“Don’t slouch!” Improve health with posture feedback

“Although I knew I slouched and often corrected myself, I never realized how often and how long I slouched until the vibratory posture feedback from the UpRight Go 2 cued me to sit up (see Figure 1).”  -Erik Peper

Fig 1 Erik wearing uprightFigure 1. Wearing an UpRight Go 2™ to increase awareness of slouching and as a reminder to change position.

For thousands of years we sat and stood erect. In those earlier times, we looked down to identify specific plants or animal track and then looked up and around to search for possible food sources, identify friends, and avoid predators.  The upright, not slouched posture body posture, is innate and optimizes body movement as illustrated in Figure 2 (for more information, see Gokhale, 2013).

Fig 2 baby and adultFigure 2. The normal aligned spine of a toddler and the aligned posture of a man carrying a heavy load.

Being tall and erect allows the head to freely rotate. Head rotation is reduced when we look down at our cell phones, tablets or laptops (Harvey, Peper, Booiman, Heredia Cedillo, & Villagomez, 2018). Our digital world captures us as illustrated in Figure 3.

Fig 3 head down computer cellphoneFigure 3. Captured by the screen with a head forward positions.

Looking down and focusing on the screen for long time periods is the opposite of what supported us to survive and thrive when we lived as hunters and gatherers. When we look down, we become more oblivious to our surroundings and unaware of the possible predators that would have been hunting us for food.

This slouched position increases back, neck, head and eye tension as well as affecting respiration and digestion (Devi, Lakshmi, & Devi, 2018; Peper, Lin, & Harvey, 2017).  After looking at the screens for a long time, we may feel tired or exhausted and lack initiative to do something else. Our mood may turn more negative since it is easier to evoke hopeless, helpless and powerless thoughts and memories when looking down than when looking up (Wilson, & Peper, 2004; Peper, Lin, Harvey, & Perez, 2017).   In the down position, our brain has to work harder to evoke positive thoughts and memories or perform cognitive tasks as compared to when the head is erect (Tsai, Peper, & Lin, 2016; Peper, Harvey, Mason, & Lin, 2018).  By looking down and focusing at the screen, our eyes may begin to strain. To be able to see objects near us, the extraocular muscles of the eyes contract to converge the eyes and the cilia muscles around the lens contract to increase the curvature of the lens so that the reading material is in focus.

Become aware how nearby vision increases eye strain.

Hold your arm straight ahead of you at eye level with your thumb up. While focusing on your thumb, slowly bring your thumb closer and closer to your nose.  Observe the increase in eyestrain as you bring your thumb closer to your nose.  

Eyestrain tends to develop when we do not relax the eyes by periodically looking away from the screen.  When we look at the horizon or trees in the far distance the ciliary muscles and the extraocular muscles  relax (Schneider, 2016).

Head forward posture increases neck and back tension

When we look down and concentrate, our head moves significantly forward. The neck and back muscles have to work much harder to hold the head up when the neck is in this flexed position. As Dr. Kenneth Hansraj, Chief of Spine Surgery New York Spine Surgery & Rehabilitation Medicine reported, “The weight seen by the spine dramatically increases when flexing the head forward at varying degrees. An adult head weighs 10-12 pounds in the neutral position. As the head tilts forward the forces seen by the neck surges to 27 pounds at 15 degrees, 40 pounds at 30 degrees, 49 pounds at 45 degrees and 60 pounds at 60 degrees.” (Hansraj, 2014).  Our head tends to tilt down when we look at the text, videos, emails, photos, or games and stay in this position for long time periods. We are captured by the digital display and are unaware of our tight overused neck and back muscles. Straightening up so that the back of the head is re-positioned over the spine and looking into the distance may help relax those muscles.

To reduce discomfort caused by slouching, we need to reintegrate our prehistoric life style pattern of alternating between looking down to being tall and looking at the distant scenery or across the room. The first step is awareness of knowing when slouching begins. Yet, we tend to be unaware until we experience discomfort or are reminded by others (e.g,  “Don’t slouch! Sit up straight!”). If we could have immediate posture feedback when we begin to slouch, our awareness would increase and remind us to change our posture.

Posture feedback with UpRight Go

Simple posture feedback device such as an UpRight Go 2™ can provide vibratory feedback each time slouching starts as the neck as the head goes forward.  The wearable feedback device consists of a small sensor that is attached to the back of the neck or back (see Figure 1). After being paired with a cellphone and calibrated for the upright position, the software algorithm detects changes in tilt and provides vibratory feedback each time the neck/back tilts forward.

