Cellphones affects social communication, vision, breathing, and health: What to do!

Posted: September 4, 2024 | Author: | Filed under: ADHD, attention, behavior, Breathing/respiration, cellphone, computer, digital devices, educationj, ergonomics, health, laptops, Neck and shoulder discomfort, posture, screen fatigue, self-healing, stress management, techstress, Uncategorized, vision, zoom fatigue | Tags: , , , , | 7 Comments

Adapted from: Peper, E. & Harvey, R. (2024). Cell phones affects social communication, vision, breathing, and mental and physical health: What to do! TownsendLetter-The Examiner of Alternative Medicine,September 15, 2024. https://townsendletter.com/smartphone-affects-social-communication-vision-breathing-and-mental-and-physical-health-what-to-do/

Abstract

Smartphones are an indispensable part of our lives. Unfortunately too much of a ‘good thing’ regarding technology can work against us, leading to overuse, which in turn influences physical,  mental and emotional development among current ‘Generation Z’ and ‘Millennial’ users (e.g., born 1997-2012, and 1981-1996, respectively). Compared to older technology users, Generation Z report more mental and physical health problems. Categories of mental health include attentional deficits, feelings of depression, anxiety social isolation and even suicidal thoughts, as along with physical health complaints such as sore neck and shoulders, eyestrain and increase in myopia. Long duration of looking downward at a smartphone affects not only eyestrain and posture but it also affects breathing which burden overall health. The article provides evidence and practices so show how technology over use and slouching posture may cause a decrease in social interactions and increases in emotional/mental and physical health symptoms such as eyestrain, myopia, and body aches and pains.  Suggestions and strategies are provided for reversing the deleterious effects of slouched posture and shallow breathing to promote health.

We are part of an uncontrolled social experiment

We, as technology users, are all part of a social experiment in which companies examine which technologies and content increase profits for their investors (Mason, Zamparo, Marini, & Ameen, 2022). Unlike University research investigations which have a duty to warn of risks associated with their projects, we as participants in ‘profit-focused’ experiments are seldom fully and transparently informed of the physical, behavioral and psychological risks (Abbasi, Jagaveeran, Goh, & Tariq, 2021; Bhargava, & Velasquez, 2021). During university research participants must be told in plain language about the risks associated with the project (Huh-Yoo & Rader, 2020; Resnik, 2021). In contrast for-profit technology companies make it possible to hurriedly ‘click through’ terms-of-service and end-user-license-agreements, ‘giving away’ our rights to privacy, then selling our information to the highest bidder (Crain, 2021; Fainmesser, Galeotti, & Momot, 2023; Quach et al., 2022; Yang, 2022).

Although some people remain ignorant and or indifferent (e.g., “I don’t know and I don’t care”) about the use of our ‘data,’ an unintended consequence of becoming ‘dependent’ on technology overuse includes the strain on our mental and physical health (Abusamak, Jaber & Alrawashdeh, 2022; Padney et al., 2020). We have adapted new technologies and patterns of information input without asking the extent to which there were negative side effects (Akulwar-Tajane, Parmar, Naik & Shah, 2020; Elsayed, 2021).  As modern employment shifted from predominantly blue-collar physical labor to white collar information processing jobs, people began sitting more throughout the day. Workers tended to look down to read and type.  ‘Immobilized’ sitting for hours of time has increased as people spend time working on a computer/laptop and looking down at smartphones (Park, Kim & Lee, 2020). The average person now sits in a mostly immobilized posture 10.4 hours/day and modern adolescents spent more than two thirds of their waking time sitting and often looking down at their smartphones (Blodgett, et al., 2024; Arundell et al., 2019).

Smartphones are an indispensable part of our lives and is changing the physical and mental emotional development especially of Generation Z who were born between 1997-2012 (Haidt, 2024). They are the social media and smartphone natives (Childers & Boatwright, 2021). The smartphone is their personal computer and the gateway to communication including texting, searching, video chats, social media (Hernandez-de-Menendez, Escobar Díaz, & Morales-Menendez, 2020; Nichols, 2020; Schenarts, 2020; Szymkowiak et al., 2021). It has 100,000 times the processing power of the computer used to land the first astronauts on the moon on July 20, 1969 according to University of Nottingham’s computer scientist Graham Kendal (Dockrill, 2020).  More than one half of US teens spend on the average more than 7 hours on daily screen time that includes watching streaming videos, gaming, social media and texting and their attention span has decreased from 150 seconds in 2004 to an average of 44 seconds in 2021 (Duarte, F., 2023; Mark, 2022, p. 96).

For Generation Z, social media use is done predominantly with smartphones while looking down. It has increased mental health problems such as attentional deficits, depression, anxiety suicidal thoughts, social isolation as well as decreased physical health (Haidt, 2024; Braghieri et al., 2023; Orsolini, Longo & Volpe, 2023; Satılmış, Cengız, & Güngörmüş, 2023; Muchacka-Cymerman, 2022; Fiebert, Kistner, Gissendanner & DaSilva, 2021;  Mohan et al., 2021; Goodwin et al., 2020).

The shift in communication from synchronous (face-to-face) to asynchronous (texting) has transformed communications and mental health as it allows communication while being insulated from the other’s reactions (Lewis, 2024).  The digital connection instead of face-to-face connection by looking down at the smart phone also has decreased the opportunity connect with other people and create new social connections, with three typical hypotheses examining the extent to which digital technologies (a) displace/ replace; (b) compete/ interfere with; and/or, (c) complement/ enhance in-person activities and relationships (Kushlev & Leitao, 2020).

As described in detail by Jonathan Haidt (2024), in his book, The Anxious Generation, the smartphone and the addictive nature of social media combined with the reduction in exercise, unsupervised play and childhood independence was been identified as the major factors in the decrease in mental health in your people (Gupta, 2023). This article focuses less on distraction such as attentional deficits, or dependency leading to tolerance, withdrawal and cravings (e.g., addiction-like symptoms) and focuses more on ‘dysregulation’ of body awareness (posture and breathing changes) and social communication while people are engaged with technology (Nawaz,Bhowmik, Linden & Mitchell, 2024).

The excessive use of the smartphones is associated with a significant reduction of physical activity and movement leading to a so-called sedentarism or increases of sitting disease (Chandrasekaran & Ganesan, 2021; Nakshine, Thute, Khatib, & Sarkar, 2022). Unbeknown to the smartphone users their posture changes, as they looks down at their screen, may also affect their mental and physical health (Aliberti, Invernizzi, Scurati & D’lsanto, 2020).

(1) Explore how looking at your smartphone affects you (adapted from: Peper, Harvey, & Rosegard, 2024)

For a minute, sit in your normal slouched position and look at your smartphone while intensely reading the text or searching social media. For the next minute sit tall and bring the cell phone in front of you so you can look straight ahead at it. Again, look at your smartphone while intensely reading the text or searching social media.

Compare how the posture affects you. Most likely, your experience is similar to the findings from students in a classroom observational study. Almost all experienced a reduction in peripheral awareness and breathed more shallowly when they slouched while looking at their cellphone.

Decreased peripheral awareness and increased shallow breathing that affects physical and mental health and performance. The students reported looking down position reduces the opportunity of creating new social connections. Looking down my also increases the risk for depression along with reduced cognitive performance during class (Peper et al., 2017; Peper et al., 2018). 

(2) Explore how posture affects eye contact (adapted from the exercise shared by Ronald Swatzyna, 2023)[2]

Walk around your neighborhood or through campus either looking downwards or straight ahead for 30 minutes while counting the number of eye contacts you make.

Most likely, when looking straight ahead and around versus slouched and looking down you had the same experience as Ronald Swatzyna (2023), Licensed Clinical Social Worker. He observed that when he walked a three-mile loop around the park in a poor posture with shoulders forward in a head down position, and then reversed direction and walked in good posture with the shoulders back and the head level, he would make about five times as many eye contacts with a good posture compared to the poor posture.

Anecdotal observations, often repeated by many educators, suggest before the omnipresent smartphone, students would look around and talk to each other before a university class began. Now, when Generation Z students enter an in-person class, they sit down, look down at their phone and tend not to interact with other students.

(3) Experience the effect of face-to-face in-person communication

During the first class meeting, ask students to put their cellphones away, meet with three or four other students for a few minutes, and share a positive experience that happened to them last week as well as what they would like to learn in the class.  After a few minutes, ask them to report how their energy and mood changed.

