360-Degree Belly Breathing with Jamie McHugh
Posted: April 26, 2024 Filed under: attention, Breathing/respiration, emotions, healing, health, meditation, mindfulness, Pain/discomfort, relaxation, self-healing | Tags: abdominal braething, belly breathing, daiphragm, effortless breathing, passive attention, self-acceptance, somatic awreness 1 Comment
Breathing is a whole mind-body experience and reflects our physical, cognitive and emotional well-being. By allowing the breath to occur effortlessly, we provide ourselves the opportunity to regenerate. Although there are many directed breathing practices that specifically directs us to inhale or exhale at specific rhythms or depth to achieve certain goals, healthy breathing is whole body experience. Many focus on being paced at a specific rhythm such as 5.5 breath per minute; however, effortless breathing is dynamic and constantly changing. It is contstantly adapting to the body’s needs: sometimes the breath is slightly slower, sometimes slightly faster, sometimes slightly deeper, sometimes slightly more shallower. The breathing process is effortless. This process can be described by the Autogenic training phrase, “It breathes me” (Luthe, 1969; Luthe, 1979; Luthe & de Rivera, 2015). Read the essay by Jamie McHugh, Registered Master Somatic Movement Therapist and then let yourself be guided in this non-striving somatic approach to allow effortless 360 degree belly breathing for regeneration.
The 360 degree belly breathing by Jamie McHugh, MSMT, is a somatic exploration to experience that breathing is not just abdominal breathing by letting the belly expand forward, but a rhythmic 360 degree increase and decrease in abdominal volume without effort. This effortless breathing pattern can often be observed in toddlers when they sit peacefully erect on the floor. This pattern of breathing not only enhances gas exchange, more importantly, it enhances abdominal blood and lymph circulation.
“The usual psychodynamic foundation for the self-experience is that of hunger, not breath. The body is experienced as an alien entity that has to be kept satisfied; the way an anxious mother might experience a new baby. When awareness is shifted from appetite to breath, the anxieties about not being enough are automatically attenuated. It requires a settling down or relaxing into one’s own body. When this fluidity moves to the forefront of awareness…there is a relaxation of the tensed self…and the emergence of a simpler, breath-based self that is capable of surrender to the moment.” – Mark Epstein (2013).
The intention behind 360 Degree Belly Breathing is to access and express the movement of the breath in all three dimensions. This is the basis for all subsequent somatic explorations within the Embodied Mindfulness protocol, a body-based approach to traditional meditation practices I have developed over the past 20 years (McHugh, 2016). Embodied Mindfulness explores the inner landscape of the body with the essential somatic technologies of breath, vocalization, self-contact, stillness and subtle movement. We focus and sustain mental attention while pleasurably cultivating bodily calm and clarity as a daily practice for survival in these turbulent times. Coupled with individual variations and experimentation, this practice becomes a reliable sanctuary from overwhelm, scattered attention, and emotional turmoil.
The Central Diaphragm
The central diaphragm, a dome-shaped muscular sheath that divides the thorax (chest) and the abdomen (belly), is the primary mechanism for breathing. It is the floor for your heart and lungs and the ceiling for your belly. The central diaphragm is a mostly impenetrable divide, with a few openings through it for the aorta, vena cava and the esophagus. Each time you inhale, the diaphragm contracts and flattens out a bit as it presses down towards your pelvis. Each time you exhale, the diaphragm relaxes and floats back up towards your heart. The motion of the diaphragm impacts the barometric pressure in your chest: the downward movement of the diaphragm on the inhale pulls oxygen into your lungs, and the subsequent exhale expels carbon dioxide into the world as the diaphragm releases upwards.
The movement of the diaphragm is twofold: involuntary and voluntary. Involuntary, ordinary breathing is a homebase and a point of return. Breathing just automatically happens – you don’t have to think about it. Breathing is also voluntary; you can choose to change the tempo (quick or slow), the duration (short or long) and quality (smooth or sharp) of this movement to “charge up and chill out” at will. Knowing how to collaborate with your diaphragm, discovering your own rhythm of diaphragmatic action, and undulating between the automatic and the chosen is a foundation for physiological equilibrium and emotional “self-soothing”.
Watch these two brief videos to get a visual image of your diaphragm in motion:
Beginning Sitting Practice
“When your back becomes straight, your mind will become quiet.” – Shunryu Suzuki
What does it mean to have a “straight back”? What are the inner coordinates and outer parameters of this position in space? And what kind of environment is needed to support this uprightness? This simple orientation to sitting can create more comfort, ease and support in your structure, which will stimulate more fluidity in your breathing and your thinking.
As you sit on a chair, consider two points of focus: body and environment. Can I sit upright with ease and comfort on this chair? If not, what changes can I make with my body and how can I adapt the environment of this chair to meet my needs? Since we are all various heights, it is not surprising a one-size-fits-all chair would need adaptation. Don’t be content with your first solution – experiment until you find just the right configuration. Valuing and seeking bodily comfort and ease are simple yet profound acts of self-kindness.
Do you need to move your pelvis forward on the chair or back? If you move your pelvis back, do you get the necessary support from the back of the chair for your pelvic bowl? If the back of the chair is too far away and/or makes you lean back into space, place a small cushion or two between the back of the chair and the base of your spine. With your back supported, are your feet on the floor? If not, place a folded blanket or a cushion under them.
With pelvis and feet in place, take a few full breaths to stabilize your pelvis and let your weight drop down through your sitz bones into the chair. The upper body receives more support from the core muscles of the lower body when your center of gravity drops – you don’t have to work so hard to maintain uprightness. Finally, rock on your sitz bones forward, backward, and side-to-side. Movement awakens bodily feedback so you can feel where center is in this moment. That sense of center will continue to change throughout the duration of the practice period so feel free to periodically adjust your position.
After this initial structural orientation, the next step is attending to the combination of breath and self-contact to fill out our self-perception. Self-contact is like using a magnifying glass – focusing the mind by feeling the substance of the belly’s movement in our hands. Since the diaphragm is a 360-degree phenomenon that generates movement in our sides and our back as well as our front, spreading awareness out not only creates different patterns of muscular activation – it also changes the brain’s map of the body and how we perceive ourselves. This change of orientation over time recalibrates our alignment and how we settle in ourselves, with awareness of our back in equal proportion to our front and sides.
360-Degree Belly Breath
“To stop your mind does not mean to stop the activities of the mind. It means your mind pervades your whole body.” – Shunryu Suzuki
Read text below or be guided by the audio file or YouTube video. http://somaticexpression.com/classes/360DegreeBreathingwithJamieMcHugh.mp3
Sit comfortably and place your hands on the front of your belly. With each inhale, become aware of the forward movement of your belly swelling. Then, with each exhale, notice the release of your belly and the settling back to center. Give this action and each subsequent action at least 5-7 breath cycles. Intersperse this way of breathing with ordinary, effortless breathing by letting the body breathe automatically. Return time and again to ordinary breathing, letting go of the focus and the effort to rest in the aftermath.
Now, slide your hands to the sides of your belly. Notice with each breath cycle how your belly moves laterally out to the sides on the inhale and then settles back to center again on the exhale.
Now, slide your hands to the back of your belly. You may wish to make contact with the back of your hands instead of your palms if it is more comfortable. With each inhale, focus on the movement into the backspace – this will be much smaller than the movement to the front; and with each exhale, the movement settling back to center.
Finally, connect all three directions: your belly radiates out 360 degrees on the horizon with each inhale, simultaneously moving forward, backward, and out to both sides, and then settles inward with each exhale.
Finish with open awareness – scanning your whole inner landscape from feet to head, back to front, and center to extremities, and letting your body breathe itself, as you notice what is alive in you now.
Inhale – Belly Radiates Outwards; Exhale – Belly Settles Inwards
“The belly is an extraordinary diagnostic instrument. It displays the armoring of the heart as a tension in the belly. Trying tightens the belly. Trying stimulates judgment. Hard belly is often judging belly. Observing the relative openness or closedness of the belly gives insight into when and how we are holding (on) to our pain. The deeper our relationship to the belly, the sooner we discover if we are holding in the mind or opening into the heart.” – Steven Levine (1991)
The contact of your hands on your belly helps the mind pay attention to the subtle movement created by the inhale-exhale cycle of the diaphragm. The combination of tactility and interoceptive awareness focusing on the belly shifts attention into our “second brain” (the enteric nervous system) and signals the mind it can rest and soften. More pleasurable sensation is often accompanied by an emergent feeling of safety as you settle into sensing the rhythm of a slower, more even breath, creating a feedback loop between bodily/somatic ease and mental calm. Giving yourself some daily “breathing room” in this way can help you build the calm muscle!