In our initial exploration, employees, students and clients used the UpRight feedback devices at work, at school, at home, while driving, walking and other activities to identify situations that caused them to slouch. The most common triggers were:

  1. Ergonomic caused movement such as bring the head closer to the screen or looking down at their cell phone (for suggestions to improve ergonomics see recommendations at the end of the article)
  2. Tiredness
  3. Negative self-critical/depressive thoughts
  4. Crossing the legs protectively, shallow breathing, and other factors

After having identified some of the factors that were associated with slouching, we compared the health outcome of students who used the device for a minimum for 15 minutes a day for four weeks as compared to a control group who did not use the device. The students who received the UpRight feedback were also encouraged to use the feedback to change their posture and behavior and implemented some of the following strategies.

  • Head down when looking at their laptop, tablet or cellphone.
    • Change the ergonomics such as using a laptop stand and an external keyboard so that they could be upright while looking at the screen.
    • Take many movement breaks to interrupt the static tension.
  • Feeling tired.
    • Take a break or nap to regenerate.
    • Do fun physical activity especially activities where you look upward to re-energize.
  • Negative self-critical, powerless, self-critical and depressive thoughts and feelings.
    • Reframe internal language to empowering thoughts.
    • Change posture by wiggling and looking up to have a different point of view.
  • Crossing the legs.
    • Sit in power position and breathe diaphragmatically.
    • Get up and do a few movements such as shoulder rolls, skipping, or  arm swings.
  • Other causes.
    • Identify the trigger and explore strategies so that you can sit erect without effort.
    • Wiggle, move and get up to interrupt static muscle tension.
    • Stand up and look out of the window and the far distance while breathing slowly

Posture feedback improves health

After four weeks of using the feedback device and changing behavior,  the treatment group reported significant improvements in physical and mental health as shown in Figure 4 & 5.

Figurer 4

Figure 4. Using the posture feedback significantly improved the Physical Health and Mental Health Composite Scores for the treatment group as compared to the control group (reproduced from Mason, L., Joy, Peper, & Harvey, 2018).

Fig 5

Figure 5. Pre to post changes after using posture feedback (reproduced from Colombo, Joy, Mason, L., Peper, Harvey, & Booiman, 2017).

Summary

Slouched posture and head forward and down position usually occurs without awareness and often results in long-term discomfort. We recommend that practitioners integrate wearable biofeedback devices to facilitate home practice especially for people with neck, shoulder, back and eye discomfort as well as for those with low energy and depression (Mason et al., 2018).  We observed that a small wearable posture feedback device helped participants improve posture and decreased symptoms.  The vibratory posture feedback provided the person with the opportunity to identify the triggers associated with slouching and the option to change their posture, behavior and environment. 

As one participant reported, “I have been using the Upright device for a few weeks now. I mostly use the device while studying at my desk and during class. I have found that it helps me stay focused at my desk for longer time. Knowing there is something monitoring my posture helps to keep me sitting longer because I want to see how long I can keep an upright posture. While studying, I have found whenever I become frustrated, tired, or when my mind begins to wander I slouch. The Upright then vibrates and I become aware of these feelings and thoughts, and can quickly correct them. This device has improved my posture, created awareness, and increased my overall study time.”

Suggestions to reduce slouching and improve ergonomics

How to arrange your computer and laptop: https://peperperspective.com/2014/09/30/cartoon-ergonomics-for-working-at-the-computer-and-laptop/

Relieve neck and shoulder stiffness: https://peperperspective.com/2019/05/21/relieve-and-prevent-neck-stiffness-and-pain/

Cellphone health: https://peperperspective.com/2014/11/20/cellphone-harm-cervical-spine-stress-and-increase-risk-of-brain-cancer/

References

Colombo, S., Joy, M., Mason, L., Peper, E., Harvey, R., & Booiman, A. (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.

Devi, R. R., Lakshmi, V.V., & Devi, M.G. (2018). Prevalence of discomfort and visual strain due to the use of laptops among college going students in Hyderabad. Journal of Scientific Research & Reports, 20(4), 1-5.

Ehrlich, D.L. (1987). Near vision stress: vergence adaptation and accommodative fatigue.Ophthalmic Physiology Opt.,7(4), 353-357.

Gokhale, E. (2013). 8 Steps to a Pain-Free Back. Pendo Press.