In our observational class study with 24 junior and senior college students in the in-person class and 54 students in the online zoom class, almost all report that that their energy and positive mood increased after they interacted with each other. The effects were more beneficial for the in-person small group sharing than the online breakout groups sharing on Zoom as shown in Figure 1.

Figure 1. Change in subjective energy and mood after sharing experiences synchronously in small groups either in-person or online.

Without direction of a guided exercise to increase social connections, students tend to stay within their ‘smartphone bubble’ while looking down (Bochicchio et al., 2022). As a result, they appear to be more challenged to meet and interact with other people face-to-face or by phone as is reflected in the survey data that Generation Z is dating much less and more lonely than the previous generations (Cox et al., 2023).  

What to do:

  • Put the smartphone away so that you do not see it in social settings such as during meals or classes. This means that other people can be present with you and the activity of eating or learning.
  • Do not permit smartphones in the classroom including universities unless it is required for a class assignment.
  • In classrooms and in the corporate world, create activities that demands face-to-face synchronous communication.
  • Unplug from the audio programs when walking and explore with your eyes what is going on around you.

(4) Looking down increases risk of injury and death

Looking down at a close screen reduces peripheral awareness and there by increases the risk of accidents and pedestrian deaths. Pedestrian deaths are up 69% since 2011 (Cova, 2024) and have consistently increased since the introduction of the iPhone in 2007 as shown in Figure 3.

Figure 3. Increase in pedestrian death since the introduction of the iphone (data plotted from https://www.iihs.org/topics/fatality-statistics/detail/pedestrians)

In addition, the increase use of mobile phones is also associated with hand and wrist pain from overuse and with serious injuries such as falls and texting while driving due to lack of peripheral awareness.  McLaughlin et al (2023) reports an increase in hand and wrist injuries as well serious injuries related to distracted behaviors, such as falls and texting while driving. The highest phone related injuries (lacerations) as reported from the 2011 to 2020 emergency room visits were people in the age range from 11–20 years followed by 21–30 years.

What to do:

(5) Looking at screens increases the risk of myopia

Looking at a near screen for long periods of time increases the risk of myopia (near sightedness) which means that distant vision is more blurry. Myopia has increased as children predominantly use computers or, smartphones with smaller screen at shorter distances.  By predominantly focusing on nearby screens without allowing the eye to relax remodels the eyes structure. Consequently, myopia has increase in the U.S. from 25 percent in the early 1970s to nearly 42 percent three decades later (OHSU, 2022).

Looking only at nearby screens, our eyes converge and the ciliary muscles around the lens contract and remain contracted until the person looks at the far distance. The less opportunity there is to allow the eyes to look at distant vision, the more myopia occurs. in Singapore 80 per cent of young people aged 18 or below have nearsightedness and  20 % of the young people have high myopia as compared to 10 years ago (Singapore National Eye Centre, 2024). The increase in myopia is a significant concern since high myopia is associated with an increased risk of vision loss due to cataract, glaucoma, and myopic macular degeneration (MMD). MMD is rapidly increasing and one of the leading causes of blindness in East Asia that has one of the highest myopia rates in the world (Sankaridurg et al., 2021).

What to do:

  • Every 20 minutes stop looking at the screen and look at the far distance to relax the eyes for 20 seconds.
  • Do not allow young children access to cellphones or screens.  Let them explore and play in nature where they naturally alternate looking at far and near objects.
  • Implement the guided eye regenerating practices descrubed in the article, Resolve eyestrain and screen fatigue,  by Peper (2021).
  • Read Meir Schneider’s (2016) book, Vision for Life, for suggestions how to maintain and improve vision.

(6) Looking down increases tech neck discomfort

Looking down at the phone while standing or sitting strains the neck and shoulder muscles because of the prolonged forward head posture as illustrated in the YouTube video, Tech Stress Symptoms and Causes (DeWitt, 2018). Using a smartphone while standing or walking causes a significant increase in thoracic kyphosis and trunk (Betsch et al., 2021).  When the head is erect, the muscle of the neck balance a weight of about 10 to 12 pounds or, approximately 5 kilograms; however, when the head is forward at 60 degrees looking at your cell phone the forces on the muscles are about 60 pound or more than 25 kilograms, as illustrated in Figure 4 (Hansraj, 2014).  

Figure 4. The head forward position puts as much as sixty pounds of pressure on the neck muscles and spine (by permission from Dr. Kenneth Hansraj, 2014).

This process is graphically illustrated in the YouTube video, Text Neck Symptoms and Causes Video, produced by Veritas Health (2020).

What to do:

(7) Looking down increases negative memory recall and depression

In our previous research, Peper et al. (2017) have found that recalling hopeless, helpless, powerless, and defeated memories is easier when sitting in a slouched position than in an upright position. Recalling positive memories is much easier when sitting upright and looking slightly upward than sitting slouched position. If attempting to recall positive memories the brain has to work hard as indicated by an significantly higher amplitudes of beta2, beta3, and beta4 EEG (i.e., electroencephalograph) when sitting slouched then when sitting upright  (Tsai et al., 2016). 

Not only does the postural position affect memory recall, it also affects mental math under time-pressure performance.  When students sit in a slouched position, they report that is much more difficult to do mental math (serial 7ths) than when in the upright position (Peper et al., 2018).  The effect of posture is most powerful for the 70% of students who reported that they blanked out on exams, were anxious, or worried about class performance or math. For the 30% who reported no performance anxiety, posture had no significant effect.  When students become aware of slouching thought posture feedback and then interrupt their slouching by sitting up, they report an increase in concentration, attention and school performance (Peper et al., 2024).

How we move and walk also affects our subjective energy. In most cases, when people sit for a long time, they report feeling more fatigue; however, if participants interrupt sitting with short movement practices they report becoming less fatigue and improved cognition (Wennberg et al., 2016). The change in subjective energy and mood depends upon the type of movement practice.  Peper & Lin (2012) reported that when students were asked to walk in a slow slouching pattern looking down versus to walk quickly while skipping and looking up, they reported that skipping significantly increased their subjective energy and mood while the slouch walking decreased their energy.  More importantly, student who had reported that they felt depressed during the last two years had their energy decrease significantly more when walking very slowly while slouched than those who did not report experiencing depression.  Regardless of their self-reported history of depression, when students skipped, they all reported an increase in energy (Peper & Lin, 2012; Miragall et al., 2020).

What to do:

  • Walk with a quick step while looking up and around.
  • Wear a posture feedback device such as the UpRight Go 2 to remind you when you slouch to change posture and activity (Peper et al., 2019; Roggio et al., 2021).
  • When sitting put a small pillow in the mid back so that you can sit more erect (for more suggestions, see the article by Peper et al., 2017a, Posture and mood: Implications and applications to therapy).
  • Place photo and other objects that you like to look a slightly higher on your wall so that you automatically look up.

(8) Shallow breathing increases the risk for anxiety

When slouching we automatically tend to breathe slightly faster and more shallowly.  This breathing pattern increases the risk for anxiety since it tends to decrease pCO2  (Feinstein et al., 2022; Meuret, Rosenfield, Millard & Ritz, 2023; Paulus, 2013; Smits et al., 2022; Van den Bergh et al., 2013). Sitting slouched also tends to inhibit abdominal expansion during the inhalation because the waist is constricted by clothing or a belt –sometimes labeled as ‘designer jean syndrome’ and may increase abdominal symptoms such as acid reflux and irritable bowel symptoms (Engeln & Zola, 2021; Peper et al., 2016; Peper et al., 2020). When students learn diaphragmatic breathing and practice diaphragmatic breathing whenever they shallow breathe or hold their breath, they report a significant decrease in anxiety, abdominal symptoms and even menstrual cramps (Haghighat et al., 2020; Peper et al., 2022; Peper et al., 2023).

What to do:

  • Loosen your belt and waist constriction when sitting so that the abdomen can expand.
  • Learn and practice effortless diaphragmatic breathing to reduce anxiety.