Naturally, there can be hiccups along the way so it is not all unicorns and rainbows! By giving the mind bodily tasks to accomplish, particularly in relationship to deepening and expanding the movement of the breath, we ease the self into a slower, more receptive state of being. Yet, in this receptive state of ease, whatever is in the background of awareness can arise and slip through the “border control”, sometimes taking us by surprise and causing distress. Depending upon the nature of the information, there are layers of action strategies that can be progressively taken to modulate and buffer what arises:
Tether your awareness to the breath rhythm with hands on your belly to stay present as a witness. Next step up: open your eyes softly and look around to orient in your present environment. Further step up: breath flow, hands-on belly, eyes open a wee bit looking around, and adding simple movement, like rocking a bit in all directions or expressing an exhale as a sigh, a yawn or a hum.
Note: If you find your personal resources are insufficient, find a guide to work with one-on-one to discover your own individual path for increasing the “window of capacity”. Above all, be gentle with yourself – take your time – cultivate your garden – and enjoy your breath!
References
Epstein, M. (2013) Thoughts without a Thinker: Psychotherapy from a Buddhist Perspective. New York: Basic Books. https://www.amazon.com/Thoughts-Without-Thinker-Psychotherapy-Perspective/dp/0465050948
Levine, S. (1991). Guided Meditations, Explorations and Healings. New York: Anchor. https://www.amazon.com/Guided-Meditations-Explorations-Healings-Stephen/dp/0385417373
Luthe, W. (1969). Autogenic Therapy Volume 1 Autogenic Methods. New York: Grune and Stratton. https://www.amazon.com/Autogenic-Therapy-1-Methods/dp/B0013457B4/
Luthe, W. (1979). About the Methods of Autogenic Therapy. In: Peper, E., Ancoli, S., Quinn, M. (eds). Mind/Body Integration. Springer, Boston, MA. https://doi.org/10.1007/978-1-4613-2898-8_12
Luthe, W. & de Rivera, L. (2015). Wolfgang Luthe Introductory workshop: Introduction to the Methods of Autogenic Training, Therapy and Psychotherapy (Autogenic Training & Psychotherapy). CreateSpace Independent Publishing Platform. https://www.amazon.com/WOLFGANG-LUTHE-INTRODUCTORY-WORKSHOP-Psychotherapy/dp/1506008038/
Quick Rescue Techniques When Stressed
Posted: February 4, 2024 Filed under: attention, behavior, biofeedback, Breathing/respiration, CBT, cognitive behavior therapy, education, emotions, Evolutionary perspective, Exercise/movement, health, mindfulness, Neck and shoulder discomfort, posture, relaxation, stress management, Uncategorized | Tags: alarm reaction, anxiety, box breathing, Breathing, conditioning, defense reaction, health, huming, Parasympathetic response, rumination, safety, sniff inhale, somatic practices, stress, sympathetic arousal, tactical breathing, Toning, yoga 2 CommentsErik Peper, PhD, Yuval Oded, PhD, and Richard Harvey, PhD
Adapted from Peper, E., Oded, Y, & Harvey, R. (2024). Quick somatic rescue techniques when stressed. Biofeedback, 52(1), 18–26. https://doi.org/10.5298/982312
“If a problem is fixable, if a situation is such that you can do something about it, then there is no need to worry. If it’s not fixable, then there is no help in worrying. There is no benefit in worrying whatsoever.” ― Dalai Lama XIV
To implement the Dalai Lama’s quote is challenging. When caught up in an argument, being angry, extremely frustrated, or totally stressed, it is easy to ruminate, worry. It is much more challenging to remember to stay calm. When remembering the message of the Dalai Lama’s quote, it may be possible to shift perspective about the situation although a mindful attitude may not stop ruminating thoughts. The body typically continues to reacti to the torrents of thoughts that may occur when rehashing rage over injustices, fear over physical or psychological threats, or profound grief and sadness over the loss of a family member. Some people become even more agitated and less rational as illustrated in the following examples.
I had an argument with my ex and I am still pissed off. Each time I think of him or anticipate seeing them, my whole body tightened. I cannot stomach seeing him and I already see the anger in his face and voice. My thoughts kept rehashing the conflict and I am getting more and more upset.
A car cut right in front of me to squeeze into my lane. I had to slam on my brakes. What an idiot! My heart rate was racing and I wanted to punch the driver.
When threatened, we respond quickly in our thoughts and body with a defense reaction that may negatively affect those around us as well as ourselves. What can we do to interrupt negative stress reactions?
Background
Many approaches exist that allow us to become calmer and less reactive. General categories include techniques of cognitive reappraisal (seeing the situation from the other person’s point of view and labeling your own feelings and emotions) and stress management techniques. Practices that are beneficial include mindfulness meditation, benign humor (versus gallows humor), listening to music, taking a time out while implementing a variety of self-soothing practices, or incorporating slow breathing (e.g., heart rate variability and/or box breathing) throughout the day.
No technique fits all as we respond differently to our stressful life circumstances. For example, some people during stress react with a “tend and befriend stress response” (Cohen & Lansing, 2021; Taylor et al., 2000). This response appears to be mostly mediated by the hormone oxytocin acting in ways that sooth or calm the nervous system as an analgesic. These neurophysiological mechanisms of the soothing with the calming analgesic effects of oxytocin have been characterized in detail by Xin, et al. (2017).
The most common response is a fight/flight/freeze stress response that is mediated by excitatory hormones such as adrenalin and inhibitory neurotransmitters such as gamma amino butyric acid (GABA). There is a long history of fight/flight/freeze stress response research, which is beyond the scope of this blog with major theories and terms such as interior milleau (Bernard, 1872); homeostasis and fight/flight (Cannon, 1929); general adaptation syndrome (Selye, 1951); polyvagal theory (Porges, 1995); and, allostatic load (McEwen, 1998). A simplified way to start a discussion about stress reactions begins with the fight/flight stress response. When stressed our defense reactions are triggered. Our sympathetic nervous system becomes activated our mind and body stereotypically responds as illustrated in Figure 1.
Figure 1. An intense confrontation tends to evoke a stress response (reproduced from Peper et al., 2020).
The flight/fight response triggers a cascade of stress hormones or neurotransmitters (e.g., hypothalamus-pituitary-adrenal cascade) and produces body changes such as the heart pounding, quicker breathing, an increase in muscle tension and sweating. Our body mobilizes itself to protect itself from danger. Our focus is on immediate survival and not what will occur in the future (Porges, 2021; Sapolsky, 2004). It is as if we are facing an angry lion—a life-threatening situation—and we feel threatened and unsafe.
Rather than sitting still, a quick effective strategy is to interrupt this fight/flight response process by completing the alarm reaction such as by moving our muscles (e.g., simulating a fight or flight behavior) before continuing with slower breathing or other self-soothing strategies. Many people have experienced their body tension is reduced and they feel calmer when they do vigorous exercise after being upset, frustrated or angry. Similarly, athletes often have reported that they experience reduced frequency and/or intensity of negative thoughts after an exhausting workout (Thayer, 2003; Liao et al., 2015; Basso & Suzuki, 2017).
Becoming aware of the escalating cascades of physical, behavioral and psychological responses to a stressor is the first step in interrupting the escalating process. After becoming aware, reduce the body’s arousal and change the though patterns using any of the techniques described in this blog. The self-regulation skills presented in this blog are ideally over-learned and automated so that these skills can be rapidly implemented to shift from being stressed to being calm. Examples of skills that can shift from sympathetic neervous system overarousal to parasympathetic nervous system calm include techniques of autogenic traing (Schulz & Luthe, 1959), the quieting reflex developed by Charles Stroebel in 1985 or more recently rescue breathing developed by Richard Gevirtz (Stroebel, 1985; Gevirtz, 2014; Peper, Gibney & Holt, 2002; Peper & Gibney, 2003).
Concepts underlying the rescue techniques
- 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” (Green et al. 1970, p. 3).
- Posture evokes memories and feelings associated with the position. When the body posture is erect and tall while looking slightly up. It is easier to evoke empowering, positive thoughts and feelings. When looking down it is easier to evoke hopeless, helpless and powerless thoughts and feelings (Peper et al., 2017).
- Healing occurs more easily when relaxed and feeling safe. Feeling safe and nurtured enhances the parasympathetic state and reduces the sympathetic state. Use memory recall to evoke those experiences when you felt safe (Peper, 2021).
- Interrupting thoughts is easier with somatic movement than by redirecting attention and thinking of something else without somatic movement.
- Focus on what you want to do not want to do. Attempting to stop thinking or ruminating about something tends to keeps it present (e.g., do not think of pink elephants. What color is the elephant? When you answer, “not pink,” you are still thinking pink). A general concept is to direct your attention (or have others guide you) to something else (Hilt & Pollak, 2012; Oded, 2018; Seo, 2023).
- Skill mastery takes practice and role rehearsal (Lally et al., 2010; Peper & Wilson, 2021).
