How can you demonstrate that yoga practices are beneficial?
How do you know you are tightening the correct muscles or relaxing the muscle not involved in the movement when practicing asanas?
How can you know that the person is mindful and not sleepy or worrying when meditating?
How do you know the breathing pattern is correct when practicing pranayama?
The obvious answer would be to ask the instructor or check in with the participant; however, it is often very challenging for the teacher or student to know. Many participants think that they are muscularly relaxed while in fact there is ongoing covert muscle tension as measured by electromyography (EMG). Some participants after performing an asana, do not relax their muscles even though they report feeling relaxed. Similarly, some people practice specific pranayama breathing practice with the purpose of restoring the sympathetic/parasympathetic system; however, they may not be doing it correctly. Similarly, when meditating, a person may become sleepy or their attention wanders and is captured by worries, dreams, and concerns instead of being present with the mantra. These problems may be resolved by integrating bio- and neurofeedback with yoga instruction and practice. Biofeedback monitors the physiological signals produced by the body and displays them back to the person as shown in Figure 1.
Figure 1: Biofeedback is a methodology by which the participant receives ongoing feedback of the physiological changes that are occurring within the body. Reproduced with permission from Peper et al, 2008.
With the appropriate biofeedback equipment, one can easily record muscle tension, temperature, blood flow and pulse from the finger, heart rate, respiration, sweating response, posture alignment, etc.** Neurofeedback records the brainwaves (electroencephalography) and can selectively feedback certain EEG patterns. In most cases participants are unaware of subtle physiological changes that can occur. However, when the physiological signals are displayed so that the person can see or hear the changes in their physiology they learn internal awareness that is associated with these physiological changes and learn mastery and control. Biofeedback and neuro feedback is a tool to make the invisible, visible; the unfelt, felt and the undocumented, documented.
Biofeedback can be used to document that a purported yoga practice actually affects the psychophysiology. For example, in our research with the Japanese Yogi, Mr. Kawakami, who was bestowed the title “Yoga Samrat’ by the Indian Yoga Culture Federation in 1983, we measured his physiological responses while breathing at two breaths a minute as well as when he inserted non-sterilized skewers through his tongue tongue (Arambula et al, 2001; Peper et al, 2005a; Peper et al, 2005b). The physiological recordings confirmed that his Oxygen saturation stayed normal while breathing two breaths per minute and that he did not trigger any physiological arousal during the skewer piercing. The electroencephalographic recordings showed that there was no response or registration of pain. A useful approach of using biofeedback with yoga instruction is to monitor muscle activity to measure whether the person is performing the movement appropriately. Often the person tightens the wrong muscles or performs with too much effort, or does not relax after performing. An example of recording muscle tension as shown in Figure 2.
Figure 2: Recording the muscle tension with Biograph Infinity while performing an asana.
In our research it is clear that many people are unaware that they tighten muscles. For example, Mcphetridge et al, (2011) showed that when participants were asked to bend forward slowly to touch their toes and then hang relaxed in a forward fold, most participants reported that they were totally relaxed in their neck. In actuality, they were not relaxed as their neck muscles were still contracting as recorded by electromyography (EMG). After muscle biofeedback training, they all learned to let their neck muscles be totally relaxed in the hanging fold position as shown in Figure 3 & 4.
Figure 3: Initial assessment of neck SEMG while performing a toe touch. Reproduced from Harvey, E. & Peper, E. (2011).
Figure 4: Toe touch after feedback training. The neck is now relaxed; however, the form is still not optimum. . Reproduced from Harvey, E. & Peper, E. (2011).
Thus, muscle feedback is a superb tool to integrate with teaching yoga so that participants can perform asanas with least amount of inappropriate tension and also can relax totally after having tightened the muscles. Biofeedback can similarly be used to monitor body posture during meditation. Often participants become sleepy or their attention drifts and gets captured by imagery or worries. When they become sleepy, they usually begin to slouch. This change in body position can be readily be monitored with a posture feedback device. The UpRight,™ (produced by Upright Technologies, Ltd https://www.uprightpose.com/) is a small sensor that is placed on the upper or lower spine and connects with Bluetooth to the cell phone. After calibration of erect and slouched positions, the device gives vibratory feedback each time the participant slouches and reminds the participant to come back to sitting upright as shown in Figure 5.