Conclusion

There are many topics related to postural health and technology overuse that were addressed in this article. Some topics are beyond the scope of the article, and therefore seen as limitations. These relate to diagnosis and treatment of attentional deficits, or dependency leading to tolerance, withdrawal and cravings (e.g., addiction-like symptoms), or of modeling relationships between factors that contribute to the increasing epidemic of mental and physical illness associated with smartphone use and social media, such as hypotheses examining the extent to which digital technologies (a) displace/ replace; (b) compete/ interfere with; and/or, (c) complement/ enhance in-person activities and relationships. Typical pharmaceutical ‘treat-the-symptom’ approaches for addressing ‘tech stress’ related to technology overuse includes prescribing ‘anxiolytics, pain-killers and muscle relaxants’ (Kazeminasab et al., 2022; Kim, Seo, Abdi, & Huh, 2020). Although not usually included in diagnosis and treatment strategies, suggesting improving posture and breathing practices can significantly affect mental and physical health.  By changing posture and breathing patterns, individuals may have the option to optimize their health and well-being.

See the book, TechStress-How Technology is Hijacking our Lives, Strategies for Coping and Pragmatic Ergonomics by Erik Peper, Richard Harvey and Nancy Faass. Available from: https://www.amazon.com/Beyond-Ergonomics-Prevent-Fatigue-Burnout/dp/158394768X/

Explore the following blogs for more background and useful suggestions

Reflections on the increase in Autism, ADHD, anxiety and depression: Part 1-bonding, screen time, and circadian rhythm
Increase attention, concentration and school performance
Reduce anxiety
Reduce stress, anxiety and negative thoughts with posture, breathing and reframing

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[1] Correspondence should be addressed to: Erik Peper, Ph.D., Institute for Holistic Health Studies, Department of Recreation, Parks, Tourism and Holistic Health, San Francisco State University, 1600 Holloway Avenue, San Francisco, CA 94132  Email: epeper@sfsu.edu;  web: www.biofeedbackhealth.org;  blog: www.peperperspective.com

[2] I thank Ronald Swatzyna (2023), Licensed Clinical Social Worker for sharing this exercise with me.  He discovered that a difference in the number of eye contacts depending how he walked. When he walked a 3.1 mile loop around the park  in a poor posture- shoulders forward, head down position- and then reversed direction and walked in good posture with the shoulders back and the head level, that  that he make about 5 times as many eye contacts with good posture compared to the poor posture. He observed that he make about five times as many eye contacts with good posture as compared to the poor posture.

Grandmother Therapy: A Common-Sense Approach to Health and Wellness

Posted: July 24, 2024 | Author: | Filed under: ADHD, attention, behavior, education, Evolutionary perspective, Exercise/movement, Nutrition/diet, Pain/discomfort, relaxation, self-healing | Tags: , , , , , , , , , | 1 Comment

Erik Peper, PhD and Angelika Sadar, MA

In today’s fast-paced world, college students and young adults often struggle with various health issues. From anxiety and depression to ADHD and epilepsy, these challenges can significantly impact their daily lives. But what if the solution to many of these problems lies in something as simple as “Grandmother Therapy”?

What is Grandmother Therapy? Grandmother Therapy is all about going back to basics and establishing healthy lifestyle habits. It’s the common-sense approach that our grandmothers might have suggested: regular sleep patterns, balanced nutrition, increased social connections, and regular physical activity.

The Problem: Many college students:

  • Skip breakfast before their first class
  • Rely on fast food and sugary stimulants
  • Have irregular sleep schedules
  • Spend excessive time on gaming and social media

The Medical Approach: Often, the quick solution is medication:

  • Depression? Take antidepressants.
  • Insomnia? Use sleeping pills.
  • Anxiety? Try anti-anxiety medication.
  • ADHD? Prescribe Ritalin or similar drugs.

While these treatments may help manage symptoms, they often overlook the underlying lifestyle factors contributing to these issues.

The Grandmother Therapy Approach:

  1. Establish regular sleep patterns
  2. Adopt healthy eating habits
  3. Increase social connections
  4. Incorporate regular physical activity
  5. Reduce gaming and social media use

Case Study #1: The Power of Sleep

This illustrates the simple intervention of having a bedtime routine.  A college student in a holistic health class complained that she was tired most of the time and had difficulty focusing her attention and continuously drifted off in class. 

Here is her reported sleep schedule:

  • last night I went to bed at 3am and woke up 7;
  • the day before, I went to bed at 1pm and woke up at 6,
  • two nights before, I went to bed at 4pm and woke up at 10 am.

Holistic treatment approach:

Set a sleep schedule: she was provided with information about  the importance of having a regular pattern of sleep and waking.  Namely,  go to bed at the same time and get up 8 hours later. She agreed to do an experiment for a week to go to bed at 12 and wake up at 8m.  To her surprise, she felt so much more energized and could pay attention in class during the week of the experiment. 

Case Study #2:  Beyond Seizures: A Holistic Approach to Treating Psychogenic Nonepileptic Seizures

This case study highlights the importance of a comprehensive, lifestyle-based approach to treating psychogenic nonepileptic seizures (PNES). It follows a 24-year-old male student initially diagnosed with intractable epilepsy, experiencing over 10 seizures per week that didn’t respond to medication.

Key points:

1. Initial misdiagnosis: Despite normal MRI and EEG results, the client was initially treated for epilepsy.

2. Limited assessment: Traditional medical evaluations focused solely on seizure descriptions and diagnostics, overlooking crucial lifestyle factors.

3. Comprehensive evaluation: A psychophysiological assessment revealed high sympathetic arousal, including rapid breathing, sweaty palms, and muscle tension.

4. Lifestyle factors: The client’s diet consisted of high-glycemic fast foods, excessive caffeine, alcohol, and daily marijuana use. He also had significant student debt and a history of abdominal surgery.

Holistic treatment approach:

   – Dietary changes: Switching to unprocessed, low-glycemic foods and increasing vegetable and fruit intake

   – Breathing techniques: Learning and practicing slow diaphragmatic breathing

   – Stress management: Addressing underlying stressors and practicing relaxation techniques

   – Supplements: Adding omega-3 and multivitamins to support brain health

Remarkable results: Within four months, the patient became seizure-free, reduced marijuana use significantly, and decreased medication dosage.

Summary

These cases underscore the potential of integrating lifestyle modifications and stress management techniques in treating attention, anxiety and even psychogenic nonepileptic seizures; offering hope for patients who don’t respond to traditional treatments alone. Before turning to medication or complex treatments, consider the power of Grandmother Therapy. By addressing fundamental lifestyle factors, we can often improve our health and well-being significantly. Remember, sometimes the most effective solutions are the simplest ones.

The Challenges of Simplicity: While Grandmother Therapy may seem straightforward, its simplicity can make it challenging to implement. It requires commitment and a willingness to change long-standing habits.

Implement many Life Style Changes at once: Recommending one change at the time is logical; however, participants will more likely experience rapid benefits and are more motivated to continue when they change multiple lifestyle factors at once.

Call to Action: Are you struggling with health issues? Try implementing some aspects of Grandmother Therapy in your life. Implement changes and see how they impact your overall well-being.

Please let us know your experience with implementing Grandmother Therapy.

See the following blogs for more background information

Reflections on the increase in Autism, ADHD, anxiety and depression: Part 2- Exposure to neurotoxins and ultra-processed foods
Quick Rescue Techniques When Stressed
Rethink the monies spent on cancer screening tests
Hope for menstrual cramps (dysmenorrhea) with breathing

Playful practices to enhance health with biofeedback

Posted: May 4, 2024 | Author: | Filed under: attention, behavior, biofeedback, Breathing/respiration, computer, Exercise/movement, health, Neck and shoulder discomfort, Pain/discomfort, self-healing, Uncategorized | Tags: , , , , | 1 Comment

Adapted from: Gibney, K.H. & Peper, E. (2003). Exercise or play? Medicine of fun. Biofeedback, 31(2), 14-17.

Homework assignments are sometimes viewed as chore and one more thing to do. Changing the perception from that of work to fun by encouraging laughter and joy often supports the healing process.  This blog focusses on utilizing childhood activities and paradoxical movement to help clients release tension patterns and improve range of motion. A strong emphasis is placed on linking diaphragmatic breathing to movement.

When I went home I showed my granddaughter how to be a tree swaying in the wind, she looked at me and said, “Grandma, I learned that in kindergarten!”