- Use classical conditioning concepts to facilitate shifting states. Practice the skills and associate them with an aroma, memory, sounds or touch cues. Then when you the situation occurs, use these classical conditioned cues to facilitate the regeneration response (Peper & Wilson, 2021).
Rescue techniques
Coping When Highly Stressed and Agitated
- Complete the alarm/defense reaction with physical activity (Be careful when you do these physical exercises if you have back, hip, knee, or ankle problems).
- Acknowledge you have reacted and have chosen to interrupt your automatic response.
- Check whether the situation is actually a threat. If yes, then do anything to get out of immediate danger (yell, scream, fight, run away, or dial 911).
- If there is no actual physical threat, then leave the situation and perform vigorous physical activity to complete your alarm reaction, such as going for a run or walking quickly up and down stairs. As you do the exercise, push yourself so that the muscles in your thighs are aching, which focusses your attention on the sensations in your thighs. In our experience, an intensive run for 20 minutes quiets the brain while it often takes 40 minutes when walking somewhat quickly.
- After recovering from the exhaustive exercise, explore new options to resolve the conflict.
- Complete the alarm/defense reaction and evoke calmness with the S.O.S™ technique (Oded, 2023)
- Acknowledge you have reacted and have chosen to interrupt your automatic response.
- Squat against a wall (similar to the wall-sit many skiers practice). While tensing your arms and fists as shown in Figure 2, gaze upward because it is more difficult to engage in negative thinking while looking upwards. If you continue to ruminate, then scan the room for object of a certain color or feature to shift visual attention and be totally present on the visual object.
- Do this set of movements for 7 to 10 seconds or until you start shaking. Than stand up and relax hands and legs. While standing, bounce up and down loosely for 10 to 15 seconds as you become aware of the vibratory sensations in your arms and shoulders, as shown in Figure 3.
Figure 2.Defense position wall-sit to tighten muscles in the protective defense posture (Oded, 2023). Figure 3. Bouncing up and down to loosen muscles ((Oded, 2023).
- Acknowledge you have reacted and have chosen to interrupt your automatic response. Swing your arms back and forth for 20 seconds. Allow the arms to swing freely as illustrated in Figure 4.
Figure 4. Swinging the arms to loosen the body and spine (Oded, 2023).
- Rest and ground. Lie on the floor and put your calves and feet on a chair seat so that the psoas muscle can relax, as illustrated in Figure 5. Allow yourself to be totally supported by the floor and chair. Be sure there is a small pillow under your head and put your hand on your abdomen so that you can focus on abdominal breathing.
Figure 5. Lying down to allow the psoas muscle to relax and feel grounded (Oded, 2023).
- While lying down, imagine a safe place or memory and make it as real as possible. It is often helpful to listen to a guided imagery or music. The experience can be enhanced if cues are present that are associated with the safe place, such as pictures, sounds, or smells. Continue to breathe effortlessly at about six breaths per minute. If your attention wanders, bring it back to the memory or to the breathing. Allow yourself to rest for 10 minutes.
In most cases, thoughts stop and the body’s parasympathetic activity becomes dominant as the person feels safe and calm. Usually, the hands warm and the blood volume pulse amplitude increases as an indicator of feeling safe, as shown in Figure 6.
Figure 6. Blood volume pulse increases as the person is relaxing, feels safe and calm.
Coping When You Can’t Get Away (adapted from Peper, Harvey & Faass, 2020)
In many cases, it is difficult or embarrassing to remove yourself from the situation when you are stressed out such as at work, in a business meeting or social gathering.
- Become aware that you have reacted.
- Excuse yourself for a moment and go to a private space, such as a restroom. Going to the bathroom is one of the only acceptable social behaviors to leave a meeting for a short time.
- In the bathroom stall, do the 5-minute Nyingma exercise, which was taught by Tarthang Tulku Rinpoche in the tradition of Tibetan Buddhism, as a strategy for thought stopping (see Figure 7). Stand on your toes with your heels touching each other. Lift your heels off the floor while bending your knees. Place your hands at your sides and look upward. Breathe slowly and deeply (e.g., belly breathing at six breaths a minute) and imagine the air circulating through your legs and arms. Do this slow breathing and visualization next to a wall so you can steady yourself if necessary to keep balance. Stay in this position for 5 minutes or longer. Do not straighten your legs—keep squatting despite the discomfort. In a very short time, your attention is captured by the burning sensation in your thighs. Continue. After 5 minutes, stop and shake your arms and legs.
Figure 7. Stressor squat Nyingma exercise (reproduced from Peper et al., 2020).
- Follow this practice with slow abdominal breathing to enhance the parasympathetic response. Be sure that the abdomen expands as the inhalation occurs. Breathe in and out through the nose at about six breaths per minute.
- Once you feel centered and peaceful, return to the room.
- After this exercise, your racing thoughts most likely will have stopped and you will be able to continue your day with greater calm.
What to do When Ruminating, Agitated, Anxious or Depressed
(adapted from Peper, Harvey, & Hamiel, 2019).
- Shift your position by sitting or standing erect in a power position with the back of the head reaching upward to the ceiling while slightly gazing upward. Then sniff quickly through nose, hold and again sniff quickly then very slowly exhale. Be sure as you exhale your abdomen constricts. Then sniff again as your abdomen gets bigger, hold, and sniff one more time letting the abdomen get even bigger. Then, very slow, exhale through the nose to the internal count of six (adapted from Balban et al., 2023). When you sniff or gasp, your racing thoughts will stop (Peper et al., 2016).
- Continue with box breathing (sometimes described as tactical breathing or battle breathing) by exhaling slowly through your nose for 4 seconds, holding your breath for 4 seconds, inhaling slowly for 4 seconds through your nose, holding your breath for 4 seconds and then repeating this cycle of breathing for a few minutes (Röttger et al., 2021; Balban et al., 2023). Focusing your attention on performing the box breathing makes it almost impossible to think of anything else. After a few minutes, follow this with slow effortless diaphragmatic breathing at about six breaths per minute. While exhaling slowly through your nose, look up and when you inhale imagine the air coming from above you. Then as you exhale, imagine and feel the air flowing down and through your arms and legs and out the hands and feet.
- While gazing upward, elicit a positive memory or a time when you felt safe, powerful, strong and/or grounded. Make the positive memory as real as possible.
- Implement cognitive strategies such as reframing the issue, sending goodwill to the person, seeing the problem from the other person’s point of view, and ask is this problem worth dying over (Peper, Harvey, & Hamiel, 2019).
What to Do When Thoughts Keep Interrupting
Practice humming or toning. When you are humming or toning, your focus is on making the sound and the thoughts tend to stop. Generally, breathing will slow down to about six breaths per minute (Peper, Pollack et al., 2019). Explore the following:
- Box breathing (Röttger et al., 2021; Balban et al., 2023)
- Humming also known as bee breath (Bhramari Pranayama) (Abishek et al., 2019; Yoga, 2023) – Allow the tongue to rest against the upper palate, sit tall and erect so that the back of the head is reaching upward to the ceiling, and inhale through your nose as the abdomen expands. Then begin humming while the air flows out through your nose, feel the vibration in the nose, face and throat. Let humming last for about 7 seconds and then allow the air to blow in through the nose and then hum again. Continue for about 5 minutes.
- Toning – Inhale through your nose and then vocalize a single sound such as Om. As you vocalize the lower sound, feel the vibration in your throat, chest and even going down to the abdomen. Let each toning exhalation last for about 6 to 7 seconds and then inhale through your nose. Continue for about 5 minutes (Peper, al., 2019).
Many people report that after practice these skills, they become aware that they are reacting and are able to reduce their automatic reaction. As a result, they experience a significant decrease in their stress levels, fewer symptoms such as neck and holder tension and high blood pressure, and they feel an increase in tranquility and the ability to communicate effectively.
Practicing these skills does not resolve the conflicts; they allow you to stop reacting automatically. This process allows you a time out and may give you the ability to be calmer, which allows you to think more clearly. When calmer, problem solving is usually more successful. As phrased in a popular meme, “You cannot see your reflection in boiling water. Similarly, you cannot see the truth in a state of anger. When the waters calm, clarity comes” (author unknown).
Boiling water (photo modified from: https://www.facebook.com/photo/?fbid=388991500314839&set=a.377199901493999)
Below are additional resources that describe the practices. Please share these resources with friends, family and co-workers.