Figure 5: UpRigh™ device placed on the upper spine to provide feedback during meditation. Each time person slouches which often occurs when they become sleepy or loose meditative focus, the device provides feedback by vibrating.
Alternatively, the brainwaves patterns (electroencephalography could be monitored with neurofeedback and whenever the person drifts into sleep or becomes excessively aroused by worry, neurofeedback could remind the person to be let go and be centered. Finally, biofeedback can be used with pranayama practice. When a person is breathing approximately six breaths per minute heart rate variability can increase. This means that during inhalation heart rate increases and during exhalation heart rate decreases. When the person breathes so that the heart rate variability increases, it optimizes sympathetic/parasympathetic activity. There are now many wearable biofeedback devices that can accurately monitor heart rate variability and display the changes in heart rate as modulated by breathing.
Conclusion: Biofeedback is a useful strategy to enhance yoga practice as it makes the invisible visible. It allows the teacher and the student to become aware of the dysfunctional patterns that may be occurring beneath awareness.
Arambula, P., Peper, E., Kawakami, M., & Gibney, K. H. (2001). The physiological correlates of Kundalini Yoga meditation: a study of a yoga master. Applied psychophysiology and biofeedback, 26(2), 147-153.
Harvey, E. & Peper, E. (2011). I thought I was relaxed: The use of SEMG biofeedback for training awareness and control. In W. A. Edmonds, & G. Tenenbaum (Eds.), Case studies in applied psychophysiology: Neurofeedback and biofeedback treatments for advances in human performance. West Sussex, UK: Wiley-Blackwell, 144-159.
Mcphetridge, J., Thorne, E., Peper, E., & Harvey, R. (2011) SEMG for training awareness and muscle relaxation during toe touching. Paper presented at the 15th Annual Meeting of the Biofeedback Foundation of Europe. Munich, Germany, February 22-26, 2011.
Peper, E., Kawakami, M., Sata, M., Franklin, Y, Gibney, K. H. & Wilson, V.S. (2005a). Two breaths per minute yogic breathing. In: Kawakami, M. (2005). The Theses of Mitsumasa Kawakami II: The Theory of Yoga-Based Good Health. Tokyo, Japan: Samskara. 483-493. ISBN 4-434-06113-5
Peper, E., Kawakami, M., Sata, M. & Wilson, V.S. (2005b). The physiological correlates of body piercing by a yoga master: Control of pain and bleeding. Subtle Energies & Energy Medicine Journal. 14(3), 223-237.
**Biofeedback and neurofeedback takes skill and training. For information on certification, see http://www.bcia.org Two useful websites are:
“It was the best meet of my life.” -Jo Aita
Setting a personal best and winning the Gold medal is a remarkable feat. Jo Aita, age 46 and weighing 58 kg, set the Masters World Records and Masters Games Records in Snatch, Clean & Jerk and Total Olympic weight lifting at the World Masters Games in Auckland, New Zealand, April 26th, 2017. She lifted 71 kg in the Snatch and 86 kg in the Clean and Jerk Olympic lifts in the 45-49-year-old age group (see video in figure 1). What makes this more remarkable is that her combined lifts were 3 kilograms more than her life-time best in previous competition. She refuted the conventional wisdom that weight lifters peak in their mid to late twenties. There is hope for improvement as aging may not mean we have to decline.
Figure 1. Video of Jo Aita successful lift at the World Masters Games in Auckland, NZ., April 26, 2017.
There are many factors–and many more which we do not know–which contribute to this achievement such as genetics, diligent training and superb coaching at the Max’ Gym in Oakland as a member of Team Juggernauts. In the last three years, Jo Aita also incorporated biofeedback and visualization training to help optimize her performance. This report summarizes how breathing and electromyography feedback combined with imagery may have contributed to achieving her personal best. As Jo Aita stated, “I recommend this to everyone and hope that you can work with athletes in my gym.”