‘Betty’ laughed heartily as she relayed this story.  Her delight in being able to sway her arms like the limbs of a tree starkly contrasted with her demeanor only a month prior. Betty was referred for biofeedback training after a series of 9 surgeries – wrists, fingers, elbows and shoulders. She arrived at her first session in tears with acute, chronic pain accompanied by frequent, incapacitating spasms in her shoulders and arms.  She was unable to abduct her arms more than a few inches without triggering more painful spasms. Her protective bracing and rapid thoracic breathing probably exacerbated her pain and contributed to a limited range of motion of her arms.  Unable to work for over a year, she was coping not only with pain, but also with weight gain, poor self-esteem and depression.

The biofeedback training began with effortless, diaphragmatic breathing which is often the foundation of health (Peper and Gibney, 1994).  Each thoracic breath added to Betty’s chronic shoulder pain.  Convincing Betty to drop her painful bracing pattern and to allow her arms to hang freely from her shoulders as she breathed diaphragmatically was the first major step in regaining mobility. She discovered in that first session that she could use her breathing to achieve control over muscle spasms when she initiated the movement during the exhalation phase of breathing as shown in Figure 1. 

Figure 1. Initiate the physical activity after exhaling has begun and body is relaxing especially if the movement or procedure such as an injection would cause pain. Pause the movement when inhaling and then continue the movement again during the exhalation phase. The simple rule is to initiate the activity slightly after beginning exhaling and when the heart rate started to decrease (reproduced with permission from Gorter & Peper, 2012).

During the first week, she practiced her breathing assiduously at home and had fewer spasms. Betty was able to move better during her physical therapy sessions. Each time she felt the onset of muscle spasms she would stop all activity for a moment and ‘go into my trance’ to prevent a recurrence. For the first time in many months, she was feeling optimistic.

Subsequent sessions built upon the foundation of diaphragmatic breathing: boosting Betty’s confidence, increasing range of motion (ROM), and bringing back some fun in life. Activities included many childhood games: tossing a ball, swaying like a tree in the wind, pretending to conduct an orchestra, bouncing on gym balls, playing “Simon Says” (following the movements of the therapist), and dancing. Laughter and childlike joy became a common occurrence. She looked forward to receiving the sparkly star stickers she was given after successful sessions. With each activity, Betty gained more confidence, gradually increased ROM, and began losing weight. Although she had some days where the pain was strong and spasms threatened, Betty reframed the pain as occurring as a result of healing and expanding her ROM—she was no longer a victim of the pain. In addition, her family was proud of her, she was doing more fun activities, and she felt confident that she would return to work.

Betty’s story is similar to other clients whom we have seen.  The challenge presented to therapists is to help the client better cope with pain, increase ROM, regain function and, often the most important, to reclaim a “joie de vivre”.  Increasing function includes using the minimum amount of effort necessary for the task, allowing unnecessary muscles to remain relaxed (inhibition of dysponesis[i]), and quickly releasing muscle tension when the muscle is no longer required for the activity (work/rest) (Whatmore & Kohli, 1974; Peper et al, 2010; Sella, 2019). The challenge is to perform the task without concurrent evocation of components of the alarm reaction, which tend to be evoked when “we try to do it perfectly,” or “it has to work,” “If I do not do it correctly,” or “I will be judged.” For example, when people learn how to implement micro-breaks (1–2 second rest periods) at the computer, they often sit quietly believing that they are relaxed; however, they may continue a bracing pattern (Peper et al, 2006).  Alternatively, tossing a small ball rather than resting at the keyboard will generally evoke laughter, encourage generalization of skills, and covertly induce more relaxation.  In some cases, therapists in their desire to help clientss to get well assign structured exercises as homework that evoke striving for performance and boredom—this striving to perform the structured exercises may inhibit healing.   Utilizing tools other than those found in the work setting helps the client achieve a broader perspective of the healing/preventive concepts that are taught.

To optimize success, clients are active participants in their own healing process which means that they learn the skills during the therapeutic session and practice at home and at work. Home practices are assigned to integrate the mastery of news skills into daily life. To help clients achieve increased health through physical activity three different approaches are often used:  movement reeducation, youthful play, and pure exercise. How the client performs the activity may be monitored with surface electromyography (SEMG) to identify muscles tightening that are not needed for the task and how the muscle relaxes when not needed for the task performance.  This monitoring can be done with a portable biofeedback device or multi-channel system when walking or performing the exercises. Clients can even use a single channel SEMG at home.

When working to improve ROM and physical function, explore the following:

  1. Maintain diaphragmatic breathing – rhythm or tempo may change but the breath must be generated from the diaphragm with emphasis on full exhalation. Use strain gauge feedback and/or SEMG feedback to monitor and train effortless breathing (Peper et al., 2016).  Strain gauge feedback is used to teach a slower and diaphragmatic breathing pattern, while SEMG recorded from the scalene to trapezius is used to teach how to reduce shoulder and ancillary muscle tension during inhalation
  2. Perform activities or stretching/strengthening exercises so slowly that they don’t  trigger or aggravate pain during the exhalation phase of breathing.
  3. Use the minimum amount of tension necessary for the task and let unnecessary muscles remain relaxed. Use SEMG feedback recorded from muscles not needed for the performance of the task to teach clients awareness of inappropriate muscle tension and to learn relaxation of those muscles.
  4. Release muscle tension immediately when the task is accomplished. Use SEMG feedback to monitor that the muscles are completely relaxed.  If rapid relaxation is not achieved, first teach the person to relax the muscles before repeating the muscle activity.
  5. Perform the exercises as if you have never performed them and do them with a childlike, beginner’s mind, and exploratory attitude (Kabat-Zinn, 1990).
  6. Create exercises that are totally new and novel so that the participant has no expectancy of outcome can be surprised by their own experience. This approach is part of many somatic educational and therapeutic approaches such as Feldenkrais or Somatics (Hanna, 2004; Feldenkrais, 2009).

Movement and exercise can be taught as pure physical exercise, movement reeducation or youthful playing. Physical exercise is necessary for strength and endurance and at the same time, improves our mood (Thayer, 1996; Mahindru et al., 2023).  However, many exercises are considered a burden and are often taught without a sense of lightness and fun, which results in the client thinking in terms that are powerless and helpless (depressive)—“I have to do them.”  Helping your clients to understand that exercise is simply a part of every day life, that it encourages healing and improves health, and that they can “cheat” at it, may help them to reframe their attitudes toward it and accomplish their healing goals. 

Pure Physical Exercise—Enjoyment through Strength and Flexibility

The major challenge of structured exercises is that the person is very serious and strives too hard to attain the goal.  In the process of striving, the body is often held rigid: Breath is shallow and halted and shoulders are slightly braced. Maintaining a daily chart is an excellent tool to show improvement (e.g., more repetitions, more weight, increased flexibility; since, structured exercises are very helpful for improving ROM and strength. When using pure exercise, remember that injured person may have a sense of urgency – they want to get well quickly and, if work stress was a factor in developing pain, they often rush when they need to meet a deadline. 

As much as possible make the exercise fun. Help the client understand that he/she can be quick while not rushed.  For example, monitor SEMG from an upper trapezius muscle using a portable electromyography.  For example, begin by walking slowly.  Add a ramp or step to ensure that there is no bracing when climbing (a common occurrence). Walk around the room, down the hall, around the block.  Maintain relaxed shoulders, an even swing of the arms, and diaphragmatic breathing.  Walk more quickly while emphasizing relaxation with speed rather than rushing. Go faster and faster.  Up the stairs.  Down the stairs.  Walk backward.  Skip.  Hop.  Laugh.

Movement Reeducation – Be ‘Oppositional’ And Do It Differently

Movement reeducation, such as Feldenkrais, Alexander Technique or Hannah Somatics, involves conscious awareness of movement (Alexander, 2001; Hanna, 2004; Murphy, 1993).  Many daily patterns of movement become imbedded in our consciousness and, over the years, may include a pain trigger.  A common trigger is lifting the shoulders when reaching for the keyboard or mouse, people suffering from thoracic outlet syndrome (TOS) often have such patterns (Peper & Harvey, 2021).  A keyboard can often inadvertently cue the client to trigger this dysponetic, and frequently painful, pattern.  Have the client do movement reeducation exercises as they are guided through practices in which they have no expectancy and the movements are novel.  The focus is on awareness without triggering any fight/flight or startle responses.  

