Biofeedback, breathing and health

In the video interview recorded at the 2018 Conference of the New Psychology Association, Jagiellonian University, Krakow, Poland,  Erik Peper, PdD, defines biofeedback and suggests three simple breathing and imagery approaches that we can all apply to reduce pain, resentment and improve well-being.


Breathing reduces acid reflux and dysmenorrhea discomfort

“Although difficult and going against my natural reaction to curl up in the response to my cramps, I stretched out on my back and breathed slowly so that my stomach got bigger with each inhalation.  My menstrual pain slowly decreased and disappeared.

“For as long as I remember, I had stomach problems and when I went to doctors, they said, I had acid reflux. I was prescribed medication and nothing worked. The problem of acid reflux got really bad when I went to college and often interfered with my social activities. After learning diaphragmatic breathing so that my stomach expanded instead of my chest, I am free of my symptoms and can even eat the foods that previously triggered the acid  reflux.”

In the late 19th earlier part of the 20th century many women were diagnosed with Neurasthenia.  The symptoms included fatigue, anxiety, headache, fainting, light headedness, heart palpitation, high blood pressure, neuralgia and depression. It was perceived as a weakness of the nerves. Even though the diagnosis is no longer used, similar symptoms still occur and are aggravated when the abdomen is constricted with a corset or by stylish clothing (see Fig 1).

Fig 1a

Figure 1. Wearing a corset squeezes the abdomen.

The constricted waist compromises the functions of digestion and breathing. When the person inhales, the abdomen cannot expand as the diaphragm is flattening and pushing down. Thus, the person is forced to breathe more shallowly by lifting their ribs which increases neck and shoulder tension and the risk of anxiety, heart palpitation, and fatigue. It also can contribute to abdominal discomfort since abdomen is being squeezed by the corset and forcing the abdominal organs upward.  It was the reason why the room on top of stairs in the old Victorian houses was call the fainting room (Melissa, 2015).

During inhalation the diaphragm flattens and attempts to descend which increases the pressure of the abdominal content.  In some cases this causes the stomach content to be pushed upward into the esophagus which could result in heart burn and acid reflux.  To avoid this, health care providers often advice patients with acid reflux to sleep on a slanted bed with the head higher than their feet so that the stomach content flows downward. However, they may not teach the person to wear looser clothing that does not constrict the waist and prevent designer jean syndrome. If the clothing around the waist is loosened, then the abdomen may expand in all directions in response to the downward movement of the diaphragm during inhalation and not squeeze the stomach and thereby pushing its content upward into the esophagus.

Most people have experienced the benefits of loosening the waist when eating a large meal. The moment the stomach is given the room to spread out, you feel more comfortable.   If you experienced this, ask yourself, “Could there be a long term cost of keeping my waist constricted?”  A constricted waist may be as harmful to our health as having the emergency brake on while driving for a car.

We are usually unaware that shallow rapid breathing in our chest can contribute to symptoms such as anxiety, neck and shoulder tension, heart palpitations, headaches, abdominal discomfort such as heart burn, acid reflux, irritable bowel syndrome, dysmenorrhea and even reduced fertility (Peper,  Mason, & Huey, 2017; Domar, Seibel, & Benson, 1990).

Assess whether you are at risk for faulty breathing

Stand up and observe what happens when you take in a big breath and then exhale.  Did you feel taller when you inhaled and shorter/smaller when you exhaled?

If the answer is YES, your breathing pattern may compromise your health.   Most likely when you inhaled you lifted your chest, slightly arched your back, tightened and raised your shoulders, and lifted your head up while slightly pulling the stomach in. When you exhaled, your body relaxed and collapsed downward and even the stomach may have relaxed and expanded. This is a dysfunctional breathing pattern and the opposite of a breathing pattern that supports health and regeneration as shown in figure 2.

Fig 2a

Figure 2.  Incorrect and correct breathing. Source unknown.

