Healing from vulvodynia

Pamela Jertberg and Erik Peper

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

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

The Client’s Experience

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

Triggers for Illness

Not Having a Positive Relationship with the Doctor

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

Depression

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

Being Sedentary

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

Stress

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

Processed Foods

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

Menstruation

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

Triggers for Healing

A Good Doctor

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

Positive Thoughts and Beliefs

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

Journaling

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

Meditation

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

Imagery and Visualization

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

Biofeedback

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

Regular Exercise and Yoga

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

Sex

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

Listening to the Mind-Body Connection

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

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

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

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

Conclusion

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

Useful blogs

References

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

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

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

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


Hope for menstrual cramps (dysmenorrhea) with breathing

Adapted from: Peper, E., Chen, S., Heinz, N., & Harvey, R. (in press). Hope for menstrual cramps (dysmenorrhea) with breathing. Biofeedback.

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

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

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

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

Background: What is dysmenorrhea?

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

Economic cost of dysmenorrhea

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

Treatment

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

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

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

Self-regulation strategies to reduce stress and influence dysmenorrhea

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

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

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

Observations from Integrated stress management  program

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

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

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

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

Results.

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

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

Discussion

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

Why would breathing reduce dysmenorrhea?

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

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

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

How to integrate self-care to reduce dysmenorrhea     

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

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

Conclusion

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

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

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

Useful blogs to learn diaphragmatic breathing

References

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

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

Armour, M., Parry, K., Manohar, N., Holmes, K., Ferfolja, T., Curry, C., MacMillan, F., & Smith, C. A. (2019). The prevalence and academic impact of dysmenorrhea in 21,573 young women: a systematic review and meta-analysis. Journal of women’s health28(8), 1161-1171.https://doi.org/10.1089/jwh.2018.7615

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

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

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

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

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

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

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De Sanctis, V., Soliman, A. T., Daar, S., Di Maio, S., Elalaily, R., Fiscina, B., & Kattamis, C. (2020). Prevalence, attitude and practice of self-medication among adolescents and the paradigm of dysmenorrhea self-care management in different countries. Acta Bio Medica: Atenei Parmensis91(1), 182. https://doi.org/10.23750/abm.v91i1.9242

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

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Jacobson, E. (1938). Progressive Relaxation: A Physiological and Clinical Investigation of Muscular States and Their Significance in Psychology and Medical Practice. Chicago: University of Chicago Press

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

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

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

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Breathing: Informative YouTube videos and blogs

Breathing is a voluntary and involuntary process and affects our body, emotions, mind and performance.  The focus of breathing is to bring oxygen into the body and eliminate carbon dioxide.  This is the basic physiological process that underlies the concepts described in the videos; however, it does not included the concept as breathing as a pump to optimize abdominal venous and lymph circulation. The pumping action may reduce abdominal discomfort such as irritable bowel disease, acid reflux and pelvic floor discomfort. Effortless whole body breathing also supports pelvic floor muscle tone balance and spinal column dynamics. Effortless diaphragmatic breathing can only occur if the abdomen is able to expand and constrict in 360 degrees and not constricted by tight clothing around the waist (designer’s jean syndrome), self-image (holding the abdomen in to look slimmer), or learned disuse of abdominal movement (breathing shallowly and in the chest to avoid movement at the incisionsafter abdominal surgery).

The outstanding videos discuss the psychophysiology, mechanics, chemistry of respiration as well as useful practices practices to enhance health..

The videos provide additional approaches to improve breathing and health

The blogs that explores how diaphragmatic breathing may reduce symptoms of irritable bowel syndrome, acid reflux, and pelvic floor pain.

Below are the descriptions of the youtube videos.