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

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

Mason, L., Joy, M., Peper, E., & Harvey, R. (2018).Wearable Posture Feedback Training: Effects on Health. Poster presented at the 2018 meeting of the 49th Annual Meeting of the Association for Applied Psychophysiology and Biofeedback, Orlando, FL. April 11-14.

Mason, L., Joy, M., Colombo, S., Peper, E., & Harvey, R. (2017). Biofeedback Strategies to Increase Social Justice and Health Equity: A wearable device to teach awareness of posture and improve self-care. Presented at the 19th Annual meeting of the Biofeedback Federation of Europe, Aveiro, Portugal, April 24-29th, 2017. Abstract in Applied Psychophysiology and Biofeedback,43(1), 93

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.

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

Schneider, M. (2016). Vision for Life.  Berkeley, CA: North Atlantic.

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.

Wilson, V. E., & Peper, E. (2004). The Effects of Upright and Slumped Postures on the Recall of Positive and Negative Thoughts. Applied Psychophysiology and Biofeedback, 29(3), 189- 95.

 

 


Relieve and prevent neck stiffness and pain

Is your neck stiff, uncomfortable and painful?

When driving is it more difficult to turn your head?

Neck and shoulder pain affect more than 30% of people (Fejer et al, 2006; Cohen, 2015).  This blog explores some strategies to reduce or prevent neck stiffness and discomfort and suggests practices to reduce discomfort and increase flexibility if you already are uncomfortable.

Shifts in posture may optimize neck flexibility

In our modern world, we frequently engage in a forward head position while looking at electronic devices or typing on computers. Prolonged smart phone usage has the potential to negatively impact posture and breathing functions (Jung et al., 2016) since we tilt our head down to look at the screen. Holding the head in a forward position, as displayed in Figure 1, can result in muscle tension in the spine, neck, and shoulders.

head forward alignedFig 1. Forward head and neck posture in comparison to a neutral spine. Source: https://losethebackpain.com/conditions/forward-head-posture/

Whenever you bring your head forward to look at the screen or tilt it down to look at your cellphone, your neck and shoulder muscles tighten and your breathing pattern become more shallowly.  The more the head is forward, the more difficulty is it to rotate your  head as is describe in the blog, Head position, it matters! (Harvey et al, 2018). Over time, the head forward position may lead to symptoms such as headaches and backpain. On the other hand, when we shift to an aligned upright position throughout the day, we create an opportunity to relieve this tension as shown in Figure 2.

EMG head forward uprightFigure 2. EMG and respiration recording from a subject sitting with a forward head position and a neutral, aligned head position.  The neck and shoulder muscle tension was recorded from the right trapezius and left scalene muscles (Mason et all, unpublished).    .

The muscle tension recorded from scalene and trapezius muscles (neck and shoulder) in Figure 2 shows that as the head goes forward or tilts down, the muscle tension significantly increases. In most cases participants are totally unware that their neck tightens. It is only after looking at the screen or focus our eyes until the whole day that we notice discomfort in the late afternoon.

Experience this covert muscle tension pattern in the following video, Sensing neck muscle tension-The eye, head, and neck connection.

Interrupt constant muscle tension

One possible reason why we develop the stiffness and discomfort is that we hold the muscles contracted for long time in static positions. If the muscle can relax frequently, it would significantly reduce the probability of developing discomfort. Experience this concept of interrupting tension practice by practicing the following:

  • Sit on a chair and lift your right foot up one inch up from the floor. Keep holding it up? For some people, as soon as five seconds, they will experience tightening and the onset of discomfort and pain in the upper thigh and hip.

How long could you hold your foot slight up from the floor?  Obviously, it depends on your motivation, but most people after one minute want to put the foot down as the discomfort become more intense.  Put the foot down and relax.  Notice the change is sensation and for some it takes a while for the discomfort to fade out.

  • The reason for the discomfort is that the function of muscle is to move a joint and then relax. If tightening and relaxation occurs frequently, then there is no problem
  • Repeat the same practice except lift the foot, relax and drop it down and repeat and repeat. Many people can easily do this for hours when walking.

What to do to prevent neck and shoulder stiffness.