Observe babies, young children, dogs, and cats when they are peaceful.  The abdomen is what moves during breathing.   While breathing in, the abdomen expands in all 360 degrees directions and when breathing out, the abdomen constricts and comes in.   Similarly when dogs or cats are lying on their sides, their stomach goes up during inhalation and goes down during exhalation.

Many people tend to breathe shallowly in their chest and have forgotten—or cannot– allow their abdomen and lower ribs to widen during inhalation (Peper et al, 2016). These factors include:

  • Constriction by the modern corset called “Spanx” to slim the figure or by wearing tight fitting pants. In either case the abdominal content is pushed upward and interferes with normal healthy breathing.
  • Maintaining a slim figure by pulling the abdomen (I will look fat when my stomach expands; I will suck it in).
  • Avoiding post-surgical abdominal pain by inhibiting abdominal movement. Numerous patients have unknowingly learned to shallowly breathe in their chest to avoid pain at the site of the incision of the abdominal surgery such as for hernia repair or a cesarean operation. This dysfunctional breathing became the new normal unless they actively practice diaphragmatic breathing.
  • Slouching as we sit or watch digital screens or look down at our cell phone.

Observe how slouching affects the space in your abdomen.

When you shift from an upright erect position to a slouched or protective position the distance between your pubic bone and the bottom of the sternum (xiphoid process) is significantly reduced.

  • Tighten our abdomen to protect ourselves from pain and danger as shown in Figure 3.

Fig 3a

Figure 3. Erect versus collapsed posture. There is less space for the abdomen to expand in the protective collapsed position. Reproduced by permission from Clinical Somatics (http://www.clinicalsomatics.ie/).

Regardless why people breathe shallowly in their chest or avoid abdominal and lower rib movement during breathing, by re-establishing normal diaphragmatic breathing many symptoms may be reduced.  Numerous students have reported that when they shift to diaphragmatic breathing which means the abdomen and lower ribs expand during inhalation and come in during exhalation as shown in Figure 4, their symptoms such as acid reflux and menstrual cramp significantly decrease.

Fig 4a

Figure 4. Diaphragmatic breathing. Reproduced from:  www.devang.house/blogs/thejob/belly-breathing-follow-your-gut.

Reduce acid reflux

A 21-year old student, who has had acid reflux (GERD-gastroesophageal reflux diseases) since age 6, observed that she only breathed in her chest and that there were no abdominal movements.  When she learned and practiced slower diaphragmatic breathing which allowed her abdomen to expand naturally during inhalation and reduce in size during exhalation her symptoms decreased. The image she used was that her lungs were like a balloon located in her abdomen. To create space for the diaphragm going down, she bought larger size pants so that her abdominal could spread out instead of squeezing her stomach (see Figure 5).

squeezing the stomach

Figure 5. Hydraulic model who inhaling without the abdomen expanding increases pressure on the stomach and possibly cause stomach fluids to be pushed into the esophagus.

She practiced diaphragmatic breathing many times during the day. In addition, the moment she felt stressed and tightened her abdomen, she interrupted this tightening and re-established abdominal breathing.  Practicing this was very challenging since she had to accept that she would still be attractive even if her stomach expanded during inhalation. She reported that within two weeks her symptom disappeared and upon a year follow-up she has had no more symptoms.  For a detailed description how this successfully cured irritable bowel syndrome see: https://peperperspective.com/2017/06/23/healing-irritable-bowel-syndrome-with-diaphragmatic-breathing/

Take control of menstrual cramps

Numerous college students have reported that when they experience menstrual cramps, their natural impulse is to curl up in a protective cocoon. If instead they interrupted this natural protective pattern and lie relaxed on their back with their legs straight out and breathe diaphragmatically with their abdomen expanding and going upward during inhalation, they report a 50 percent decrease in discomfort (Gibney & Peper, 2003). For some the discomfort totally disappears when they place a warm pad on their lower abdomen and focused on breathing slowly about six breaths per minute so that the abdomen goes up when inhaling and goes down when exhaling. At the same time, they also imagine that the air would flow like a stream from their abdomen through their legs and out their feet while exhaling.  They observed that as long as they held their abdomen tight the discomfort including the congestive PMS symptoms remained.  Yet, the moment they practice abdominal breathing, the congestion and discomfort is decreased. Most likely the expanding and constricting of the abdomen during the diaphragmatic breathing acts as a pump in the abdomen to increase the lymph and venous blood return and improve circulation.

