 1989).  Autonomic training combine with biofeedback in clinical practices produced better results than control group for headache population (Luthe, 1979). Empirical research found that autonomic training was applied efficiently in emotional and behavioral problems, and physical disorder (Klott, 2013), such as skin disorder (Klein & Peper, 2013), insomnia (Bowden et al., 2012), Meniere’s disease (Goto, Nakai, & Ogawa, 2011) and the multitude of  stress related symptoms (Wilson et al., 2023).

Bio/neurofeedback training

Starting in the late 1960s, biofeedback procedures have been developed as a successful treatment approach for numerous illnesses ranging from headaches, hypertension, to ADHD (Peper et al., 1979; Peper & Shaffer, 2010; Khazan, 2013).  In most cases, the similar instructions that are part of mindfulness meditation are also embedded in the bio/neurofeedback instructions. The participants are instructed to learn control over some physiological parameter and then practice the same skill during daily life. This means that during the learning process, the person learn passive attention and is not be captured by marauding thoughts and feeling.  and during the day develop awareness Whenever they become aware of  dysfunctional patterns, thoughts, emotions, they  initiated their newly learned skill.  The ongoing biological feedback signals continuously reminds them to focus.

Transcendental meditation

The next fad to hit the American shore was Transcendental Meditation (TM)– a meditation practice from the ancient Vedic tradition in India.  The participant were given a mantra that they mentally repeated and if their attention wanders, they go back to repeating the mantra internally.  The first study that captured the media’s attention was by Wallace (1970) published in the Journal Science which reported that “During meditation, oxygen consumption and heart rate decreased, skin resistance increased, and the electroencephalogram showed specific changes in certain frequencies. These results seem to distinguish the state produced by Transcendental Meditation from commonly encountered states of consciousness and suggest that it may have practical applications.” (Wallace, 1970).

The participants were to practice the mantra meditation twice a day for about 20 minutes. Meta-analysis studies have reported that those who practiced TM as compared to the control group experienced significant improved of numerous disorders such as CVD risk factors, anxiety, metabolic syndrome, drug abuse and hypertension (Paul-Labrador et al, 2006; Rainforth et al., 2007; Hawkins, 2003).

To make it more acceptable for the western audience, Herbert Benson, MD, adapted and simplified techniques from TM training and then labelled a core element, the ‘relaxation response’  (Benson et al., 1974) Instead of giving people a secret mantra and part of a spiritual tradition,  he recommend using the word “one”  as the mantra. Numerous studies have demonstrated that when patients practice the relaxation response, many clinical symptoms were reduced. The empirical research found that practiced transcendental meditation caused increasing prefrontal low alpha power (8-10Hz) and theta power of EEG; as well as higher prefrontal alpha coherence than other locations at both hemispheres. Moreover, some individuals also showed lower sympathetic activation and higher parasympathetic activation, increased respiratory sinus arrhythmic and frontal blood flow, and decreased breathing rate (Travis, 2001, 2014). Although TM and Benson’s relaxation response continues to be practiced, mindfulness has taking it place.

Conclusion

Mindfulness-Based Stress Reduction (MBSR) and Mindfulness-Based Cognitive Therapy (MBCT) are very beneficial and yet may be considered ‘old wine in new bottles’ where the metaphor refers to millennia old meditation techniques as ‘old wine’ and the acronyms such as MBSR or MBCT as ‘new bottles’.  Like many other ‘new’ therapeutic approaches or for that matter, many other ‘new’ medications, use it now before it becomes stale and loses part of its placebo power.  As long as the application of a new technique is taught with the intensity and dedication of the promotors of the approach, and as long as the participants are required to practice while receiving support, the outcomes will be very beneficial, and most likely similar in effect to other mind-body approaches. 

The challenge facing mindfulness practices just as those from Autogenic Training, Progressive Relaxation and Transcendental Meditation, is that familiarity breeds contempt and that clients and therapists are continuously looking for a new technique that promises better outcome. Thus as Mindfulness training is taught to more and more people, it may become less promising.  In addition, as mindfulness training is taught in less time, (e.g. fewer minutes and/or fewer sessions), and with less well-trained instructors, who may offer less support and supervision for people experiencing possible negative effects, the overall benefits may decrease.  Thus, mindfulness practice, Autogenic training, progressive relaxation, Transcendental Meditation, movement practices, meditation, breathing practices as well as the many spiritual practices all appear to share common fate of fading over time.  Whereas the core principles of mind-body techniques are ageless, the execution is not always assured.

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Rethink the monies spent on cancer screening tests

Posted: November 24, 2023 | Author: | Filed under: behavior, cancer, Evolutionary perspective, healing, health, Nutrition/diet, self-healing | Tags: , , , , , , , , | 3 Comments

Erik Peper, PhD and Richard Harvey, PhD

Adapted from: Peper, E. & Harvey, R. (2024).  Rethinking the monies spent on cancer screening tests. Townsend e-Letter, Townsend Letters. The Examiner of Alternative Medicine, May 18, 2024. https://www.townsendletter.com/e-letter-34-are-we-reducing-cancer-or-just-looking-for-it/

Abstract
While cancer screening tests are commonly promoted for early detection and treatment, evidence increasingly suggests that widespread screening of asymptomatic individuals may not significantly extend lifespan and could contribute to overdiagnosis, overtreatment, and harm. Although billions are spent annually on screenings—$40 billion for colon, $15 billion for breast, and $4 billion for prostate cancer—some of these money might be more effectively invested in lifestyle interventions that reduce cancer risk and improve longevity. Meta-analyses indicate that only sigmoidoscopy for colorectal cancer shows a clear benefit in extending life, while other common screenings (e.g., mammography, PSA, FOBT) show minimal or no effect on overall mortality. Interestingly, breast cancer mortality declines have occurred in similarly European countries that delayed screening implementation as compared to countries that started screen earlier. This suggests that other contributing factors such as improved lifestyle, nutrition, and environmental changes may be the major factor in the reduction of breast cancer. We recommend shifting from profit-driven, generalized screening toward personalized, risk-adjusted methods using multi-omics technology and preventative lifestyle patterns. More critically, the focus should be prevention through diet, physical activity, stress management, sleep hygiene, environmental protections, and social support; since, it is estimated that 70 percent of all cancers are related to diet and environmental factors. Thus, resources need to be allocated toward empowering individuals and communities to adopt health-promoting behaviors and thereby reduce cancer incidence.

Keywords: cancer screening, overdiagnosis, lifestyle modification, preventive health,
immune competence

Cancer screening tests are based upon the rational that early detection of fatal cancers enables earlier and more effective treatments (Kowalski, 2021), however, there is some controversy.  Early screening may increase the risk of over diagnosis, treating false positives (people who did not have the cancer but the test indicates they have cancer) and potentially fatal treatment of cancers that would never progress to increase morbidity or mortality (Kowalski, 2021).

Today about $40 billion spent on colon cancer screening, $15 billion spent on breast cancer screening, and $4 billion spent on prostate cancer screening annually (CSPH, 2021). A question is raised whether the billions and billions of dollars spent on screening asymptomatic participants would be more wisely spent on promoting and supporting life style changes that reduce cancer risks and actually extend life span? That cancer screening is expensive does not mean no one should be screened. Instead, the argument is that the majority of healthcare dollars could be spent on health promotion practices and reserving screening for those people who are at highest risk for developing cancers.

What is the evidence that screening prolongs life?

Cancer screening tests appear correlated with preventing deaths since deaths due to cancers in the USA have decreased by about 28% from 1999 to 2020 (CDC, 2023a). Although cancer causes many of the deaths in the USA,  overall life expectancy has increased by less than 1% from 1999 to 2020. If cancer screening were more effective, the life expectancy should have increased more because cancer is the second leading cause of death (CDC, 2023b).  Consider also that deaths due to cancers may be coincident and or comorbid with other circumstances. For example, during the last four years, overall life expectancy in the USA has precipitously declined in part due to other causes of death such as the COVID pandemic and opioid overdose epidemic (Lewis, 2022). Decline in life expectancy in the USA has many contributing factors, including the ‘harms’ associated with cancer screening procedures. For example, perforations during colon cancer screening can lead to internal bleeding, or complications related to surgeries, radiotherapies or chemotherapies. Bretthauer et al., (2023) commented: “A cancer screening test may reduce cancer-specific mortality but fail to increase longevity if the harms for some individuals outweigh the benefits for others or if cancer-specific deaths are replaced by deaths from competing cause” (p. 1197).

Bretthauer et al. (2023) conducted a systematic review and meta-analysis of 18 long-term randomized clinical trials involving 2.1 million Individuals with more than nine years of follow-up reporting on all-cause mortality. They reported that“…this meta-analysis suggest that current evidence does not substantiate the claim that common cancer screening tests save lives by extending lifetime, except possibly for colorectal cancer screening with sigmoidoscopy.”  

Following is a summary of Bretthauer et al. (2023) findings:

  • The only cancer screening with a significant lifetime gain (approximately 3 months) was sigmoidoscopy.
  • There was no significant difference between harms of screening and benefits of screening for:
    • mammography
    • prostate  cancer screening
    • FOBT (fecal occult blood test) screening every year or every other year
    • lung cancer screening Pap test cytology for cervical cancer screening, no randomized clinical trials with cancer-specific or all-cause mortality end points and long term follow-up were identified.

Potential for loss or harm (e.g., iatrogenic and nosocomial) versus potential for benefit and extended life

More than 35 years ago a significant decrease in breast cancer mortality was observed after mammography was implemented. The correlation suggested a causal relationship that screening reduced mortality (Fracheboud, 2004).  This correlation made logical sense since the breast cancer screening test identified cancers early which could then be treated and thereby would result in a decrease in mortality.

How much money is spent on screening that may  correlate with unintended harms?

The annual total expenditure for cancer screening is estimated to be between $40-$50 billion annually (CSPH, 2021).  Below are some of the estimated expenditures for common tests other than colorectal cancer screening, which arguably is costly; however, has potential benefits that outweigh potential harms.

What is the correlation between initiation of mammography and decrease in breast cancer mortality?

The conclusion that mammography reduced breast cancer mortality was based upon studies without control groups; however, this relationship could be causal or synchronistic.  The ambiguity of correlation or causation was resolved with the use of natural experimental control groups. Some European countries began screening 10 years earlier than other countries. Using statistical techniques such as propensity score matching when comparing the data from countries that initiated mammography screening early (Netherlands, Sweden and Northern Ireland) to countries that started screening 10 year later (Belgium, Norway and Republic of Ireland), the effectiveness of screening could be compared.

The comparisons showed no difference in the decrease of breast cancer mortality in countries that initiated breast cancer screening early or late. For example, there was no difference in the decrease of breast cancer mortality rates of women who lived in the Netherlands that started screening early versus those who lived in Belgium that began screening 10 years later, as is shown Figure 1 (Autier et al, 2011).

Figure 1. No difference in age adjust breast cancer mortality between the two adjacent countries even though breast cancer screening began ten years earlier in the Netherlands than in Belgium (graph reproduced from Autier et al, 2011).

The observations are similar when comparing neighboring countries: Sweden (early screening) to Norway (late screening) as well as Northern Ireland, UK  (early screening) compared to the Republic of Ireland (late screening). The systematic comparisons showed that screening did not account for the decrease in breast cancer mortality. To what extent could the decrease in mortality be related to other factors such as better prenatal and early childhood diet and life style, improved nutrition, reduction in environmental pollutants, and other unidentified  life style and environmental factors which improve immune competence?

A simplistic model to reduce the risk of cancers is described in the following equation (Gorter & Peper, 2011).

Cancer risk can be reduced, arguably by influencing risk factors that contribute to cancers as well as increasing factors to enhance immune competence. In the simple model above, ‘Cancer burden’ refers to the set of exposures that increase the odds of cancer formations. Categories include exposures to oncoviruses, environmental exposures (e.g., ionizing radiation, carcinogenic chemicals) as well as genetic (e.g., chromosomal aberrations, replication errors) and epigenetic factors (e.g., lifestyle categories related to eating, exercising, sleeping, and relaxing). In the model above, ‘Immune competence’ refers to a set of categories of immune functioning related to DNA repair, orderly cell death (i.e., processes of apoptosis), expected autophagy, as well as ‘metabolic rewiring,’ also called cellular energetics, that would allow the body to be able to reduce manage cancers from progressing (Fouad & Aanei, 2017) .

How do we examine the cancer burden/immune competence relationship?

Schmutzler et al., (2022) have suggested personalized and precision-medicine risk-adjusted cancer screening incorporating “… high-throughput “multi-omics” technologies comprising, among others, genomics, transcriptomics, and proteomics, which have led to the discovery of new molecular risk factors that seem to interact with each other and with non-genetic risk factors in a multiplicative manner.” The argument is that ‘profit-centered’ medicine could incorporate ‘multi-omics’ into risk-adjusted cancer screening as a way to reduce potential loss or harm due to other cancer screening procedures. Rather than simply screening for cancers using currently invasive or toxic procedures which may do more harm than good, consider more nuanced screening tests aimed at the so-called ‘hallmarks of cancer?’  For example, Hanahan (2022) suggests some technical targets for the multi-omics technologies. The following are some of the precision screening tests possible topersonalized medicine of 14 factors or processes related to:

  • cells evading growth suppression
  • non-mutational epigenetic reprogramming
  • avoiding immune destruction
  • enabling replicative immortality
  • tumor-promoting inflammation
  • polymorphic microbiomes
  • activating invasion and metastasis
  • inducing or accessing vasculature formation/angiogenesis
  • cellular senescence
  • genome instability and mutation
  • resisting cell death
  • deregulating cellular metabolism
  • unlocking phenotypic plasticity
  • sustaining proliferative signaling

Of the listed categories above, ‘phenotypic plasticity’ (cf. Feinberg, 2007; Gupta et al., 2019) suggests that lifestyle behaviors and environmental exposures play a role in cancer progression and regression.

Lifestyle and environmental factors can contribute to the development of cancers.

The 2008-2009 report from the President’s Cancer Panel appraised the National Cancer Program in accordance with the National Cancer Act of 1971 stated (Reuben, 2010):

“We have grossly underestimated the link between environmental toxins, plastics, chemicals, and cancer risk. It is estimated that 70 percent of all cancers were related to diet and environment “

Multiple research studies have shown that a healthy life style pattern is associated with decreased cancer risks and increased longevity. Lifestyle factors that have been documented to increase cancer risks in the United Kingdom (UK) as shown in figure 2.

Figure 2. Percentages of cancer cases in the UK attributable to different exposures. Adapted from Brown et al., 2018 and reproduced by permission from Key et al., 2020.

Similar findings have been reported by Song et al. (2016) from the long term follow-up of 126901 adult health care professionals.  People who never smoked, drank no alcohol or moderate alcohol (< 1 drink/d for women; < 2 drinks/d for men}, had a body-mass index (BMI) of at least 18.5 but lower than 27.5, did weekly aerobic physical activity of at least 75 vigorous-intensity minutes or 150 150 moderate-intensity minutes compared to those who smoked, drank, had high BMI and did not exercise had nearly half the cancer death rate. Song et al (2016) concludes:

“…about 20% to 40% of carcinoma cases and about half of carcinoma deaths can be potentially prevented through lifestyle modification. Not surprisingly, these figures increased to 40% to 70% when assessed with regard to the population of US whites which has a much worse lifestyle pattern than other cohorts. Notably, approximately 80% to 90% of lung cancer deaths can be avoided if Americans adopted the lifestyle of the low-risk group, mainly by quitting smoking. For other cancers, a range of 10% to 70% of deaths can be prevented. These results provide strong support for the importance of environmental factors in cancer risk and reinforce the enormous potential of primary prevention for cancer control.”

Said another way, primary prevention should remain a priority for cancer control.

Given that many cancers are related to diet, environment and lifestyle, it is estimated that 50% of all cancers and cancer deaths could be prevented by modifying personal behavior. Thus, the monies spent on screening or even developing new treatments could better be spent on prevention along with implementing programs that promote a healthier environment, diet and personal behavior (AACR, 2011).

What can be done? Addressing systems not symptoms

From a ‘systems perspective,’ the first step is to reduce the cancer burden and carcinogenic agents that occur in our environment such environmental pollution (Turner et al., 2022). In many cases, governmental regulations that reduce cancer risk factors have been weakened, delayed, and contested for years through industry’s lobbying. It often takes more than 30 years after risk factors have been observed and documented before government regulations are successfully implemented, as exemplified in the battle over tobacco or, air pollution regulations related to particulates from burning fossil fuels (Stratton et al, 2001). 

Sadly, we cannot depend upon governments or industries to implement regulations known to reduce cancer risks. More within our control is implementing lifestyle changes that enhance immune competence and promote health. 

Implement a healthy life style that enhances immune competence and, supports health and well-being

Paraphrasing a trope of what some physicians may state: ‘Take two pills, and call me in the morning. Oh, and eat well, exercise, and get good rest.’ Broadly stated, the following are some controllable lifestyle behaviors that can decrease cancer risks and promotes health. Implementing environmental and lifestyle changes are very challenging because they are highly related to socio economic factors, cultural factors, industry push for profits over health, and self-care challenges since there are no immediate results experienced by behavior and lifestyle changes.

In many cases, the effects of harmful life-style and environment factors are only observed twenty or more years later (e.g., diabetes, lung cancer, cirrhosis of the liver). The individual does not experience immediate benefits of lifestyle changes thus it is more challenging to know that your healthy life style has an effect.  The process is even more complex because in most cases it is not a single factor but the interaction of multiple factors (genetics, lifestyle, and environment). The complexity of causality so often conflicts with the simplistic research studies to identify only one isolated risk factor. Instead of waiting for the definitive governmental guidelines and regulations, adopt a ‘precautionary principle’ which means do not take an action when there is uncertainty about its potential harm (Goldstein, 2001).  Do not wait for screening; instead, take charge of your health and implement as many of the following behaviors and strategies to enhance immune competence and thereby reduce cancer risks.

Eat organic foods, especially vegetable and fruits.

Many studies have suggested that eating organic foods and in particular more fruits and vegetable such as a Mediterranean diet is associated with increased health and longevity. Similarly, people who eat do not eat highly-processed or ultra-processed foods have better health status (Van Tulleken, 2023).   For example, In the large prospective study of 68, 946 participants, adults who consumed the most organic fruits, vegetables, dairy products, meat and other foods had 25% fewer cancers when compared with adults who never ate organic food (Baudry et al., 2018; Rabin, 2018). Similarly, many studies have reported that those who adhere consistently to a Mediterranean diet have a significantly lower incidence of chronic diseases (such as cardiovascular diseases, diabetes, etc.) and cancers compared to  those who do not adhere to a Mediterranean diet (Mentella et al., 2019).

Reduce environmental pollution exposure

Air pollution and the exposure to airborne carcinogens are a significant risk factor for cancers as illustrated by the increased cancer rates among smokers. In the USA, the reduction of smoking has significantly decreased the lung cancer deaths (US Department of Health and Human Services, 2014).