Interrupt static muscle neck tension by moving your head neck and shoulder frequently while looking at the screen or performing tasks.  Explore some of the following:

  • Look away from the screen, take a breath and as you exhale, wiggle your head light heartedly as if there is a pencil at reaching from the top of your head to the ceiling and you are drawing random patterns on the ceiling. Keep breathing make the lines in all directions.
  • Push the chair back from the desk, roll your right shoulder forward, up and back let it drop down and relax. Then roll you left shoulder forward up and back and drop down and relax. Again, be sure to keep breathing.
  • Stand up and skip in place with your hands reaching to the ceiling so that when your right foot goes up you reach upward with your left hand toward the ceiling while looking at your left hand. Then, as your left foot goes up your reach upward to the ceiling with your right hand and look at your right hand.  Smile as you are skipping in place.
  • Install a break reminder program on your computer such as Stretch Break to remind you to stretch and move.
  • Learn how to sit and stand aligned and how to use your body functionally such as with the Gokhale Method or the Alexander Technique (Gokhale, 2013; Peper et al, in press, Vineyard, 2007).
  • Learn awareness and control neck and shoulder muscle tension with muscle biofeedback. For practitioners certified in biofeedback BCB, see https://certify.bcia.org/4dcgi/resctr/search.html
  • Become aware of your collapsed and slouching wearing a posture feedback device such as UpRight Go on your upper back. This device provides vibratory feedback every time you slouch and reminds you to interrupt slouching and be upright and alighned.

Improve ergonomics

Arrange your computer screen and keyboard so that the screen is at eye level instead of having to reach forward or look down. Similarly, hold your cell phone so that it is at eye level as shown in Figure 3 and 4.

laptop ergonomicsFigure 3. Slouching forward to see the laptop screen can be avoided by using an external keyboard, mouse and desktop riser. Reproduced by permission from www.backshop.nl

Cellphone

Figure 4.  Avoid the collapsed while looking down at a cell phone by resting the arms on a backpack or purse and keeping the spine and head alighned. Photo of upright position reproduced with permission from Imogen Ragone, https://imogenragone.com/

Check vision

If you are squinting, bringing your nose to the screen, or if the letters are too small or blurry, have your eyes checked to see if you need computer glasses.  Generally do not use bifocals or progressive glasses as they force you to tilt your head up or down to see the material at a specific focal length. Other options included changing the display size on screen by making the text and symbols larger may allow you see the screen without bending forward.  Just as your muscle of your neck, your eyes need many vision breaks.  Look away from the screen out of the window at a distant tree or for a moment close your eyes and breathe.

What to do if you have stiffness and discomfort

My neck was stiff and it hurt the moment I tried to look to the sides.  I was totally surprised that I rapidly increased my flexibility and reduced the discomfort when I implemented the following two practices.

Begin by implementing the previous described preventative strategies. Most important is to interrupt static positions and do many small movement breaks. Get up and wiggle a lot. Look at the blog, Freeing the neck and shoulder, for additional practices.

Then, practice the following exercises numerous times during the day to release neck and shoulder tension and discomfort. While doing these practices exhale gently when you are stretching.  If the discomfort increases, stop and see your health professional.

 

REFERENCES

Cohen, S.P. (2015). Epidemiology, Diagnosis, and Treatment of Neck Pain. Mayo Clinic Proceedings, 90 (2), 284-299. https://doi.org/10.1016/j.mayocp.2014.09.008

Fejer, R., Kyvik, K.Ohm, & Hartvigesen, J. (2006). The prevalence of neck pain in the world population: a systematic critical review of the literature. European Spine Journal, 15(6), 834-848. https://doi.org/10.1007/s00586-004-0864-4

Gokhale, E. (2013). 8 Steps to a Pain-Free Back. Pendo Press.

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

Mason, L., Peper, E., Harvey, R., & Hernandez, W. (unpublished). Healing headaches. Does success sustain over time?

Peper, E., Krüger, B., Gokhale, E., & Harvey, R. (in press). Comparing Muscle Activity and Spine Shape in Various Sitting Styles. Biofeedback.

 Vineyar, M. (2007). How You Stand, How You Move, How You Live: Learning the Alexander Technique to Explore Your Mind-Body Connection and Achieve Self-Mastery. Boston: Da Capo Lifelong Books.


Head position, it matters!*

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

presentation1

Why is it so difficult to turn your head to see what is behind you?

How come so many people feel pressure in the back of the head or have headaches after working on the computer?