Conclusion

Breathing is the body-mind bridge and offers hope for numerous disorders. Slower diaphragmatic breathing with the corresponding abdomen movement at about six breaths per minute may reduce autonomic dysregulation. It has profound self-healing effects and may increase calmness and relaxation. At the same time, it may reduce heart palpitations, hypertension, asthma, anxiety, and many other symptoms.

References

DeVault, K.R. & Castell, D.O. (2005). Updated guidelines for the diagnosis and treatment of gastroesophageal reflux disease. The American Journal of Gastroenterology, 100, 190-200.

Domar, A.D., Seibel, M.M., & Benson, H. (1990). The Mind/Body Program for Infertility: a new behavioral treatment approach for women with infertility. Fertility and sterility, 53(2), 246-249.

Gibney, H.K. & Peper, E. (2003). Taking control: Strategies to reduce hot flashes and premenstrual mood swings. Biofeedback, 31(3), 20-24.

Johnson, L.F. & DeMeester, T.R. (1981).  Evaluation of elevation of the head of the bed, bethanechol, and antacid foam tablets on gastroesophageal reflux. Digestive Diseases Sciences, 26, 673-680. https://www.ncbi.nlm.nih.gov/pubmed/7261830

Melissa. (2015). Why women fainted so much in the 19th century. May 20, 2015.  Donloaded October 2, 1018. http://www.todayifoundout.com/index.php/2015/05/women-fainted-much-19th-century/

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.

Peper, E., Mason, L., Huey, C. (2017).  Healing irritable bowel syndrome with diaphragmatic breathing. Biofeedback. (45-4)

Stanciu, C. & Bennett, J.R.. (1977). Effects of posture on gastro-oesophageal refluxDigestion, 15, 104-109. https://www.karger.com/Article/Abstract/197991

 

 

 

 


Do better in math: Don’t slouch-Be tall!

“When I saw the exam questions, I blanked out and slouched in defeat. Then I shifted to an erect/tall position and took a diaphragmatic breath. All of a sudden I remembered the answer.”                                                                                                                        College student

Anticipating that math is difficult, experiencing test anxiety, blanking out on exams, or being scared when asked to give class presentation are common experiences of many students.  Their thoughts include, “I am not good enough,“What will the other students think,”  “I am embarrassed and can’t remember what to say,” or “I only thought of the correct answer after it was all over.” Many students report some test anxiety: 32% report severe test anxiety, fear of math and blanking out on exams while less than 10 percent report minimal test anxiety, fear of math and blanking out on exams.

When students anticipate that they will perform poorly on an exam or class presentation, they tend to sit in a slouched or collapsed position, coincident with feelings of powerlessness, hopelessness and defeat. This posture not only communicates to others that they are powerless and defeated, it also decreases their self-esteem, mood and cognitive performance.  In previous research, Tsai et al (2016) and Peper et al (2017) observed that when participants sat in a slouched posture, they could access hopeless, helpless, powerless and defeated memories much more easily than when they sat in the upright/erect position.  In the upright position it was much easier to access positive and empowering memories. For numerous participants they also experienced being captured and flooded by emotions associated with defeat and hopelessness when they slouched. These feelings and memories associated with a slouched posture may affect how we feel and perform. Nair et al (2015) found that adopting an upright seated posture in the face of stress can maintain self-esteem, reduce negative mood, and increase positive mood as compared to a slumped posture. Furthermore, sitting upright increases rate of speech and reduces self-focus.” Posture may also affect our hormone levels. Harvard Social Psychologist Amy Cuddy has reported that sitting in a slouched posture (powerless position) decreased testosterone (the hormone associated dominance and assertiveness) and increased cortisol (the hormone associated with stress) and performance on a stressor test (Cuddy, 2012; Carney et al, 2010). 