Stressor squat instructions
Toning instructions
Diaphragmatic breathing instructions
Reduce stress with posture and breathing
Conditioning
References
Abishek, K., Bakshi, S. S., & Bhavanani, A. B. (2019). The efficacy of yogic breathing exercise bhramari pranayama in relieving symptoms of chronic rhinosinusitis. International Journal of Yoga, 12(2), 120–123. https://doi.org/10.4103/ijoy.IJOY_32_18
Balban, M. Y., Neri, E., Kogon, M. M., Weed, L., Nouriani, B., Jo, B., Holl, G., Zeitzer, J. M., Spiegel, D., Huberman, A. D. (2023). Brief structured respiration practices enhance mood and reduce physiological arousal. Cell Reports Medicine, 4(1), 10089. https://doi.org/10.1016/j.xcrm.2022.100895
Basso, J. C. & Suzuki, W. A. (2017). The effects of acute exercise on mood, cognition, neurophysiology, and neurochemical pathways: A review. Brain Plast, 2(2), 127–152. https://doi.org/10.3233/BPL-160040
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Cohen, L. & Lansing, A. H. (2021). The tend and befriend theory of stress: Understanding the biological, evolutionary, and psychosocial aspects of the female stress response. In: Hazlett-Stevens, H. (eds), Biopsychosocial Factors of Stress, and Mindfulness for Stress Reduction. pp. 67–81, Springer, Cham. https://doi.org/10.1007/978-3-030-81245-4_3
Gevirtz, R. (2014). HRV Training and its Importance – Richard Gevirtz, Ph.D., Pioneer in HRV Research & Training. Thought Technology. Accessed December 29, 2023. https://www.youtube.com/watch?v=9nwFUKuJSE0
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Hilt, L. M., & Pollak, S. D. (2012). Getting out of rumination: comparison of three brief interventions in a sample of youth. Journal of Abnormal Child Psychology, 40(7), 1157–1165.
https://doi.org/10.1007/s10802-012-9638-3
Lally, P., VanJaarsveld, C. H., Potts, H. W., & Wardle, J. (2010). How habits are formed: Modelling habit formation the real world. European Journal of Social Psychology, 40, 998–1009. https://doi.org/10.1002/ejsp.674
Liao, Y., Shonkoff, E. T., & Dunton, G. F. (2015). The acute relationships between affect, physical feeling states, and physical activity in daily life: A review of current evidence. Frontiers in Psychology. 6, 1975. https://doi.org/10.3389/fpsyg.2015.01975
McEwen, B. S. (1998). Stress, adaptation, and disease: Allostasis and allostatic load. Annals of the New York Academy of Sciences, 840(1), 33–44.
https://doi.org/10.1111/j.1749-6632.1998.tb09546.x
Oded, Y. (2018). Integrating mindfulness and biofeedback in the treatment of posttraumatic stress disorder. Biofeedback, 46(2), 37-47. https://doi.org/10.5298/1081-5937-46.02.03
Oded, Y. (2023). Personal communication. S.O.S 1™ technique is part of the Sense Of Safety™ method. www.senseofsafety.co
Peper, E. (2021). Relive memory to create healing imagery. Somatics, XVIII(4), 32–35.https://www.researchgate.net/publication/369114535_Relive_memory_to_create_healing_imagery
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Peper, E., & Gibney, K.H. (2003). A teaching strategy for successful hand warming. Somatics. XIV(1), 26–30. https://www.researchgate.net/publication/376954376_A_teaching_strategy_for_successful_hand_warming
Peper, E., Harvey, R., & Faass, N. (2020). TechStress: How Technology is Hijacking Our Lives, Strategies for Coping, and Pragmatic Ergonomics. North Atlantic Books. https://www.amazon.com/Beyond-Ergonomics-Prevent-Fatigue-Burnout/dp/158394768X
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Healing a Shoulder/Chest Injury
Posted: August 14, 2023 Filed under: behavior, biofeedback, Breathing/respiration, emotions, Exercise/movement, healing, Neck and shoulder discomfort, Pain/discomfort, relaxation, self-healing, Uncategorized | Tags: electromyograph, guided imagery, shoulder pain Leave a commentAdapted from Peper, E. & Fuhs, M. (2004). Applied psychophysiology for therapeutic use: Healing a shoulder injury, Biofeedback, 32(2), 11-18.
“It has been an occurrence of the third dimension for me! How come my pain — that lasted for more than 10 days and was still so strong that I really had difficulties in breathing, couldn’t laugh without pain nor move my arm not even to fulfil my daily routines such as dressing and eating — disappeared within one single session of 20 minutes? And not only that, I was able to freely rotate my arm as if it had never been injured before.” —23 year old woman
The participant T., aged 23, was a psychology student who participated in an educational workshop for Healthy Computing. She volunteered to be a subject for a surface electromyographic (SEMG) monitoring and feedback demonstration. Ten days prior to this workshop, she had a severe skiing accident. She described the accident as follows:
I went skiing and may be I had too much snow in my ski-binding and while turning, I slipped out of my binding and fell head first down into the hill. As I fell, I landed on my ski pole which hit my left upper chest and breast area. Afterwards, my head was humming and I assumed that I had a light concussion. I stopped skiing and stayed in bed for a while. The next day it started hurting and I couldn’t turn my head or put my shoulders back (they were rotated forward). Also, I couldn’t ski as I was not able to look down to my feet–my muscles were too contracted and I felt searing pain whenever I moved. I hoped that it would go away however, the pain and left forward shoulder rotation stayed.
Assessment
Observation and Palpation
T.´s left shoulder was rolled forward (adducted and in internal rotation). She was not able to breathe or laugh without pain or move her arm freely. All movements in vertical and horizontal directions and rotations were restricted by at least 50 % as compared to her right arm (limitations in shoulder extension, flexion and external rotation). Also, her hands were ice-cold and she breathed very shallowly and rapidly in her chest. She was not able to stand in an upright position or sit in a comfortable position without maintaining her left upper extremity in a protected position. Her left shoulder blade (scapula) was winging.
After visually observing her, the instructor placed his left hand on her left shoulder and pectoralis muscles and his right hand on the back of her shoulder. Using palpation and anchoring her back with his leg so that she could not rotate her trunk, he explored the existing range of shoulder movement. He also attempted to rotate the left shoulder outward and back–not by forcing or pulling—but by very gentle traction. No change in mobility was observed and the pectoralis muscle felt tight (SEMG monitoring is helpful to the therapist during such a diagnostic assessment by helping to identify the person’s reactivity and avoiding to evoke and condition even more bracing). T. reported afterwards that she was very scared by this assessment because there was one point in the back which was highly reactive to touch. T. appeared to tighten automatically out of fear and trigger a general flexor contraction pattern—a process that commonly occurs if a person is guarding an area.
Often a traumatic injury first induces a general shock that triggers an automatic freeze and fear reaction. Therefore, an intervention needed to be developed that did not trigger vigilance or fear and thereby allowed the muscle to relax. If pain is experienced or increased, it is another negative reinforcement for generalizing guarding and bracing and tightening the muscles. This guarding decreases mobility – a common reaction that may occur when health professionals in the process of assessment increase the client’s discomfort. T.’s vigilance was also “telegraphed” to the therapist by her ice-cold hands and very shallow chest breathing. Therefore, it was important to increase her comfort level and to not induce any further pain. We hypothesized that only if she felt safe it would be possible for her muscle tension to decrease and thereby increase her mobility.
Underlying concept: The very cold hands and shallow breathing probably indicated excessive vigilance and arousal—a possible indicator of a catabolic state that could limit regeneration. The chronic cold hands most likely implied that she was very sensitive to other people’s emotions and continuously searches/scans the environment for threats. In addition, she indicated that she liked to do/perform her best which induced more anxiety and fear of judgement.
Single Channel Surface Electromyographic (SEMG)Assessment
The triode electrode with sensor was placed over the left pectoralis muscle area as shown in Figure 1. The equipment was a MyoTrac™ produced by Thought Technology Ltd. which is a small portable SEMG with the preamplifiers at the triode sensor to eliminate electrode lead and movement artefacts (Peper & Gibney, 2006). Such a device is an inexpensive option for people who may use biofeedback for demonstrating and teaching awareness and control over muscle tension from a single electrode location.
Figure 1. Location of the Triode electrode placement on the left pectoralis muscle area of another participant.
The MyoTrac was placed on a table within view, so that the therapist and the subject could simultaneously see the visual feedback signal and observe what was going on as well as demonstrate expected changes. The feedback was used for T. as a tool to see if she could reduce her SEMG activity. It was also used by the therapist to guide his interventions: To keep the SEMG activity low and to stop any intervention that would increase the SEMG activity as this would prevent bracing as a possible reaction to, or anticipation of, pain.
1. Assessment of Muscle Reactivity. After the electrode was attached on her pectoralis muscle and with her arm resting on her lap, she was asked to roll her left shoulder slightly more forward, hold the tension for the count of 10 and then let go and relax. Even with feedback, the muscle activity stayed high and did not relax and return to a lower level of activity as shown in Figure 2. This lack of return to baseline is often a diagnostic indicator of muscle irritability or injury (Sella, 1998; Sella, 2006). If the muscle does not relax immediately after contraction, movement or exercise should not be prescribed, since it may aggravate the injury. Instead, the person first needs to learn how to relax and then learn how to relax between activation and tensing of the muscle. The general observation of T. was that at the initiation of any movement (active or passive) muscle tension increased and did not return to baseline for more than two minutes.