How to Breathe Correctly for Optimal Health, Mood, Learning & Performance | Huberman Lab Podcast

In this episode, I explain the biology of breathing (respiration), how it delivers oxygen and carbon dioxide to the cells and tissues of the body and how is best to breathe—nose versus mouth, fast versus slow, deliberately versus reflexively, etc., depending on your health and performance needs. I discuss the positive benefits of breathing properly for mood, to reduce psychological and physiological stress, to halt sleep apnea, and improve facial aesthetics and immune system function. I also compare what is known about the effects and effectiveness of different breathing techniques, including physiological sighs, box breathing and cyclic hyperventilation, “Wim Hof Method,” Prānāyāma yogic breathing and more. I also describe how to breath to optimize learning, memory and reaction time and I explain breathing at high altitudes, why “overbreathing” is bad, and how to breathe specifically to relieve cramps and hiccups. Breathwork practices are zero-cost and require minimal time yet provide a unique and powerful avenue to improve overall quality of life that is grounded in clear physiology. Anyone interesting in improving their mental and physical health or performance in any endeavor ought to benefit from the information and tools in this episode.

Dr. Jack Feldman: Breathing for Mental & Physical Health & Performance | Huberman Lab Podcast #54

This episode my guest is Dr. Jack Feldman, Distinguished Professor of Neurobiology at University of California, Los Angeles and a pioneering world expert in the science of respiration (breathing). We discuss how and why humans breathe the way we do, the function of the diaphragm and how it serves to increase oxygenation of the brain and body. We discuss how breathing influences mental state, fear, memory, reaction time, and more. And we discuss specific breathing protocols such as box-breathing, cyclic hyperventilation (similar to Wim Hof breathing), nasal versus mouth breathing, unilateral breathing, and how these each effect the brain and body. We discuss physiological sighs, peptides expressed by specific neurons controlling breathing, and magnesium compounds that can improve cognitive ability and how they work. This conversation serves as a sort of “Master Class” on the science of breathing and breathing related tools for health and performance.

5 Ways To Improve Your Breathing with James Nestor

James Nestor believes we’re all breathing wrong. Here he breaks down 5 ways to transform your breathing, from increasing your lung capacity to stopping breathing through your mouth. There is nothing more essential to our health and wellbeing than breathing: take air in, let it out, repeat 25,000 times a day. Yet, as a species, humans have lost the ability to breathe correctly, with grave consequences. In Breath, journalist James Nestor travels the world to discover the hidden science behind ancient breathing practices to figure out what went wrong and how to fix it. Modern research is showing us that making even slight adjustments to the way we inhale and exhale can: – jump-start athletic performance – rejuvenate internal organs – halt snoring, allergies, asthma and autoimmune disease, and even straighten scoliotic spines None of this should be possible, and yet it is. Drawing on thousands of years of ancient wisdom and cutting-edge studies in pulmonology, psychology, biochemistry and human physiology, Breath turns the conventional wisdom of what we thought we knew about our most basic biological function on its head. You will never breathe the same again.

Patrick McKeown – Why We Breathe: How to Improve Your Sleep, Concentration, Focus & Performance

Watch Oxygen Advantage founder and world-renowned breathing expert Patrick McKeown speak to an influential group of health professionals at the recent Health Optimisation Summit in London. Patrick was presenting his very well-received topic: ‘Why We Breathe: How to Improve Your Sleep, Concentration, Focus & Performance’. The aim of the event was to “unite the health, wellness and science disciplines”, and in doing so, it brought together thousands of industry professionals and members of the public. Patrick would like to take this opportunity to thank the organisers of The Health Optimisation Summit for an excellent event and for giving him the opportunity to speak among such luminaries of the health and wellbeing world and on a subject about which he is very passionate.

Breathing is more than gas exchange

Effortless diaphragmatic breathing is optimized when the abdomen is able to expand and constrict in 360 degrees like and not constricted by tight clothing (designer’s jean syndrome induced by the constriction of the waist), self-image (holding the abdomen in to look slimmer), or learned disuse of abdominal movement (breathing shallowly and in the chest to avoid movement at the incisions site after abdominal surgery).


Biofeedback, posture and breath: Tools for health

Two recent presentations that that provide concepts and pragmatic skills to improve health and well being.  

How changing your breathing and posture can change your life.

In-depth podcast in which Dr. Abby Metcalf, producer of Relationships made easy, interviews Dr. Erik Peper.  He discusses how changing your posture and how you breathe may result in major improvement with issues such as anxiety, depression, ADHD, chronic pain, and even insomnia! In the presentation he explain how this works and shares practical tools to make the changes you want in your life.