Your mother may have been right when she said, “Sit up straight! Don’t slouch!”  Sitting slouched and collapsed is the new norm as digital devices force us to slouch or tilt our head downward. Sometimes we scrunch our neck to look at the laptop screen or cellphone. This collapsed position also contributes to an increased in musculoskeletal dysfunction (Nahar & Sayed, 2018).  The more you use a screen for digital tasks, the more you tend to have head-forward posture, especially when the screens are small (Kang, Park, Lee, Kim, Yoon, & Jung, 2012). In addition, the less time children play outside and the more time young children watch the screen, the more likely will they become near sighted and need to have their vision corrected (Sherwin et al, 2012). In addition, the collapsed head forward position unintentionally decreases subjective energy level and may amplify defeated, helpless, hopeless thoughts and memories (Bader, 2015; Peper & Lin, 2012; Tsai, Peper, & Lin, 2016; Peper et al, 2017).

Explore the following two exercises to experience how the head forward position immediately limits head rotation and how neck scrunching can rapidly induce back of the head pressure and headaches.  

Exercise 1. Effect of head forward position on neck rotation

Sit at the edge of the chair and bring your head forward, then rotate your head to the right and to the left and observe how far you can rotate. Then sit erect with the crown of the head reaching towards the ceiling and again rotate your head from right to left and observe how far you can rotate as shown in Figure 1.

fig 2 head rotationFigure 1. Head-erect versus head-forward position.

What did you experience?

Most likely your experience is similar to the 87 students (Mean Age = 23.6 years) who participated in this classroom activity designed to bring awareness of the effect of head and neck position on symptoms of muscle tension.  92.0% of the students reported that is was much easier to rotate their head and could rotate further during the  head-erect position as compared to the head-forward position (see Figure 2).

fig 4 ease of rotationFigure 2.  Self-report of ease of head rotation.

What does this mean?

Almost all participants were surprised that the head forward position restricted head rotation as well as reduced peripheral awareness (Fernandez-de-Las-Penas et al., 2006). The collapsed head forward may directly affect personal safety; since, it reduces peripheral awareness while walking, biking or driving a car. In addition, when the head is forward, the cervical vertebrae are in a more curved position compared to the erect head with the normal cervical curve (Kang et al., 2012). This means that in the head-forward position, the pressure on the vertebrae and the intervertebral disc is elevated compared to the preferred position with a stretched neck. This increases the risk of damage to the vertebrae and intervertebral disc (Kang et al, 2012). It also means that the muscles that hold the head in the forward position have to work much harder. 

Be aware that of factors that contribute to a head-forward position.

  • Sitting in a car seat in which the headrest pushes the head forward. Solutions: Tilt the headrest back or put pillow in your back from your shoulders to your pelvis to move your body slightly forward.
  • If you wear a bun or ponytail, the headrest (car, airplane seat, or chair) will often push your head forward.  This causes a change of the head to a more forward position and it becomes a habit without the person even knowing it. Solution: Place a pillow in your back to move your body forward or loosen the bun or ponytail.
  • Difficulty reading the text on the digital screen. The person automatically cranes their head forward to read the text. Solutions: Have your eyes checked and,  if necessary, wear computer-reading glasses; alternatively,  increase the font size and reduce glare. 
  • Working on a laptop and looking down on the screen. Solutions: Detachable keyboard and laptop on a stand to raise screen to eye level as shown in Figure 3.laptop with keyboard raised

Figure 3. Trying to read the laptop screen, which causes the head to go forward as compared to raising the screen and using an external keyboard. Reproduced by permission from www.backshop.nl

  • Being tired or exhausted encourages the body to collapse and slouch and increases the muscle tension in the upper cervical region. You can explore the effect of tiredness that causes slouching and head-forward position during the day by observing the following if you drive a car.

In the morning, adjust your rear mirror and side mirrors. Then at the end of the day when you sit in the car, you may note that you may need to readjust your inside rear mirror. No, the mirror didn’t change of position during the day by itself—you slouched unknowingly. Solutions: Take many breaks during the day to regenerate, install stretch break reminders, or wear an UpRight Go posture feedback device to remind you when you begin to slouch (Peper, Lin & Harvey, 2017).

Exercise 2: Effect of neck scrunching on symptom development

Sit comfortably and your nose forward and slightly. While the head is forward tighten your neck as if your squeezing the back of the head downward into the shoulders and hold this contracted neck position for 20 seconds. Let go and relax.

What did you experience?

Most likely your experience was similar to 98.4% of the 125  college students who reported a rapid increase in discomfort after neck scrunching as shown in Figure 4.

fig 9 symptoms by scrunchingFigure 4.  Symptoms induced by 30 seconds of neck scrunching.

During scrunching there was a significant increase in the cervical and trapezius sEMG activity recorded from 12 volunteers as shown in Figure 5.fig 10 cervical and trap semgFigure 5. Change in cervical and trapezius sEMG during head forward and neck scrunching.