This blog points out how posture significantly impacts math performance especially for students who have test anxiety, are fearful of math, and blank out on exams and is adapted from our published research article, Peper, E., Harvey, R., Mason, L., & Lin, I-M. (2018). Do better in math: How your body posture may change stereotype threat response. NeuroRegulation, 5(2), 67-74 

In our study 125 university students participated. Half the students sat in an erect position while the other half sat in a slouched position and were asked to mentally subtract 7 serially from 964 for 30 seconds. They then reversed the positions before repeating the math subtraction task beginning at 834. They rated the math task difficulty on a scale from 0 (none) to 10 (extreme).

Fig 1 Slouch collapse positionFigure 1. Sitting in a collapsed position and upright position (photo from: http://news.sfsu.edu/news-story/good-posture-important-physical-and-mental-health)

The students rated the mental math significantly more difficult while sitting slouched than while sitting erect as shown in Figure 2.

Fig 2 difficulty in math by positionFigure 2. The subjective rating of difficulty in performing the serial 7 math subtraction when sitting in a collapsed or upright position.

For the students with the lowest 30% test anxiety, math difficulty and blanking out scores, there was no significant difference between slouched and erect positions in mental math performance.  More importantly, students with the highest 30% test anxiety, math difficulty and blanking out scores rated the math task significantly more difficult and some could not do it at all and blanked out in the slouched position as compared to the erect position as shown in Figure 3.

Fig 3 30 percent math performanceFigure 3. Effect of posture on math performance for students with test anxiety, math difficulty and blanking out.

 The students with the highest test anxiety, math difficulty and blanking out scores also reported significantly more somatic symptoms as compared with those with the lowest scores as shown in Figure 4.

Fig 4 SymptomsFigure 4. Self-reported symptoms associated with the highest and lowest 30% of summed test anxiety, math difficulty and blanking out.

Discussion

Posture affects mental math and inhibit abstract thinking. By incorporating posture changes clinicians and teachers may help students improve performance.  The slouched position was associated with increased difficulty in performing a math subtraction task for 15 seconds, especially for students reporting higher test anxiety, math difficulty and blanking out on exams. In contrast, slouched position had no significant effect on students who reported that they were not stressed about performance. For participants who report higher test anxiety, math difficulty and blanking out they also reported significant increase in breathing difficulty, neck and shoulder tension, headaches, depression and anxiety. Most likely, the students attribute physiological reactions such as increased heart rate and breathing changes negatively, which amplifies their negative self-perception and exacerbates their anxiety symptoms which then may inhibit their cognitive ability to perform on math tasks.

The slouched position combined with the somatic symptoms activate are part of the a “defense reaction.” The slouch posture evokes a classically conditioned response to protect oneself under conditions of perceived physical threat. The activation of this defense pattern is associated with reduced levels of abstract thinking and frontal cortical deactivation as observed in this study.  This biological defense response is triggered when the person expects the situation to be ‘dangerous’ and include conditions of social-evaluative threat. By changing posture to an erect/upright posture appears to inhibit the defense reaction; thus, the person may perform better on cognitive tasks. 

Summary

Head-upright/erect postures may make it easier to access ‘positive and empowering’ thoughts and memories, thereby helping students, especially those who are anxious or fearful of math and blank-out during exams,   Anxious students who also slouch may benefit from training with a posture feedback  devices such as the UpRight Go™[1].  We recommend that students use posture feedback to become aware of the situations that are associated with slouching, such as ergonomic factors (looking down at the screen), being tired, or having depressive thoughts or feeling of powerless and defeat. 