Components of the 30 sessions of biofeedback, internal language and visualization training program
The training was started in September 2014 to reduce anxiety and improve performance. The components embedded in the training are listed sequentially; however, training did not occur sequentially. They were dynamically interwoven throughout the many sessions and augmented with homework practices, as well as storytelling of other people achieving success using similar approaches. The major components included:
1. Mastering effortless slow diaphragmatic breathing in which the abdomen expanded during inhalations and constricted during exhalation. The respiration feedback and training was recorded with BioGraph Infinity respiration sensors and recorded from the abdomen and upper chest. Her homework included monitoring situations where she held her breath and then anticipate breath holding by continuing to breathe. She also practiced slower breathing with heart rate variability feedback from a Stress Eraser. Practicing these allowed her to become centered and regenerate more quickly. As she stated, “It helped me during the day when I am anxious to calm down.” Throughout the training, the focus was to use breathing to rapidly regenerate after exertion especially after training.
2. Learning to relax her shoulder muscles with electromyography (EMG) feedback to regenerate and learn awareness of minimal trapezius muscle tension. She could use this awareness to identify her emotional reactivity (Peper, Booiman, Lin, & Shaffer, 2014). Often emotional reactivity increases muscle tension. She learned to relax here muscles quickly after muscle contractions to allow regeneration
3. Experiencing how cognition affect performance. This was initially demonstrated by arm resistance test. In this experiential practice, she extended her arm and attempted to resist the downward pressure applied to her wrist while she recalled either a hopeless, helpless, powerless or defeated memory or an empowered positive memory (for detailed description see, Gorter and Peper, pp 186-188, 2011). When she recalled the powerless memory she was significantly weaker than when she recalled the empowering memory. This experience demonstrated to her the power of her thoughts.
4. Rewriting failure into success. Each time she missed the lift, she would think, “I should not have done that,” or “I was doubtful or nervous during competition,” she shifted her focus to:
- Accepting what happened by acknowledging she did the best she could have done under the circumstances.
- Exploring how she could have done it differently and imagine herself doing it in the new optimum way.
- Using the trigger of the beginning thought of failure or defeat to evoke the new empowering memory thus interrupting the chained behavior.
The underlying concept was that what we mentally rehearse is what we may become and that our thoughts affect performance which she previously experienced by the arm resistance test. If you keep thinking about a defeat you are training the physiological pattern of defeat. This practice of transforming self-defeating thoughts into empowering thoughts can be applied to all phases of one’s life and was continued throughout the training sessions. The focus was to acknowledge and realize that whatever you did, it was the only thing you could have done because you did not yet have the skills to do it differently. She would then create a new strategy of mental rehearsal that lead to a positive outcome (for detailed description of this practice see Peper, Harvey, Lin, & Duvvuri, 2014).
5. Identifying whether imagery rehearsal is somatically connected. It is our bias that imagery rehearsal is useful if the body responds in a similar pattern when the person images the task as it would during an actual activity (Hall, 2001; Peper et al, 2015). The concurrent physiological activity would indicate that the person is experientially involved in the task and not just observing as a witness/second party.
Her performance is weightlifting and this would involve major muscle activity. Surface EMG was recorded from muscles that would be activated during the actual performance of the task to identify if they would be activated during mental rehearsal. The muscle activity during mental rehearsal is usually at a much smaller amplitude than that occurred during actual physical performance; however, should follow a similar timing sequence. In our experience there are three responses:
- Muscle activity in the appropriate muscles that are in the same timing as in and actual performance. This implies that mental rehearsal is actually training the motor pattern and facilitate performance. Thus continue practicing with mental rehearsal.
- Muscle activity in the appropriate muscles are not generally in the same timing sequence as the actual performance. This may mean that the person was performing too slow or was skipping sequences in the mental rehearsal and mental training may not be useful. The person needs to master and exhibit the same muscle pattern during mental rehearsal as during actual performance of the task.
- No muscle activity or inappropriate muscle activity during the during the mental rehearsal. This implies that during mental rehearsal there is no motor pattern training and the approach would not be useful unless the person learned to activate appropriate motor activity. It is possible that some people who have experienced past traumas may have coped by shutting off feelings and sensations in their bodies.