Increase movement and exercise

Many studies have documented that people who exercise regularly and are otherwise non–sedentary but are active their entire lives have the lowest risk for breast cancers and colon cancers. Women who exercise 3 hours a week or more have a 30-40% lower risk of developing breast cancer (NIH NCI, 2023).  The NIH National Cancer Institute summary concludes that exercises also significantly benefited the following cancer survivors (NIH NCI, 2023):

  • Breast cancer: In a 2019 systematic review and meta-analysis of observational studies, breast cancer survivors who were the most physically active had a 42% lower risk of death from any cause and a 40% lower risk of death from breast cancer than those who were the least physically active (Spei et al, 2019). 
  • Colorectal cancer: Evidence from multiple epidemiologic studies suggests that physical activity after a colorectal cancer diagnosis is associated with a 30% lower risk of death from colorectal cancer and a 38% lower risk of death from any cause (Patel et al., 2019). 
  • Prostate cancer: Limited evidence from a few epidemiologic studies suggests that physical activity after a prostate cancer diagnosis is associated with a 33% lower risk of death from prostate cancer and a 45% lower risk of death from any cause ((Patel et al., 2019). 
  • Implement stress management. 

Chronic stress may reduce immune competence and increase the risk of cancers as well as hinders healing from cancer treatments (Dai et al., 2020). The results of numerous studies have shown that implementing stress management spractices uch as  Cognitive-behavioral stress management (CBSM) improves mood and lowers distress during treatment and, is also associated with longer survival compared to control groups in the 8-15 year follow up (Stagl et al., 2015).

Respect your biological rhythm.

The International Agency for Research on Cancer (IARC) reports that, when the human circadian clock is disrupted, the likelihood of developing cancers, including lung cancers, intestinal cancers, and breast cancers, dramatically increases (Huang, et al.,  2023). Go to bed at the same time and, have about 8 hours of sleep. As much as possible avoid night shifts at work along with frequent jet lag as that highly disrupts the circadian rhythm.

Increase social connections and be part of a social community

Absence of social support, feeling lonely and socially isolated tends reduces immune competence and increases cancer mortality risk while having more social support satisfaction is associated with lower mortality risks (Salazaor et al., 2023; Boen et al., 2018).  Meta-analysis of 148 studies (308,849 participants) found that that on the average there is a 50% increased likelihood of survival for participants with stronger social relationships (Holt-Lunstad et al., 2010).

Live a life with meaning and purpose

Having meaning and purpose make each moment worth living and may contribute to improving immune function and possible cancer survival (LeShan, 1994; Rosenbaum & Rosenbaum, 2023).

Summary

The research suggests that cancer screening does not extend life span unless specifically performed for certain diagnostic purposes or, with individuals who are at high risk of developing cancers (e.g., have a genetic predisposition).  Implementing self-care health behaviors that have been identified to promote health and increase lifespan. Implementing health behaviors is challenging since there is limited governmental and corporate support. Thus, take charge and implement a holistic self-care lifestyle that reduces cancer risk factors and supports health.  

See also the following blogs:

Cancer: What you can do to prevent and support healing
Are food companies responsible for the epidemic in diabetes, cancer, dementia and chronic disease and do their products need to be regulated like tobacco? Is it time for a class action suit?
Live longer, enhance fertility and increase stress resistance: Eat organic foods
Reversing breast cancer with metastasis to the liver: A patient documentary

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Kowalski, A.E. (2021). Mammograms and mortality: How has the evidence evolved? J Econ Perspect,  35(2), 119-140. https://doi.org/10.1257/jep.35.2.119

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Lewis, T. (2022). The U.S. just lost 26 years’ worth of progress on life expectancy. Scientific American. October 17, 2022. Accessed November 11, 2023. https://www.scientificamerican.com/article/the-u-s-just-lost-26-years-worth-of-progress-on-life-expectancy/

Ma, X., Wang, R., Long, J.B., Ross, J.S., Soulos, P.R., Yu, J.B., Makarov, D.V., Gold, H.T. and Gross, C.P. (2014), The cost implications of prostate cancer screening in the Medicare population. Cancer, 120: 96-102. https://doi.org/10.1002/cncr.28373

Mentella, M.C., Scaldaferri, F., Ricci, C., Gasbarrini, A., & Miggiano, G.A.D. (2019).  Cancer and Mediterranean Diet: A Review. Nutrients,11(9):2059. https://doi.org/10.3390/nu11092059

NIH NCI (2023). Physical Activity and Cancer. National Institutes of Health National Cancer Institute. Accessed November 18, 2023. https://www.cancer.gov/about-cancer/causes-prevention/risk/obesity/physical-activity-fact-sheet

Patel, A,V., Friedenreich, C.M., Moore, S.C, et al. (2019). American College of Sports Medicine Roundtable Report on physical activity, sedentary behavior, and cancer prevention and control. Medicine and Science in Sports and Exercise,  51(11), 2391-2402. https://doi.org/10.1249/MSS.0000000000002117

Rabin, R.C. (2018). Can eating organic food lower your cancer risk? The New York Times. Oct 23, 2018. Accessed November 17, 2023. https://www.nytimes.com/2018/10/23/well/eat/can-eating-organic-food-lower-your-cancer-risk.html

Reuben, S.H. (2010). Reducing environmental cancer risk – What We Can Do Now. The President’s Cancer Panel Report. Washington, D.C: U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES,  National Institutes of Health, National Cancer Institute. https://deainfo.nci.nih.gov/advisory/pcp/annualReports/pcp08-09rpt/PCP_Report_08-09_508.pdf

Rosenbaum, E. H. & Rosenbaum, I.R. (2023) The Will to Live. Stanford Center for Integrative Medicine. Surviving Cancer. Accessed November 23, 2023. https://med.stanford.edu/survivingcancer/cancers-existential-questions/cancer-will-to-live.html

Salazar, S.M.D.C., Dino, M.J.S., & Macindo, J.R.B. (2023). Social connectedness and health-related quality of life among patients with cancer undergoing chemotherapy: a mixed method approach using structural equation modelling and photo-elicitation. J Clin Nurs. Published online March 9, 2023. https://doi.org/10.1111/jocn.16675

Schmutzler, R. K., Schmitz-Luhn, B., Borisch, B., Devilee, P., Eccles, D., Hall, P., … & Woopen, C. (2022). Risk-adjusted cancer screening and prevention (RiskAP): complementing screening for early disease detection by a learning screening based on risk factors. Breast Care, 17(2), 208-223. https://doi.org/10.1159/000517182

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Be Skeptical: Finding and Evaluating Online Health Resources

Posted: October 22, 2023 | Author: | Filed under: Evolutionary perspective, healing, health, Nutrition/diet, placebo | Tags: , , , , , , , , | 2 Comments

Adapted from: Peper, E. & Harvey, R. (2023). Be skeptical: Finding and evaluating online health resources. Townsend Letters. The Examiner of Alternative Medicine, October 21, 2023. https://www.townsendletter.com/e-letter-20-evaluate-sources-to-make-informed-choices/

Erik Peper, PhD, BCB and Richard Harvey, PhD

Source: https://live.staticflickr.com/65535/48445803437_726b61e3d1_b.jpg


An unprecedented flood of information is available today at our fingertips in the form of cell phone apps, news stories, blog posts, social media feeds, advertisements, websites, videos, and audio resources. Artificial intelligence (AI) applications such as ChatGPT are also capable of curating health and wellness information all proclaiming to optimize our health or treat our illnesses. This article provides strategies to determine how to trust the information.  It offers strategies for assessing information, reasons to have a skeptical perspective, suggestions for finding credible resources and includes a framework to identify beneficial health information, which may be used for improving activities of daily living. The recommendations are based upon an evolutionary perspective in which anything that was not part of our evolutionary past should be viewed with healthy skepticism.

“It is simply no longer possible to believe much of the clinical research that is published, or to rely on the judgment of trusted physicians or authoritative medical guidelines.  I take no pleasure in this conclusion, which I reached slowly and reluctantly over my two decades as an editor of The New England Journal of Medicine.” —Dr. Marcia Angell (2009), the first woman editor of the highly respected New England Journal of Medicine.

How to make sense of the flood of health information

An unprecedented flood of health information is available today proclaiming useful information to optimize our health or treat our illnesses, A simple question is, “How do we know which information is accurate?” To what extent do we trust the information in an era of fake news, commercial health apps trying to sell us things, and news stories from publishers and media conglomerates that are dependent on advertising revenues? This article offers strategies for assessing information, reasons to have a skeptical perspective, and suggestions for finding relevant and accurate information.

Skepticism about health information takes many forms including ‘conspiracy theories’ about vaccines such as when people claim a SARS-COVID-19 vaccine will kill you, to when people doubt the efficacy of HIV or similar vaccines. Several authors have suggested political as well as individual personality factors which explain conspiratorial skepticism about health information, most commonly about vaccines (Crescenzi-Lanna, Valente, Cataldi, & Martire, 2023; Koinig, & Kohler, 2021; Putois, & Helms,. 2022). This article takes a broader view of health information skepticism, focusing on perspective building as well as asking relevant, accurate and meaningful questions about health care decisions. 

Take a skeptical perspective and ask, “What is the evidence that the product, procedure, or treatment is going to be effective for me compared to others?” The answer could appear obvious: published peer-reviewed systematic meta-analyses of double blind, randomized, controlled trials describing specific products or procedures. However, the answer is more complex. In numerous cases, finding relevant reports can be challenging. In some cases, it may be unethical or impossible to run double blind, randomized, controlled trials to detect the scope of effectiveness or generalize the finding from animal studies to human beings. For example, surgery cannot be evaluated in a double-blind study. (Would you really want your surgeon not to be aware of what he/she was doing?). Although treatment effectiveness can be studied using a matched comparison or a control group receiving mock surgery, in those cases the surgeon would still be aware of the procedure.

The Challenges of Assessing Clinical Efficacy

It is challenging to know what actually contributes to the beneficial outcomes as well as how to measure the outcome.  Some of the factors that affect the outcomes include:

Placebo interactions: Intrinsic to all procedures are placebo and nocebo components. In some cases the direct benefit effects of a drug or procedure demonstrated in a randomized controlled trial may still not be due solely to the direct effects of the drug or procedure, but rather due to positive indirect effects triggered by the placebo response to non-specific side effects (Peper and Harvey, 2017).

Lack of evidence is not proof that it does not work. Lack of replicable evidence for some cases implies that a positive response will not occur in all cases. Unfortunately, commercial interests may bias interpretations of research studies when the efforts to replicate a study had limitations in the first place, or the replication efforts did not retain transferable conditions to the next study. In other words, ‘ceteris paribus’ may not apply as all things are not always equal during replication studies. Similarly, individual differences that are outliers or extreme values during a study (e.g. positive benefit from placebo) can be ‘explained away’ with statistics because statistics may also skew the interpretations based on the biases of the researchers.   

Clinical trials are very expensive. The average clinical trial for a new therapeutic agent, 2015–2017, was $48 million dollars (Moore et al., 2020). The cost of achieving Food and Drug Administration (FDA) approval is so high that it is often out of reach for small companies. It is no wonder that most clinical trials are funded by the pharmaceutic industry and only for those drugs for which they foresee significant profits.  The estimated research and development investment to bring a new medicine to market is estimated to range between $314 million to $2.8 billion (Wouters et al, 2020). To be financially viable, this usually means that drugs must be used by a large consumer base and ideally be taken for the rest of the individual’s life. Non-drug approaches may be less profitable, so without a profit incentive, investigations of non-drug efficacy accumulates less evidence compared to multi-million dollar trials.

Human beings are not rats, mice, or monkeys.  The findings from animal studies in numerous studies provide some useful insights into the effects of medications or procedures on living organisms. Unfortunately, many results from animal studies could not be replicated in humans or, the findings may not apply to human beings. The basic assumption that animal studies could mimic human studies may not be valid since almost all test animals are not typical of normal animals, implying test animals are ‘abnormal’ in terms of results. For example, the animals such as rats are usually housed in small cages 24 hours a day which is analogous to a human being held in solitary confinement without social contact or ability to move for a lifetime. Thus, their physiology and their response to interventions are often different from healthy free ranging animals (Shaw, 2023).

Even when animal studies show that the medications are not harmful, they could be harmful for some human beings. For example, thalidomide was approved for use in Germany, so doctors prescribed it to treat morning sickness in pregnant women. However, in humans Thalidomide interfered with embryonic and fetal development in ways not observed in rodent tests (Tantibanchachai & Yang, 2019).

Statistical significance may not indicate meaningful clinical improvement. Many clinical studies demonstrate that the studied interventions have contributed to improvement. However, does the improvement make a quality of life (QOL) difference and/or clinically relevant difference for the person? For example, a successful study that demonstrated lowering of patients’ systolic pressure by 5 mm from 175 mm/Hg to 170mm/Hg may be statistically significant, but is not clinically meaningful, since, a resting systolic blood pressure of 170 mm/Hg is still a cause for concern.

Similarly, in the recent systematic review by Arciero et al. (2021) of approved oncology therapies, 40% of Food and Drug Administration (FDA)-approved as well as 58% of European Medicine Agency (EMA)-approved indications had published QOL evidence. However, only 6% of FDA- and 11% of EMA-approved indications had clinically meaningful improvements in QOL beyond minimally clinically relevant differences. This means that medication therapies are often approved without demonstrating Quality of Life improvement for the long term.

Statistics which describe how large an effect is may be referred to as an ‘effect size estimate, which is a better index of efficacy compared to other statistics such as a difference in statistical mean values. The effect size can be assessed by using various statistics such as Cohen’s d-statistic (Mean A minus Mean B divided by pooled standard deviation; Cohen, 1988)[i].

Number of people need to be treated for one person to benefit. Effect size calculation estimates the average number of people in a trial needing treatment so that one of them experiences benefit.  This statistic can be referred to as the number needed to treat (NNT) (Mendes et al., 2017). To calculate the NNT, divide 1 by the control event rate (CER) minus the treatment event rate (TER) or 1/CER-TER. For example, the number patients needed to be treated for five years with cholesterol lowering (e.g., statin drugs) medications to prevent one coronary heart disease event ranges from 53 (high risk group) to 146 (low risk group) (Rossignol et al., 2018). This means that many of the participants could experience negative side effects related to the medications while only one participant benefits from the prevention of a heart attack.

Focus on short-term versus long-term benefits. Many studies measure outcomes under highly controlled conditions of a study and are conducted for a relatively short time period—often for less than 3 months. However, effects that may be beneficial in the short term may not be beneficial or may even be harmful in the long term. For example, opioid medications are very useful in the short term to alleviate intense pain. However, over time, drug dependency may develop, contributing to addiction, inability to function, or death. Shockingly, opioid-related deaths in the U.S. numbered more than 100,000 people in 2022 (CDC, 2022).

Benefits do not enhance quality of life.  If the data indicate benefits of treatment, do the interventions improve quality of life and not simply prolong life for a few days, weeks, or months? Does the patient or client value quality of life over quantity of days lived (e.g., ”palliative care with shorter life, but some relief from pain and suffering versus prolonged life with pain and suffering”)?

Results may only apply to a select group. Biochemical individuality means that each person is unique to some degree, differing genetically, biochemically, and physiologically. Similarly, responses vary widely to medical procedures, medications, and other substances. A common example is alcohol sensitivity— the genetic predisposition to metabolizing alcohol breakdown— manifesting in highly visible facial flushing which occurs in 47%-85% of Asians and 3%-29% of Caucasians (Chan, 1986). In the context of medicine, individual differences that influence clinical outcomes include genetic predisposition, as well as age, gender, income, education level, job status, geographic region (e.g., climate and food sources) and other demographic factors, individually or in combination.

Consider that many interventions and medications have only been tested on narrowly defined subgroups such college students (true of most psychological studies), or men (true for most pharmaceuticals since women could be pregnant or in different phases of their menstrual cycle). The promise of personalized or ‘precision’ medicine will likely advance in the coming years, making medications more tailored to individual differences based on age, sex, and other demographic factors. 

There is no free lunch. Similar to the concept of short-term versus long-term benefits, when a drug offers a quick improvement, it may be effective, but may cause long-term harm. A representative example is the use of high-dose and multi-doses of anabolic steroids to increase muscle mass and athletic performance. There is a potential cost: “High and multi-doses of anabolic steroids used for athletic enhancement can lead to serious and irreversible organ damage” (Maravelias, et al., 2005).

Risks of hazardous exposures and risks associated with the treatment.  Could the procedure or medication result in loss or harm? Given bio-individuality, there can be broad “variability” in response and outcome, which depends on the vulnerability of a given individual (their adaptive capacity) and the risks involved. Additionally, there are sometimes important variables that have not been investigated deliberately because those important variables complicate interpretation, and or, there may be important variables that are missed The most obvious example of omission is when animal studies were or are conducted exclusively on male animals because interpreting results can be more complicated given female reproductive hormones. Beside sex variables other important variables that may be missed include covert illnesses and co-morbidities which are unknown at the time of the study. Taken together, studies which oversimplify variables may make it difficult interpret the results for individuals.

Below is a set of images relevant to climate change and farming, depicting the relationship between the exposure to hazards of systemic climate change and the vulnerabilities, sensitivities, and adaptive capacities of individuals and the community (Wilhelmi and Hayden, 2016).

Use “Uncommon” Sense

The attractive look and feel of a website are not evidence of accuracy or credibility. Rather, good design simply means it was developed by a skilled web designer or that the client paid a great deal of money to have it created. It does not make the content valid. The comments of Yucha (2002) and Yucha and Montgomery (2008) remind readers to increase literacy regarding ”health claims” made on websites, especially a commercial website intended to sell products or services.

Evaluating dietary supplements. If you’re thinking about using a dietary supplement, check the recommendations from reliable sources. Make it a point to purchase a reputable brand, since some supplements contain ingredients not listed on the label. In addition, they may interact with medications or other supplements. Share and discuss all your supplements you are taking with your healthcare provider. For example, vitamin E acts as anticoagulants and may increase clotting time and bleeding especially if one is taking “blood thinners.”

Follow the money. Ask who would financially benefit from the product or service? For example, physicians increase their referrals for lab testing, MRIs (Magnetic Resonance Images), or other diagnostic procedures if they have ownership in those testing centers or, if they receive significant reimbursement for those services, although there is no evidence that patients benefit more (Bishop et al, 2010).

Beware of advertised claims. Most highly advertised drugs are largely no better at treating a disease than generic medication or other options (Patel et al., 2023). Pharmaceutical companies in 2021 spend $6.88 billion for direct to consumer advertising (Faria, 2023). The advertisement suggests that their branded medication is better; however, generics are about 80% cheaper and have the same active ingredient and are similar in their action (AAM, 2020).

If the claims seem unbelievable, they are probably are unbelievable. If it is too good to be true, it probably is not true. Historically, Thomas Lupton (1580) wrote a thoughtful inquiry about religion and utopian societies, introducing a skeptics point of view, describing people and societies that are ”too good to be true.”  Modern skeptics consider the preponderance of evidence based on scientific replicability (the replication of findings in subsequent clinical trials) as proof of what they believe to be true.