The moment students experience the feedback that they are slouching, they become aware and have the option to shift to an upright posture and perform interventions to counter the factors that caused the slouching.  These interventions included ergonomic changes of their computer or laptop, transforming self-critical thoughts to empowering thoughts, or taking a break or performing movements. When students practice these interventions for four weeks, they report an increase of confidence, decrease in stress levels and an improvement in health and performance (Colombo et al, 2017; Harvey et al, in press). Equally important is to teach the participants self-regulation strategies  such as slower breathing, heart rate variability training, and muscle relaxation to reduce symptoms. The training needs to be generalized and practiced at home, school or work.

We recommend that students guide themselves through the posture positions as described in this research while performing mental math to experience how posture impacts performance. This experiential practice may increase motivation to be tall since the participant can now have a choice based upon self-experience.

Take home message echoes what your mother said, “Don’t slouch. Sit up tall!” 

  • If you feel secure and safe, posture has little to no effect on performance–you can be collapsed or slouched.
  • If you are anxious and fearful, sitting tall/erect may improve your performance.
  • If you want to become aware when you slouch, posture feedback from a wearable posture feedback device such as an UpRight Go can provide vibration feedback each time you slouch. The feedback can be the reminder to sit tall and change your thoughts.
  • If you automatically slouch while working at the computer or sitting in chair, change your furniture so that you sit in an upright position while studying or watching digital devices.
  • If you experience significant somatic symptoms (e.g., headaches, breathing difficulty, neck and shoulder tension, or depression and anxiety) learn self-regulation skills such as slower diaphragmatic breathing and heartrate variability training in conjunction with transforming negative self-talk to positive self-talk to improve performance.

Changing posture may also impact other areas of one’s life besides improving math performance as illustrated by the report from a mother of ten-year old boy.  

”At the moment I am trying to be aware of the situation in front of me rather that reacting to it. For example, yesterday my son who is 10 had a bad mood and I did not know what had happened, and he at first refused to tell me. Because I was aware of the posture information I could help him open up by making him change his posture without knowing. He became more open and told me what had happened earlier and I could help him move forward.”

REFERENCES

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

Colombo, S., Joy, M., Mason, L., Peper, E., Harvey, R., & Booiman, A.C. (2017). Posture Change Feedback Training and its Effect on Health. Poster presented at the 48th Annual Meeting of the Association for Applied Psychophysiology and Biofeedback, Chicago, IL March, 2017. Abstract published in Applied Psychophysiology and Biofeedback.42(2), 147.

Cuddy, A. (2012). Your body language shapes who you are. Technology, Entertainment, and Design (TED) Talk, available at:  www.ted.com/talks/amy_cuddy_your_body_language_shapes_who_you_are

Harvey, R., Mason, L., Joy, M., & Peper, E. (in press). Effect of Posture Feedback Training on Health, Applied Psychophysiology and Biofeedback. 

Nair, S., Sagar, M., Sollers, III, J., Consedine, N. & Broadbent, E.  (2015). Do Slumped and Upright Postures Affect Stress Responses? A Randomized Trial. Health Psychology, 34(6), 632–641.

Peper, E., Harvey, R., Mason, L., & Lin, I-M. (2018). Do better in math: How your body posture may change stereotype threat response. NeuroRegulation, 5(2), 67-74

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

Tsai, H. Y., Peper, E., & Lin, I. M.* (2016). EEG patterns under positive/negative body postures and emotion recall tasks. NeuroRegulation, 3(1), 23-27.

[1] UpRight Go is produced by Upright Technologies. LTD, Ha’atzmaut 56, Yehud 5630425, Israel  https://www.uprightpose.com

 


Posture and mood: implications and applications to health and therapy

This blog has been reprinted from: Peper, E., Lin, I-M, & Harvey, R. (2017). Posture and mood: Implications and applications to therapy. Biofeedback.35(2), 42-48.