Ask the client to explore performing many functional activities with the opposite hand, such as brushing his/her hair or teeth, eating, blowing his/her hair dry, or doing household chores, such as vacuuming.  (Explore  this for yourself, as well!). Be aware of how much shoulder muscle tension is needed to raise the arms for combing or blow-drying the hair. Explore how little effort is required to hold a fork or knife (you might want to do this in the privacy of your own home!).

Do movements differently such as, practicing alternating hands when leading with the vacuum or when sweeping, changing routes when driving/walking to work or the store, getting out of bed differently. Break up habitual conditioned reflex patterns such as eye, head and hand coordination.  For example, slowly rotate your head from left to right and simultaneously shift your eyes in the opposite direction (e.g., turn your head fully to the right while shifting your eyes fully to the left, and then reverse) or before reaching forward, drop your elbows to your sides then, bend your elbows and touch your shoulders with your thumbs then, reach forward.  Often, when we change our patterns we increase our flexibility, inhibit bracing and reduce discomfort.

Free Your Neck and Shoulders (adapted from a demonstration by Sharon Keane and developed by Ilana Rubenfeld, 2001)

–Push away from the keyboard and sit at the edge of the chair with your knees bent at right angles and your feet shoulder-width apart and flat on the floor.  Do the following movements slowly.  Do NOT push yourself if you feel discomfort.  Be gentle with yourself.

–Look to the right and gently turn your head and body as far as you can go to the right. When you have gone as far as you can comfortably go, look at the furthest spot on the wall and remember that spot.  Gently rotate your head back to center.  Close your eyes and relax.

–Reach up with your left hand; pass it over the top of your head and hold on to your right ear. Then, gently bend to the left lowering your elbow towards the floor.  Slowly straighten up.  Repeat for a few times feeling as if you are a sapling flexing in the breeze.  Observe what your body is doing as it bends and comes back up to center. Notice the movements in your ribs, back and neck.  Then, drop your arm to your lap and relax.  Make sure you continue to breathe diaphragmatically throughout the exercise.

–Reach up with your right hand and pass it over the top of your head and hold on to your left ear.  Repeat as above except bending to the right.

–Reach up with your left hand and pass it over the top of your head and hold on to your right ear.  Then, look to the left with your eyes and rotate your head to the left as if you are looking behind you. Return to center and repeat the movement a few times.  Then, drop your arm to your lap and relax for a few breaths.

–Again, reach over your head with your left hand and hold onto your right ear. Repeat the same rotating motion of your head to the left except that your eyes look to the right. Repeat this a few times then, drop your arm to your lap and relax for a few breaths.

–Reach up with your right hand and pass it over the top of your head and hold on to your left ear.  Then, look to the right with your eyes and rotate your head to the right as if you are looking behind you.  Return to center and repeat a few times.  Then, drop your arm to your lap and relax for a few breaths.

–Again, reach over your head with your right hand and hold onto your left ear. Repeat the same rotating motion of your head to the right except that your eyes look to the left.  Repeat this a few times then, drop your arm to your lap and relax for a few breaths.

–Now, look to the right and gently turn your head and body as far as you can go. When you can not go any further, look at that point on the wall. Did you rotate further than at the beginning of the exercise?

–Gently rotate your head back to center, close your eyes, relax and notice the feeling in your neck, shoulders and back.

Youthful Playing – Pavlovian Practice

Evoking positive past memories and actually acting them out may enhance health as is illustrated by the recovery of serious illness of Ivan Pavlov, the discovery of classical conditioning.  When Pavlov quietly lay in his hospital bed, many, including his family, thought he was slipping into death. He then ask the nurse to get him a bowl of water with earth in it and the whole night long he gently played with the mud. He recreated the experience when as a child he was playing in mud along a river’s bank. Pavlov knew that evoking the playful joy of childhood would help to encourage mental and physical healing. The mud in hands was the conditioned stimulus to evoke the somatic experience of wellness (Peper, Gibney, & Holt, 2002). 

Having clients play can encourage laughter and joie de vivre, which may help in physical healing. Being involved in childhood games and actually playing these games with children removes one from worries and concerns—both past and future—and allows one to be simply in the present.  Just being present is associated with playfulness, timelessness, passive attention, creativity and humor.  A state in which one’s preconceived mental images and expectancies—the personal, familial, cultural, and healthcare provider’s hypnotic suggestions—are by-passed and for that moment, the present and the future are yet undefined.  This is often the opposite of the client’s expectancy; since, remembering the past experiences and the diagnosis creates a fixed mental image that may expect pain and limitation.

Explore some of the following practices as strategies to increase movement and flexibility without effort and to increase joy.  Use your creativity and explore your own permutations of the practices.  Observe how your mood improves and your energy increases when you play a childhood game instead of an equivalent exercise. For example, instead of dropping your hands to your lap or stretching at the computer terminal during a micro- or meso-break[ii], go over to your coworker and play “pattycake.” This is the game in which you and your partner face each other and then clap your hands and then touch each other’s palms.  Do this in all variations of the game.

For increased ROM in the shoulders explore some of the following (remember the basics: diaphragmatic breathing, minimum effort, rapid release) in addition, do the practices to the rhythm of the music that you enjoyed as a young person.

Ball Toss:  a hand-sized ball that is easily squeezed is best for this exercise.  Monitor respiration patterns, and SEMG forearm extensors and/or flexors, and upper trapezii muscles. Sit quietly in a chair and focus on a relaxed breathing rhythm. Toss the ball in the air with your right hand and catch it with your left hand. As soon as you catch the ball, drop both hands to your lap.  Toss the ball back only when you achieve relaxation—both with the empty hand and the hand holding the ball.  Watch for over-efforting in the upper trapezii. Begin slowly and increase the pace as you train yourself to quickly release unnecessary muscle tension.  Go faster and faster (just about everyone begins to laugh, especially each time they drop the ball).

Ball Squeeze/Toss:  Expand upon the above by squeezing the ball prior to tossing.  When working with a client, call out different degrees of pressure (e.g., 50%, 10%, 80%, etc.).  The same rules apply as with the ball toss.

Ball Hand to Hand:  Close your eyes and hand the ball back and forth.  Go faster and faster and add ball squeezes prior to passing the ball.

Gym Ball Bounces:  Sit on a gym ball and find your balance.  Begin bouncing slowly up and down.  Reach up and lower your left then, right hand.  Abduct your arms forward then, laterally. Turn on the radio and bounce to music.

Simon Says:  This can be done standing, sitting in a chair or on a gym ball.  When on a gym ball, bounce during the game.  Have your client do a mirror image of your movements: reaching up, down, left, right, forward or backward.  Touch your head, nose, knees or belly.  Have fun and go more quickly.

Back-To-Back Massage: With a partner, stand back-to-back.  Lean against each other’s back so that you provide mutual support.  Then each rub your back against each other’s back.  Enjoy the wiggling movement and stimulation.  Be sure to continue to breathe.

Summary: An Attitude of Fun

In summary, it is not what you do; it is also the attitude by which you do it that affects health.  From this perspective,when exercises are performed playfully, flexibility, movement and health are enhanced while discomfort is decreased.  Inducing laughter promotes healing and disrupts the automatic negative hypnotic suggestion/self-images of what is expected. The clients begins to live in the present moment and thereby decreases the anticipatory bracing and dysponetic activity triggered by striving.  By decreasing striving and concern for results, clients may allow themselves to perform the practices with a passive attentive attitude that may facilitate healing.  For that moment, the client forgets the painful past and a future expectances that are fraught with promises of continued pain and inactivity. At moment, the pain cycle is interrupted  which provides hope for a healthier future.

References

Alexander, F.M. (2001). The Use of the Self. London: Orion Publishing. https://www.amazon.com/Use-Self-F-M-Alexander/dp/0752843915

Feldenkrais, M. (2009). Awareness Through Movement Easy-to-Do Health Exercises to Improve Your Posture, Vision, Imagination, and Personal Awareness. New York: HarperOne. https://www.amazon.com/Awareness-Through-Movement-Easy-Do/dp/0062503227

Gibney, K.H. & Peper, E. (2003). Exercise or play? Medicine of fun. Biofeedback, 31(2), 14-17. https://www.researchgate.net/publication/380317304_EXERCISE_OR_PLAY_MEDICINE_OF_FUN

Gorter, R. & Peper, E. (2012). Fighting Cancer- A Nontoxic Approach to Treatment. Berkeley: North Atlantic Books. https://www.amazon.com/Fighting-Cancer-Nontoxic-Approach-Treatment/dp/1583942483

Hanna, T. (2004). Somatics: Reawakening The Mind’s Control Of Movement, Flexibility, And Health. Da Capo Press. https://www.amazon.com/Somatics-Reawakening-Control-Movement-Flexibility/dp/0738209570

Kabat-Zinn, J. (1990). Full catastrophe living. New York: Dela­corte Press.