Source: Indiana University of Pennsylvania, last accessed March 3, 2023 https://www.iup.edu/instructional-design/images/assessment.jpg

Assessing Online Information

What do we know about the accuracy of online health information? A skeptical viewpoint is that bias exists in sources of information from a wide range of commercial, organizational, governmental and educational institutions (identified by ending with .com, .org, .gov and .edu, respectively). Most all institutions set out to prove their own bias; however, people working in educational institutions by and large require their investigators go through a peer-review process, so they tend to be more trusted as sources of information. Commercial, organizational, and governmental institutions all have biased perspectives. However, they are less likely to reveal their biases, simply stating that “a study was conducted” without providing enough information who funded the study or the importance of positive results to achieve academic recognition.

“A lot of what is published is incorrect … much of the scientific literature, perhaps half, may simply be untrue.  Afflicted by studies with small sample sizes, tiny effects, invalid exploratory analyses, and flagrant conflicts of interest, together with an obsession for pursuing fashionable trends of dubious importance, science has taken a turn towards darkness.”  Dr. Richard Horton (2015), Editor-in-Chief of The Lancet.

Be skeptical of university or published research findings that are directly or indirectly funded/influenced by industry or commercial sources. Government research published in highly respected scientific journals may not be replicable because the investigations were narrowly designed to favor a particular bias. For example, industries that produce pharmaceuticals and medical devices, as well as agribusinesses that produce tobacco and sugar products, have been accused of a ”profit-first” bias (Bruening, 2019; Hill et al., 2019). These industries often support studies conducted by “independent” researchers at universities. However, grant funding quickly disappears if the findings are negative which may affect the career of the researcher because many university faculty positions and promotions depend upon the faculty member’s ability to garner grants.

Compare US safety guidelines to those of the EU. In many cases, the acceptable values are different. The safety limits for herbicide and pesticide residues in foods are often much lower in the EU than in the US (e.g., safer with lower exposure levels). For example, the US allows six times as much residue of the pesticide, Round-Up, with a toxic ingredient, glyphosate, in foods consumed in the American diet (Tano, 2016).  The USA allows this higher exposure even though about half of the human gut microbiota are vulnerable to glyphosate exposure (Puigbo et al., 2022).  A skeptical view of research could adapt a precautionary principle such as “if you think it could cause harm then do not use it until proven safe.”

Government guidelines and directions may not always be accurate. For example, after 9/11 the CDC initially announced that the particulate dust from the World Trade Center collapse was not harmful The CDC made this claim without any data, in efforts to reassure the public. In fact, the dust was harmful. More recently, some of the politicization of the CDC COVID-19 recommendations have raised questions. For example at the beginning of the pandemic, the CDC publicly recommended “If you are NOT sick: You do not need to wear a facemask unless you are caring for someone who is sick (and they are not able to wear a facemask)” which suggested that masks were not necessary. (McReynolds, 2020). Most likely, the statement was made so that more masks would be available for medical workers. The statement would have engendered more trust if the CDC had stated, Masks are useful; however, please make your own, since the medical-grade n95 masks are in very short supply and needed to protect the frontline health professionals who are most at risk.

The National Personal Protective Technology Laboratory (NPPTL) describes the types of masks needed to protect medical and other types of workers such as fire fighters, where the numbers represent the percentage of particulates filtered (e.g., 95%, 99%, 100%) and the letters represent the types of particles (e.g., N = not resistant to oils, R = resistant to oils and, P = strongly resistant to oils). Other countries have similar mask standards, where a N95 mask in the United States (i.e., N95; NIOSH-42 CRF 84) is equivalent to masks in Europe (FFP2; EN149-2001), China (KN95; GB2626-2019), Australia (P2; AS/NZ 1716-2012), Korea (KF94; KMOEL 2017-64), Japan (DS2; JMIHLW 214-2018) and, Brazil (PFF2; ABNT/NBR 13.698.2011). The reason for including the technical details about masks is to remind the reader that both governments as well as other sources of health information may hide some of the information about potentials for loss or harm behind lots of technical details, so knowing how to compare information becomes relevant when making health decisions.

Patient population in the research study may not represent the average patient (referred to as Berkson’s bias). Research study subjects may have multiple co-morbidities or may all be healthy young males. In either case, they may not be representative of the general patient population nor of individuals (Westreich, 2012).

The data does not discuss or excludes outliers? Positive findings, even in randomized, placebo-controlled studies, mean that the treatment approach is more beneficial than the control condition. In almost all cases, some participants respond extremely well and some very poorly, often referred to as statistical outliers. What is usually not reported are the characteristic of the ‘super responders’ or ‘non-responders.’ Have more trust in studies that provide a full range or a wider range of information about the positive and negative responders, rather than simply reporting about the average response.

The research review is highly selective. Meta-analyses and review articles evaluate the outcomes of multiple research studies. However, typically they include only well designed randomized controlled trials. In many of these studies, 95% of the published articles are excluded because they did not fit the narrow criteria of the randomized selection. Thus, these meta-analyses may exclude conditions under which the treatment approach would be highly beneficial to a specific set of people. When the meta-analyses identify the studies that are excluded and why, it is possible to learn of the biases of the meta-analyses.

Funding for research or clinical trials favors products or technologies which can be patented, commercialized and support industry profits. There is extensive funding for new drug development for the treatment of COVID-19 or hypertension, but limited funding for diet or lifestyle changes that could optimize the immune system. If a product or drug is beneficial however not patentable, it is unlikely that a pharmaceutical company will further develop and market it because competitors could easily produce it. For example, pharmaceutical companies do not advertise vitamin D3 supplements because it is not patent protected even though a preponderance of independent research has clearly demonstrated that the incidence of symptoms following metastatic cancer diagnosis is reduced with vitamin D3 supplements (Chandler et al., 2020).

Be aware of the revolving door. The top administrators of numerous US regulating agencies such as the Food and Drug Administration (FDA) and the US Department of Agriculture (USDA) are often rewarded with well-paying jobs in the pharmaceutical, healthcare, and agribusiness industries after leaving jobs in the US government. For example,

A skeptical question to be raised is to what extent does the promise of well-paying jobs impact the decisions of administrators who are in charge of regulating industries that may offer a high paying job in the future.  Would you avoid antagonizing those companies thereby risk a future financial windfall? Similar conflicts of interest may be at play in other industries. For example, Boeing’s close relationship with the Federal Aviation Administration (FAA) by giving initial approval of Boeing 737 Max airplane that may have contributed to the two fatal airplane crashes (Cassidy, 2020).

Use critical thinking and don’t rely solely on the first internet search results resources when making decisions about your health. Many commercial companies (e.g., internet resources ending with ‘.com’) will pay to be on the first page of an internet search. Consider using more advanced internet search results that access ‘scholarly’ information, often available from ‘.edu’ sources. Consult with your health care provider when you are considering complementary health care approaches if you have a medical condition.  Remember that some health providers may have personal biases as well as financial incentives in keeping you as their patient. Request evidence on which the provider is making their judgements and be sure to discuss the following two kinds of questions: (1) What are the risks, costs and benefit as well as potential for loss or harm? (2) Does the product or service interfere with other treatments? If not, then do what you think is useful. At worst, all you will lose is money.

Source: http://library.med.utah.edu/blog/eccles/files/2011/08/logoHealthLiteracy.png

Finding Health Information on the Internet

The following guidelines have been adapted from an online paper from the National Center for Complementary and Integrative Health (NCCIH) entitled, Finding and Evaluating Online Resources. The text in italic is reproduced directly from the online paper (NCCIH, 2023).

“Your search for published and online health information may start at a known, trusted site, but after following several links, you may find yourself on an unfamiliar site. Can you trust this site? Here are some key questions you need to ask.”

When checking online sources of health information, ask the following questions:

Who operates and pays for the website? Can you trust them? Any reliable health-related website should make it easy for you to learn who is responsible for the site. You should be able to find out who runs a website and its purpose on the “About Us” page. For example, on the NCCIH Website, each major page identifies NCCIH and, because NCCIH is part of the NIH, provides a link to the NIH home page.

Does the site sell advertising? Or Why does the site or app exist? Is it sponsored by a company that sells dietary supplements, markets drugs, provides other product, or services? Confirm any information you find on a site that sells products with an independent site that is not a commercial site.

What is the source of the information? Many health or medical sites post information collected from other websites or sources, and that information should be identified. For example, the Health Topics A-Z page on the NCCIH site provides links to documents that NCCIH did not create—but names the sources of the documents.

How do you know if the information is accurate? Is it based on scientific research? The site should describe the evidence (such as articles in medical journals) on which the material is based. Opinions or advice should be clearly set apart from information that is evidence-based (based on research results). For example, if a site discusses health benefits you can expect from a treatment, look for references to scientific research that clearly support what is said. Keep in mind that testimonials, anecdotes, unsupported claims, and opinions are not the same as objective, evidence-based information. [It is important to remember that this does not mean that it is incorrect; it just may mean the appropriate study was not done as there was no funding for it.]

Is the content a sales pitch masquerading as a news report? Some of these reports are reliable, but others are confusing, conflicting, misleading, or missing important information. For insight on how to evaluate news stories about health, wellness, and complementary therapies, visit our interactive module Know the Science: The Facts About Health News Stories.

Has the information been reviewed by experts? You can be more confident in the quality of medical information on a website if health experts reviewed it. Some websites have an editorial board that reviews content. Others put the names and credentials of reviewers in an Acknowledgments section near the end of the page and declare any conflict of interest. [Yet, even this is challenging as stated in the previous quotes by the Lancet journal editor-in-chief Horton. Thus having sign-off by someone with an advanced degree may not guarantee veracity.]

How current is the information? When was the information written or reviewed? Outdated medical information can be misleading or even dangerous. Responsible health websites review and update much of their content on a regular basis.  Content such as news reports or meeting summaries that describe an event usually is not updated. To find out whether information is outdated, look for a date on the page (it’s often near the bottom). [However, old information does not mean that it is incorrect. Information from the past may be valid and even fundamental and foundational. Sometimes an older medication may be more effective; however, it is no longer recommended because it has outlasted the time period of its patent protection and, the pharmaceutical company has created a slightly new variation which may or may not be more effective.]

What is the website or smartphone app promising or offering? When claims seem too good to be true, the claims probably are not true.

Useful websites for information resources. Start with one of these organized collections of quality resources suggested by the University of Utah (2023):

  • Google Scholar ( https://scholar.google.com/ ) provides access to many peer-reviewed resources.
  • MedlinePlus, (https://medlineplus.gov/) sponsored by the National Library of Medicine, which is part of the National Institutes of Health (NIH)
  • healthfinder.gov, sponsored by the Office of Disease Prevention and Health Promotion in the U.S. Department of Health and Human Services.
  • National Center for Complementary and Integrative Health (NCCIH), (https://www.nccih.nih.gov/) the Federal Government’s lead agency for scientific research on complementary and integrative health approaches. Keep in mind that many integrative health and complementary techniques have not been assessed because of a lack of research and funding, however, the procedures can be highly beneficial. The absence of controlled studies does not mean the absence of benefit.
  • Follow NCCIH on Facebook, Twitter, Pinterest, and Instagram. These accounts are updated and managed by NCCIH and provide the latest resources on a variety of complementary health approaches.
  • For information on dietary supplements, visit the NIH Office of Dietary Supplements website (https://ods.od.nih.gov/factsheets/list-all/). [Remember that many of the dietary values were initially identified as the minimum value to prevent the develop of the vitamin deficiency disease. This value may only prevent an obvious disease. It may not be the appropriate value for optimum health. Most of the data was based on healthy young Caucasian males and the values may not be accurate for women, other age groups, or genetic phenotypes and most likely need to be significantly higher.]

Finding Health Information on Social Media

Credible sources of health information may be found on some social media websites. One suggestion by Kington et al., (2021) is to apply the ‘CRAP’ test developed originally by librarian Molly Beestrum at Northwestern University using four major considerations labeled: “Currency/Credibility, Reliability, Authority, and Purpose/Point of View.” Also, consider the following:

  • Check the sponsor’s website. Health information on social networking sites is often very brief. For more information, go to the sponsoring organization’s website. On Twitter, look for a link to the website in the header; on Facebook, look in the About section.
  • Verify that social media accounts are what they claim to be. Some social networking sites have a symbol that an account has been verified. For example, Twitter uses a blue badge but people now pay fee for this badge. Is it really verified or only demonstrates that the person paid a fee. Use the link from the organization’s official website to go to its social networking sites.

Finding Health Information on Mobile Health Apps

The National Academy of Medicine (NAM, 2023) builds on the Kington et al. (2021) article about identifying credible sources of health information. Some of the reminders suggested in the NAM website (cf. https://nam.edu/identifying-credible-sources-of-health-information-in-social-media-principles-and-attributes/) are paraphrased below:

There are thousands of mobile apps (a software program you access using your phone or other mobile device) that provide health information you can read on your mobile devices. Almost 20 percent of smartphone owners had at least one health app on their phones in 2012. Keep these things in mind when using a mobile health app:

  • The content of most apps is not written or reviewed by medical experts. The information could be inaccurate and unsafe. In addition, the information you enter when using an app may not be secure in terms of protecting personal or private health information (PHI) . [Even if the content is written by medical experts, remember they most likely got paid for it or received university grants from these companies.]
  • There is little research on the benefits, risks, and the impact of apps as a source of health information. For example, the ketogenic diet has been found to improve certain medical conditions such as intractable epilepsy. However, for individuals who tend to put weight on easily with a high fat diet, the sudden versus gradual use of a ketogenic diet may be potentially harmful and could shorten lifespan.
  • How secure is the technology?It’s not always easy to know what personal information on an app will accessed by third parties or how personal information will be stored or transferred in an unsecure manner.
  • Consider the source. Before you download an app, find out if the store you get the app from says who created it. Don’t trust the app if contact or website information for the creator isn’t available. Health apps created by Government agencies can be found by visiting: Centers for Disease Control and Prevention.
  • What is the site’s policy about linking to other sites? Some sites don’t link to any other sites, some link to any site that asks or pays for a link, and others link only to sites that meet certain criteria. You may be able to find information on the site about its linking policy. (For example, NCCIH’s linking policy is available on the NCCIH Website Information and Policies page.) Unless the site’s linking policy is strict, don’t assume that the sites that it links to are reliable. You should evaluate the linked sites just as you would any other site that you’re visiting for the first time.
  • How does the site collect and handle personal information? Today, most websites track what pages you’re looking at. They may also ask you to “subscribe” or “become a member.” Any credible site collecting this kind of information should tell you exactly what it will and won’t do with your information.
  • Will they sell your data? Many commercial sites sell aggregated data about their users’ demographics to other companies (for example, information such as the percentage of their users that are men over 40 or under 25). In some cases, they may collect and reuse information that’s “personally identifiable,” such as your ZIP Code, gender, and birth date. Read any privacy policy or similar language on the site, and don’t sign up for anything you don’t fully understand. You can find NICCIH’s privacy policy on the NCCIH website.
  • Is the site encrypted? See if the address (URL) for the site starts with “https://” instead of “http://.” Sites that use HTTPS (Secure Hyper Text Transfer Protocol) are encrypted, less likely to be hacked, and more likely to protect your privacy.
  • Can you communicate with the owner of the website? You should always be able to contact the site owner if you run across problems or have questions or feedback. If the site hosts online discussion forums or message boards, the site should explain the terms of use.

Are You Reading News or Advertising?

The Federal Trade Commission (FTC) has warned the public about fake online news sites. The site may look real, but is actually an advertisement. The site may use the logos of legitimate news organizations or similar names and web addresses. To get you to sign up for whatever they’re selling, they may describe an “investigation” into the effectiveness of the product. But everything is fake: there is no reporter, no news organization, and no investigation. Only the links to a sales site are real. Fake news sites have promoted questionable products, including weight loss products, work-at-home opportunities, and debt reduction plans. You should suspect that a news site may be fake if it:

  • Endorses a product. Real news organizations generally don’t do this.
  • Only quotes people who say good things about the product (includes only positive reader comments, and you can’t add a comment of your own).
  • Presents research findings that seem too good to be true. (If something seems too good to be true, it usually is too good to be true.)
  • Contains links to a sales site.

Use common sense and incorporate an Evolutionary Perspective in making decisions

To make sense of the flood of information use critical thinking and ask yourself whether the claims make sense in context of human evolution. Over millions of years of evolution, nature has “performed” ongoing experiments through natural selection to improve reproductive fitness. As (Talib, 2014) stated, “It [is] an insult to Mother Nature to override her programmed reactions unless we [have] a good reason to do so, backed by proper empirical testing to show that we humans can do better; the burden of evidence falls on us humans.”

Source: https://www.publicdomainpictures.net/pictures/130000/velka/darwin-evolution.jpg

How can we improve health with some simple procedures or drugs when nature has experimented for millions of years. Adapt the rules to maintain health as described by Talib (2014) in the book, Antifragile: Things That Gain from Disorder (2014), summarized with the following points:

  • Anything that was not part of our evolutionary past should be viewed with healthy skepticism. There is a good possibility that it is harmful, because there has not been sufficient time for humanity to adapt genetically to the new variation. For example, the addition of altered trans fats to commercially available foods, which are not recognized by the human immune system and a result, can promote inflammation, cardiovascular disease, and cancer.
  • We do not need evidence of harm to claim that a drug or an unnatural procedure involves potential risk.  Take a cautionary approach with a healthy dose of skepticism. If possible then wait until more evidence is discovered. If evidence of harm does not exist, that does not mean harm does not exist.
  • Only resort to medical techniques when the health payoff is very large (i.e., to save a life). Does the intervention exceed its potential harm, in cases such as emergency surgery or a lifesaving medicine (e.g., penicillin).

Take charge of your health—talk with your health care providers about any complementary health approaches you use. Together, you can make shared, well-informed decisions.

Key Background Source material for the NCCIH (2023) article, “Finding and Evaluating Online Resources“

Recommended sources for the NIH (2023) article, “Finding and Evaluating Online Resources“

References

[i]This is a measure of size of the  association as measured by as  statistic  such as  Cohen’ d; namely, if it is small–although statistically significant– it probably would not be clinically meaningful. Cohen (1988) suggested a ”d” statistic (e.g. Cohen’s d) comparing the group differences (e.g. treatment group vs. comparison group change scores; [M2 – M1]) divided by the standard deviation of both groups [square root of SD1+SD2]/2], interpreting moderate effects between 0.50 and 0.79 and larger effects above 0.80. Treatment group vs comparison group effects are also estimated by examining percentages.  Relative risk ratio or odds ratio is a single number that reflects the increased or decreased risk. For example, a doubled risk would be expressed as a relative risk of 2. Risk decreased by 50% would be expressed as RR 0.5. This number is calculated as the percent of people with clinically meaningful outcomes divided by percent of people without clinically meaningful outcomes. This provides a ‘relative’ estimate of effectiveness, where a ratio close to 1 indicates no difference between treatment and comparison groups, and ratios greater than 3 to 1 (e.g. treatment group was twice as effective as comparison group) are considered moderate effects and 4 to 1 are considered larger effects.