When Jo Aita initially practiced mental rehearsal while being monitored with surface EMG recorded with Myoscan Pro sensors (filter set narrow 100-200Hz) from the right and left upper trapezius muscles, there was no corresponding muscle activity as shown in Figure 2. Although she imaged, she did not feel/experience the lifting. The training focused upon reconnecting imagery and body experience.
Figure 2. Left and right upper trapezius EMG showed no increase in activity while Jo Aita mentally imaged performing her lift.
6. Integrating imagery and body experience with EMG. After identifying that imagery did not elicit concurrent muscle activity, the training focused on developing the imagery muscle connection. The training consisted of:
- Monitoring EMG activity from her right and left quadriceps and right and left upper trapezius muscle and have her simulate her actually lifting in practice and competition by going through the complete sequence which included standing and waiting till her name was called, caulking her hands, performing a ritual activity to be ready to lift the weights, lifting the weights, and releasing them. The pattern is shown in Figure 3.
Figure 3. Simulating the actual Snatch and Jerk lift (Clean is lifting the weights to the chest and punching Jerk is pushing the weigh upward is labelled).
- Practicing imagery by going through the same procedure and purposely slightly activating the movements which were necessary to lift the weight. As she stated, “I learned to do mental rehearsal in a more structured way and visualized the total sequence from chalking up to doing all six lifts”. This was monitored by the EMG to see that there occurred EMG activation of the muscles. This was repeated numerous times till, the activation occurred in imagery as shown in Figure 4.
Figure 4. EMG activity during mental rehearsal.
She then reported that imagery was a real experience.
7. Training mental rehearsal and imagery for peak performance (Cumming, Hall, & Shambrook, 2004). The major components of the mental rehearsal focused upon performing perfectly, visualizing lifting more weight easily than actually lifted in the gym, performing in the gym as she would during competing, practicing performing when interruptions occurred, and punching the weight through the ceiling.
- Performing perfectly. During the day she would mentally rehearse practicing lifting perfectly. In addition, as part of her readiness routine she would image performing the lift perfectly.
- Practicing recovery and being centered when interruptions would occur. For example, she was asked to role play competition and waiting for the judge to give the signal to start, I delayed giving her the signal to begin and told her the weights had to be adjusted because they had miss-loaded the bar. This way there would be no novelty during actual competition. This concept of coping with the unexpected was illustrated by Michael Phelps swimming the 200-meter butterfly in 2012 Being Olympics when his googles filled up with water when he dove in. Michael still won his 10th gold medal even though he swam part of the race blind (Fanning, E., June 25, 2012). He could do this because numerous time in the past, his coach had purposely trained Michael to swim with leaking googles
- Imagining lifting 10 kg more while competing. The concept of feeling/imagining yourself performing more that you can do at this moment creates the possibility for improvement since the limits of imagination may limit the experience/performance. As she reported, “This was incredibly helpful last year in competition when I needed to lift more than I had done before to qualify for the American Open, so I had mentally done it so often, then I just did it and made the qualifying lift.”
- Feeling your arms extending way up into the ceiling. Extending beyond your mental boundary of the test allows more power because the body tends to stop at the boundary. For example, when running 100 meters you want to see the finish line at least ten meters beyond the actual finish line this way you continue to run at maximum speed through the finish. If you focus on the actual finish line, you often slow down before reaching it. I told her how we used this concept with young male gymnasts to be able to do the iron cross for the first time by thinking of their arms being an iron beam and extending through the rings into the wall. In the case of lifting, you want to feel yourself punching the weight through the ceiling instead of just driving it upward. This portion of the lift when punching up into the ceiling is call the Jerk. This concept was experientially demonstrated by the following Aikido exercise of the iron arm.
Two people pair up and face each other. One stretches his arm straight out and rests the wrist and back of the palm on the shoulder of his partner. The partner put both hands on the elbow and then then pulls down trying to bend the elbow while his partner is try resist the downward force and try not to bend it as shown in Figure 5.
Figure 5. Testing the effect of imagery on resisting downward pull at the elbow with wrist facing palm up.