Mahindru, A., Patil, P., & Agrawal, V. (2023). Role of Physical Activity on Mental Health and Well-Being: A Review. Cureus, I5(1), e33475. https://doi.org/10.7759/cureus.33475

Murphy, M. (1993). The future of the body. New York: Jeremy P. Tarcher/Perigee. https://www.amazon.com/Future-Body-Explorations-Further-Evolution/dp/0874777305

Peper, E., Booiman, A., Lin, I-M, Harvey, R., & Mitose, J. (2016). Abdominal SEMG Feedback for Diaphragmatic Breathing: A Methodological Note. Biofeedback. 44(1), 42-49. https://www.researchgate.net/publication/300365890_Abdominal_SEMG_Feedback_for_Diaphragmatic_Breathing_A_Methodological_Note

Peper, E., Booiman, A., Tallard, M., & Takebayashi, N. (2010). Surface electromyographic biofeedback to optimize performance in daily life: Improving physical fitness and health at the worksite. Japanese Journal of Biofeedback Research, 37(1), 19-28. https://doi.org/10.20595/jjbf.37.1_19

Peper, E., Gibney, K. & Holt, C. (2002).  Make health happen: Training yourself to create wellness. Dubuque, IA: Kendall-Hunt. https://he.kendallhunt.com/product/make-health-happen-training-yourself-create-wellness

Peper, E. & Harvey, R. (2021). Causes of TechStress and ‘Technology-Associated Overuse’ Syndrome and Solutions for Reducing Screen Fatigue, Neck and Shoulder Pain, and Screen Addiction. Townsend Letter-The examiner of Alternative Medicine, Oct 28, 2021. https://www.townsendletter.com/article/459-techstress-how-technology-is-hurting-us

Peper, E., Harvey, R. & Tylova, H. (2006). Stress protocol for assessing computer related disorders.  Biofeedback. 34(2), 57-62. https://www.researchgate.net/publication/242549995_FEATURE_Stress_Protocol_for_Assessing_Computer-Related_Disorders

Peper, E. & Tibbetts, V. (1994). Effortless diaphragmatic breathing. Physical Therapy Products. 6(2), 67-71.  Also in:  Electromyography:  Applications in Physical Therapy. Montreal: Thought Technology Ltd. https://www.bfe.org/protocol/pro10eng.htm

Rubenfeld, I. (2001). The listening hands: Self-healing through Rubenfeld Synergy method of talk and touch. New York: Random House. https://www.amazon.com/Listening-Hand-Self-Healing-Through-Rubenfeld/dp/0553379836

Sella, G. E. (2019). Surface EMG (SEMG): A Synopsis.  Biofeedback, 47(2), 36–43. https://doi.org/10.5298/1081-5937-47.1.05

Thayer, R.E. (1996). The origin of everyday moods—Managing energy, tension, and stress.  New York:  Oxford University Press. https://www.amazon.com/Origin-Everyday-Moods-Managing-Tension/dp/0195118057

Whatmore, G. and Kohli, D.  The Physiopathology and Treatment of Functional Disorders.  New York: Grune and Stratton, 1974. https://www.amazon.com/physiopathology-treatment-functional-disorders-biofeedback/dp/0808908510

 

[i] Dysponesis involves misplaced muscle activities or efforts that are usually covert and do not add functionally to the movement. From:  Dys” meaning bad, faulty or wrong, and “ponos” meaning effort, work or energy (Whatmore and Kohli, 1974)

[ii] A meso-break is a 10 to 90 second break that consists of a change in work position, movement or a structured activity such as stretching  that automatically relaxes those muscles that were previously activated while performing a task.

360-Degree Belly Breathing with Jamie McHugh

Posted: April 26, 2024 | Author: | Filed under: attention, Breathing/respiration, emotions, healing, health, meditation, mindfulness, Pain/discomfort, relaxation, self-healing | Tags: , , , , , , | 4 Comments

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/

McHugh, J. (2016). An introduction to embodied mindfulness-The art of stillness. http://www.somaticexpression.com/documents/FINAL.pdf

Reduce the risk for colds and flu and superb science podcasts

Posted: January 24, 2024 | Author: | Filed under: attention, behavior, education, Evolutionary perspective, Exercise/movement, healing, health, Nutrition/diet, self-healing, stress management, Uncategorized, vision | Tags: , , , , | 2 Comments

What can we do to reduce the risk of catching a cold or the flu?  It is very challenging to make sense out of all the recommendations found on internet and the many different media site such as X(Twitter), Facebook, Instagram, or TikTok.  The following podcasts are great sources that examine different topics that can affect health. They are in-depth presentations with superb scientific reasoning.

Huberman Lab podcasts discusses science and science based tools for everyday life. https://www.hubermanlab.com/podcast.  Select your episode and they are great to listen to on your cellphone.

THE PODCAST episode, How to prevent and treat cold and flu, is outstanding. Skip the long sponsor introductdion and start listening at the 6 minute point.  In this podcast, Professor Andrew Huberman describes behavior, nutrition and supplementation-based tools supported by peer-reviewed research to enhance immune system function and better combat colds and flu. I also dispel common myths about how the cold and flu are transmitted and when you and those around you are contagious. I explain if common preventatives and treatments such as vitamin C, zinc, vitamin D and echinacea work. I also highlight other compounds known to reduce contracting and duration of colds and flu. I discuss how to use exercise and sauna to bolster the immune response. This episode will help listeners understand how to reduce the chances of catching a cold or flu and help people recover more quickly from and prevent the spread of colds and flu.   

PODCAST, ScienceVS, is an outstanding podcast series that takes on fads, trends, and opinionated mob to find out what’s fact, what’s not, and what’s somewhere in between. Select your episode and listen.

Link: https://gimletmedia.com/shows/science-vs/episodes#show-tab-picker

PODCAST episode, The Journal club podcast and Youtube, presentation from Huberman Lab is a example of outstanding scientific reasoning. In this presentation, Professor Andrew Huberman and Dr. Peter Attia  (author of Outlive: The Science and Art of Longevity) discuss two peer-reviewed scientific papers in-depth. The first discussion explores the role of bright light exposure during the day and dark exposure during the night and its relationship to mental health. The second paper explores a novel class of immunotherapy treatments to combat cancer.

Is mindfulness training old wine in new bottles?

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

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

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

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

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

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

The Relationship Between Mindfulness and Other Self-Regulation Techniques

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

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

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

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

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

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

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

Could there be negative side effects?

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

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

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

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

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

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

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

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

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

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

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

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

Areas to explore.

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

  • Who drops out?

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

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

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

  •  Strategies to cope with wandering attention.

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

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

Therapeutic and education strategies that implicitly incorporate mindfulness

Progressive relaxation

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

Autogenic Training

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

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

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

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

Bio/neurofeedback training

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

Transcendental meditation

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

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

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

Conclusion

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

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

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Rethink the monies spent on cancer screening tests

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

Erik Peper, PhD and Richard Harvey, PhD

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

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

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

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

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

What is the evidence that screening prolongs life?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

What can be done? Addressing systems not symptoms

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

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

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

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

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

Eat organic foods, especially vegetable and fruits.

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

Reduce environmental pollution exposure

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

Increase movement and exercise

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

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

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

Respect your biological rhythm.