About the Authors

Erik Peper’s teaching and research focuses on self-healing strategies, illness prevention, the effects of posture and respiration, and how to use biofeedback and wearable devices. Each year he mentors undergraduate student researchers to create and complete studies that are presented at scientific meetings. He is an international authority on biofeedback and self-regulation and author of scientific articles and books such as Make Health Happen, Fighting Cancer-A Nontoxic Approach to Treatment, and Biofeedback Mastery. His most recent co-authored book is, TechStress: How Technology is Hijacking Our Lives, Strategies for Coping, and Pragmatic Ergonomics.  He publishes the blog, The Peper Perspective–ideas on illness, health and well-being (peperperspective.com). In 2013 was received the Biofeedback Distinguished Scientist Award in recognition of outstanding career & scientific contributions from the Association for Applied Psychophysiology. 

Richard Harvey has a Ph.D. for the UC Irvine Social Ecology program. His research includes developing stress-reduction interventions which promote psychological courage and hardiness. Before teaching at SF State, he was a research fellow at the UC Irvine Transdisciplinary Tobacco Use Research Center for five years, developed and ran the UC Irvine Counseling Center Biofeedback and Stress Management Program, and worked as a Maternal, Child and Adolescent Health Research Analyst in Orange County. He is the co-chair of the American Public Health Association, Alternative and Complementary Health Practices Special Interest Group, as well as a board member of the Biofeedback Society of California and the San Francisco Psychological Association. He has published in the areas of biofeedback, stress and computer-related disorders, tobacco cessation, and the psychology of hardiness and courage. 

Copyright © 2023 Townsend Letter

Healing a Shoulder/Chest Injury

Posted: August 14, 2023 | Author: | Filed under: behavior, biofeedback, Breathing/respiration, emotions, Exercise/movement, healing, Neck and shoulder discomfort, Pain/discomfort, relaxation, self-healing, Uncategorized | Tags: , , | Leave a comment

Adapted from Peper, E. & Fuhs, M. (2004). Applied psychophysiology for therapeutic use: Healing a shoulder injury, Biofeedback, 32(2), 11-18. 

“It has been an occurrence of the third dimension for me! How come my pain — that lasted for more than 10 days and was still so strong that I really had difficulties in breathing, couldn’t laugh without pain nor move my arm not even to fulfil my daily routines such as dressing and eating — disappeared within one single session of 20 minutes? And not only that, I was able to freely rotate my arm as if it had never been injured before.” —23 year old woman

The participant T., aged 23, was a psychology student who participated in an educational workshop for Healthy Computing. She volunteered to be a subject for a surface electromyographic (SEMG) monitoring and feedback demonstration. Ten days prior to this workshop, she had a severe skiing accident. She described the accident as follows:

I went skiing and may be I had too much snow in my ski-binding and while turning, I slipped out of my binding and fell head first down into the hill. As I fell, I landed on my ski pole which hit my left upper chest and breast area. Afterwards, my head was humming and I assumed that I had a light concussion. I stopped skiing and stayed in bed for a while. The next day it started hurting and I couldn’t turn my head or put my shoulders back (they were rotated forward). Also, I couldn’t ski as I was not able to look down to my feet–my muscles were too contracted and I felt searing pain whenever I moved. I hoped that it would go away however, the pain and left forward shoulder rotation stayed.

Assessment

Observation and Palpation

T.´s left shoulder was rolled forward (adducted and in internal rotation). She was not able to breathe or laugh without pain or move her arm freely. All movements in vertical and horizontal directions and rotations were restricted by at least 50 % as compared to her right arm (limitations in shoulder extension, flexion and external rotation). Also, her hands were ice-cold and she breathed very shallowly and rapidly in her chest. She was not able to stand in an upright position or sit in a comfortable position without maintaining her left upper extremity in a protected position. Her left shoulder blade (scapula) was winging.

After visually observing her, the instructor placed his left hand on her left shoulder and pectoralis muscles and his right hand on the back of her shoulder. Using palpation and anchoring her back with his leg so that she could not rotate her trunk, he explored the existing range of shoulder movement.  He also attempted to rotate the left shoulder outward and back–not by forcing or pulling—but by very gentle traction. No change in mobility was observed and the pectoralis muscle felt tight (SEMG monitoring is helpful to the therapist during such a diagnostic assessment by helping to identify the person’s reactivity and avoiding to evoke and condition even more bracing). T. reported afterwards that she was very scared by this assessment because there was one point in the back which was highly reactive to touch. T. appeared to tighten automatically out of fear and trigger a general flexor contraction pattern—a process that commonly occurs if a person is guarding an area.

Often a traumatic injury first induces a general shock that triggers an automatic freeze and fear reaction. Therefore, an intervention needed to be developed that did not trigger vigilance or fear and thereby allowed the muscle to relax. If pain is experienced or increased, it is another negative reinforcement for generalizing guarding and bracing and tightening the muscles. This guarding decreases mobility – a common reaction that may occur when health professionals in the process of assessment increase the client’s discomfort.  T.’s vigilance was also “telegraphed” to the therapist by her ice-cold hands and very shallow chest breathing. Therefore, it was important to increase her comfort level and to not induce any further pain.  We hypothesized that only if she felt safe it would be possible for her muscle tension to decrease and thereby increase her mobility.

Underlying concept:  The very cold hands and shallow breathing probably indicated excessive vigilance and arousal—a possible indicator of a catabolic state that could limit regeneration. The chronic cold hands most likely implied that she was very sensitive to other people’s emotions and continuously searches/scans the environment for threats. In addition, she indicated that she liked to do/perform her best which induced more anxiety and fear of judgement.

Single Channel Surface Electromyographic (SEMG)Assessment

The triode electrode with sensor was placed over the left pectoralis muscle area as shown in Figure 1. The equipment was a MyoTrac™ produced by Thought Technology Ltd. which is a small portable SEMG with the preamplifiers at the triode sensor to eliminate electrode lead and movement artefacts (Peper & Gibney, 2006). Such a device is an inexpensive option for people who may use biofeedback for demonstrating and teaching awareness and control over muscle tension from a single electrode location. 

Figure 1. Location of the Triode electrode placement on the left pectoralis muscle area of another participant.

The MyoTrac was placed on a table within view, so that the therapist and the subject could simultaneously see the visual feedback signal and observe what was going on as well as demonstrate expected changes. The feedback was used for T. as a tool to see if she could reduce her SEMG activity. It was also used by the therapist to guide his interventions: To keep the SEMG activity low and to stop any intervention that would increase the SEMG activity as this would prevent bracing as a possible reaction to, or anticipation of, pain.

1. Assessment of Muscle Reactivity. After the electrode was attached on her pectoralis muscle and with her arm resting on her lap, she was asked to roll her left shoulder slightly more forward, hold the tension for the count of 10 and then let go and relax. Even with feedback, the muscle activity stayed high and did not relax and return to a lower level of activity as shown in Figure 2. This lack of return to baseline is often a diagnostic indicator of muscle irritability or injury (Sella, 1998; Sella, 2006).  If the muscle does not relax immediately after contraction, movement or exercise should not be prescribed, since it may aggravate the injury.  Instead, the person first needs to learn how to relax and then learn how to relax between activation and tensing of the muscle. The general observation of T. was that at the initiation of any movement (active or passive) muscle tension increased and did not return to baseline for more than two minutes.

Figure 2. Simulation of the effect on the pectoralis sEMG (this is a recording from another subject who showed a similar response pattern that was visually observed from T. with the Myotrac). After the muscle is contracted it takes a long time to return to baseline level

2.  Exploration.  Self-exploration with feedback was encouraged. T. was instructed to let go of muscle tension in her left shoulder girdle. In addition the therapist tried to induce her letting go by gently and passively rocking her left arm. The increased SEMG activity and the protective bracing in her shoulder showed that she couldn’t reduce the muscle tension.  Each time her arm was moved, however slightly, she helped with the movement and kept control. In addition, T. was asked to reduce the muscle tension using the biofeedback signal; again she was not able to reduce her muscle tension with feedback.

3.  Passive Stretch and Movements.  The next step was to passively stretch the pectoralis muscle by holding the shoulder between both hands and very gently externally rotate the shoulder — a process derived from the Alexander technique (Barlow, 1991). Each time the instructor attempted to rotate her shoulder, the SEMG increased and T. reported an increased fear of pain. T.’s SEMG response most likely consisted of the following components:

  • Movement induced pain
  • Increased splinting and guarding
  • Increased arousal/vigilance to perform well

These three assessment and self-regulation procedures were unsuccessful in reducing muscle tension or increasing shoulder movement. This suggested that another therapeutic intervention would need to be developed to allow the left pectoralis area to relax. The SEMG could be used as an indicator whether the intervention was successful as indicated by a reduction in SEMG activity. Finally, the inability to relax after tightening (bracing and splinting) probably aggravated her discomfort.

Multiple levels of injury: The obvious injury and discomfort was due to her left chest wall being hit by the ski pole. She then guarded the area by bracing the muscles to protect it which limited movement. The guarding tightened the muscles and limited blood circulation and lymphatic flow which increased local ischemia, irritation and pain. This led to a self-perpetuating cycle: Pain triggers guarding and guarding increases pain and impedes self-healing.

As the SEMG and passive stretching assessment were performed, the therapist concurrently discussed the pain process.  Namely, from this perspective, there were at least two types of pains:

  • Pain caused by the physiological injury
  • Pain as the result of guarding

The pain from the guarding is similar to having exercised for a long time after not having exercised.  The next day you feel sore.  However, if you feel sore, you know that it was due to the exercise therefore it is defined as a good pain.  In T.’s case, the pain indicated that something was wrong and did not heal and therefore she would need to protect it. We discussed this process as a way to use cognitive reframing to change her attitude toward guarding and pain.

Rationale: The intention was to interrupt her negative image of pain that acted as a post hypnotic suggestion. The objective was to change her image and thoughts from “pain indicates the muscle is damaged” to “pain indicates the muscle has worked too hard and long and needs time to regenerate.”

Treatment interventions

The initial intervention focused upon shifting shallow thoracic breathing to diaphragmatic breathing. Generally, when people breathe rapidly and predominantly in their chest, they usually tighten their neck and shoulder muscles during inhalation. One of the reasons T. breathed in her chest was that her clothing–very tight jeans–constricted her waist (MacHose & Peper, 1991; Peper et al., 2015). This breathing pattern probably contributed to sub-clinical hyperventilation and was part of a fear or flexor response pattern.  When she loosened the upper buttons of her jeans and allowed her stomach to expand her pectoralis muscle relaxed as she breathed as shown in Figure 3. As she began to breathe in this pattern, each time she exhaled her pectoralis muscle tension decreased.

Figure 3. Illustration of the effect of loosening tight waist constriction (eliminating designer’s jean syndrome) on blood flow and pectoralis sEMG. Abdominal breathing became possible and finger temerature increased (this recording is from another subject whose physiological responses were similar to that was observed with the Myotrac from T.) 

Following the demonstration that breathing significantly lowered her chest muscle tension, the discussion focussed on the importance of effortless diaphragmatic breathing for health and reduction of vigilance. Being awkward and uncomfortable at loosening her pants, she struggled with allowing her abdomen to expand and her pants to be looser because she thought that she looked much more attractive in tight clothing. Yet, she agreed that her boy friend would love her regardless whether she wore loose or tight clothing. To encourage an acceptance for wearing looser clothing and thereby permit diaphragmatic breathing during the day, an informal discussion focused on “designer jeans syndrome” (chest breathing induced by tight clothing) with humorous examples such as discussing the name of the room that is located on top of the stairs in the Victorian houses in San Francisco. It is called the fainting room–in the 19th century women who wore corsets and had to climb the stairs would have to breathe rapidly and then would faint when they reached the top of the stairs (Peper, 1990).

Rationale: Rapid shallow chest breathing can induce a catabolic state that inhibits healing while diaphragmatic breathing may induce an anabolic state that promotes regeneration.  Moreover, effortless diaphragmatic breathing would increase respiratory sinus arhythmia  (RSA)–heart rate variability linked to breathing– and thereby facilitate sympathetic-parasympathetic balance that would promote self-healing.  

The discussion included the use of the YES set which meant asking a person questions in such a way that she/he answers the question with YES. When a person answers YES at least three times in a row rapport is often facilitated (Erikson, 1983, pp. 237-238). Questions were framed in such a way that the client would answer with YES. For example, if the therapist thought the person did not do their homework, a yes question could be framed as, “It must have been difficult to find time to do the homework this week?”  In T.’s case, the therapist said, “I see, you would rather wear tight clothing than allow your shoulder to heal.” She answered, “Yes.” This was the expected answer, however, the question was framed in an intuitive guess on the therapist’s part.  Nevertheless, the strategy would have been successful either way because if she had answered “No,” it would have broken the “Yes: set, but she would then be committed to change her clothing. 

Throughout this discussion, the therapist placed his left hand on her abdomen over her belly button and overtly and covertly guided her breathing movement.  As she exhaled, he pressed gently on her abdomen; as she inhaled he drew his hand away–as if her abdomen was like a balloon that inflated during inhalation and deflated during exhalation.  To enhance learning diaphragmatic breathing and slower exhalation, the therapist covertly breathed at the same rhythm and gently exhaled as she exhaled while allowing the breathing movement to be mainly in his abdomen. In this process, learning occurred without demand for performance and she could imitate the breathing process that was covertly modelled by the therapist.

The Change

The central observation was that each time she tried to relax or do something, she would slight brace which increased her pectoralis SEMG activity.  The chronic tension from guarding probably induced localized ischemia, inhibited lymphatic flow and drainage, and reduced blood circulation which would increase tissue irritation. Whenever the therapist began to move her arm, she would anticipate and try to help with the movement.  Overall she was vigilant (also indicated by her very cold hands) and wanted to perform very well (a possible need for approval).  Her muscle bracing and helping with movement was reframed as a combined activity that consisted of guarding to prevent further injury and as a compliment that she would like to perform well.

Labelling her activity as a “compliment” was part of a continuing YES set approach. The therapist was deliberately framing whatever happened as adaptive behaviour, with positive intent. Further, if one tries and does something with too much effort while being vigilant, the arousal would probably induce hand cooling. If the activity can be performed with passive attention, then increased blood flow and warmth may occur. The therapeutic challenge was how to reduce vigilance, perfectionism and guarding so that the muscles that were guarding the traumatized area would relax.

Therapeutic concept:  If a direct approach does not work, an indirect approach needs to be employed. Through an indirect approach, the person experiences a change without trying to focus on doing or achieving it.  Underlying this approach is the guideline: If something does not work, try it once more and then if it does not work, do something completely different.  This is analogous to sexual arousal: If you demand from a male to have an erection: The more performance you demand the less likely will there be success. On the other hand, if you remove the demand for performance and allow the person to become interested and thereby feel an erotic experience an erection may occur without effort.

The shift to an indirect intervention was done through active somatic visualization. T. was encouraged to visualize and remember a positive image or memory from her past. She chose a memory of a time when she was in Paris with her grandmother.  While T. visualized being with her grandmother, the therapist asked another older women participant to help and hold T’s right hand in a grandmother-like way as if she was her grandmother. The “grandmother” then moved T.’s hand in a playful way as if dancing with T.’s right arm. Through this kinesthetic experience, T. became more and more absorbed in her memory experience. At the same time, T´s left hand was being held and gently rocked by the therapist. During this gentle rocking, the SEMG activity decreased completely in her left pectoralis area. The therapist used the SEMG feedback to guide him in the gentle rocking motion of T.’s left arm and very slowly increased the range of her arm and shoulder motion. Gentle movement was done only as long as the SEMG activity did not increase. It allowed the muscle to stay relaxed and facilitated the experience of trust. The following is T. report two days later of what happened.

“Initially it was very difficult for me to let go of control because I found this idea somewhat strange and I was puzzled.  I expected the therapist to intervene and I felt frightened. The therapist’s soft and gentle touch and his very soft voice in this kind of meditation helped me to let go of control and I was surprised about my own courage to give myself into the process without knowing what would happen next.” 

Rationale: Every corresponding thought and emotion has an associated body response and every body response has an associated mental/emotional response (Green & Green, 1977; Green, 1999). Therefore, an image and experience of a happy and safe past memory will allow the body to evoke the same state and vigilance can be abated. The intensity of the experience is increased when multi-sensory cues are included such as actual handholding. The more senses are involved, the more the experience can become real.  In addition, the tactile sensation of feeling the grandmother’s hand diverted her attention away from her shoulder into her hand and thereby reduced her active efforts of trying to relax the shoulder and pectoralis area. Doing something she did not expect to happen also helped her loose control – an implicit confusion approach.

SEMG feedback was used as the guide for controlling the movement. The therapist gently increased the range of the movements in abduction and external rotation directions while continuously rocking her arm until her injured arm was able to move unrestricted in full range of motion.  The arm and shoulder relaxation and continuous subtle movement without evoking any SEMG activation facilitated blood flow and lymphatic drainage which probably reduced congestion. After a few minutes, the therapist gently dropped her arm on her lap. After her arm was resting on her lap, she reported that it felt very heavy and relaxed and that she didn’t feel any pain. However, she initially didn’t really realize that her mobility had increased dramatically.

Rationale: When previous movements that had been associated with pain are linked to an experience of pleasure, the movement is often easier. The conditioned muscle bracing patterns associated with anticipation of pain and/or concern for improvement/results are reduced.

Process to deepen and generalize the relaxation and breathing. She was asked to imagine breathing the air down and through her arms and legs–a strategy that she could then do at home with her boyfriend. We wanted to involve another person because it is often difficult to do homework practices without striving and concern for results and focussing on the area of discomfort. Her response to asking if her boyfriend would help was an automatic “naturally” (the continuation of the YES set).  With her agreement, we role played how her boyfriend was to encourage diaphragmatic breathing. He was to gently stroke down her legs as she exhaled. She could then just focus on the sensations and allow the air to flow down her legs.  Then, while she continued to breathe effortlessly, he would gently rock and move her arm. 

To be sure that she knew how to give the instructions, the therapist role played her boyfriend and then asked her to rock his arm so that she would know how to teach her boy friend how to move her arm.  The therapist sat on her left side, and, as she now held his right arm and gently rocked it with her left arm, the therapist gently moved backwards.  This meant that she externally rotated her left arm and shoulder more and more. He moved in such a way that in the process of rocking his arm, she moved her “previously injured shoulder” in all directions (up, down, forward and backwards) and was unaware that she could move her arm and shoulder as she did not experience any discomfort. Afterwards, we shared our observations and she was asked to move her arm and shoulder. She moved it without any restrictions or discomfort.

Rationale: By focusing outside herself and not being concerned about herself, she did not think of herself or of trying to move her arm and shoulder.  Hence, she did not evoke the anticipatory guarding and thus significantly increased her flexibility. 