What does this mean?

Nearly all participants were surprised that 30 seconds of neck scrunching would rapidly increase induce discomfort and cause symptoms. This experience provided motivation to identify situations that evoked neck scrunching and avoid those situations or change the ergonomics that induced the neck scrunching. If you experience headaches or neck discomfort, scrunching could be a contributing factor.

Factors that contribute to neck scrunching and discomfort.

  • Bringing your head forward to see the text or graphics more clearly. There may be multiple causes such as blurred vision, tiny text font size, small screen and ergonomic factors. Possible solutions. Have your eyes checked and if appropriate wear computer-reading glasses. Increase the text font size or use a large digital screen. Reduce glare and place the screen at the appropriate height so that the top of the screen is no higher than your eyebrows.
  • Immobility and working in static position for too long a time period. Possible solutions. Interrupt your static position with movements every few minutes such as stretching, standing, and wiggling.

Conclusion

These two experiential practices are “symptom prescription practices” that may help you become aware that head position contributes to symptoms development. For example, if you suffer from headaches or neck and backaches from computer work, check your posture and make sure your head is aligned on top of your neck–as if held by an invisible thread from the ceiling and take many movement breaks.The awareness may help you to identify situations that cause these dysfunctional body patterns that could cause symptoms. By inhibiting these head and neck patterns, you may be able to reduce or avoid discomfort. Just as a picture is worth a thousand words, self-experience through feeling and seeing is believing.

REFERENCES

Bader, E. E. (2015). The Psychology and Neurobiology of Mediation. Cardozo J. Conflict Resolution, 17, 363.

Fernandez-de-Las-Penas, C., Alonso-Blanco, C., Cuadrado, M. L., & Pareja, J. A. (2006).  Forward head posture and neck mobility in chronic tension-type headache: A blinded, controlled study. Cephalalgia, 26(3), 314-319.

Kang, J. H., Park, R. Y., Lee, S. J., Kim, J. Y., Yoon, S. R., & Jung, K. I. (2012). The effect of the forward head posture on postural balance in long time computer based worker. Annals of rehabilitation medicine, 36(1), 98-104.

Lee, M. Y., Lee, H. Y., & Yong, M. S. (2014). Characteristics of cervical position sense in subjects with forward head postureJournal of physical therapy science26(11), 1741-1743.  https://doi.org/10.1589/jpts.26.1741

Nahar, S., & Sayed, A. (2018). Prevalence of musculoskeletal dysfunction in computer science students and analysis of workstation characteristics-an explorative studyInternational Journal of Advanced Research in Computer Science9(2), 21-27.  https://doi.org/10.26483/ijarcs.v9i2.5570

Peper, E., & Lin, I. M. (2012). Increase or decrease depression: How body postures influence your energy level. Biofeedback40(3), 125-130

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

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

Sherwin, J.C., Reacher, M.H., Keogh, R.H., Khawaja, A.P, Mackey, D.A., & Foster, P.J. (2012). The Association between Time Spent Outdoors and Myopia in Children and Adolescents: A Systematic Review and Meta-analysis. Ophthalmology, 119(10), 2141-2151. https://doi.org/10.1016/j.ophtha.2012.04.020

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.

*This blog was adapted from our published article, The blog has been adapted from our research article, Harvey, R., Peper, E., Booiman, A., Heredia Cedillo, A., & Villagomez, E. (2018). The effect of head and neck position on head rotation, cervical muscle tension and symptoms. Biofeedback. 46(3), 65–71.


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.

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

Guan, X., Fan, G., Chen, Z., Zeng, Y., Zhang, H., Hu, A., … He, S. (2016). Gender difference in mobile phone use and the impact of digital device exposure on neck posture. Ergonomics59(11), 1453–1461.

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

Kerry, R., Taylor, A.J., Mitchell, J., McCarthy, C., & Brew, J. (2008). Manual therapy and cervical arterial dysfunction, directions for the future: A clinical perspective. Journal of Manual & Manipulative Therapy, 16(1), 39–48.

Matsui, T. & Fujimoto, T. (2011). Treatment for depression with chronic neck pain completely cured in 94.2% of patients following neck muscle treatment. Neuroscience & Medicine, 2, 71­77.

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

Peper, E. & Lin, I. M. (2012). Increase or decrease depression-How body postures influence your energy level. Biofeedback, 40 (3), 126-130.

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We thank Frank Andrasik for his constructive comments.