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

Increase social connections and be part of a social community

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

Live a life with meaning and purpose

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

Summary

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

See also the following blogs:

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

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US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. https://aahb.org/Resources/Pictures/Meetings/2014-Charleston/PPT%20Presentations/Sunday%20Welcome/Abrams.AAHB.3.13.v1.o.pdf

Van Tulleken, C. (2023). Ultra-processed people. The science behind food that isn’t food. New Yoerk: W.W. Norton & Company. https://www.amazon.com/gp/product/1324036729/ref=ox_sc_act_title_1?smid=ATVPDKIKX0DER&psc=1

Healing a Shoulder/Chest Injury

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

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

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

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

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

Assessment

Observation and Palpation

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

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

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

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

Single Channel Surface Electromyographic (SEMG)Assessment

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Treatment interventions

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

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

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

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

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

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

The Change

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

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

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

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

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

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

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

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

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

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

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

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

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

RESULTS

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

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

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

Psychophysiological Follow-up: 3 Weeks Later

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

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

Summary

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

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

For additional intervention approaches see the following two blogs.

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

References

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

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

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

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

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

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

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

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

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

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

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

Are food companies responsible for the epidemic in diabetes, cancer, dementia and chronic disease and do their products need to be regulated like tobacco? Is it time for a class action suit?

Posted: July 15, 2023 | Author: | Filed under: behavior, cancer, Evolutionary perspective, health, Nutrition/diet, self-healing | Tags: , , , , , , , , , | 4 Comments

Adapted from: Peper, E. & Harvey, R. (2024). Are Food Companies Responsible for the Epidemic in Diabetes, Cancer, Dementia and Chronic Disease and Do Their Products Need to Be Regulated Like Tobacco? Is It Time for a Class Action Suit? Thownsend Letter-the examiner of alternative medicine.  https://www.townsendletter.com/e-letter-26-ultra-processed-foods-and-health-issues/

Erik Peper, PhD and Richard Harvey, PhD

Why are one third of young Americans becoming obese and at risk for diabetes?

Why are heart disease, cancer, and dementias occurring earlier and earlier?  Is it genetics, environment, foods, or lifestyle?

Is it individual responsibility or the result of the quest for profits by agribusiness and the food industry?

Like the tobacco industry that sells products regulated because of their public health dangers, is it time for a class action suit against the processed food industry? The argument relates not only to the regulation of toxic or hazardous food ingredients (e.g., carcinogenic or obesogenic chemicals) but also to the regulation of consumer vulnerabilities. Addressing vulnerabilities to tobacco products include regulations such as how cigarette companies may not advertise their products for sale within a certain distance from school grounds.

Is it time to regulate nationally the installation of vending machines on school grounds selling sugar-sweetened beverages? Students have sensitivity to the enticing nature of advertised, and/or conveniently available consumable products such as ‘fast foods’ that are highly processed (e.g., packaged, preserved and practically imperishable). Whereas ‘processed foods’ have some nutritive value, and may technically pass as ‘nutritious’ food, the quality of processed ‘nutrients’ can be called into question. For the purpose of this blog other important questions to raise relate to ingredients which, alone or in combination, may contribute to the onset of or, the acceleration of a variety of chronic health outcomes related to various kinds of cancers, cardiovascular diseases, and diabetes.

It may be an over statement to suggest that processed food companies are directly responsible for the epidemic in diabetes, cancer, dementia and chronic disease and need to be regulated like tobacco. On the other hand, processed food companies should become much more regulated than they are now.

More than 80 years ago, smoking was identified as a significant factor contributing to lung cancer, heart disease and many other disorders. In 1964 the Surgeon Generals’ report officially linked smoking to deaths of cancer and heart disease (United States Public Health Service, 1964).  Another 34 years pased before California prohibited smoking in restaurants in 1998 and, eventually inside all public buildings. The harms of smoking tobacco products were well known, yet many years passed with countless deaths and suffering which could have been prevented before regulation of tobacco products took place.  Reviewing historical data there is about a 20 year delay (e.g., a whole generation) before death rates decrease in relation to when regulations became effective and smoking rates decreased, as shown in figure 1.   

Figure 1. The relationship between smoking and lung cancer. Reproduced by permission from Roser, M. (2021). Smoking: How large of a global problem is it? And how can we make progress against it? Our world in data.

During those interim years before government actions limited smoking more effectively, tobacco companies hid data regarding the harmful effects of smoking. Arguably, the ‘Big Tobacco’ industry paid researchers to publish data which could confuse readers about tobacco product harm. There is evidence of some published articles suggesting that the harm of cigarette smoking was a hoax– all for the sake of boosting corporate profits (Bero, 2005).

Now we are experiencing a similar problem with the processed food industry. It has been suggested that alongside smoking and vaping, opioid use, a sedentary ‘couch potato’ lifestyle, and lack of exercise, ultra-processed food (UPF) that we eat severely affects our health.

Ultra-processed foods, which for many constitutes a majority of calories ranging from 55% to over 80% of the food they eat, contain chemical additives that trick the tastebuds, mouth and eventually our brain to desire those processed foods and eat more of them (Srour et al., 2022).

What are ultra-processed foods? Any foods that your great grandmother would not recognize as food. This includes all soft drinks, highly processed chips, additives, food coloring, stabilizers, processed proteins, etc. Even oils such as palm oil, canola oil, or soybean are ultra processed since they heated, highly processed with phosphoric acid to remove gums and waxes, neutralized with chemicals, bleached, and deodorized with high pressure steam (van Tulleken, 2023).

The data is clear! Since the 1970s obesity and inflammatory disease have exploded after ultra-processed foods became the constituents of the modern diet as shown in figure 2.

Figure 2. A timeline from 1850 to 2000 reflects the increase in use of refined sugar and high fructose corn syrup (HFCS) to the U.S. diet, together with the increase in U.S. obesity rate. The data for sugar, dairy and HFCS consumption per capita are from USDA Economic Research Service (Johnson et al., 2009) and reflects  historical estimates before 1967  (Guyenet et al., 2017). The obesity data (% of U.S. adult population) are from the Robert Wood Johnson Foundation’s Trust for America’s Health. (stateofobesity.org). Total U.S. television advertising data are from the World Advertising Research Center (www.warc.com). The vertical measure (y–axis) for kilograms per year (kg/yr) on the left covers all data except advertising expenditures, which uses the vertical measure for advertising on the right. Reproduced by permission from Bentley et al, 2018.

This graph clearly shows a close association between the years that high fructose corn syrups (HFCS) were introduced into the American diet and an increase in TV advertising with corresponding increase in obesity. HFCS is an ultra-processed food and is a surrogate marker for all other ultra-processed foods.  The best interpretation is that ultra-processed foods, which often contain HFCS, are a causal factor of the increase in obesity, and diabetes and in turn are risk factors for heart disease, cancers and dementias. 

Ultra-processed foods are novel from an evolutionary perspective.

The human digestive system has only recently encountered sources of calories which are filled with so many unnatural chemicals, textures and flavors.  Ultra-processed foods have been engineered, developed and product tested to increase the likelihood they are wanted by consumers and thereby increase sales and profits for the producers.   These foods contain the ‘right amount’ processed materials to evoke the taste, flavor and feel of desired foods that ‘trick’ the consumer it eat them because they activate evolutionary preference for survival.  Thus, these ultra-processed foods have become an ‘evolutionary trap’ where it is almost impossible not to eat them.  We eat the food because it capitalized on our evolutionary preferences even though doing so is ultimately harmful for our health (for a detailed discussion on evolutionary traps, see Peper, Harvey & Faass, 2020).

An example is a young child wanting the candy while waiting with her parents at the supermarket checkout line. The advertised images of sweet foods trigger the cue to eat. Remember, breast milk is sweet and most foods in nature that are sweet in taste, provide calories for growth and survival and are not harmful. Calories are essential of growth. Thus, we have no intrinsic limit on eating sweets unlike foods that taste bitter.

As parents, we wish that our children (and even adults) have self-control and no desire to eat the candy or snacks that is displayed at eye level (eye candy) especially while waiting at the cashier. When reflecting about food advertising and the promotion of foods that are formulated to take advantage of ‘evolutionary traps’, who is responsible?  Is it the child, who does not yet have the wisdom and self-control or, is it the food industry that ultra-processes the foods and adds ingredients into foods which can be harmful and then displays them to trigger an evolutionary preference for food that have been highly processed?

Every country that has adapted the USA diet of ultra-processed foods has experienced similar trends in increasing obesity, diabetes, cardiovascular disease, etc. The USA diet is replacing traditional diets as illustrated by the availability of Coca-Cola. It is sold in over 200 countries and territories (Coca-Cola, 2023).