Process of acceptance. Often after an injury, we are frustrated with our bodies. This frustration may interfere with healing.  Therefore, the session concluded by asking her to be appreciative of her shoulder and arm. She was asked to think of all the positive things her shoulder, chest and arm have done for her in the past instead of the many limitations and pains caused by the injury. Instead of being angry at her shoulder that it had not healed or restricted her movement, we suggested that she should appreciate her shoulder and pectoralis area for all it had done without her awareness such as: How the shoulder moved her arm during love-making, how without complaining her shoulder moved during walking, writing, skiing, eating, etc., and how many times in the past she had abused her shoulder without giving it proper respect and appreciation.  This process reframes the way one symbolically relates to the injured area.  Every thought of discomfort or negative judgement becomes the trigger and is transformed into breathing lower and slower and evokes an appreciation of the positive nice things her shoulder has done for her in the past.

Rationale:  When injured we often evoke negative mental and emotional images which become post- hypnotic suggestions. Those negative thoughts, images and emotions interfere with healing while positive thoughts, images and emotions tend to promote healing.  A possible energetic process that occurs when injured is that we withdraw awareness/ consciousness from the injured area which reduces blood and lymph circulation. Caring and positive feelings about an area tends to increase blood flow and warmth (a heart-warming experience) and promotes healing.

RESULTS

She left the initial session without any pain and with total range of motion. At the two week follow-up she reported continued pain relief and complete range of motion. T.s reflection of the experience was:

“I really was not aware that I could move my arm freely like before the accident, I was just feeling a kind of trance and was happy to not feel any pain and to feel much more upright than before. Then I watched the faces of the two other therapists who sat there with big eyes and a grin on their face and then become aware of my own arms position which was rotated backwards and up, a movement that was impossible to do before. I remember this evening that I left with this feeling of trance and that I often tried to go back to my collapsed posture but this was not possible anymore and I felt very tall and straight. Now two weeks later I still feel like that and know that I had an amazing experience which I will store in my brain!

My father who is an orthopedic surgeon tested me and found out, that I had hurt my rib. He said that I have a contusion and it will go away in a few weeks. Before this experience, I would say that he was not open to Biofeedback. However he was so captivated by my experiences that he spontaneously promised me to pay for my own biofeedback equipment and to support me with my educational program and even offered me a job in his practice to do this work!”  

Psychophysiological Follow-up: 3 Weeks Later

The physiological assessment included monitoring thoracic and abdominal breathing patterns, blood volume pulse, heart rate and SEMG from her left pectoralis muscle while she was asked to roll her left shoulder forward (adducted and internally rotated) for the count of 10 and then relax. The physiological recording showed that she breathed more diaphragmatically and that her pectoralis muscle relaxed and returned directly to baseline after rotation as shown in Fig. 4.

Figure 4. Physiological profile during the rolling left shoulder forward (tense) and relaxing at thethree week follow-up. Note that the pectoralis sEMG activity returned rapidly to baseline after contracting and her breathing pattern is abdomninal and slower.

Summary

This case example demonstrates the usefulness of a simple one-channel SEMG biofeedback device to guide the interventions during assessment and treatment. It suggests that the therapist and client can use the SEMG activity as an indicator of guarding–a visual representation of the subjective experience of fear, pain and range of mobility–that can be evoked during assessment and therapeutic interventions. The anticipation of increased pain commonly occurs during diagnosis and treatment and often becomes an obstacle for healing because increased pain may increase anticipation of pain and trigger even more bracing. To avoid triggering this vicious circle of guarding/fear, the feedback signal allows the therapist and the client to explore strategies that reduce muscle activity by indirect interventions. 

By using an indirect approach that the client may not expect, the interventions shift the focus of attention and striving and may allow increased freedom and relaxation.  The biofeedback signal may guide the therapeutic process to reduce the patterns of fear, panic, and bracing that are commonly associated with injury and illnesses. Once this excessive sympathetic activity is reduced, the actual pathophysiology may become obvious (in most cases is much less then before) and the healing process may be accelerated. This case description may offer an approach in diagnosis and treatment for many therapists and open a door for a gentle, painless and yet successful way of treatment and encourage therapists to be creative and use both experience/technique and intuition.

For additional intervention approaches see the following two blogs.

Healing chronic back pain
Compassion supports healing: Case report how a “bad eye” became an “amazing eye”*

References

Barlow, W. (1991).  The Alexander technique: How to use your body without stress. Rochester, VT: Healing Arts Press https://www.amazon.com/Alexander-Technique-Your-without-Stress/dp/0892813857#:~:text=Barlow%2C%20the%20foremost%20exponent%20and,and%20movement%20in%20everyday%20activities.

Erikson, M. H. (1983). Healing in hypnosis, volume 1 (Edited by E. L. Rossi, M. O. Ryan, M. & F. A. Sharp). New York: Irvington Publishers, Inc.. https://www.amazon.com/Hypnosis-Seminars-Workshops-Lectures-Erickson/dp/0829007393/ref=sr_1_1?keywords=9780829007398&linkCode=qs&qid=1692038804&s=books&sr=1-1

Green, E. (1999). Psychophysical Principal. Accessed August 14, 2023 https://www.elmergreenfoundation.org/psychophysiological-principal/

Green, E., & Green, A. (1977). Beyond biofeedback. New York:
Delacorte Press/Seymour. https://elmergreenfoundation.org/wp-content/uploads/2019/02/Beyond-Biofeedback-Green-Green-Searchable.pdf

MacHose, M., & Peper, E. (1991). The effect of clothing on inhalation volume. Biofeedback and Self-Regulation. 16(3), 261-265. https://doi.org/10.1007/BF01000020

Peper, E. (1990). Breathing for health. Montreal: Thought Tech­nology Ltd.

Peper, E. & Gibney, K.H. (2006). Muscle biofeedback at the computer-A manual to prevent repetitive strain injury (RSI) by taking the guesswwork out of assessment, monitoring and training. Biofeedback Foundation of Europe. https://thoughttechnology.com/muscle-biofeedback-at-the-computer-book-t2245/

Peper, E., Gilbert, C.D., Harvey, R. & Lin, I-M. (2015). Did you ask about abdominal surgery or injury? A learned disuse risk factor for breathing dysfunction. Biofeedback. 34(4), 173-179.  https://doi.org/10.5298/1081-5937-43.4.06

Sella, G. E. (2006). SEMG: Objective methodology in muscular dysfunction investigation and rehabilitation. Weiner’s pain management: A practical guide for clinicians, CRC Press, 645-662. https://www.taylorfrancis.com/chapters/edit/10.1201/b14253-45/semg-objective-methodology-muscular-dysfunction-investigation-rehabilitation-gabriel-sella

Sella, G. E. (1998). Towards an Integrated Approach of sEMG Utilization: Quantative Protocols of Assessment and Biofeedback. Electromyography: Applications in Physical Medicine. Thought Technology, 13. https://www.bfe.org/protocol/pro13eng.htm

[1] We thank Theresa Stockinger for her significant contribution and Candy Frobish for her helpful comments.

Mouth breathing and tongue position: a risk factor for health

Posted: June 8, 2023 | Author: | Filed under: ADHD, behavior, Breathing/respiration, cognitive behavior therapy, Evolutionary perspective, healing, health, Nutrition/diet, self-healing, Uncategorized | Tags: , , , , , , , , , | Leave a comment

Erik Peper, PhD, BCB and Ron Swatzyna, PhD, LCSW, BCB, BCN

Adapted from: Peper, E., Swatzyna, R., & Ong, K. (2023).  Mouth breathing and tongue position: a risk factor for health. Biofeedback. 51(3), 74–78 https://doi.org/10.5298/912512

Breathing usually occurs without awareness unless there are problems such as asthma, emphysema, allergies, or viral infections. Infant and child development may affect how we breathe as adults. This blog discusses the benefits of nasal breathing, factors that contribute to mouth breathing, how babies’ breastfeeding and chewing decreases the risk of mouth breathing, recommendations that parents may implement to support healthy development of a wider palate, and the embedded video presentation, How the Tongue Informs Healthy (or Unhealthy) Neurocognitive Development, by  Karindy Ong, MA, CCC-SLP, CFT, .

Benefits of nasal breathing

Breathing through the nose filters, humidifies, warms, or cools the inhaled air as well as reduces the air turbulence in the upper airways.  In addition, the epithelial cells of the nasal cavities produce nitric oxide that are carried into the lungs when inhaling during nasal breathing (Lundberg & Weitzberg, 1999). The nitric oxide contributes to healthy respiratory function by promoting vasodilation, aiding in airway clearance, exerting antimicrobial effects, and regulating inflammation. Breathing through the nose is associated with deeper and slower breathing rate than mouth breathing. This slower breathing also facilitates sympathetic parasympathetic balance and reduces airway irritation.

Mouth breathing

Some people breathe predominantly through their mouth although nose breathing is preferred and health promoting. Mouth breathing negatively impacts the ability to perform during the day as well as affect our cognitions and mood (Nestor, 2020). It contributes to disturbed sleep, snoring, sleep apnea, dry mouth upon waking, fatigue, allergies, ear infections, attention deficit disorders, crowded mis-aligned teeth, and poorer quality of life (Kahn & Ehrlich, 2018). Even the risk of ear infections in children is 2.4 time higher for mouth breathers than nasal breathers (van Bon et al, 1989) and nine and ten year old children who mouth breath have significantly poorer quality of life and have higher use of medications (Leal et al, 2016).

One recommendation to reduce mouth breathing is to tape the mouths closed with mouth tape (McKeown, 2021). Using mouth tape while sleeping bolsters nose breathing and may help people improve sleep, reduce snoring, and improves alertness when awake (Lee et al, 2022).

Experience how mouth breathing affects the throat and upper airway

Inhale quickly, like a gasp, as much air as possible through your open mouth. Exhale letting the air flow out through your mouth. Repeat once more.

Inhale quickly as much air through the nose, then exhale by allow the airflow out through the nose.  Repeat once more.

What did you observe? Many people report that rapidly inhaling through the mouth causes the back of the throat and even upper airways to feel drier and irritated. This does not occur when inhaling through the nose. This simple experiment illustrates how habitual mouth breathing may irritate the airways.

Developmental behavior that contributes to mouth breathing

The development of mouth breathing may begin right at birth when the mouth, tongue, jaw and nasal area are still developing. The arch of the upper palate forms the roof of the oral cavity that separates the oral and nasal cavities. When the palate and jaw narrows, the arch of the palate increases and pushes upwards into the nasal area. This reduces space in the nasal cavity for the air to flow and obstructs nasal breathing. The highly vaulted palate is not only genetically predetermined but also by how we use our tongue and jaw from birth. The highly arched palate is only a recent anatomical phenomena since the physical structure of the upper palate and jaw from the pre- industrial era was wider (less arched upper palate) than many of our current skulls (Kahn & Ehrlich, 2018).

The role of the tongue in palate development

After babies are born, they breastfeed by sucking with the appropriate tongue movements that help widen the upper palate and jaw. On the other hand, when babies are bottle fed, the tongue tends to move differently which causes the cheek to pull in and the upper palate to arch which may create a high narrow upper palate and making the jaw narrower. There are many other possible factors that could cause mouth breathing such as tongue-tie (ankyloglossia), septal deviation, congenital malformation, enlarged adenoids and tonsils (Aden tonsillar hyperplasia), inflammatory diseases such as allergic rhinitis (Trabalon et al, 2012). Whatever the reasons, the result of the impoverished tongue movement and jaw increases the risk for having a higher arched upper palate that impedes nasal breathing and contributes to habitual mouth breathing.

The forces that operate on the mouth, jaw and palate during bottle feeding may be similar to when you suck on straw and the cheeks coming in with the face narrowing. The way the infants are fed will change the development of the physical structure that may result in lifelong problems and may contribute to developing a highly arched palate with a narrow jaw and facial abnormalities such as long face syndrome (Tourne, 1990).

To widen the upper palate and jaw, the infant needs to chew, chew and tear the food with their gums and teeth. Before the industrialization of foods, children had to tear food with their teeth, chew fibrous foods or gnaw at the meat on bones.  The chewing forces allows the jaw to widen and develop so that when the permanent teeth are erupting, they would more likely be aligned since there would be enough space–eliminating the need for orthodontics.  On the other hand, when young children eat puréed and highly processed soft foods (e.g., cereals soaked in milk, soft breads), the chewing forces are not powerful enough to encourage the widening of the palate and jaw. 

Although the solution in adults can be the use of mouth tape to keep the mouth closed at night to retrain the breathing pattern, we should not wait until we have symptoms.  The focus needs to be on prevention. The first step is an assessment whether the children’s tongue can do its job effectively or limited by tongue-tie and the arch of the palate.  These structures are not totally fixed and can change depending on our oral habits. The field of orthodontics is based upon the premise that the physical structure of the jaw and palate can be changed, and teeth can be realigned by applying constant forces with braces.

Support healthy development of the palate and jaw

Breastfeed babies (if possible) for the first year of life and do NOT use bottle feeding. When weaning, provide chewable foods (fruits, vegetable, roots, berries, meats on bone) that was traditionally part of our pre-industrial diet. These foods support in infants’ healthy tongue and jaw development, which helps to support the normal widening of the palate to provide space for nasal breathing.

Provide fresh organic foods that children must tear and chew. Avoid any processed foods which are soft and do not demand chewing.  This will have many other beneficial health effects since processed foods are high in simple carbohydrates and usually contain color additives as well as traces of pesticides and herbicides. The highly processed foods increase the risk of developing depression, type 2 diabetes, inflammatory disease, and colon cancer (Srour et al., 2019).

Sadly, the USA allows much higher residues of pesticide and herbicides that act as neurotoxins than are allowed in by the European Union.  For example, the acceptable level of the herbicide glyphosate (Round-Up) is 0.7 parts per million in the USA while in the acceptable level is 0.01 parts per million in European countries (Tano, 2016; EPA, 2023; European Commission, 2023).  The USA allows this higher exposure even though about half of the human gut microbiota are vulnerable to glyphosate exposure (Puigbò et al., 2022).

The negative effects of herbicides and pesticides are harmful for growing infants. Even fetal exposure from the mother (gestational exposure) is associated with an increase in behaviors related to attention-deficit/hyperactivity disorders and executive function in the child when they are 7 to 12 years old (Sagiv et al., 2021) and organophosphate exposure is correlated with ADHD prevalence in children (Bouchard et al., 2010). 

To implement these basic recommendations are very challenging. It means the mother has to breastfeed her infant during the first year of life. This is often not possible because of socioeconomic inequalities; work demands and medical complications.  It also goes against the recent cultural norm that fathers should participate in caring for the baby by giving the baby a bottle of stored breast milk or formula.  

From our perspective, women who give birth must have a year paid maternity leave to provide their infants with the best opportunity for health (e.g., breast-feeding, emotional bonding, and reduced financial stress).  As a society, we have the option to pay the upfront cost now by providing a year- long maternity leave to mothers or later pay much more costs for treating chronic conditions that may have developed because we did not support the natural developmental process of babies.

Relevance to the field of neurofeedback and biofeedback

Clinicians often see clients, especially children with diagnostic labels such as ADHD who have failed to respond to numerous psychotherapies and pharmacotherapies. In the recent umbrella review and meta-analytic evaluation of recent meta-analyses, Leichsenring et al. (2022) found only small benefits overall for both types of intervention. They suggest that a paradigm shift in research seems to be required to achieve further progress in resolving mental health issues. As the past director of National Institute of Health, Dr. Thomas Insel pointed out that the Diagnostic and Statistical Manual of Mental Disorders (DSM) is not a valid instrument and should be a big wake up call for all of us to think outside the box (Insel, 2009). One factor that starts right at birth is the oral cavity development by dysfunctional tongue movements.

We want to make all of you aware of a serious issue in children that you may come across. For those of us who work with children children, we need to ask their parents about the following: tongue-tie, mouth breathing, bedwetting, high-vaulted palate, thumb sucking, abnormal eating issues, apraxia, dysarthria, and hypotonia. Research suggests that the palates of these children are so arched that the tongue cannot do its job effectively, causing multiple issues which may be related.

Please view the webinar from May 17, 2023.  Presented by Karindy Ong, MA, CCC-SLP, CFT, How the Tongue Informs Healthy (or Unhealthy) Neurocognitive Development.    The presentation explains the developmental process of the role the tongue plays and how it contributes to nasal breathing.  Please pass it on to others who may have interest.

References

Bouchard, M.F., Bellinger, D.C., Wright, R.O., & Weisskopf, M.G. (2010).  Attention-deficit/hyperactivity disorder and urinary metabolites of organophosphate pesticides. Pediatrics, 125(6), e1270-7. https://doi.org/10.1542/peds.2009-3058

EPA. (2023). Glyphosate. United States Environmental Protection Agency. Accessed April 1, 2023. https://www.epa.gov/ingredients-used-pesticide-products/glyphosate

European Commission. (2023). EU legislation on MRLs.Food Safety. Assessed April 1, 2023. https://food.ec.europa.eu/plants/pesticides/maximum-residue-levels/eu-legislation-mrls_en#:~:text=A%20general%20default%20MRL%20of,e.g.%20babies%2C%20children%20and%20vegetarians.