Slouched posture is very common and tends to increase access to helpless, hopeless, powerless and depressive thoughts as well as increased head, neck and shoulder pain. Described are five educational and clinical strategies that therapists can incorporate in their practice to encourage an upright/erect posture. These include practices to experience the negative effects of a collapsed posture as compared to an erect posture, watching YouTube video to enhance motivation, electromyography to demonstrate the effect of posture on muscle activity, ergonomic suggestions to optimize posture, the use of a wearable posture biofeedback device, and strategies to keep looking upward. When clients implement these changes, they report a more positive outlook and reduced neck and shoulder discomfort.

Background

Most people slouch without awareness when looking at their cellphone, tablet, or the computer screen (Guan et al., 2016) as shown in Figure 1. Many clients in psychotherapy and in biofeedback or neurofeedback training experience concurrent rumination and depressive thoughts with their physical symptoms. In most therapeutic sessions, clients sit in a comfortable chair, which automatically creates a posterior pelvic tilt and encourages the spine to curve so that the client sits in a slouched position. While at home, they sit on an easy chair or couch, which lets them slouch as they watch TV or surf the web.Figure 1 three collapsed positions

Figure 1. (A). Employee working on his laptop. (B). Boy with ADHD being trained with neurofeedback in a clinic. (C). Student looking at cell phone. When people slouch and look at the screen, they tend to slouch and scrunch their neck.

In many cases, the collapsed position also causes people to scrunch their necks, which puts pressure on their necks that may contribute to developing headache or becoming exhausted. Repetitive strain on the neck and cervical spine may trigger a cervical neuromuscular syndrome that involves chronic neck pain, autonomic imbalance and concomitant depression and anxiety (Matsui & Fujimoto, 2011), and may contribute to vertebrobasilar insufficiency –a reduction in the blood supply to the hindbrain through the left and right vertebral arteries and basilar arteries (Kerry, Taylor, Mitchell, McCarthy, & Brew, 2008). From a biomechanical perspective, slouching also places more stress is on the cervical spine, as shown in Figure 2. When the neck compression is relieved, the symptoms decrease (Matsui & Fujimoto, 2011).

Figure 2 head collapseFigure 2. The more the head tilts forward, the more stress is placed on the cervical spine. Reproduced by permission from: Hansraj, K. K. (2014). Assessment of stresses in the cervical spine caused by posture and position of the head. Surgical Technology International, 25, 277–279.

Most people are totally unaware of slouching positions and postures until they experience neck, shoulder, and/or back discomfort. Neither clients nor therapists are typically aware that slouching may decrease energy levels and increase the prevalence of negative (hopeless, helpless, powerless, or defeated) memories and thoughts (Peper & Lin, 2012; Peper et al, 2017)

Recommendations for posture awareness and training in treatment/education 

The first step in biofeedback training and therapy is to systematically increase awareness and training of posture before attempting further bio/neurofeedback training and/or cognitive behavior therapy. If the client is sitting in a collapsed position in therapy, then it will be much more difficult for them to access positive thoughts, which interferes with further training and effective therapy. For example, research by Tsai, Peper, & Lin (2016) showed that engaging in positive thinking while slouched requires greater mental effort then when sitting erect. Sitting erect and tall contributes to elevated mood and positive thinking. An upright posture supports positive outcomes that may be akin to the beneficial effects of exercise for the treatment of depression (Schuch, Vancampfort, Richards, Rosenbaum, Ward, & Stubbs., 2016).

Most people know that posture affects health; however, they are unaware of how rapidly a slouching posture can impact their physical and mental health. We recommend the following educational and clinical strategies to teach this awareness.

  1. Practicing activities that raise awareness about a collapsed posture as compared to an erect posture

Guide clients through the practices so that they experience how posture can affect memory recall, physical strength, energy level, and possible triggering of headaches.