How to cope with TechStress

A wide ranging discussing between Dr. Russel Jaffe and Dr Erik that explores the power of biofeedback, self-healing strategies and how to cope with tech-stress.

These concepts are also explored in the book, TechStress-How Technology is Hijacking our Lives, Strategies for Coping and Pragmatic Ergonomics.  You may find this book useful as we spend so much time working online. The book describes the impacts personal technology on our physical and emotional well-being. More importantly, “Tech Stress” provides all of the basic tools to be able not only to survive in this new world but also thrive in it.

Additiona resources:

Gonzalez, D. (2022). Ways to improve your posture at home.


Reversing Pandemic-Related Increases in Back Pain

Reversing Pandemic-Related Increases in Back Pain

By: Chris Graf

Reproduced by permission from: https://www.paintreatmentdirectory.com/posts/reversing-pandemic-related-increases-in-back-pain

Back pain increased significantly during the pandemic

Google searches for the words “back pain” reached an all-time high in January 2022. In a Harris Poll in September 2021, 56% of respondents said they had chronic pain, up from about 30% before the pandemic. There are probably multiple reasons for the uptick in pain in general and back pain in particular related to COVID, including added stress and ongoing symptoms of long COVID. Poor posture while working at home is another likely contributor.

Back pain and Ergonomics

According to Dr. Erik Peper, co-author of Tech Stress: How Technology is Hijacking Our Lives, Strategies for Coping, and Pragmatic Ergonomics, It is likely that poor ergonomics in the home office are partially to blame for the apparent rise in back pain. “With COVID, ergonomics have become a disaster—especially with people who use laptops.” Peper, an internationally known expert in biofeedback and Professor of Holistic Health Studies at San Francisco State University, said that it is “almost impossible” to sit correctly when using a laptop. “In order for the hands to be at the correct level for the keyboard, the head must be tilted down. The more the head tilts forward, the most stress that is placed on the cervical spine,” he said, noting that the arms will no longer be in the proper position if the laptop is placed on a stand to raise it to eye level.

For laptop users, Peper recommends using either an external monitor or external keyboard. When using an external keyboard, a laptop stand can be used to elevate the screen to the proper eye level. University of California at Berkeley recommends other tips for ergonomic laptop positioning. 

When using both laptops and desktops, attention should be focused on proper sitting posture. Ergonomic chairs are only part of the equation when it comes to achieving proper posture.

 “A good chair only gives you the opportunity to sit correctly,” Peper said. The goal is to achieve anterior pelvic tilt by having the seat pan slightly lower in the front that in the back. He recommends using a seat insert or cushion to achieve proper positioning (see figure 1).

Figure 1.  A small pillow or rolled up towel can be placed behind the back at kidney level in order to keep the spine slightly arched (see figure 2).

Figure 2. Sitting Disease: Cause of Back Pain and Much More

According to Peper, people who spend extended periods of time at their computers are at risk  of developing   sitting disease—a  condition of increased sedentary behavior associated with adverse health effects. A  study   that appeared in the American Journal of Preventative Medicine found that prolonged sitting was associated with an increased risk of 34 chronic diseases and conditions including chronic back and musculoskeletal pain. According to the study, “Being seated alters the activation patterns of multiple weight-bearing muscles and, therefore, excessive desk use is associated with adverse back curvature, back pain and upper extremity problems such as carpel tunnel syndrome.”

To Avoid Back Pain, Don’t Slouch!

Sitting for prolonged periods of time can cause back, neck, arm, and leg pain, but slouching is even worse and can damage spinal structures. “Most people slouch at computer, and when you slouch, our spine becomes more like the letter C, our abdomen is compressed, the diaphragm goes up which causes us to shallow breathe in our upper chest,” Peper said. “That impacts our back and digestion and many other things.”

According to Peper, slouching can also impact our mood. “Slouching is the posture associated with depression and low energy. That posture collapse may evoke negative and hopeless emotions. If I sit up and look up, I have less of that. I can have more positive and uplifting thinking.”

 Peper recommends a simple device to help people improve their posture. Called an Upright Go, it attaches to the neck and provides vibrational feedback when slouching occurs. “Every time it starts buzzing, it’s a reminder to stop slouching and to get up, wiggle, and move,” he said. “We have published some studies on it, but I have no investment in the company.”