Insel, T.R. (2009). Translating scientific opportunity into public health impact: a strategic plan for research on mental illness. Arch Gen Psychiatry, 66(2), 128-133. https://doi.org/10.1001/archgenpsychiatry.2008.540

Kahn, S. & Ehrlich, P.R. (2018). Jaws. Stanford, CA: Stanford University Press. https://www.amazon.com/Jaws-Hidden-Epidemic-Sandra-Kahn/dp/1503604136/ref=tmm_hrd_swatch_0?_encoding=UTF8&qid=1685135054&sr=1-1

Leal, R.B., Gomes, M.C., Granville-Garcia, A.F., Goes, P.S.A., & de Menezes, V.A. (2016). Impact of Breathing Patterns on the Quality of Life of 9- to 10-year-old Schoolchildren. American Journal of Rhinology & Allergy, 30(5):e147-e152.  https://doi.org/10.2500/ajra.2016.30.4363

Lee, Y.C., Lu, C.T., Cheng, W.N., & Li, H.Y. (2022).The Impact of Mouth-Taping in Mouth-Breathers with Mild Obstructive Sleep Apnea: A Preliminary Study. Healthcare (Basel), 10(9), 1755. https://doi.org/10.3390/healthcare10091755

Leichsenring, F., Steinert, C., Rabung, S. and Ioannidis, J.P.A. (2022), The efficacy of psychotherapies and pharmacotherapies for mental disorders in adults: an umbrella review and meta-analytic evaluation of recent meta-analyses. World Psychiatry, 21: 133-145. https://doi.org/10.1002/wps.20941

Lundberg, J.O. &  Weitzberg, E. (1999). Nasal nitric oxide in man. Thorax. (10):947-52. https://doi.org/10.1136/thx.54.10.947

McKeown, P. (2021). The Breathing Cure: Develop New Habits for a Healthier, Happier, and Longer Life.  Boca Raton, Fl “Humanix Books. https://www.amazon.com/BREATHING-CURE-Develop-Healthier-Happier/dp/1630061972/

Nestor, J. (2020). Breath: The New Science of a Lost Art. New York: Riverhead Books. https://www.amazon.com/Breath/dp/0593191358/ref=tmm_pap_swatch_0?_encoding=UTF8&qid=1686191995&sr=8-1

Puigbò, P., Leino, L. I., Rainio, M. J., Saikkonen, K., Saloniemi, I., & Helander, M. (2022). Does Glyphosate Affect the Human Microbiota?. Life, 12(5), 707. https://doi.org/10.3390/life12050707

Sagiv, S.K., Kogut, K., Harley, K., Bradman, A., Morga, N., & Eskenazi, B. (2021). Gestational Exposure to Organophosphate Pesticides and Longitudinally Assessed Behaviors Related to Attention-Deficit/Hyperactivity Disorder and Executive Function, American Journal of Epidemiology, 190(11), 2420–2431.  https://doi.org/10.1093/aje/kwab173

Srour, B. et al. (2019).  Ultra-processed food intake and risk of cardiovascular disease: prospective cohort study (NutriNet-Santé).BMJ, 365.  https://doi.org/10.1136/bmj.l1451 

Tano, B. (2016). The Layman’s Guide to Integrative Immunity. Integrative Medical Press. https://www.amazon.com/Laymans-Guide-Integrative-Immunity-Discover/dp/0983419299/_

Tourne, L.P. (1990). The long face syndrome and impairment of the nasopharyngeal airway. Angle Orthod, 60(3):167-76. https://doi.org/10.1043/0003

Trabalon, M. & Schaal, B. (2012). It takes a mouth to eat and a nose to breathe: abnormal oral respiration affects neonates’ oral competence and systemic adaptation. Int J Pediatr, 207605. https://doi.org/10.1155/2012/207605

van Bon, M.J., Zielhuis, G.A., Rach, G.H., & van den Broek, P. (1989). Otitis media with effusion and habitual mouth breathing in Dutch preschool children. Int J Pediatr Otorhinolaryngol, (2), 119-25. https://doi.org/10.1016/0165-5876(89)90087-6

Healing from vulvodynia

Posted: May 4, 2023 | Author: | Filed under: behavior, biofeedback, Breathing/respiration, emotions, healing, health, Pain/discomfort, relaxation, self-healing, Uncategorized | Tags: , , , , | 1 Comment

Pamela Jertberg and Erik Peper

Adapted from: Jertberg, P. & Peper, E. (2023). The healing of vulvodynia from the client’s perspective. Biofeedback, 51 (1), 18–21.  https://doi.org/10.5298/1081-5937-51.01.02

This introspective report describes how a young woman who experienced a year-long struggle with vulvodynia, or vulvar vestibulitis, regained her health through biofeedback training and continues to be symptom-free 7 years after the intervention. This perspective may offer insight into factors that promote health and healing and provide an approach to reduce symptoms and promote health. The methodology of this case was described previously by Peper et al. (2015).

The Client’s Experience

I have been a healthy young woman my whole life. Growing up in a loving, dedicated family, I always ate home-cooked meals, went to bed at a reasonable time, and got plenty of exercise by playing with my family members and friends. I never once thought that at age 23 I might be at risk of undergoing vulvar surgery. There are many factors that contributed to the genesis of my vulvar pain, and many other factors that worsened this pain. Traditional medicine did not help me, and I did not find relief until I met my biofeedback practitioner, who taught me biofeedback. Through the many strategies I learned, such as visualization, diaphragmatic breathing techniques, diet tips, and skills to reframe my thoughts, I finally began to feel relief and hope. Practicing all these elements every day helped me overcome my physical pain and enjoy a normal life once again. Today, I do not have any vulvar discomfort. I am so grateful to my biofeedback practitioner for the many skills he taught me. I can enjoy my daily activities once again without experiencing pain. I have been given a second chance at loving life, and now I have learned the techniques that will help me sustain a more balanced path for the rest of my life. Seven years later, I am healthy and have no symptoms.

Triggers for Illness

Not Having a Positive Relationship with the Doctor

The first factor that aggravated my pain was having a doctor with whom I did not have a good relationship. Although the vulvar specialist I was referred to had treated hundreds of women with vulvar vestibulitis, his methods were very traditional: medicine, low oxalate diet, ointments, and surgery. Whenever I left his office, I would cry and feel like surgery was the only option. Vaginal surgery at 23 was one of the scariest and most unexpected thoughts my brain had ever considered. The doctor never thought of the impact that his words and treatment would have on my mental state.

Depression

Being depressed also triggered more pain. Whenever I would have feelings of hopelessness and create irrational beliefs in my mind (“I will never get better,” “I will never have sex again,” “I am not a woman anymore”), my physical pain would increase. Having depression only triggered more depression and pain, and this became a vicious cycle. The depression deeply affected my relationships with my boyfriend, friends, and family and my performance in my college classes.

Being Sedentary

Being sedentary and not exercising also increased my pain. At first, I believed that the mere act of sitting down hurt me due to the direct pressure on the area, but after a few months I came to realize that it was inactivity itself that triggered pain. Whenever I would sit for too long writing a paper or I would stay home all day because of my depression, my pain would increase, perhaps because I was inhibiting circulation. Still, when I am inactive most of the day, I feel lethargic and bloated. When I exercise, the pain goes away 100%. Exercise is almost magical.

Stress

Stress is the worst trigger for pain. Throughout my life, I always strived to be perfect in every way, meaning I was stressed about the way I looked, performed in school, drove, etc. Through the sessions with my biofeedback practitioner, I learned that my body was in a state of perpetual stress and tightness, which induced pain in certain areas. My body’s way of releasing such tension was to send pain signals to my vulvar area, perhaps because of a yeast infection a couple of months back. Still, if I become very stressed, I will feel pain or tightness in certain parts of my body, but now I have strategies for performing proper stress-relieving techniques.

Processed Foods

Junk food affects me instantly. When I eat processed foods for a week straight, I feel groggy, bloated, lethargic, and in pain. Processed sugar, white flour, and salt are a few of the foods that make the pain increase. I used to love sugar, so I would enjoy the occasional milkshake and cheeseburger and feel mostly okay. However, in times of stress it became crucial for me to learn to refrain from any junk food, because it would worsen my vulvar pain and increase my overall stress levels.

Menstruation

Menstruation is unavoidable, and unfortunately it would always worsen my vulvar pain. Right about the time of my period, my sensitivity and pain would massively increase. Sometimes as my pain would increase incredibly, I would question myself: “What am I doing wrong?” Then, I would remember: “Oh yes, I am getting my period in a few days.” The whole area became very sensitive and would get irritated easily. It became imperative to listen to my body and nurture myself especially around that time of the month.

Triggers for Healing

A Good Doctor

Just as I learned which factors triggered the pain, I also learned how to reduce it. The most important factor that helped me find true relief was meeting a good health professional (which could be a healer, nurse, or professor). The first time I met my biofeedback practitioner and told him about my issues, he really listened, gave me positive feedback, and even made jokes with me. To this day we still have a friendship, which has really aided me in getting better. In contrast to the vulvar specialist, I would leave the biofeedback practitioner’s office feeling powerful, able to defeat vulvodynia, and truly happy. Just having this support from a professional (or a friend, boyfriend, or relative) can make all the difference in the world. I don’t know where I would be right now if I hadn’t worked with him.

Positive Thoughts and Beliefs

Along with having a good support group, having positive thoughts and believing in a positive result helped me greatly. When I actually set my mind to feel “happy” and to believe that I was getting better, I began to really heal. After months of being depressed and feeling incomplete, when I began to practice mantras such as “I am healing,” “I am healthy,” and “I am happy,” my pain began to go away, and I was able to reclaim my life.

Journaling

One of the ways in which “happiness” became easier to achieve was to journal every day. I would write everything: from my secrets to what I ate, my pain levels, my goals for the day, and my symptoms. Writing down everything and knowing that no one would ever read it but me gave me relief, and my journal became my confidante. I still journal every day, and if I forget to write, the next day I will write twice as much. Now that writing has become a habit and a hobby, it is hard to imagine my life without that level of introspection.

Meditation

Although I would do yoga often, I would never sit and meditate. I began to use Dr. Peper’s guided meditations and Dr. Kabat-Zinn’s CD (Kabat-Zinn, 2006; Peper et al., 2002). The combination of these meditation techniques, whether on different days or on the same day, helped me focus on my breathing and relax my muscles and mind. Today, I meditate at least 20 min each day, and I feel that it helps me see life through a more willing and patient perspective. In addition, through meditation and deep breathing I have learned to control my pain levels, concentration, and awareness.

Imagery and Visualization

Imagery is a powerful tool that allowed me to heal faster. My biofeedback practitioner instructed me to visualize how I wanted to feel and look. In addition, he suggested that I draw and color how I was feeling at any given moment, my imagined healing process, and how I would look and feel after the healing process had traveled throughout my body (Peper et al., 2022). It is still amazing to me how much imagery helped me. Even visualizing here and there throughout the day helped. Now I envision how I want to feel as a healthy woman, I take a deep breath, and as a I breathe out I let my imagined healing process go through my body into all my tight areas along with the exhalation.

Biofeedback

Biofeedback is the single strategy that helped me the most. During my first session with my biofeedback practitioner, he pointed out that my muscles were always contracted and stressed and that I was not breathing diaphragmatically. As I learned how to take deep belly breaths, I began to feel the tight areas in my body loosen up. I started to practice controlled breathing 20 min every day. Through biofeedback, my body and muscles became more relaxed, promoting circulation and ultimately reducing the vulvar pain.

Regular Exercise and Yoga

Exercising daily decreased my pain and improved the quality of my life greatly. When I first started experiencing significant vulvar pain, I stopped exercising because I felt that movement would aggravate the pain. To my surprise, the opposite was true. Being sedentary increased the feelings of discomfort, whereas exercising released the tension. The exercise I found most helpful was yoga because it is meditation in movement. I became so focused on my breathing and the poses that my brain did not have time to think about anything else. After attending every yoga class, I felt like I could take on anything. Swimming, Pilates, and gentle cardiovascular exercises have also helped me greatly in reducing stress and feeling great.

Sex

Although sex was impossible for almost a year due to the pain, it became possible and even enjoyable after implementing other relaxation strategies. When I first reintroduced sex back into my life, my partner at the time and I would go gently and stop if it hurt my vulvar area at all. Today, sex again is joyful. Being able to engage in intercourse has boosted my self-esteem and helped me feel sexy again, which empowers me to keep practicing the relaxation techniques.

Listening to the Mind-Body Connection

The mind-body connection is present in all of us, but I am fortunate to have a very strong connection. My thoughts influence my body almost instantly, which is why when I would get depressed my pain would increase, and when I would see my biofeedback practitioner or believe in a good outcome, my pain would decrease. Being aware of this connection is crucial because it can help me or hurt me greatly. After a few months of practicing the relaxation strategies, I saw a different gynecologist and one dermatologist. Both professionals said that there was nothing wrong with my vulvar area—that maybe I just felt some irritation due to the medicines I had previously taken and my current stress. They said that there was no way I needed surgery. When I heard these opinions, I began to feel instantly better—thus proving that my thoughts (and even others’ thoughts) affect my body in significant ways.

Although today I am 100% better, I still experience pain and tightness in my body when I experience the “illness factors” I mentioned above. I still have to remember that feeling healthy and good is a process, not a result, and that even if I feel better one day that does not mean I can stop all my new healthy habits. To completely cure vulvodynia, I needed to change my life habits, perspective, and attitude toward the illness and life. I needed to make significant changes, and now my biggest challenge is to stick to those changes. Biofeedback, imagery, meditation, good food, and exercise are not just treatments that I begin and end on a certain day, but rather they have become essential components of my life forever.

My life with vulvodynia was ultimately a journey of introspection, decision making, and life-changing habits. I struggled with vulvar pain for over a year, and during that year I experienced severe symptoms, depression, and the loss of several friendships and relationships. I felt old, hopeless, useless, and powerless. When I began to incorporate biofeedback, relaxation techniques, journaling, visualization, a proper diet, and regular exercise, life took a turn for the better. Not only did my vulvar pain begin to decrease, but the quality of my overall life improved and I regained the self-confidence I had lost. I became happy, hopeful, and proactive. Even though I practiced the relaxation strategies every day, the pain did not go away in a day or even a month. It took me several months of diligent practice to truly heal my vulvar pain. Even today, such practices have carried on to all areas of my life, and now there is not a day when I do not meditate, even for 5 min.

As paradoxical as it may seem, vulvodynia was a blessing in disguise. I believe that vulvodynia was my body’s way of signaling to me that many areas of my life were in perpetual stress: my pelvic floor, my thoracic breathing, my romantic relationship at the time, etc. When I learned to let go and truly embrace my life, I began to feel relief. I became less irritable and more patient and understanding, with both my body and the outside world. The best advice I can give a woman with vulvar symptoms or any person with otherwise inexplicable chronic pain is to apply the strategies that work for you and stick to them every day—even on the days when you want to go astray. When I started to focus on what my body needed to be nurtured and to live my life and do the things I truly wanted to do, I became free. Today, I live in a way that allows me to find peace, serenity, pride, and fun. I live exactly the way I want to, and I find the time to follow my passions. Vulvodynia, or any kind of chronic pain, does not define who we are. We define who we are.

Conclusion

This introspective account of the client’s personal experience with biofeedback suggests that healing is multidimensional. We suggest that practitioners use a holistic approach, which can provide hope and relief to clients who suffer from vulvodynia or other disorders that are often misunderstood and underreported.

Useful blogs

Resolving pelvic floor pain-A case report
Enjoy sex: Breathe away the pain*
Hope for menstrual cramps (dysmenorrhea) with breathing
Breathing reduces acid reflux and dysmenorrhea discomfort
Healing irritable bowel syndrome with diaphragmatic breathing*

References

Kabat-Zinn, J. (2006). Coming to our senses: Healing ourselves and the world through mindfulness. Hachette Books

Peper, E., Cosby, J. & Almendras, M. (2022). Healing chronic back pain. NeuroRegulation, 9(3), 164–172.  https://doi.org/10.15540/nr.9.3.164

Peper, E., Gibney, K.H, & Holt, C.F. (2002. Make health happen: Training yourself to create wellness. Kendall/Hunt.

Peper, E. Martinex, Aranda, P. & Moss, D. (2015). Vulvodynia treated successfully with breathing biofeedback and integrated stress reduction: A case report. Biofeedback, 43(2), 103–109. https://doi.org/10.5298/1081-5937-43.2.04

Hope for menstrual cramps (dysmenorrhea) with breathing

Posted: April 22, 2023 | Author: | Filed under: behavior, biofeedback, Breathing/respiration, healing, health, meditation, Pain/discomfort, posture, relaxation, self-healing, stress management, Uncategorized | Tags: , , , , | 7 Comments

Adapted from: Peper, E., Chen, S., Heinz, N., & Harvey, R. (2023). Hope for menstrual cramps (dysmenorrhea) with breathing. Biofeedback, 51(2), 44–51. https://doi.org/10.5298/1081-5937-51.2.04; Republished in Townsend E-Letter – 18 November, 2023 https://www.townsendletter.com/e-letter-22-breath-affects-stress-and-menstrual-cramps/

“I have always had extremely painful periods. They would get so painful that I would have to call in sick and take some time off from school. I have been to many doctors and medical professionals, and they told me there is nothing I could do. I am currently on birth control, and I still get some relief from the menstrual pain, but it would mess up my moods. I tried to do the diaphragmatic breathing so that I would be able to continue my life as a normal woman. And to my surprise it worked. I was simply blown away with how well it works. I have almost no menstrual pain, and I wouldn’t bloat so much after the diaphragmatic breathing.” -22 year old student

Each semester numerous students report that their cramps and dysmenorrhea symptoms decrease or disappear during the semester when they implement the relaxation and breathing practices that are taught in the semester long Holistic Health class.  Given that so many young women suffer from dysmenorrhea, many young women could benefit by using this integrated approach as the first self-care intervention before relying on pain reducing medications or hormones to reduce pain or inhibit menstruation. Another 28-year-old student reported:

“Historically, my menstrual cramps have always required ibuprofen to avoid becoming distracting. After this class, I started using diaphragmatic breath after pain started for some relief. True benefit came when I started breathing at the first sign of discomfort. I have not had to use any pain medication since incorporating diaphragmatic breath work.” 

This report describes students practicing self-regulation and effortless breathing to reduce stress symptoms, explores possible mechanisms of action, and suggests a protocol for reducing symptoms of menstrual cramps. Watch the short video how diaphragmatic breathing eliminated recurrent severe dysmenorrhea (pain and discomfort associated with menstruation).  

Background: What is dysmenorrhea?

Dysmenorrhea is one of the most common conditions experienced by women during menstruation and affects more than half of all women who menstruate (Armour et al., 2019).  Most commonly dysmenorrhea is defined by painful cramps in the lower abdomen often accompanied by pelvic pain that starts either a couple days before or at the start of menses. Symptoms also increase with stress (Wang et al., 2003) with pain symptoms usually decreasing in severity as women get older and, after pregnancy.

Economic cost of dysmenorrhea

Dysmenorrhea can significantly interfere with a women’s ability to be productive in their occupation and/or their education. It is “one of the leading causes of absenteeism from school or work, translating to a loss of 600 million hours per year, with an annual loss of $2 billion in the United States” (Itani et al, 2022).  For students, dysmenorrhea has a substantial detrimental influence on academic achievement in high school and college (Thakur & Pathania, 2022). Despite the frequent occurrence and negative impact in women’s lives, many young women struggle without seeking or having access to medical advice or, without exploring non-pharmacological self-care approaches (Itani et al, 2022).

Treatment

The most common pharmacological treatments for dysmenorrhea are nonsteroidal anti-inflammatory drugs (NSAIDs) (e.g., Ibuprofen, Aspirin, and Naproxen Sodium) along with hormonal contraceptives. NSAIDs act by preventing the action of cyclooxygenase which prevents the production of prostaglandins.  Itani et al (2022) suggested that prostaglandin production mechanisms may be responsible for the disorder. Hormonal contraceptives also prevent the production of prostaglandins by suppressing ovulation and endometrial proliferation.

The pharmacological approach is predominantly based upon the model that increased discomfort appears to be due to an increase in intrauterine secretion of prostaglandins F2α and E2 that may be responsible for the pain that defines this condition (Itani et al, 2022). Pharmaceuticals which influence the presence of prostaglandins do not cure the cause but mainly treat the symptoms. 

Treatment with medications has drawbacks.  For example, NSAIDs are associated with adverse gastrointestinal and neurological effects and also are not effective in preventing pain in everyone (Vonkeman & van de Laar, 2010). Hormonal contraceptives also have the possibility of adverse side effects (ASPH, 2023). Acetaminophen is another commonly used treatment; however, it is less effective than other NSAID treatments.