A. The effect of collapsed and erect posture on memory recall. Participants reported that it is much easier evoke powerless, hopeless, helpless, and defeated memories when sitting in a collapsed position than when sitting upright. Guide the client through the procedure described in the article, How posture affects memory recall and mood (Peper, Lin, Harvey, and Perez, 2017) and in the blog Posture affects memory recall and mood.

B. The effects of collapsed and erect posture on perceived physical strength. Participants experience much more difficulty in resisting downward pressure at the wrist of an outstretched arm when slouched rather than upright. Guide the client through the exercise described in the article, Increase strength and mood with posture (Peper, Booiman, Lin, & Harvey, 2016) and the blog, Increase strength and mood with posture.

C. The effect of slouching versus skipping on perceived energy levels. Participants experience a significant increase in subjective energy after skipping than walking slouched. Guide the client through the exercises as described in the article, Increase or decrease depressionHow body postures influence your energy level (Peper & Lin, 2012).

D. The effect of neck compression to evoke head pressure and headache sensations. In our unpublished study with students and workshop participants, almost all participants who are asked to bring their head forward, then tilt the chin up and at the same time compress the neck (scrunching the neck), report that within thirty seconds they feel a pressure building up in the back of the head or the beginning of a headache. To their surprise, it may take up to 5 to 20 minutes for the discomfort to disappear. Practicing similar awareness activities can be a useful demonstration for clients with dizziness or headaches to experience how posture can increase their symptoms.

  1. Watching a Youtube video to enhance motivation.

Have clients watch Professor Amy Cuddy’s 2012 TED (Technology, Entertainment, and Design) Talk, Your body language shape who you are, which describes the hormonal changes that occur when adapting a upright power versus collapsed defeated posture.

  1. Electromyographic (EMG) feedback to demonstrate how posture affects muscle activity.

Record EMG from muscles such as around the cervical spine, trapezius, frontalis, and masseters or beneath the chin (submental lead) to demonstrate that having the head is forward and/or the neck compressed will increase EMG activity, as shown in Figure 3.

Figure 3 Head position

Figure 3. Electromyographic recording of the muscle under the chin while alternating between bringing the head forward or holding it back, feeling erect and tall.

The client can then learn awareness of the head and neck position. For example, one client with severe concussion experienced significant increase in head pressure and dizziness when she slouched or looked at a computer screen as well as feeling she would never get better. She then practiced the exercise of alternating her awareness by bringing her head forward and then back, and then bringing her neck back while her chin was down, thereby elongating the neck while she continued to breathe. With her head forward, she would feel her molars touching and with her neck back she felt an increase in space between the molars. When she elongated her neck in an erect position, she felt the pressure draining out of her head and her dizziness and tinnitus significantly decrease.

  1. Assessing ergonomics to optimize posture.

Change the seated posture of both the therapist and the client during treatment and training. Although people may be aware of their posture, it is much easier to change the external environment so that they automatically sit in a more erect power posture. Possible options include:

A. Seat insert or cushions. Sit in upright chairs that encourage an anterior pelvic tilt by having the seat pan slightly lower in the front than in the back or using a seat insert to facilitate a more erect posture (Schwanbeck, Peper, Booiman, Harvey, & Lin, 2015) as shown in Figure 4.

Figure 4 backjoy insert sitting with spine markers

Figure 4. An example of how posture can be impacted covertly when one sits on a seat insert that rotates the pelvis anteriorly (The seat insert shown in the diagram and used in research  is produced by BackJoy™).

B. Back cushion. Place a small pillow or rolled up towel at the kidney level so that the spine is slight arched, instead of sitting collapsed, as shown in Figure 5.

Figure 5 sitting with and without pillowFigure 5. An example of how a small pillow, placed between the back of the chair and the lower back, changes posture from collapsed to erect.