Figure 2. Simulation of the effect on the pectoralis sEMG (this is a recording from another subject who showed a similar response pattern that was visually observed from T. with the Myotrac). After the muscle is contracted it takes a long time to return to baseline level
2. Exploration. Self-exploration with feedback was encouraged. T. was instructed to let go of muscle tension in her left shoulder girdle. In addition the therapist tried to induce her letting go by gently and passively rocking her left arm. The increased SEMG activity and the protective bracing in her shoulder showed that she couldn’t reduce the muscle tension. Each time her arm was moved, however slightly, she helped with the movement and kept control. In addition, T. was asked to reduce the muscle tension using the biofeedback signal; again she was not able to reduce her muscle tension with feedback.
3. Passive Stretch and Movements. The next step was to passively stretch the pectoralis muscle by holding the shoulder between both hands and very gently externally rotate the shoulder — a process derived from the Alexander technique (Barlow, 1991). Each time the instructor attempted to rotate her shoulder, the SEMG increased and T. reported an increased fear of pain. T.’s SEMG response most likely consisted of the following components:
- Movement induced pain
- Increased splinting and guarding
- Increased arousal/vigilance to perform well
These three assessment and self-regulation procedures were unsuccessful in reducing muscle tension or increasing shoulder movement. This suggested that another therapeutic intervention would need to be developed to allow the left pectoralis area to relax. The SEMG could be used as an indicator whether the intervention was successful as indicated by a reduction in SEMG activity. Finally, the inability to relax after tightening (bracing and splinting) probably aggravated her discomfort.
Multiple levels of injury: The obvious injury and discomfort was due to her left chest wall being hit by the ski pole. She then guarded the area by bracing the muscles to protect it which limited movement. The guarding tightened the muscles and limited blood circulation and lymphatic flow which increased local ischemia, irritation and pain. This led to a self-perpetuating cycle: Pain triggers guarding and guarding increases pain and impedes self-healing.
As the SEMG and passive stretching assessment were performed, the therapist concurrently discussed the pain process. Namely, from this perspective, there were at least two types of pains:
- Pain caused by the physiological injury
- Pain as the result of guarding
The pain from the guarding is similar to having exercised for a long time after not having exercised. The next day you feel sore. However, if you feel sore, you know that it was due to the exercise therefore it is defined as a good pain. In T.’s case, the pain indicated that something was wrong and did not heal and therefore she would need to protect it. We discussed this process as a way to use cognitive reframing to change her attitude toward guarding and pain.
Rationale: The intention was to interrupt her negative image of pain that acted as a post hypnotic suggestion. The objective was to change her image and thoughts from “pain indicates the muscle is damaged” to “pain indicates the muscle has worked too hard and long and needs time to regenerate.”
Treatment interventions
The initial intervention focused upon shifting shallow thoracic breathing to diaphragmatic breathing. Generally, when people breathe rapidly and predominantly in their chest, they usually tighten their neck and shoulder muscles during inhalation. One of the reasons T. breathed in her chest was that her clothing–very tight jeans–constricted her waist (MacHose & Peper, 1991; Peper et al., 2015). This breathing pattern probably contributed to sub-clinical hyperventilation and was part of a fear or flexor response pattern. When she loosened the upper buttons of her jeans and allowed her stomach to expand her pectoralis muscle relaxed as she breathed as shown in Figure 3. As she began to breathe in this pattern, each time she exhaled her pectoralis muscle tension decreased.
Figure 3. Illustration of the effect of loosening tight waist constriction (eliminating designer’s jean syndrome) on blood flow and pectoralis sEMG. Abdominal breathing became possible and finger temerature increased (this recording is from another subject whose physiological responses were similar to that was observed with the Myotrac from T.)
Following the demonstration that breathing significantly lowered her chest muscle tension, the discussion focussed on the importance of effortless diaphragmatic breathing for health and reduction of vigilance. Being awkward and uncomfortable at loosening her pants, she struggled with allowing her abdomen to expand and her pants to be looser because she thought that she looked much more attractive in tight clothing. Yet, she agreed that her boy friend would love her regardless whether she wore loose or tight clothing. To encourage an acceptance for wearing looser clothing and thereby permit diaphragmatic breathing during the day, an informal discussion focused on “designer jeans syndrome” (chest breathing induced by tight clothing) with humorous examples such as discussing the name of the room that is located on top of the stairs in the Victorian houses in San Francisco. It is called the fainting room–in the 19th century women who wore corsets and had to climb the stairs would have to breathe rapidly and then would faint when they reached the top of the stairs (Peper, 1990).
Rationale: Rapid shallow chest breathing can induce a catabolic state that inhibits healing while diaphragmatic breathing may induce an anabolic state that promotes regeneration. Moreover, effortless diaphragmatic breathing would increase respiratory sinus arhythmia (RSA)–heart rate variability linked to breathing– and thereby facilitate sympathetic-parasympathetic balance that would promote self-healing.
The discussion included the use of the YES set which meant asking a person questions in such a way that she/he answers the question with YES. When a person answers YES at least three times in a row rapport is often facilitated (Erikson, 1983, pp. 237-238). Questions were framed in such a way that the client would answer with YES. For example, if the therapist thought the person did not do their homework, a yes question could be framed as, “It must have been difficult to find time to do the homework this week?” In T.’s case, the therapist said, “I see, you would rather wear tight clothing than allow your shoulder to heal.” She answered, “Yes.” This was the expected answer, however, the question was framed in an intuitive guess on the therapist’s part. Nevertheless, the strategy would have been successful either way because if she had answered “No,” it would have broken the “Yes: set, but she would then be committed to change her clothing.
Throughout this discussion, the therapist placed his left hand on her abdomen over her belly button and overtly and covertly guided her breathing movement. As she exhaled, he pressed gently on her abdomen; as she inhaled he drew his hand away–as if her abdomen was like a balloon that inflated during inhalation and deflated during exhalation. To enhance learning diaphragmatic breathing and slower exhalation, the therapist covertly breathed at the same rhythm and gently exhaled as she exhaled while allowing the breathing movement to be mainly in his abdomen. In this process, learning occurred without demand for performance and she could imitate the breathing process that was covertly modelled by the therapist.
The Change
The central observation was that each time she tried to relax or do something, she would slight brace which increased her pectoralis SEMG activity. The chronic tension from guarding probably induced localized ischemia, inhibited lymphatic flow and drainage, and reduced blood circulation which would increase tissue irritation. Whenever the therapist began to move her arm, she would anticipate and try to help with the movement. Overall she was vigilant (also indicated by her very cold hands) and wanted to perform very well (a possible need for approval). Her muscle bracing and helping with movement was reframed as a combined activity that consisted of guarding to prevent further injury and as a compliment that she would like to perform well.
Labelling her activity as a “compliment” was part of a continuing YES set approach. The therapist was deliberately framing whatever happened as adaptive behaviour, with positive intent. Further, if one tries and does something with too much effort while being vigilant, the arousal would probably induce hand cooling. If the activity can be performed with passive attention, then increased blood flow and warmth may occur. The therapeutic challenge was how to reduce vigilance, perfectionism and guarding so that the muscles that were guarding the traumatized area would relax.
Therapeutic concept: If a direct approach does not work, an indirect approach needs to be employed. Through an indirect approach, the person experiences a change without trying to focus on doing or achieving it. Underlying this approach is the guideline: If something does not work, try it once more and then if it does not work, do something completely different. This is analogous to sexual arousal: If you demand from a male to have an erection: The more performance you demand the less likely will there be success. On the other hand, if you remove the demand for performance and allow the person to become interested and thereby feel an erotic experience an erection may occur without effort.
The shift to an indirect intervention was done through active somatic visualization. T. was encouraged to visualize and remember a positive image or memory from her past. She chose a memory of a time when she was in Paris with her grandmother. While T. visualized being with her grandmother, the therapist asked another older women participant to help and hold T’s right hand in a grandmother-like way as if she was her grandmother. The “grandmother” then moved T.’s hand in a playful way as if dancing with T.’s right arm. Through this kinesthetic experience, T. became more and more absorbed in her memory experience. At the same time, T´s left hand was being held and gently rocked by the therapist. During this gentle rocking, the SEMG activity decreased completely in her left pectoralis area. The therapist used the SEMG feedback to guide him in the gentle rocking motion of T.’s left arm and very slowly increased the range of her arm and shoulder motion. Gentle movement was done only as long as the SEMG activity did not increase. It allowed the muscle to stay relaxed and facilitated the experience of trust. The following is T. report two days later of what happened.
“Initially it was very difficult for me to let go of control because I found this idea somewhat strange and I was puzzled. I expected the therapist to intervene and I felt frightened. The therapist’s soft and gentle touch and his very soft voice in this kind of meditation helped me to let go of control and I was surprised about my own courage to give myself into the process without knowing what would happen next.”