Self-regulation strategies to reduce stress and influence dysmenorrhea

Common non-pharmacological treatments include topical heat application and exercise. Both non-medication approaches can be effective in reducing the severity of pain. According to Itani et al. (2022), the success of integrative holistic health treatments can be attributed to “several mechanisms, including increasing pelvic blood supply, inhibiting uterine contractions, stimulating the release of endorphins and serotonin, and altering the ability to receive and perceive pain signals.”

Although less commonly used, self-regulation strategies can significantly reduce stress levels associated menstrual discomfort as well as reduce symptoms. More importantly, they do not have adverse side effects, but the effectiveness of the intervention varies depending on the individual.

  • Autogenic Training (AT), is a hundred year old treatment approach developed by the German psychiatrist Johannes Heinrich Schultz that involves three 15 minute daily practice of sessions, resulted in a 40 to 70 percent decrease of symptoms in patient suffering from primary and secondary dysmenorrhea (Luthe & Schultz, 1969). In a well- controlled PhD dissertation, Heczey (1978) compared autogenic training taught individually, autogenic training taught in a group, autogenic training plus vaginal temperature training and a no treatment control in a randomized controlled study.   All treatment groups except the control group reported a decrease in symptoms and the most success was with the combined autogenic training and vaginal temperature training in which the subjects’ vaginal temperature increased by .27 F degrees.
  • Progressive muscle relaxation developed by Edmund Jacobson in the 1920s and imagery are effective treatments for dysmenorrhea (Aldinda et al., 2022; Chesney & Tasto, 1975; Çelik, 2021; Jacobson, 1938; Proctor et al., 2007).
  • Rhythmic abdominal massage as compared to non-treatment reduces dysmenorrhea symptoms (Suryantini, 2022; Vagedes et al., 2019):
  • Biofeedback strategies such as frontalis electromyography feedback (EMG) and peripheral temperature training (Hart, Mathisen, & Prater, 1981); trapezius EMG training (Balick et al, 1982); lower abdominal EMG feedback training and relaxation (Bennink, Hulst, & Benthem, 1982); and integrated temperature feedback and autogenic training (Dietvorts & Osborne, 1978) all successfully reduced the symptoms of dysmenorrhea.
  • Breathing relaxation for 5 to 30 minutes resulted in a decrease in pain or the pain totally disappeared in adolescents (Hidayatunnafiah et al., 2022). While slow deep breathing in combination with abdominal massage is more effective than applying hot compresses (Ariani et al., 2020). Slow pranayama (Nadi Shodhan) breathing the quality of life and pain scores improved as  compared to fast pranayama (Kapalbhati) breathing and improved  quality of life and reduces absenteeism and stress levels (Ganesh et al. 2015). When students are taught slow diaphragmatic breathing, many report a reduction in symptoms compared to the controls (Bier et al., 2005). 

Observations from Integrated stress management  program

This study reports on changes in dysmenorrhea symptoms by students enrolled in a University Holistic Health class that included homework assignment for practicing stress awareness, dynamic relaxation, and breathing with imagery.

Respondents: 32 college women, average age 24.0 years (S.D. 4.5 years)

Procedure: Students were enrolled in a three-unit class in which they were assigned daily home practices which changed each week as described in the book, Make Health Happen (Peper, Gibney & Holt, 2002).  The first five weeks consisted of the following sequence: Week 1 focused on monitoring one’s reactions to stressor; week 2 consisted of daily practice for 30 minutes of a modified progressive relaxation and becoming aware of bracing and reducing the bracing during the day; Week 3 consisted of practicing slow diaphragmatic breathing for 30 minutes a day and during the day becoming aware of either breath holding or shallow chest breath and then use that awareness as cue to shift to lower slower diaphragmatic breathing; week 4 focused on evoking a memory of wholeness and relaxing; and week 5 focused on learning peripheral hand warming.

During the class, students observed lectures about stress and holistic health and met in small groups to discuss their self-regulation experiences. During the class discussion, some women discussed postures and practices that were beneficial when experiencing menstrual discomfort, such as breathing slowly while lying on their back, focusing on slow abdominal awareness in which their abdomen expanded during inhalation and contracted during exhalation.  While exhaling they focused on imagining a flow of air initially going through their arms and then through their abdomen, down their legs and out their feet. This kinesthetic feeling was enhanced by first massaging down the arm while exhaling and then massaging down their abdomen and down their thighs when exhaling. In most cases, the women also experienced that their hands and feet warmed.  In addition, they were asked to shift to slower diaphragmatic breathing whenever they observed themselves gasping, shallow breathing or holding their breath.  After five weeks, the students filled out a short assessment questionnaire in which they rated the change in dysmenorrhea symptoms since the beginning of the class.

Results.

About two-thirds of all respondents reported a decrease in overall discomfort symptoms.  In addition to any ‘treatment as usual’ (TAU) strategies already being used (e.g. medications or other treatments such as NSAIDs or birth control pills), 91% (20 out 22 women) who reported experiencing dysmenorrhea reported a decrease in symptoms when they practiced the self-regulation and diaphragmatic breathing techniques as shown in Figure 1.

Figure 1. Self-report in dysmenorrhea symptoms after 5 weeks.

Discussion

Many students reported that their symptoms were significantly reduced and they could be more productive.  Generally, the more they practiced the relaxation and breathing self-regulation skills, the more they experienced a decrease in symptoms. The limitation of this report is that it is an observational study; however, the findings are similar to those reported by earlier self-care and biofeedback approaches. This suggests that women should be taught the following simple self-regulation strategies as the first intervention to prevent and when they experience dysmenorrhea symptoms.

Why would breathing reduce dysmenorrhea?

Many women respond by ‘curling up’ a natural protective defense response when they experience symptoms. This protective posture increases abdominal and pelvic muscle tension, inhibits lymph and blood flow circulation, increases shallow breathing rate, and decreases heart rate variability.  Intentionally relaxing the abdomen with slow lower breathing when lying down with the legs extended is often the first step in reducing discomfort.

By focusing on diaphragmatic breathing with relaxing imagery, it is possible to restore abdominal expansion during inhalation and slight constriction during exhalation. This dynamic breathing while lying supine would enhance abdominal blood and lymph circulation as well as muscle relaxation (Peper et al., 2016).  While practicing, participants were asked to wear looser clothing that did not constrict the waist to allow their abdomen to expand during inhalation; since, waist constriction by clothing (designer jean syndrome) interferes with abdominal expansion.  Allowing the abdomen to fully extend also increased acceptance of self, that it was okay to let the abdomen expand instead of holding it in protectively. The symptoms were reduced most likley by a combination of the following factors.

  • Abdominal movement is facilitated during the breathing cycle. This means reducing the factors that prevent the abdomen expanding during inhalation or constricting during exhalation (Peper et al., 2016).
    • Eliminate‘Designer jean syndrome’ (the modern girdle). Increase the expansion of your abdomen by loosening the waist belt, tight pants or slimming underwear (MacHose & Peper, 1991).
    • Accept yourself as you are. Allow your stomach to expand without pulling it in.
    • Free up learned disuse:  Allow the abdomen to expand and constrict instead of inhibiting movement to avoid pain that occurred following a prior abdominal injury/surgery (e.g., hernia surgery, appendectomy, or cesarean operation), abdominal pain (e.g., irritable bowel syndrome, recurrent abdominal pain, ulcers, or acid reflux), pelvic floor pain (e.g., pelvic floor pain, pelvic girdle pain, vulvodynia, or sexual abuse).
  • The ‘defense response’ is reduced. Many students described that they often would curl up in a protective defense posture when experiencing menstrual cramps.  This protective defense posture would maintain pelvic floor muscle contractions and inhibit blood and lymph flow in the abdomen, increase shallow rapid thoracic breathing and decrease pCO2 which would increase vasoconstriction and muscle constriction (Peper et al., 2015; Peper et al., 2016). By having the participant lie relaxed in a supine position with their legs extended while practicing slow abdominal breathing, the pelvic floor and abdominal wall muscles can relax and thereby  increase abdominal blood and lymph circulation and  parasympathetic activity. The posture of lying down implies feeling safe which is a state that facilitates healing.
  • The pain/fear cycle is interrupted.  The dysmenorrhea symptoms may trigger more symptoms because the person anticipates and reacts to the discomfort. The breathing and especially the kinesthetic imagery where the attention goes from the abdomen and area of discomfort to down the legs and out the feet acts as a distraction technique (not focusing on the discomfort).  
  • Support sympathetic-parasympathetic balance.  The slow breathing and kinesthetic imagery usually increases heart rate variability and hand and feet temperature and supports sympathetic parasympathetic balance.
  • Interrupt the classical conditioned response of the defense reaction.  For some young girls, the first menstruation occurred unexpectedly.  All of a sudden, they bled from down below without any understanding of what is going on which could be traumatic.  For some this could be a defense reaction and a single trial condition response (somatic cues of the beginning of menstruation triggers the defense reaction).  Thus, when the girl later experiences the initial sensations of menstruation, the automatic conditioned response causes her to tense and curl up which would amplify the discomfort. Informal interviews with women suggests that those who experienced their first menstruation experience as shameful, unexpected, or traumatic (“I thought I was dying”) thereafter framed their menstruation negatively. They also tended to report significantly more symptoms than those women who reported experiencing their first menstruation positively as a conformation that they have now entered womanhood.

How to integrate self-care to reduce dysmenorrhea     

Be sure to consult your healthcare provider to rule out treatable underlying conditions before implementing learning effortless diaphragmatic breathing.

  • Allow the abdomen to expand during inhalation and become smaller during exhalation. This often means, loosen belt and waist constriction, acceptance of allowing the stomach to be larger and reversing learned disuse and protective response caused by stress.
  • Master diaphragmatic breathing (see: Peper & Tibbetts, 1994 and the blogs listed at the end of the article).
  • Practice slow effortless diaphragmatic breathing lying down with warm water bottle on stomach in a place that feels safe.
  • Include kinesthetic imagery as you breathe at about 6 breaths per minute (e.g. slowly inhale for 4 or 5 seconds and then exhale for 5 or 6 seconds, exhaling slightly longer than inhaling). Imaging that when you exhale you can sense healing energy flow through your abdomen, down the legs and out the feet.
  • If possible, integrate actual touch with the exhalation can provide added benefit.  Have a partner first stroke or massage down the arms from the shoulder to your fingertips as you exhale and, then on during next exhalation stroke gently from your abdomen down your legs and feet. Stroke in rhythm the exhalation.
  • Exhale slowly and shift to slow and soft diaphragmatic breathing each time you become aware of neck and shoulder tension, breath holding, shallow breathing, or anticipating stressful situations. At the same time imagine /sense when exhaling a streaming going through the abdomen and out the feet when exhaling.   Do this many times during the day.
  • Practice and apply general stress reduction skills into daily life since stress can increase symptoms. Anticipate when stressful event could occur and implement stress reducing strategies.   
  • Be respectful of the biological changes that are part of the menstrual cycle. In some cases adjust your pace and slow down a bit during the week of the menstrual cycle; since, the body needs time to rest and regenerate. Be sure to get adequate amount of rest, hydration, and nutrition to optimize health. 
  • Use self-healing imagery and language to transform negative association with menstruation to positive associations (e.g., “curse” to confirmation “I am healthy”).

Conclusion

There are many ways to alleviate dysmenorrhea.  Women can find ways to anticipate and empower themselves by practicing stress reduction, wearing more comfortable clothing, using heat compression, practicing daily diaphragmatic breathing techniques, visualizing relaxed muscles, and positive perception towards menstrual cycles to reduce the symptoms of dysmenorrhea. These self-regulation methods should be taught as a first level intervention to all young women starting in middle and junior high school so that they are better prepared for the changes that occur as they age. 

“I have been practicing the breathing techniques for two weeks prior and I also noticed my muscles, in general, are more relaxed.  Of course, I also avoided the skinny jeans that I like to wear and it definitely helped.   

I have experienced a 90% improvement from my normal discomfort.  I was still tired  – and needed more rest and sleep but haven’t experienced any “terrible” physical discomfort.  Still occasionally had some sharp pains or bloating but minor discomfort, unlike some days when I am bedridden and unable to move for half a day. –  and this was a very positive experience for me “ — Singing Chen (Chen, 2023).

Listen to the expanded podcast created from this blogpost by Google Notebook LM.

Useful blogs to learn diaphragmatic breathing

Healing irritable bowel syndrome with diaphragmatic breathing*
Breathing reduces acid reflux and dysmenorrhea discomfort
Enjoy sex: Breathe away the pain*

References

Aldinda, T. W., Sumarni, S., Mulyantoro, D. K., & Azam, M. (2022). Progressive muscle relaxation application (PURE App) for dysmenorrhea.  Medisains Jurnal IlmiahLlmiah LLmu-LLmu Keshatan, 20(2), 52-57.  https://doi.org/10.30595/medisains.v20i2.14351

Ariani, D., Hartiningsih, S.S.,  Sabarudin, U.  Dane, S. (2020). The effectiveness of combination effleurage massage and slow deep breathing technique to decrease menstrual pain in university students. Journal of Research in Medical and Dental Science, 8(3), 79-84. https://www.jrmds.in/articles/the-effectiveness-of-combination-effleurage-massage-and-slow-deep-breathing-technique-to-decrease-menstrual-pain-in-university-stu-53607.html

Armour, M., Parry, K., Manohar, N., Holmes, K., Ferfolja, T., Curry, C., MacMillan, F., & Smith, C. A. (2019). The prevalence and academic impact of dysmenorrhea in 21,573 young women: a systematic review and meta-analysis. Journal of women’s health, 28(8), 1161-1171.https://doi.org/10.1089/jwh.2018.7615

ASPH. (2023). Estrogen and Progestin (Oral Contraceptives). MedlinePlus. Assessed March 3, 2023. https://medlineplus.gov/druginfo/meds/a601050.html

Balick, L., Elfner, L., May. J., Moore, J.D. (1982). Biofeedback treatment of dysmenorrhea. Biofeedback Self Regul, 7(4), 499-520. https://doi.org/10.1007/BF00998890

Bennink, C.D., Hulst, L.L. & Benthem, J.A. (1982). The effects of EMG biofeedback and relaxation training on primary dysmenorrhea. J Behav Med, 5(3), 329-341.https://doi.org/10.1007/BF00846160

Bier, M., Kazarian, D. & Peper, E. (2005). Reducing PMS through biofeedback and breathing. Poster presentation at the 36th Annual Meeting of the Association for Applied Psychophysiology and Biofeedback. Abstract published in: Applied Psychophysiology and Biofeedback. 30 (4), 411-412.

Çelik, A.S. & Apay, S.E.  (2021). Effect of progressive relaxation exercises on primary dysmenorrhea in Turkish students: A randomized prospective controlled trial. Complement Ther Clin Pract, Feb 42,101280. https://doi.org/10.1016/j.ctcp.2020.101280

Chen, S. (2023). Diaphragmatic breathing reduces dysmenorrhea symptoms-a testimonial. YouTube. Accessed March 3, 2023. https://youtu.be/E45iGymVe3U

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De Sanctis, V., Soliman, A. T., Daar, S., Di Maio, S., Elalaily, R., Fiscina, B., & Kattamis, C. (2020). Prevalence, attitude and practice of self-medication among adolescents and the paradigm of dysmenorrhea self-care management in different countries. Acta Bio Medica: Atenei Parmensis, 91(1), 182. https://doi.org/10.23750/abm.v91i1.9242

Dietvorst, T.F. & Osborne, D. (1978). Biofeedback-Assisted Relaxation Training

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Ganesh, B.R., Donde, M.P., & Hegde, A.R. (2015). Comparative study on effect of slow and fast phased pranayama on quality of life and pain in physiotherapy girls with primary dysmenorrhea: Randomize clinical trial. International Journal of Physiotherapy and Research, 3(2), 960-965. https://doi.org/10.16965/ijpr.2015.115

Hart, A.D., Mathisen, K.S. & Prater, J.S. A comparison of skin temperature and EMG training for primary dysmenorrhea. Biofeedback and Self-Regulation 6, 367–373 (1981). https://doi.org/10.1007/BF01000661

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Hidayatunnafiah, F., Mualifah, L., Moebari, M., & Iswantiningsih, E. (2022). The Effect of Relaxation Techniques in Reducing Dysmenorrhea in Adolescents. The International Virtual Conference on Nursing. in The International Virtual Conference on Nursing, KnE Life Sciences, 473–480. https://doi.org/10.18502/kls.v7i2.10344

Itani, R., Soubra, L., Karout, S., Rahme, D., Karout, L., & Khojah, H.M.J. (2022). Primary Dysmenorrhea: Pathophysiology, Diagnosis, and Treatment Updates. Korean J Fam Med, 43(2), 101-108. https://doi.org/10.4082/kjfm.21.0103

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Iacovides, S.,  Avidon,I, & Baker, F.C. (2015).What we know about primary dysmenorrhea today: a critical review, Human Reproduction Update, 21(6), 762–778. https://doi.org/10.1093/humupd/dmv039

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Peper, E., Booiman, A., Lin, I-M, Harvey, R., & Mitose, J. (2016). Abdominal SEMG Feedback for Diaphragmatic Breathing: A Methodological Note. Biofeedback. 44(1), 42-49. https://doi.org/10.5298/1081-5937-44.1.03

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

Peper, E., Gilbert, C.D., Harvey, R. & Lin, I-M. (2015). Did you ask about abdominal surgery or injury? A learned disuse risk factor for breathing dysfunction. Biofeedback. 34(4), 173-179.  https://doi.org/10.5298/1081-5937-43.4.06

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Proctor, M.L, Murphy, P.A., Pattison, H.M., Suckling, J., & Farquhar, C.M. (2007). Behavioural interventions for primary and secondary dysmenorrhoea. Cochrane Database Syst Rev, (3):CD002248. https://doi.org/10.1002/14651858.CD002248.pub3

Suryantini, N. P. (2022). Effleurage Massage: Alternative Non-Pharmacological Therapy in Decreasing Dysmenorrhea Pain. Women, Midwives and Midwifery, 2(3), 41-50. https://wmmjournal.org/index.php/wmm/article/view/71/45

Thakur, P. & Pathania, A.R. (2022). Relief of dysmenorrhea – A review of different types of pharmacological and non-pharmacological treatments. MaterialsToday: Proceedings.18, Part 5, 1157-1162. https://doi.org/10.1016/j.matpr.2021.08.207

Vagedes, J., Fazeli, A., Boening, A., Helmert, E., Berger, B. & Martin, D. (2019). Efficacy of rhythmical massage in comparison to heart rate variability biofeedback in patients with dysmenorrhea—A randomized, controlled trial. Complementary Therapies in Medicine, 42, 438-444.  https://doi.org/10.1016/j.ctim.2018.11.009

Vonkeman, H.E. & van de Laar, M,A. (2010). Nonsteroidal anti-inflammatory drugs: adverse effects and their prevention, Semin Arthritis Rheum, 39(4), 294-312. https://doi.org/10.1016/j.semarthrit.2008.08.001

Wang, L., Wand, X., Wang, W., Chen, C. Ronnennberg, A.G., Guang, W. Huang, A. Fang, Z. Zang, T., Wang, L. & Xu, X. (2003).Stress and dysmenorrhoea: a population based prospective study. Occupation and Environmental Medicine, 61(12). http://dx.doi.org/10.1136/oem.2003.012302

Compassion supports healing: Case report how a “bad eye” became an “amazing eye”*

Posted: April 11, 2023 | Author: | Filed under: behavior, cognitive behavior therapy, healing, health, mindfulness, Pain/discomfort, self-healing, stress management, Uncategorized, vision | Tags: , | 3 Comments

Erik Peper, PhD and Dana Yirmiyahu

Adapted from: Peper, E. & Yirmiyahu, D. (2023). Transforming a “bad eye” to an “amazing eye”: a case report and protocol. Townsend Letters. The Examiner of Alternative Medicine,  Saturday, July 29, 2023

“I completely changed my perception of having a bad eye, to having an amazing eye. After two months, my eye is totally normal and healthy”

When experiencing chronic discomfort or reduced function, we commonly describe that part of our body that causes problems as broken or bad. Sometimes we even wish that it did not exist. In other cases, especially if there is pain or disfigurement, the person may attempt to dissociate from that body part. The language the person uses creates a graphic imagery that may impact the healing process; since, language can also be seen as a self-hypnotic suggestion.