Peper’s 4 Basic Tips for Avoiding Back Pain and Other Sitting Diseases:

#1 Get Up and Move

“Rule one is to take many breaks—wiggle and move,” he said. “People are unaware that they slightly raise their shoulders and their arm goes slightly forward—in their mousing especially. By the end of the day, they feel stiffness in their shoulders or back. So, you need to take many wiggly breaks. Get up from your chair every 15 minutes.”

Use Stretch Break or one of the other apps that remind people to get up out of their chairs and stretch. 

Walk around while on the phone and wear a headset to improve posture while on the phone. 

For back pain, skip in place or lift the right arm at the same time as the left knee followed by the left arm and right knee–exercises that cause a diagonal stretch along the back.

#2 Just Breathe

  • “Learn to practice lower breathing,” Peper said. “When you sit, you are forced to breath higher in your chest. You want to practice slow diaphragmatic breathing. Breathe deeply and slowly to restore a natural rhythm. Take three deep breaths, inhaling for five seconds, then exhale very slowly for six seconds.” For more instructions on slower diaphragmatic breathing visit Peper’s blog on the subject. 

#3 Take Visual Breaks:

  • Our blinking rate significantly decreases while looking at a screen, which contributes to eye strain. To relax the eyes, look at the far distance. “Looking out into the distance disrupts constant near-focus muscle tension in the eyes,” he said. By looking into the distance, near-focus muscle tension in the eyes is disrupted.
      
  • If you have children, make sure they are taking frequent visual breaks from their screens. According to Peper, there has been a 20 percent increase in myopia (nearsightedness) in young children as a result of COVID-related distance learning. “The eyes are being formed and shaped during childhood, and if you only focus on the screen, that changes the muscle structure of our eyes over time leading to more myopia.”

#4 Pay Attention to Ergonomics

  • “If you are working on a desktop, the top of screen should be at eyebrow level,” Peper said. “Your feet should be on the ground, and the angle of the knees should be about 110 degrees. You should feel support in mid back and low back and be able to sit, lean back, and be comfortable.”
      
  • Peper recommends adjustable sit/stand desks and regularly alternating between sitting and standing.  
     

For more specific guidance on ergonomics for prolonged sitting, UCLA School of Medicine offers detailed guidelines. And don’t forget to check out Dr. Peper’s book  on ergonomics as well as his blog, The Peper Perspective, where you can use the search feature to help you find exactly what you are looking for. 

But in the meantime, Dr. Peper said, “It’s time for you to get up and wiggle!”

Find a Provider Who Can Help with Back Pain

Christine Graf is a freelance writer who lives in Ballston Lake, New York. She is a regular contributor to several publications and has written extensively about health, mental health, and entrepreneurship.    


Healing chronic back pain

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

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

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

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

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

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

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

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

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

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

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

Self-healing process

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

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

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

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

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

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

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

A. I need to have patience with myself.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Results

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

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

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

Discussion

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

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

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

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

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

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

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

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

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

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

References

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

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

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

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

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

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

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

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

Koob, G.F. (2020). Neurobiology of Opioid Addiction: Opponent Process, Hyperkatifeia, and Negative Reinforcement, Biological Psychiatry, 87(1), 44-53. https://doi.org/10.1016/j.biopsych.2019.05.023

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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



Hope for insomnia, depression, anxiety, ADHD, exhaustion, and nasal congestion -Breathe light, slow and deep

Anxiety, depression, insomnia, exhaustion, ADHD, allergies, poor performance have all increased (Barendse et al., 2021; London & Landes, 2021; Peper et al, 2022a; Peper et al, 2022b; Vasileiadou et al, 2021). One of the unrecognized contributing factor is dysfunctional mouth breathing (McKeown, 2022). Improve health by learning to breathe in and out through the nose during the day and night. Listen to the inspiring presentation by Patrick McKeown, author of the superb book, The breathing cure-Develop  new habits for a healthier, happier & long life (McKeown, 2022). In this presentation, he describes the science behind these disorders, the rationale for breathing light, slow and deep and offers simple breathing exercises to reduce symptoms and improve performance.