Rationale: Every corresponding thought and emotion has an associated body response and every body response has an associated mental/emotional response (Green & Green, 1977; Green, 1999). Therefore, an image and experience of a happy and safe past memory will allow the body to evoke the same state and vigilance can be abated. The intensity of the experience is increased when multi-sensory cues are included such as actual handholding. The more senses are involved, the more the experience can become real. In addition, the tactile sensation of feeling the grandmother’s hand diverted her attention away from her shoulder into her hand and thereby reduced her active efforts of trying to relax the shoulder and pectoralis area. Doing something she did not expect to happen also helped her loose control – an implicit confusion approach.
SEMG feedback was used as the guide for controlling the movement. The therapist gently increased the range of the movements in abduction and external rotation directions while continuously rocking her arm until her injured arm was able to move unrestricted in full range of motion. The arm and shoulder relaxation and continuous subtle movement without evoking any SEMG activation facilitated blood flow and lymphatic drainage which probably reduced congestion. After a few minutes, the therapist gently dropped her arm on her lap. After her arm was resting on her lap, she reported that it felt very heavy and relaxed and that she didn’t feel any pain. However, she initially didn’t really realize that her mobility had increased dramatically.
Rationale: When previous movements that had been associated with pain are linked to an experience of pleasure, the movement is often easier. The conditioned muscle bracing patterns associated with anticipation of pain and/or concern for improvement/results are reduced.
Process to deepen and generalize the relaxation and breathing. She was asked to imagine breathing the air down and through her arms and legs–a strategy that she could then do at home with her boyfriend. We wanted to involve another person because it is often difficult to do homework practices without striving and concern for results and focussing on the area of discomfort. Her response to asking if her boyfriend would help was an automatic “naturally” (the continuation of the YES set). With her agreement, we role played how her boyfriend was to encourage diaphragmatic breathing. He was to gently stroke down her legs as she exhaled. She could then just focus on the sensations and allow the air to flow down her legs. Then, while she continued to breathe effortlessly, he would gently rock and move her arm.
To be sure that she knew how to give the instructions, the therapist role played her boyfriend and then asked her to rock his arm so that she would know how to teach her boy friend how to move her arm. The therapist sat on her left side, and, as she now held his right arm and gently rocked it with her left arm, the therapist gently moved backwards. This meant that she externally rotated her left arm and shoulder more and more. He moved in such a way that in the process of rocking his arm, she moved her “previously injured shoulder” in all directions (up, down, forward and backwards) and was unaware that she could move her arm and shoulder as she did not experience any discomfort. Afterwards, we shared our observations and she was asked to move her arm and shoulder. She moved it without any restrictions or discomfort.
Rationale: By focusing outside herself and not being concerned about herself, she did not think of herself or of trying to move her arm and shoulder. Hence, she did not evoke the anticipatory guarding and thus significantly increased her flexibility.
Process of acceptance. Often after an injury, we are frustrated with our bodies. This frustration may interfere with healing. Therefore, the session concluded by asking her to be appreciative of her shoulder and arm. She was asked to think of all the positive things her shoulder, chest and arm have done for her in the past instead of the many limitations and pains caused by the injury. Instead of being angry at her shoulder that it had not healed or restricted her movement, we suggested that she should appreciate her shoulder and pectoralis area for all it had done without her awareness such as: How the shoulder moved her arm during love-making, how without complaining her shoulder moved during walking, writing, skiing, eating, etc., and how many times in the past she had abused her shoulder without giving it proper respect and appreciation. This process reframes the way one symbolically relates to the injured area. Every thought of discomfort or negative judgement becomes the trigger and is transformed into breathing lower and slower and evokes an appreciation of the positive nice things her shoulder has done for her in the past.
Rationale: When injured we often evoke negative mental and emotional images which become post- hypnotic suggestions. Those negative thoughts, images and emotions interfere with healing while positive thoughts, images and emotions tend to promote healing. A possible energetic process that occurs when injured is that we withdraw awareness/ consciousness from the injured area which reduces blood and lymph circulation. Caring and positive feelings about an area tends to increase blood flow and warmth (a heart-warming experience) and promotes healing.
RESULTS
She left the initial session without any pain and with total range of motion. At the two week follow-up she reported continued pain relief and complete range of motion. T.s reflection of the experience was:
“I really was not aware that I could move my arm freely like before the accident, I was just feeling a kind of trance and was happy to not feel any pain and to feel much more upright than before. Then I watched the faces of the two other therapists who sat there with big eyes and a grin on their face and then become aware of my own arms position which was rotated backwards and up, a movement that was impossible to do before. I remember this evening that I left with this feeling of trance and that I often tried to go back to my collapsed posture but this was not possible anymore and I felt very tall and straight. Now two weeks later I still feel like that and know that I had an amazing experience which I will store in my brain!
My father who is an orthopedic surgeon tested me and found out, that I had hurt my rib. He said that I have a contusion and it will go away in a few weeks. Before this experience, I would say that he was not open to Biofeedback. However he was so captivated by my experiences that he spontaneously promised me to pay for my own biofeedback equipment and to support me with my educational program and even offered me a job in his practice to do this work!”
Psychophysiological Follow-up: 3 Weeks Later
The physiological assessment included monitoring thoracic and abdominal breathing patterns, blood volume pulse, heart rate and SEMG from her left pectoralis muscle while she was asked to roll her left shoulder forward (adducted and internally rotated) for the count of 10 and then relax. The physiological recording showed that she breathed more diaphragmatically and that her pectoralis muscle relaxed and returned directly to baseline after rotation as shown in Fig. 4.
Figure 4. Physiological profile during the rolling left shoulder forward (tense) and relaxing at thethree week follow-up. Note that the pectoralis sEMG activity returned rapidly to baseline after contracting and her breathing pattern is abdomninal and slower.
Summary
This case example demonstrates the usefulness of a simple one-channel SEMG biofeedback device to guide the interventions during assessment and treatment. It suggests that the therapist and client can use the SEMG activity as an indicator of guarding–a visual representation of the subjective experience of fear, pain and range of mobility–that can be evoked during assessment and therapeutic interventions. The anticipation of increased pain commonly occurs during diagnosis and treatment and often becomes an obstacle for healing because increased pain may increase anticipation of pain and trigger even more bracing. To avoid triggering this vicious circle of guarding/fear, the feedback signal allows the therapist and the client to explore strategies that reduce muscle activity by indirect interventions.
By using an indirect approach that the client may not expect, the interventions shift the focus of attention and striving and may allow increased freedom and relaxation. The biofeedback signal may guide the therapeutic process to reduce the patterns of fear, panic, and bracing that are commonly associated with injury and illnesses. Once this excessive sympathetic activity is reduced, the actual pathophysiology may become obvious (in most cases is much less then before) and the healing process may be accelerated. This case description may offer an approach in diagnosis and treatment for many therapists and open a door for a gentle, painless and yet successful way of treatment and encourage therapists to be creative and use both experience/technique and intuition.
For additional intervention approaches see the following two blogs.
References
Barlow, W. (1991). The Alexander technique: How to use your body without stress. Rochester, VT: Healing Arts Press https://www.amazon.com/Alexander-Technique-Your-without-Stress/dp/0892813857#:~:text=Barlow%2C%20the%20foremost%20exponent%20and,and%20movement%20in%20everyday%20activities.
Erikson, M. H. (1983). Healing in hypnosis, volume 1 (Edited by E. L. Rossi, M. O. Ryan, M. & F. A. Sharp). New York: Irvington Publishers, Inc.. https://www.amazon.com/Hypnosis-Seminars-Workshops-Lectures-Erickson/dp/0829007393/ref=sr_1_1?keywords=9780829007398&linkCode=qs&qid=1692038804&s=books&sr=1-1
Green, E. (1999). Psychophysical Principal. Accessed August 14, 2023 https://www.elmergreenfoundation.org/psychophysiological-principal/
Green, E., & Green, A. (1977). Beyond biofeedback. New York:
Delacorte Press/Seymour. https://elmergreenfoundation.org/wp-content/uploads/2019/02/Beyond-Biofeedback-Green-Green-Searchable.pdf
MacHose, M., & Peper, E. (1991). The effect of clothing on inhalation volume. Biofeedback and Self-Regulation. 16(3), 261-265. https://doi.org/10.1007/BF01000020
Peper, E. (1990). Breathing for health. Montreal: Thought Technology Ltd.