The negative labeling, plus being disgusted or frustrated with that part of the body that is the cause of discomfort, often increases stress, tension and sympathetic activity. This reduces our self-healing potential.   In many cases, the language is both the description and the prognosis-a self-fulfilling prophecy.  If the description is negative and judgmental, it may interfere with the healing/treatment process. The negative language may activate the nocebo process that inhibits regeneration.  On the other hand, positive affirming language may implicitly activate the placebo process that enhances healing.

By reframing the experience as positive and appreciating what the problem area of the body had done for you in the past as well as incorporating a healing compassionate process, healing is supported. Our limiting beliefs limit our possibilities. See the TED talk, A broken body isn’t a broken person,  by Janine Shepherd (2014) who, after a horrendous accident and being paralyzed, became an acrobatic pilot instructor.  Another example of a remarkable recovery is that of Madhu Anziani.  After falling from a second floor window, he was a quadriplegic and used Reiki, toning, self-compassion and hope to improve his health. He reframed the problem as an opportunity for growth. He can now walk, talk and play the most remarkable music (Anziani and Peper, 2021).

When a person can focus on what they can do instead of focusing on what they cannot do or on their suffering, pain may be reduced. For example, Jill Cosby describes undergoing two surgeries to replace her shattered L3 with a metal “cage” and fused this cage to the L4 and L2 vertebrae with bars. She used imagery to eliminate the pains in her back and stopped her pain medications (Peper et al., 2022). The healing process is similar to how children develop, growth, and learn–a process that is promoted through playfulness and support with an openness to possibilities.

Healing only goes forwards in time

After an injury, most people want to be the same as they were before the injury, and they keep comparing themselves to how they were. The person can never be what they were in the past, butthey can be different and even better.. Time flows only in a forward direction, and the person already has been changed by the experience.  Instead, the person explores ways to accept where they are, appreciate how much the problem area has done for them in the past, and continue to work to improve. This is a dynamic process in which the person appreciates the very small positive changes that are occurring  without setting limits on how much change can occur.

A useful tool while working with clients is to explore ways by which they can genuinely transform their negative beliefs and self-talk about the problem to appreciation and growth. This process is illustrated in the following report about the rapid healing of a 15-year problem with an eye that had become smaller following severe corneal abrasion.

Case report

On January 18th, 2023, I attended a workshop/ lecture by Professor Erik Peper.

During the break, I spoke to him and expressed my concern regarding my right eye. 15 years ago, the cornea of my eye was accidently scratched by my 3-year-old daughter. The eye suffered a trauma and was treated at the hospital. In addition, I had a patch over my eye for 3 weeks and suffered extrusion pain during the first 2 weeks. A scar remained on my eye, and doctors were not able to say if it would be permanent or whether the eye would heal itself eventually. An invasive operation was also suggested, which I refused. The trauma affected my eyesight for a few months, but after a year, the scar was gone and physically no permanent damage has remained.

Although it was certainly determined that my eye had healed completely, it didn’t feel that way at all. I always considered it ‘my bad eye’ and suffered irritation and pain every time I experienced tiredness, anxiety, or any other emotional discomfort. My eye was the first and only organ to reflect pain/itchiness/irritation. Over time, my eye ‘shrank’ as well. It became visibly smaller and it felt tense at all times.

For 15 years, that was my reality! I coped with it and haven’t thought of it much, until January 18, when I attended the workshop.

Professor Peper asked me to the front of the stage when we returned from break and conducted an exercise with me, where I used my imagination and words to comfort my eye and embrace it rather than call it ‘the defective/bad eye’. He pointed out that if you only describe your children as bad or evil, how can you expect them to grow? Then, he explored with me a few exercises such as evoking self-healing imagery. The self-healing imagery did not totally resonate; however, I felt I just needed to hug my eye.  I thanked my eye for its being and stroked it gently in my mind. On stage and during the rest of the lecture I felt a sense of comfort. I felt if the muscles around my eye had finally loosened–a feeling I haven’t experienced for years. I continued to follow the instructions I got at the workshop for a couple of days, but unfortunately, I did not persist, and the negative sensations returned.

On a follow-up zoom meeting 10 days after the lecture with Prof. Peper, I received additional tools to practice ‘eye physiotherapy’ as well as mindfulness regarding the eye. This practice consisted of closing my eyes and covering the non-problem eye and then as I exhaled gently and softly opening my eyes, opening them more and more while looking all around.  I completely changed my perception of having a bad eye, to having ‘an amazing eye’. At first talking to it didn’t come naturally to me but as I persisted it became easier and easier. I did it in the car, before going to sleep and when waking up in the morning. In addition, I practiced the exercises I got over zoom, where I covered my left eye (the undamaged one) and had my right eye look up and down to both sides.

It has been about three months since this zoom meeting and I am awed by the results. My eye has opened more, and no longer feels shrunk and small, I rarely feel negative sensations in it and when I do, I immediately know how to handle it.

I can say that attending this workshop has definitely been a life-changing event for  my amazing right eye and for me.  

Why did the healing occur?

The “bad eye” symptoms were most likely caused by “learned disuse”; namely, the chronic eye tension was the result of the protective response to reduce the discomfort after the injury to the cornea (Uswatte & Taub, 2005). After the injury and medical treatment, she would have unknowingly tensed her muscles around the eye to protect it. This process occurs automatically without conscious awareness.  This protective response became her “new normal” and once her eye had healed, the bracing continued.  The bracing pattern was amplified by the ongoing self-labeling of having a “bad eye.” By accepting the eye as it was, giving it compassionate caring and support, and following up with simple eye movement exercises to allow the eye to rediscover and experience the complete range of motion, the symptoms disappeared.

What can we take home from this case example?

Listen to the language a client uses to describe their problem. Does the language implicitly limit recovery, growth and hope (e.g., I will always have the problem)? Does the language inhibit caring and compassion for the problem area (e.g., I’m frustrated, angry, disgusted)? If that is the case, explore ways to reframe the language and emotional tone. A useful strategy is to incorporate self-healing imagery: the person first inspects the problem area, next imagines how it would look when it is healthy, and finally creates  self-healing imagery that transforms what was observed  to become well and whole.  Then, each moment the client’s attention is drawn to the problem, he or she evokes the self-healing imagery (Peper, Gibney, & Holt, 2002). In many cases, combining this imagery with slower breathing to reduce stress promotes healing.

References

Anziani, M. & Peper, E. (2021). Healing from paralysis-Music (toning) to activate health. the peper perspective-ideas on illness, health and well-being from Erik Peper. Accessed March 22, 2023. https://peperperspective.com/2021/11/22/healing-from-paralysis-music-toning-to-activate-health/

Mullins, A. (2009).  The opportunity of adversity. TEDMED. Accessed March 22, 2023. https://www.ted.com/talks/aimee_mullins_the_opportunity_of_adversity?language=en

Peper, E. Cosby, J. & Amendras, M. (2022). Healing chronic back pain. NeuroRegulation, 9(3), 165-172. https://doi.org/10.15540/nr.9.3.164

Peper, E., Gibney, H. K. & Holt, C. (2002). Make Health Happen. Dubuque, Iowa: Kendall-Hunt. pp. 193-236. https://he.kendallhunt.com/make-health-happen

Shepherd, J. (2014). A broken body isn’t a broken person. TEDxKC. Accessed March 20, 2023 https://www.ted.com/talks/janine_shepherd_a_broken_body_isn_t_a_broken_person?language=en

Uswatte, G. & Taub, E. (2005). Implications of the Learned Nonuse Formulation for Measuring Rehabilitation Outcomes: Lessons From Constraint-Induced Movement Therapy. Rehabilitation Psychology, 50(1), 34-42. https://doi.org/10.1037/0090-5550.50.1.34

*I thank Cathy Holt, MPH, for her supportive feedback.

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Thoughts Have the Power to Create or Eliminate Body Tension

Posted: January 31, 2023 | Author: | Filed under: Breathing/respiration, CBT, cognitive behavior therapy, computer, emotions, ergonomics, healing, health, Neck and shoulder discomfort, Pain/discomfort, posture, stress management, Uncategorized | Tags: , | 3 Comments

By Tami Bulmash republished from: Medium-Body Wisdom

View at Medium.com

Photo by Jonathan Borba on Unsplash

The mind and body have long been regarded and treated as separate entities, yet this distinction does little to promote holistic health. Understanding the direct relationship between thoughts and body tension can illustrate how the mind and body either work dysfunctionally through separation, or optimally as a unit.

Mental and physical aren’t separate entities

Stress and pain existed long before the coronavirus, though it was highlighted during this isolating era. In the height of the pandemic nearly eight in 10 American adults cited COVID-19 as a significant stressor. Though it may no longer be front page news, the aftermath of COVID still lingers. Its toll on mental health continues to impact children and adults alike. The shift to remote work was appealing at first, but later created a more pervasive sedentary lifestyle. Now the concern has shifted to an emerging pandemic of back pain.

Yet, there is nothing novel about body tension brought forth by stressful thinking. In 2014, the American Institute of Stress reported 77 percent of people regularly experience physical symptoms caused by stress. Moreover, the findings of a 2018 Gallup poll suggest 55 percent of Americans report feeling stressed for a large part of their day. This is compounded by the American Academy of Orthopaedic Surgeons finding one in two Americans have a musculoskeletal condition. Discerning between mental and physical stress is becoming increasingly obscure.

While the mind and body have long been regarded and treated as separate entities, this distinction does little to promote holistic health. Understanding the direct relationship between thoughts and tension can illustrate how the mind and body either work dysfunctionally through separation, or optimally as a unit. What’s more, viewing the body as a whole being — in thought and activity — can promote better habits which eliminate tension.

The link between stress and pain

Dividing the self into parts is common practice in the Western world. Expressions such as “I’m mentally exhausted” vs. “I’m physically exhausted” provoke differing self-reflections. However, the psycho-physical relationship is evident in the tension stimulated by either thought. For example, sitting in front of a computer necessitates both thought and action. Viewing content on a screen lends itself to a reaction from behind the screen. This response can be minimal and inconsequential, or it can be subtle, yet critical.

Repeatedly engaging in certain thinking habits like, “I have to get this done and fast” are often reflected in forms of body tension such as stiff fingers at the keyboard, a clenched jaw after a meeting, or tense neck at the end of the day. These unconscious responses are common and have a pervasive effect.

The prevalence of technology has led to a plethora of occupational ailments, now referred to as technology diseases. These include carpal tunnel syndrome, mouse shoulder, and cervical pain syndrome and occur because of excessive work at the computer — especially keyboard and mouse usage. According to the book, TechStress-How Technology is Hijacking our Lives, Strategies for Coping and Pragmatic Ergonomics, by Drs. Erik Peper, Richard Harvey and Nancy Faass, 45 million people suffer from tension headaches, carpal tunnel, and back injuries linked to computer use and more than 30 percent of North Americans who work at a computer develop a muscle strain injury every year.

Pushing through mental tasks is reflected in the physical

Dr. Peper, a biofeedback expert and Professor of Holistic Health at San Francisco State University, gives an illustration of the mind-body connection in relation to pain. His example requires the use of a computer mouse while trying to complete difficult mental tasks. He asks me to hold the mouse in my dominant hand and draw with it the last letter of an address. Then continue to go backward with each letter of the street name, making sure the letter height is only one-half of an inch. He tells me to perform the task as quickly as possible. As I’m drawing the address backwards trying to recall the letters and their order, Dr. Peper commands, “Do it quicker, quicker, quicker! Don’t make a mistake! Quicker, quicker, quicker!”

These commands reflect the endless to-do lists that pile up throughout the day and the stress associated with their efficacy and timely completion. While enacting this task, Dr. Peper asks me, “Are you tightening your shoulders? Are you tightening your trunk? Are you raising your shoulders possibly holding all this tension? If you are like most people who do this task, you did all of that and you were totally unaware. We are usually really unaware of our body posture.”

I have spent the past 20 years practicing the Alexander Technique, a method used to improve postural health. At its core the technique is about observation and utilizing psycho-physical awareness to stop repeating harmful habits. Dr. Peper’s words resonate because becoming aware of unconscious responses isn’t easy. Most people are completely unaware of the relationship between mind-body habits and how they contribute to stress-related pain.

Posture affects mood and energy levels

Posture is often thought of as a pose — most notably being associated with “sitting up straight”. Yet the health implications of good posture extend far beyond any held position. The agility and movement which are evident in good posture exemplify the mind-body connection.

It is well-known that feeling depressed has been linked to having less subjective energy. The American Psychiatric Association listed a variety of symptoms connected to depression including feeling sad or having a depressed mood, loss of interest in activities once enjoyed, and loss of energy or increased fatigue. While the treatment of depression hasn’t traditionally considered the role of posture in informing mood, researchers have started exploring this relationship.

A study by Dr. Peper and Dr. I-Mei Lin examined the subjective energy levels of university students and their corresponding expression of depression. Participants who walked in a slouched position reported lower energy levels and higher self-rated depression scores. In contrast, when those participants walked in a pattern of opposite arm and leg skipping, they experienced an increase in energy, allowing a positive mindset to ensue.

As mentioned in the study, the mind-body relationship is a two-way street: mind to body and body to mind. If thoughts are manifested in the way one holds their body, the inverse would also be true. Namely, changing the way one carries their body would also influence their thinking and subsequent mood. If stopping certain habits — such as walking in a slumped posture — could have a positive impact on mood and well-being, perhaps it’s worth exploring the mind-body relationship even further.

Supporting the mind-body connection

One of the best ways to improve the mind-body connection is through awareness. The more present you are in your activities, the more unified the relation becomes. Give yourself a couple of minutes to connect your thoughts with what you are doing at the moment.

Begin With Grounding

If you are sitting down, imagine coloring in the space of your whole body with an imaginary marker. Begin with your feet planted on the floor. Start to outline the footprints of your feet and then color in the bottom and top of each foot. Take your time. Fill in all the space. See if you discover new parts of your feet — like the spaces between your toes. Continue up through your ankles and toward your calves. Pay attention to the entire limb (front and back). Work your way upward through the knee and then the upper leg. See if you can find your sit bones along the way to the torso. Explore new joints — such as the hip joint.

Lengthen Your Body Through Thought

Continue up while circling the front and back of the torso. Extend the awareness of your thoughts through your shoulders. Allow for an exploration of the arms — noting the joints such as the elbows, wrists and fingers. Pay attention to their length and mobility. Come back up through the arms. Extend up through the shoulders again, this time noting the passage through the chest and neck. Observe the length and space within your entire being. Journey up to the head and travel around its circumference. Imagine filling your head space with air. Picture the wholeness of your head from top to bottom and side to side.

This two-minute mind-body meditation allows you to feel the full extent of the space your body takes up. It is a way to awaken the senses and include them in conscious thinking. This helps generate awareness in how to engage the mind-body relationship optimally. The next time you try it, use a visual aid like an anatomy diagram of the whole body. This can also introduce new parts and spaces of the body you may not have thought of before. However, don’t rely on the diagram each time, as it can pull away your attention from the mind-body meditation. Instead, use it as a reference or guide every once in a while.

Learn from other cultures

In Western cultures, it is common practice to divvy up musculoskeletal ailments into an array of categories such as tension headaches, tension neck syndrome, or mechanical back syndrome. For instance, in countries like the U.S., it is normal to seek a specialist for each area of concern — like a neurologist for a migraine, an orthopedist for neck strain, or chiropractors for back pain. In contrast, Eastern lifestyles have historically taken a more holistic approach to treating (and healing) their patients.

An article by Dr. Cecilia Chan, Professor of Social Sciences at the University of Hong Kong, explains how the Eastern philosophies of Buddhism, Taoism and traditional Chinese medicine adopt a holistic approach to the healing of an individual. Rather than diagnose and treat with medication, Chan and her colleagues explore health through the harmony and balance of the body-mind-spirit as a whole.

Because basic biology clearly delineates how the human head is attached to the body, it seems fitting that the entire being be regarded as a unit. By recognizing the relationship between thought stressors and their manifestation in the physical body, awareness is elevated. This, in turn, can prevent mindlessly engaging in harmful patterns that lead to stress and pain. Combating tension is possible through the realization of how thoughts — whether they are emotional or task oriented — directly impact the body as a whole.

This excerpt from Taro Gold’s book, Open Your Mind, Open Your Life: A Book of Eastern Wisdom, cites Mahatma Gandhi’s famous quote which beautifully elucidates the mind-body connection:

Keep your thoughts positive, because your thoughts become your words.

Keep your words positive, because your words become your behavior.

Keep your behavior positive, because your behavior becomes your habits.

Keep your habits positive, because your habits become your values.

Keep your values positive, because your values become your destiny.

Referring to the mind and body as separate entities perpetuates a disconnect in the being as a whole. This is why distinguishing the mental from the physical further exacerbates the notion that the two don’t work together as an indivisible unit. Understanding the relationship between stress and tension begins through the awareness of habits.

There are recurrent thinking habits like “I’ve got to get this done now” and their unconscious counterparts that become visible through posture. The unknown habits are the ones which accrue over time and often appear seemingly out of nowhere — in the form of tension or pain. Modern culture is quick to treat symptoms, such as those related to excessive technology use. However, a holistic approach to addressing the underlying issue would examine how stress and pain work hand in hand. Once the thoughts change, so will the tension.

Bring joy through kindness

Posted: December 31, 2022 | Author: | Filed under: behavior, healing, meditation, mindfulness | Tags: , | Leave a comment

As the New Year begins, bring support through simple acts of kindness. As we share generously, our own well-being improves. I wish you health, happiness and peace for the New Year. Enjoy the two videos on simple acts of kindness.

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