References

Barendse, M., Flannery, J., Cavanagh, C., Aristizabal, M., Becker, S. P., Berger, E., … & Pfeifer, J. (2021). Longitudinal change in adolescent depression and anxiety symptoms from before to during the COVID-19 pandemic: A collaborative of 12 samples from 3 countries. https://doi.org/10.31234/osf.io/hn7us

London, A.S. & Landes, S.D. (2021). Cohort Change in the Prevalence of ADHD Among U.S. Adults: Evidence of a Gender-Specific Historical Period Effect.  Journal of attention disorders, 25(6), 771-782. https://doi.org/10.1177/1087054719855689

McKeown, P. (2022). The breathing cure-Develop  new habits for a healthier, happier & long life.  West Palm Beach, FL: Humanix Books.

Peper, E. (2022). Reduce anxiety. the peperperspective. https://peperperspective.com/2022/03/23/reduce-anxiety/

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

Vasileiadou, S., Ekerljung, L., Bjerg, A., & Goksor, E. (2021). Asthma increased in young adults from 2008–2016 despite stable allergic rhinitis and reduced smoking. PLoS ONE, 16(6): e0253322. https://doi.org/10.1371/journal.pone.0253322    


Reduce anxiety

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

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

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

Background

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

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

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

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

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

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

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

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

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

Stress management as part of a university holistic health class

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

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

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

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

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

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

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

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

Lecture content

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

Daily self-practice

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

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

Discussion

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

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

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

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

See the following blogs for detailed breathing instructions

References

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

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

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You heard it before. Now do it! Three tips to reduce screen fatigue

Monica Almendras and Erik Peper

For almost a year, we have managed to survive this pandemic. As we work in front of screen many people experience screen fatigue (Bailenson, 2021). The tiredness, achiness and depressive feelings have many causes such as sitting disease, reduced social contact, constantly looking at the screen for work, education, socializing, and entertaining, and the increased stress from family illness and economic insecurity. The result is that many people experience low energy, depression, loneliness, anxiety, neck, shoulder, back pain at the end of the day (Son, Hegde, Smith, Wang, & Sasangohar, 2020; Peper & Harvey, 2018).

Yet there is hope to reduce discomfort and increase by implementing simple tips.

Take breaks and take more breaks by getting up from your chair and moving. Taking breaks helps us to clear our minds and it interrupts any ongoing rumination we may have going on. Doing this helps a person be more productive at work or when studying, and at the same time it helps retain more information (Peper, Harvey, & Faass, 2020; Kim, Park, & Headrick, 2018). How many of you reading this actually take a short break at least once during work? We stay in the same sitting position for long periods of time, even holding off to go to the restroom. We tell ourselves ‘one more minute’ or ‘I’ll just finish this and then I’ll go”. Sounds familiar? We know it is not healthy and yet, we continue doing it.

Solution: Set a reminder every twenty minutes to take a short break. Download a program on your computer that will remind you to take a break such as Stretch Break (www.stretchbreak.com). Every twenty minutes a window will pop up on your computer reminding you to stretch. It gives you simple exercises for you to move around and wiggle as shown in figure 1. You can say it breaks the spell from staying frozen in one position in front of your screen. The best part is that yet is free to download on your computer. What more can you ask for?

Figure 1.  Stretch break window that pops up on your computer to remind you to stretch.

Stop slouching in front of the screen. We tend to gaze downwards to our device and slouch, which creates tension on our neck and shoulders ((Peper, Lin, Harvey, & Perez, 2017). And yet, we still wonder why people suffer from neck-shoulder pain and headaches. It is time to make a transformation from slouching and feeling aches and pains, to an upright posture to be free of pain.

Solution: Use an UpRight Go 2 device on your upper back or neck is a great way to remind you that you are slouching (Harvey, Peper, Mason, & Joy, 2020). The UpRight is linked via Bluetooth to the App on the mobile phone, and once you calibrate it to an upright posture, you will see and feel a vibrate when you slouch. For people who are on the computer for long hours, this will help you to be aware of your posture.