Peper, E. & Gibney, K.H. (2006). Muscle biofeedback at the computer-A manual to prevent repetitive strain injury (RSI) by taking the guesswwork out of assessment, monitoring and training. Biofeedback Foundation of Europe. https://thoughttechnology.com/muscle-biofeedback-at-the-computer-book-t2245/
Peper, E., Gilbert, C.D., Harvey, R. & Lin, I-M. (2015). Did you ask about abdominal surgery or injury? A learned disuse risk factor for breathing dysfunction. Biofeedback. 34(4), 173-179. https://doi.org/10.5298/1081-5937-43.4.06
Sella, G. E. (2006). SEMG: Objective methodology in muscular dysfunction investigation and rehabilitation. Weiner’s pain management: A practical guide for clinicians, CRC Press, 645-662. https://www.taylorfrancis.com/chapters/edit/10.1201/b14253-45/semg-objective-methodology-muscular-dysfunction-investigation-rehabilitation-gabriel-sella
Sella, G. E. (1998). Towards an Integrated Approach of sEMG Utilization: Quantative Protocols of Assessment and Biofeedback. Electromyography: Applications in Physical Medicine. Thought Technology, 13. https://www.bfe.org/protocol/pro13eng.htm
[1] We thank Theresa Stockinger for her significant contribution and Candy Frobish for her helpful comments.
Healing from vulvodynia
Posted: May 4, 2023 Filed under: behavior, biofeedback, Breathing/respiration, emotions, healing, health, Pain/discomfort, relaxation, self-healing, Uncategorized | Tags: muscle tension, pelvic floor pain, therapeutic relationship, triggers for illness, vulvodynia Leave a commentPamela Jertberg and Erik Peper
Adapted from: Jertberg, P. & Peper, E. (2023). The healing of vulvodynia from the client’s perspective. Biofeedback, 51 (1), 18–21. https://doi.org/10.5298/1081-5937-51.01.02
This introspective report describes how a young woman who experienced a year-long struggle with vulvodynia, or vulvar vestibulitis, regained her health through biofeedback training and continues to be symptom-free 7 years after the intervention. This perspective may offer insight into factors that promote health and healing and provide an approach to reduce symptoms and promote health. The methodology of this case was described previously by Peper et al. (2015).
The Client’s Experience
I have been a healthy young woman my whole life. Growing up in a loving, dedicated family, I always ate home-cooked meals, went to bed at a reasonable time, and got plenty of exercise by playing with my family members and friends. I never once thought that at age 23 I might be at risk of undergoing vulvar surgery. There are many factors that contributed to the genesis of my vulvar pain, and many other factors that worsened this pain. Traditional medicine did not help me, and I did not find relief until I met my biofeedback practitioner, who taught me biofeedback. Through the many strategies I learned, such as visualization, diaphragmatic breathing techniques, diet tips, and skills to reframe my thoughts, I finally began to feel relief and hope. Practicing all these elements every day helped me overcome my physical pain and enjoy a normal life once again. Today, I do not have any vulvar discomfort. I am so grateful to my biofeedback practitioner for the many skills he taught me. I can enjoy my daily activities once again without experiencing pain. I have been given a second chance at loving life, and now I have learned the techniques that will help me sustain a more balanced path for the rest of my life. Seven years later, I am healthy and have no symptoms.
Triggers for Illness
Not Having a Positive Relationship with the Doctor
The first factor that aggravated my pain was having a doctor with whom I did not have a good relationship. Although the vulvar specialist I was referred to had treated hundreds of women with vulvar vestibulitis, his methods were very traditional: medicine, low oxalate diet, ointments, and surgery. Whenever I left his office, I would cry and feel like surgery was the only option. Vaginal surgery at 23 was one of the scariest and most unexpected thoughts my brain had ever considered. The doctor never thought of the impact that his words and treatment would have on my mental state.
Depression
Being depressed also triggered more pain. Whenever I would have feelings of hopelessness and create irrational beliefs in my mind (“I will never get better,” “I will never have sex again,” “I am not a woman anymore”), my physical pain would increase. Having depression only triggered more depression and pain, and this became a vicious cycle. The depression deeply affected my relationships with my boyfriend, friends, and family and my performance in my college classes.
Being Sedentary
Being sedentary and not exercising also increased my pain. At first, I believed that the mere act of sitting down hurt me due to the direct pressure on the area, but after a few months I came to realize that it was inactivity itself that triggered pain. Whenever I would sit for too long writing a paper or I would stay home all day because of my depression, my pain would increase, perhaps because I was inhibiting circulation. Still, when I am inactive most of the day, I feel lethargic and bloated. When I exercise, the pain goes away 100%. Exercise is almost magical.
Stress
Stress is the worst trigger for pain. Throughout my life, I always strived to be perfect in every way, meaning I was stressed about the way I looked, performed in school, drove, etc. Through the sessions with my biofeedback practitioner, I learned that my body was in a state of perpetual stress and tightness, which induced pain in certain areas. My body’s way of releasing such tension was to send pain signals to my vulvar area, perhaps because of a yeast infection a couple of months back. Still, if I become very stressed, I will feel pain or tightness in certain parts of my body, but now I have strategies for performing proper stress-relieving techniques.
Processed Foods
Junk food affects me instantly. When I eat processed foods for a week straight, I feel groggy, bloated, lethargic, and in pain. Processed sugar, white flour, and salt are a few of the foods that make the pain increase. I used to love sugar, so I would enjoy the occasional milkshake and cheeseburger and feel mostly okay. However, in times of stress it became crucial for me to learn to refrain from any junk food, because it would worsen my vulvar pain and increase my overall stress levels.
Menstruation
Menstruation is unavoidable, and unfortunately it would always worsen my vulvar pain. Right about the time of my period, my sensitivity and pain would massively increase. Sometimes as my pain would increase incredibly, I would question myself: “What am I doing wrong?” Then, I would remember: “Oh yes, I am getting my period in a few days.” The whole area became very sensitive and would get irritated easily. It became imperative to listen to my body and nurture myself especially around that time of the month.
Triggers for Healing
A Good Doctor
Just as I learned which factors triggered the pain, I also learned how to reduce it. The most important factor that helped me find true relief was meeting a good health professional (which could be a healer, nurse, or professor). The first time I met my biofeedback practitioner and told him about my issues, he really listened, gave me positive feedback, and even made jokes with me. To this day we still have a friendship, which has really aided me in getting better. In contrast to the vulvar specialist, I would leave the biofeedback practitioner’s office feeling powerful, able to defeat vulvodynia, and truly happy. Just having this support from a professional (or a friend, boyfriend, or relative) can make all the difference in the world. I don’t know where I would be right now if I hadn’t worked with him.
Positive Thoughts and Beliefs
Along with having a good support group, having positive thoughts and believing in a positive result helped me greatly. When I actually set my mind to feel “happy” and to believe that I was getting better, I began to really heal. After months of being depressed and feeling incomplete, when I began to practice mantras such as “I am healing,” “I am healthy,” and “I am happy,” my pain began to go away, and I was able to reclaim my life.
Journaling
One of the ways in which “happiness” became easier to achieve was to journal every day. I would write everything: from my secrets to what I ate, my pain levels, my goals for the day, and my symptoms. Writing down everything and knowing that no one would ever read it but me gave me relief, and my journal became my confidante. I still journal every day, and if I forget to write, the next day I will write twice as much. Now that writing has become a habit and a hobby, it is hard to imagine my life without that level of introspection.
Meditation
Although I would do yoga often, I would never sit and meditate. I began to use Dr. Peper’s guided meditations and Dr. Kabat-Zinn’s CD (Kabat-Zinn, 2006; Peper et al., 2002). The combination of these meditation techniques, whether on different days or on the same day, helped me focus on my breathing and relax my muscles and mind. Today, I meditate at least 20 min each day, and I feel that it helps me see life through a more willing and patient perspective. In addition, through meditation and deep breathing I have learned to control my pain levels, concentration, and awareness.
Imagery and Visualization
Imagery is a powerful tool that allowed me to heal faster. My biofeedback practitioner instructed me to visualize how I wanted to feel and look. In addition, he suggested that I draw and color how I was feeling at any given moment, my imagined healing process, and how I would look and feel after the healing process had traveled throughout my body (Peper et al., 2022). It is still amazing to me how much imagery helped me. Even visualizing here and there throughout the day helped. Now I envision how I want to feel as a healthy woman, I take a deep breath, and as a I breathe out I let my imagined healing process go through my body into all my tight areas along with the exhalation.
Biofeedback
Biofeedback is the single strategy that helped me the most. During my first session with my biofeedback practitioner, he pointed out that my muscles were always contracted and stressed and that I was not breathing diaphragmatically. As I learned how to take deep belly breaths, I began to feel the tight areas in my body loosen up. I started to practice controlled breathing 20 min every day. Through biofeedback, my body and muscles became more relaxed, promoting circulation and ultimately reducing the vulvar pain.
Regular Exercise and Yoga
Exercising daily decreased my pain and improved the quality of my life greatly. When I first started experiencing significant vulvar pain, I stopped exercising because I felt that movement would aggravate the pain. To my surprise, the opposite was true. Being sedentary increased the feelings of discomfort, whereas exercising released the tension. The exercise I found most helpful was yoga because it is meditation in movement. I became so focused on my breathing and the poses that my brain did not have time to think about anything else. After attending every yoga class, I felt like I could take on anything. Swimming, Pilates, and gentle cardiovascular exercises have also helped me greatly in reducing stress and feeling great.