C. Check ergonomic and work site computer use to ensure that the client can sit upright while working at the computer. For some, that means checking their vision if they tend to crane forward and crunch their neck to read the text. For those who work on laptops, it means using either an external keyboard, a monitor, or a laptop stand so the screen is at eye level, as shown in Figure 6.

Figure 6 laptop ergonomicsFigure 6. Posture is collapsed when working on a laptop and can be improved by using an external keyboard and monitor. Reproduced by permission from: Bakker Elkhuizen. (n.d.). Office employees are like professional athletes! (2017).

  1. Wearable posture biofeedback training device

The wearable biofeedback device, UpRight™, consists of a small sensor placed on the spine and works as an app on the cell phone. After calibration the erect and slouched positions, the posture device gives vibratory feedback each time the participant slouches, as shown in Figure 7.Figure 7 UpRight collapse erect

Figure 7. Illustration of a posture feedback device, UpRight™. It provides vibratory feedback to the wearer to indicate that they are beginning to slouch.

Clinically, we have observed that clients can learn to identify conditions that are associated with slouching, such as feeling tired, thinking depressive/hopeless thoughts or other situations that evoke slouching. When people wear a posture feedback device during the day, they rapidly become aware of these subjective experiences whenever they slouch. The feedback reminds them to sit in an erect position, and they subsequently report an improvement in health (Colombo et al., 2017). For example, a 26-year-old man who works more than 8 hours a day on computer reported, “I have an improved awareness of my posture throughout my day. I also notice that I had less back pain at the end of the day.”

  1. Integrating posture awareness and position changes throughout the day

After clients have become aware of their posture, additional training included having them observe their posture as well and negative changes in mood, energy level or tension in their neck and head. When they become aware of these changes, they use it as a cue to slightly arch their back and look upward. If possible have the clients look outside at the tops of trees and notice details such as how the leaves and branches move. Looking at the details interrupts any ongoing rumination. At the same time, have them think of an uplifting positive memory. Then have them take another breath, wiggling, and return to the task at hand. Recommend to clients to go outside during breaks and lunchtime to look upward at the trees, the hills, or the clouds. Each time one is distracted, return to appreciate the natural patterns. This mental break concludes by reminding oneself that humans are like trees.

Trees are rooted in the earth and reach upward to the light. Despite the trauma of being buffeted by the storms, they continue to reach upward. Similarly, clouds reflect the natural beauty of the world, and are often visible in the densest city environment. The upward movement reflects our intrinsic resilience and growth.       –Erik Peper

Have clients place family photos and art slightly higher on the wall at home so they automatically look upward to see the pictures. A similar strategy can be employed in the office, using art to evoke positive feelings. When clients integrate an erect posture into their daily lives, they experience a more positive outlook and reduced neck and shoulder discomfort.

Compliance with Ethical Standards:

Conflict of Interest: Author Erik Peper has received donations of 15 UpRight posture feedback devices from UpRight (http://www.uprightpose.com/) and 12 BackJoy seat inserts from Backjoy (https://www.backjoy.com) for use in research. Co-authors I-Mei Lin and Richard Harvey declare that they have no conflict of interest.

This report evaluated a convenience sample of a student classroom activity related to posture and the information was anonymous collected. As an evaluation of a classroom activity, this report of findings was exempted from Institutional Review Board oversight

References:

Bakker Elkhuizen. (n.d.). Office employees are like professional athletes! (2017). Retrieved from https://www.bakkerelkhuizen.com/knowledge-center/whitepaper-improving-work-performance-with-insights-from-pro-sports/

Colombo, S., Joy, M., Mason, L., Peper, E., Harvey, R., & Booiman, A. Posture Change Feedback Training and its Effect on Health. Poster presented at the 48th Annual Meeting of the Association for Applied Psychophysiology and Biofeedback, Chicago, IL March, 2017. Abstract published in Applied Psychophysiology and Biofeedback.42(2), 147.

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We thank Frank Andrasik for his constructive comments.