If wearing a small device on your back is not your cup of tea, or perhaps it is not in your budget at the moment. There is a solution for this, and that means you can download the UpRight Desktop App on your computer or laptop (Chetwynd, Mason, Almendras, Peper, & Harvey, 2020). The desktop version uses the camera from your computer or laptop to monitor your posture; however, at the camera cannot simultaneous be in use with another program such as ZOOM. This version provides immediate feedback through the graphic on the screen as well as, an adjustable auditory signal when you slouch as shown in Figure 2. It is also free to download, and it is available for PC and Mac (https://www.uprightpose.com/desktop-app/).

Figure 2. Posture feedback app. When slouching, the app provides immediate feedback through the graphic on the screen (the posture of figure turns red) and/or an adjustable auditory sound (from: Chetwynd, Mason, Almendras, Peper, & Harvey, 2020)

Relax your eyes and look away from the screen.  Many people struggle with dry eyes and eyestrain from looking at the screen for extended time periods. We log out from work, meetings, and class; to staring at the television, tablets, and mobile phones on our free time. It is a nonstop cycle of looking at the screen, while our poor eyes never have a single break. To look at the screen, we tightened our extraocular muscles and ciliary muscles; and the result is near-vision stress (Peper, 2021).

SOLUTION: The solution to relax the eyes and reduce eyestrain will not be to buy new eyeballs online. Instead, here are three easy and free things to reestablish good eyeball health. These were adapted from the superb book, Vision for life: Ten steps for natural eyesight improvement, by Meir Schneider, PhD.

  • Look out through a window at a distance tree for a moment after reading an email or clicking a link
  • Look up at a distant tree and focus at the details of the branches and leaves each time you have finished a page from a book or eBook.
  • Rest and regenerate your eyes with palming (Peper, 2021). To do palming, all you need to do is sit upright, place an object under your elbows (pillow or books) to avoid tensing the neck and shoulders, and cover the eyes with your hands (see figure 3). Cup your hands to avoid pressure on your eyes and with your eyes closed, imagine seeing blackness while breathing slowing from your diaphragm. For five minutes, feel how your shoulders, head, and eyes are relaxing, while doing six breaths per minutes through your nose. Once your five minutes are up, stretch or wiggle around before returning to your work. For detailed instructions, see the YouTube video, Free Webinar by Meir Schneider: May 6, 2019.

Figure 3. Position for palming.

Implement these tips as an experiment for a week and note how it affects you. Many people report that after three weeks, they experience less pain and more energy. By taking charge of your own computer work patterns, you have taken a first e first step into transforming your health.

REFERENCES

Bailenson, J. N. (2021). Nonverbal Overload: A Theoretical Argument for the Causes of Zoom Fatigue. Technology, Mind, and Behavior2(1). https://doi.org/10.1037/tmb0000030

Chetwynd, J., Mason, L., Almendras, M., Peper, E., & Harvey, R. (2020). “Posture awareness training.” Poster presented at the 51st Annual meeting of the Association for Applied Psychophysiology and Biofeedback. https://doi.org/10.13140/RG.2.2.20194.76485

Harvey, R., Peper, E., Mason, L., & Joy, M. (2020). “Effect of posture feedback training on health”. Applied Psychophysiology and Biofeedback. 45(3). https://DOI.org/10.1007/s10484-020-09457-0

Kim, S., Park, Y., & Headrick, L. (2018). Daily micro-breaks and job performance: General work engagement as a cross-level moderator. Journal of Applied Psychology, 103(7), 772–786. https://doi.org/10.1037/apl0000308

Peper, E. & Harvey, R. (2018). Digital addiction: increased loneliness, depression, and anxiety. NeuroRegulation. 5(1),3–8doi:10.15540/nr.5.1.3  https://www.neuroregulation.org/article/view/18189/11842

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

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

Peper, E. (2021). “Resolve eyestrain and screen fatigue.” Well Being Journal,.30, Winter 2021 https://www.researchgate.net/publication/345123096_Resolve_Eyestrain_and_Screen_Fatigue

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

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

Son. C., Hegde, S., Smith, A., Wang, X., & Sasangohar, F. (2020). Effects of COVID-19 on College Students’ Mental Health in the United States: Interview Survey Study. J Med Internet Res, 22(9):e21279 https://doi.org/10.2196/21279