Sex
Although sex was impossible for almost a year due to the pain, it became possible and even enjoyable after implementing other relaxation strategies. When I first reintroduced sex back into my life, my partner at the time and I would go gently and stop if it hurt my vulvar area at all. Today, sex again is joyful. Being able to engage in intercourse has boosted my self-esteem and helped me feel sexy again, which empowers me to keep practicing the relaxation techniques.
Listening to the Mind-Body Connection
The mind-body connection is present in all of us, but I am fortunate to have a very strong connection. My thoughts influence my body almost instantly, which is why when I would get depressed my pain would increase, and when I would see my biofeedback practitioner or believe in a good outcome, my pain would decrease. Being aware of this connection is crucial because it can help me or hurt me greatly. After a few months of practicing the relaxation strategies, I saw a different gynecologist and one dermatologist. Both professionals said that there was nothing wrong with my vulvar area—that maybe I just felt some irritation due to the medicines I had previously taken and my current stress. They said that there was no way I needed surgery. When I heard these opinions, I began to feel instantly better—thus proving that my thoughts (and even others’ thoughts) affect my body in significant ways.
Although today I am 100% better, I still experience pain and tightness in my body when I experience the “illness factors” I mentioned above. I still have to remember that feeling healthy and good is a process, not a result, and that even if I feel better one day that does not mean I can stop all my new healthy habits. To completely cure vulvodynia, I needed to change my life habits, perspective, and attitude toward the illness and life. I needed to make significant changes, and now my biggest challenge is to stick to those changes. Biofeedback, imagery, meditation, good food, and exercise are not just treatments that I begin and end on a certain day, but rather they have become essential components of my life forever.
My life with vulvodynia was ultimately a journey of introspection, decision making, and life-changing habits. I struggled with vulvar pain for over a year, and during that year I experienced severe symptoms, depression, and the loss of several friendships and relationships. I felt old, hopeless, useless, and powerless. When I began to incorporate biofeedback, relaxation techniques, journaling, visualization, a proper diet, and regular exercise, life took a turn for the better. Not only did my vulvar pain begin to decrease, but the quality of my overall life improved and I regained the self-confidence I had lost. I became happy, hopeful, and proactive. Even though I practiced the relaxation strategies every day, the pain did not go away in a day or even a month. It took me several months of diligent practice to truly heal my vulvar pain. Even today, such practices have carried on to all areas of my life, and now there is not a day when I do not meditate, even for 5 min.
As paradoxical as it may seem, vulvodynia was a blessing in disguise. I believe that vulvodynia was my body’s way of signaling to me that many areas of my life were in perpetual stress: my pelvic floor, my thoracic breathing, my romantic relationship at the time, etc. When I learned to let go and truly embrace my life, I began to feel relief. I became less irritable and more patient and understanding, with both my body and the outside world. The best advice I can give a woman with vulvar symptoms or any person with otherwise inexplicable chronic pain is to apply the strategies that work for you and stick to them every day—even on the days when you want to go astray. When I started to focus on what my body needed to be nurtured and to live my life and do the things I truly wanted to do, I became free. Today, I live in a way that allows me to find peace, serenity, pride, and fun. I live exactly the way I want to, and I find the time to follow my passions. Vulvodynia, or any kind of chronic pain, does not define who we are. We define who we are.
Conclusion
This introspective account of the client’s personal experience with biofeedback suggests that healing is multidimensional. We suggest that practitioners use a holistic approach, which can provide hope and relief to clients who suffer from vulvodynia or other disorders that are often misunderstood and underreported.
Useful blogs
References
Kabat-Zinn, J. (2006). Coming to our senses: Healing ourselves and the world through mindfulness. Hachette Books
Peper, E., Cosby, J. & Almendras, M. (2022). Healing chronic back pain. NeuroRegulation, 9(3), 164–172. https://doi.org/10.15540/nr.9.3.164
Peper, E., Gibney, K.H, & Holt, C.F. (2002. Make health happen: Training yourself to create wellness. Kendall/Hunt.
Peper, E. Martinex, Aranda, P. & Moss, D. (2015). Vulvodynia treated successfully with breathing biofeedback and integrated stress reduction: A case report. Biofeedback, 43(2), 103–109. https://doi.org/10.5298/1081-5937-43.2.04
Hope for menstrual cramps (dysmenorrhea) with breathing
Posted: April 22, 2023 Filed under: behavior, biofeedback, Breathing/respiration, healing, health, meditation, Pain/discomfort, posture, relaxation, self-healing, stress management, Uncategorized | Tags: dysmenorrhea, Imagery, menstrual cramps, stroking, visualization 1 CommentAdapted from: Peper, E., Chen, S., Heinz, N., & Harvey, R. (2023). Hope for menstrual cramps (dysmenorrhea) with breathing. Biofeedback, 51(2), 44–51. https://doi.org/10.5298/1081-5937-51.2.04
“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 health, 28(8), 1161-1171.https://doi.org/10.1089/jwh.2018.7615
ASPH. (2023). Estrogen and Progestin (Oral Contraceptives). MedlinePlus. Assessed March 3, 2023. https://medlineplus.gov/druginfo/meds/a601050.html
Balick, L., Elfner, L., May. J., Moore, J.D. (1982). Biofeedback treatment of dysmenorrhea. Biofeedback Self Regul, 7(4), 499-520. https://doi.org/10.1007/BF00998890
Bennink, C.D., Hulst, L.L. & Benthem, J.A. (1982). The effects of EMG biofeedback and relaxation training on primary dysmenorrhea. J Behav Med, 5(3), 329-341.https://doi.org/10.1007/BF00846160
Bier, M., Kazarian, D. & Peper, E. (2005). Reducing PMS through biofeedback and breathing. Poster presentation at the 36th Annual Meeting of the Association for Applied Psychophysiology and Biofeedback. Abstract published in: Applied Psychophysiology and Biofeedback. 30 (4), 411-412.
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Breathing: Informative YouTube videos and blogs
Posted: March 20, 2023 Filed under: behavior, Breathing/respiration, health, mindfulness, Pain/discomfort, relaxation, self-healing | Tags: anxiety, box breathing, carbon dioxide, exhaling, hickups 3 Comments
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..
- How to Breathe Correctly for Optimal Health, Mood, Learning & Performance | Huberman Lab Podcast (Skip the advertisements embedded in this video)
- Dr. Jack Feldman: Breathing for Mental & Physical Health & Performance | Huberman Lab Podcast #54 (Skip the advertisements embedded in this video)
The videos provide additional approaches to improve breathing and health
- 5 Ways to Improve your Breathing with James Nestor
- Patrick McKeown-Why we breathe: How to improve your sleep, concentration, focus & performance
The blogs that explores how diaphragmatic breathing may reduce symptoms of irritable bowel syndrome, acid reflux, and pelvic floor pain.
- Healing irritable bowel syndrome with diaphragmatic breathing
- Breathing to reduce acid reflux and dysmenorrhea
- Enjoy sex: Breath away the pain
- Resolving pelvic floor pain-a casae report
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
Posted: December 1, 2022 Filed under: ADHD, behavior, biofeedback, Breathing/respiration, CBT, cognitive behavior therapy, computer, digital devices, education, emotions, ergonomics, Evolutionary perspective, Exercise/movement, healing, health, laptops, mindfulness, Neck and shoulder discomfort, Pain/discomfort, posture, relaxation, screen fatigue, self-healing, stress management, Uncategorized, vision, zoom fatigue 2 CommentsTwo 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
Posted: August 30, 2022 Filed under: behavior, Breathing/respiration, digital devices, ergonomics, Exercise/movement, health, laptops, Neck and shoulder discomfort, Pain/discomfort, posture, relaxation, self-healing, stress management, Uncategorized | Tags: back pain 1 Comment
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
Posted: July 31, 2022 Filed under: behavior, Breathing/respiration, CBT, cognitive behavior therapy, education, healing, health, meditation, relaxation, self-healing, stress management, surgery | Tags: back pain, Imagery, self-care, visualization 2 CommentsErik 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.
- Inspection the problem and drawing a graphic illustration of the problem as it is experienced at that moment of time.
- Drawing of how that area/problem would look when being completely well/whole or disappeared.
- 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.
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Hope for insomnia, depression, anxiety, ADHD, exhaustion, and nasal congestion -Breathe light, slow and deep
Posted: July 9, 2022 Filed under: ADHD, behavior, Breathing/respiration, emotions, Exercise/movement, health, Pain/discomfort, relaxation, Uncategorized | Tags: allergies, anxiety, asthma, depression, hyperventilation, insomnia, nasal congestion, nose breathing Leave a commentAnxiety, 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
the peper perspective 