An increase in ultra-processed foods by 10 percent was associated with a 25 percent increase in the risk of dementia and a 14 per cent increase in the risk of Alzheimers’s (Li et al., 2022). More importantly, people who eat the highest proportion of their diet in ultra-processed foods had a 22%-62% increased risk of death compared to the people who ate the lowest proportion of processed foods (van Tulleken, 2023). In the USA, counties with the highest food swamp scores (the availability of fast food outlets in a county) had a 77% increased odds of high obesity-related cancer mortality (Bevel et al., 2023). The increase risk has also been observed for cardiovascular disease, coronary heart disease, cerebrovascular disease and all cause mortality as is shown in figure 3 (Srour et al., 2019; Rico-Campà et al., 2019).  

Figure 3. Association between consumption of ultra-processed foods and all cause mortality. Reproduced from Rico-Campà et al, 2019.

The harmful effects of UPF holds up even when correcting for the amount of sugars, carbohydrates or fats in the diet and controlling for socio economic variables.

The logic that underlies this perspective is based upon the writing by Nassim Taleb (2012) in his book, Antifragile: Things That Gain from Disorder (Incerto). He provides an evolutionary perspective and offers broad and simple rules of health as well as recommendations for reducing UPF risk factors:

  • Assume that anything that was not part of our evolutionary past is probably harmful.
  • Remove the unnatural/unfamiliar (e.g. smoking/ e-cigarettes, added sugars, textured proteins, gums, stabilizers (guar gum, sodium alginate), emulsifiers (mono-and di-glycerides), modified starches, dextrose, palm  stearin, and fats, colors and artificial flavoring or other ultra-processed food additives).

What can we do?

The solutions are simple and stated by Michael Pollan in his 2007 New York Times article, “Eat food. Not too much. Mostly Plants.” Eat foods that your great grandmother would recognize as foods (Pollan, 2009).  Do not eat any of the processed foods that fill a majority of a supermarket’s space.

  • Buy only whole organic natural foods and prepare them yourself.
  • Request that food companies only buy and sell non-processed foods.
  • Demand government action to tax ultra-processed food and limit access to these foods.  In reality, it is almost impossible to expect people to choose healthy, organic foods when they are more expensive and not easily available in the American ‘food swamps and deserts’ (the presence of many fast food outlets  or the absence of stores that have fresh produce and non-processed foods). We do have a choice.  We can spend more money now for organic, health promoting foods or, pay much more later to treat illness related to UPF.
  • It is time to take our cues from the tobacco wars that led to regulating tobacco products.  We may even need to start class action suits against producers and merchants of UPF for causing increased illness and premature morbidity.

For more background information and the science behind this blog, read, the book, Ultra-processed people, by Chris van Tulleken. 

Look at the following blogs for more background information.

Live longer, enhance fertility and increase stress resistance: Eat organic foods
Yes, fresh organic food is better!
Our food is not the same as 50 years ago
What to eat? Low fat foods, high fat foods…..?
Food for thought- Is my “healthy diet” harming me?

References

Bentley, R.A., Ormerod, P. & Ruck, D.J. (2018). Recent origin and evolution of obesity-income correlation across the United States. Palgrave Commun 4, 146. https://doi.org/10.1057/s41599-018-0201-x

Bero, L. A. (2005). Tobacco Industry Manipulation of Research. Public Health Reports (1974-), 120(2), 200–208.  http://www.jstor.org/stable/20056773

Bevel, M.S., Tsai, M., Parham, A., Andrzejak, S.E., Jones, S., & Moore, J.X. (2023). Association of Food Deserts and Food Swamps With Obesity-Related Cancer Mortality in the US. JAMA Oncol. 9(7), 909–916. https://doi.org/10.1001/jamaoncol.2023.0634

Coca-Cola. (2023). More on Coca-Cola. Accessed July 14, 2023. https://www.coca-cola.co.uk/our-business/faqs/how-many-countries-sell-coca-cola-is-there-anywhere-in-the-world-that-doesnt

Johnson, R.K., Appel, L.J., Brands, M., Howard, B.V., Lefevre, M., Lustig, R.H., Sacks, F., Steffen, L.M., & Wylie–Rosett, J. (2009). Dietary sugars intake and cardiovascular health: a scientific statement from the American Heart Association. Circulation, 120(10), 1011–1020. https://doi.org/10.1161/CIRCULATIONAHA.109.192627

Li, H., Li, S., Yang, H., et al, 2022. Association of ultraprocessed food consumption with the risk of dementia: a prospective cohort study. Neurology, 99, e1056-1066. https://doi.org/10.1212/WNL.0000000000200871

Peper, E., Harvey, R. & Faass, N. (2020). TechStress: How Technology is Hijacking Our Lives, Strategies for Coping, and Pragmatic Ergonomics. Berkeley: North Atlantic Books, pp 18-22, 151. https://www.amazon.com/Beyond-Ergonomics-Prevent-Fatigue-Burnout/dp/158394768X/ref=sr_1_1?crid=1U9Y82YO4DKKP&keywords=erik+peper&qid=1689372466&sprefix=erik+peper%2Caps%2C187&sr=8-1

Pollan, M. (2007). Unhappy meals. The New York Times Magazine. https://www.nytimes.com/2007/01/28/magazine/28nutritionism.t.html

Pollan, M. (2009). Food Rules: An Eater’s Manual. New York: Penguin Books. https://www.amazon.com/Food-Rules-Eaters-Michael-Pollan/dp/014311638X/ref=tmm_pap_swatch_0?_encoding=UTF8&qid=1689373484&sr=8-2

Rico-Campà, A., Martínez-González, M. A.,  Alvarez-Alvarez, I., de Deus Mendonça, R., Carmen de la Fuente-Arrillaga, C.,  Gómez-Donoso, C., & Bes-Rastrollo, M.  (2019). Association between consumption of ultra-processed foods and all cause mortality: SUN prospective cohort study. BMJ; 365: l1949  https://doi.org/10.1136/bmj.l1949 

Roser, M. (2021).Smoking: How large of a global problem is it? And how can we make progress against it? Our world in data. Assessed July 13, 2023. https://ourworldindata.org/smoking-big-problem-in-brief

Srour, B., Fezeu, L.K., Kesse-Guyot, E.,Alles, B., Mejean, C…(2019). Ultra-processed food intake and risk of cardiovascular disease: prospective cohort study (NutriNet-Santé) BMJ,365:l1451. https://doi.org/10.1136/bmj.l1451 

Srour, B., Kordahi, M. C., Bonazzi, E., Deschasaux-Tanguy, M., Touvier, M., & Chassaing, B. (2022). Ultra-processed foods and human health: from epidemiological evidence to mechanistic insights. The Lancet Gastroenterology & Hepatology.  https://doi.org/10.1016/S2468-1253(22)00169-8

Taleb, N. N. (2012). Antifragile: Things That Gain from Disorder (Incerto). New York: Random House Publishing Group. (Kindle Locations 5906-5908).  https://www.amazon.com/Antifragile-Things-Disorder-ANTIFRAGILE-Hardcover/dp/B00QOJ6MLC/ref=sr_1_4?crid=3BISYYG0RPGW5&keywords=Antifragile%3A+Things+That+Gain+from+Disorder+%28Incerto%29&qid=1689288744&s=books&sprefix=antifragile+things+that+gain+from+disorder+incerto+%2Cstripbooks%2C158&sr=1-4

Van Tulleken, C. (2023). Ultra-processed people. The science behind food that isn’t food. New Yoerk: W.W. Norton & Company. https://www.amazon.com/gp/product/1324036729/ref=ox_sc_act_title_1?smid=ATVPDKIKX0DER&psc=1

United States Public Health Service. (1964). The 1964 Report on Smoking and Health. United States. Public Health Service. Office of the Surgeon General. https://profiles.nlm.nih.gov/spotlight/nn/catalog?f%5Bexhibit_tags%5D%5B%5D=smoking

Mouth breathing and tongue position: a risk factor for health

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

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

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

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

Benefits of nasal breathing

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

Mouth breathing

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

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

Experience how mouth breathing affects the throat and upper airway

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

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

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

Developmental behavior that contributes to mouth breathing

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

The role of the tongue in palate development

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

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

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

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

Support healthy development of the palate and jaw

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

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

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

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

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

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

Relevance to the field of neurofeedback and biofeedback

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

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

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

References

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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