Then relax, and repeat the same exercise except the person imagines that his arm is like a metal bar extending from their shoulders out through his hand into the wall. Once the person is imaging this, then the partner again attempts to bend the arm.
In almost all cases, when the person imagines the arm extending like an iron bar into the wall, it is much stronger and much more difficult to bend. Jo integrated this felt imagery in her lifting during practice and she experienced increased strength while imagining/feeling the iron bar and reported that she had the “best Jerks in her life.”
Achieving a new world and personal record at age 46 in the master’s competition is a remarkable tribute to the athlete’s dedication and coaching. Although I (EP) may think I contributed, and hopefully what I taught was beneficial, in the end it is the athlete herself who has to perform in the competition–she is alone stands on the platform to lift the weights. When I (EP) asked whether the biofeedback visualization training was useful, Jo inequitably said, “Yes, and I would recommend this approach and training to everyone!” Watch the in-depth interview with Jo Aita in which she describes her experience of integrating imagery techniques and biofeedback to enhance performance on May 26, 2017.
What is interesting to ask is, how come a 46-year-old woman could lift 3 kg more than at any other time during her competitive career of Olympic lifting? It gives hope that loss of strength that commonly occurs as we age may be due less to aging than to learned disuse, injuries and lack of recovery. Most important factors are personal motivation and hope—you want to perform your best and know/believe that it is possible (Wilson and Peper, 2011). As Jo stated, “It helped for me to focus on doing my personal best.” I love Olympic lifting, I like taking care of my body, and I like feeling strong.” Finally, Jo is a recent athlete in her sport. She started lifting when she was 33 and competed one year later. She then took time out to give birth to her son and in a couple of months came back quickly and continued to become stronger. As she stated, “I always wanted to get stronger no matter what my age was.”
From a performance perspective it is interesting that she lifted more than ever before. Would it be possible that she is similar to many performers who achieve maximum performance after about 10 to 15 years of dedicated training? As she gets older, she improves her skills, increases efficiency of here muscles and neural connections. Is a possible that loss of performance as we age less due to aging than loss of motivation after years of practice, competition and achieving your goal. At that point life may offer other challenges and new opportunities.
* This blog was adapted and expanded from: Peper, E. & Aita, J. (2017). Winning the Gold in Weightlifting Using Biofeedback, Imagery and Cognitive Change. Biofeedback, 45(4), 77–82. DOI: 10.5298/1081-5937-45.4.01 https://biofeedbackhealth.files.wordpress.com/2018/02/a-winning-the-gold-in-weightlifting-published.pdf
Cumming, J., Hall, C., & Shambrook, C. (2004). The influence of an imagery workshop on athletes’ use of imagery. Athletic insight, 6(1), 52-73.
Fanning, E. (June 25, 2012). 50 stunning Olympic Moments No 42: Michael Phelps goes big in Being. Downloaded May 30, 2017 from https://www.theguardian.com/sport/blog/2012/jun/25/50-stunning-olympic-moments-michael-phelps
Gorter, R. & Peper, E. (2011). Fighting Cancer-A Non Toxic Approach to Treatment. Berkeley: North Atlantic.
Hall, C. (2001). Imagery in sport and exercise. In R. Singer, H. Hausenblas, & C. Janelle (Eds.), Handbook of Sport Psychology (pp. 529 – 549). New York, NY: John Wiley & Sons, Inc.
Peper, E., Harvey, R., Lin, I-M, & Duvvuri, P. (2014). Increase productivity, decrease procrastination and increase energy. Biofeedback, 42(2), 82-87.
Peper, E., Booiman, A., Lin, I-M., & Shaffer, F. (2014). Making the Unaware Aware-Surface Electromyography to Unmask Tension and Teach Awareness. Biofeedback.42(1), 16-23.
 Correspondence: Erik Peper, Ph.D., Institute for Holistic Health Studies, Department of Health Education, San Francisco State University, 1600 Holloway Avenue, San Francisco, CA 94132. email: email@example.com; web: www.biofeedbackhealth.org; blog: www.peperperspective.com
 We thank Dr. Sue Wilson for her helpful and constructive feedback.
 We purposely use the word “may” because it is a case report and not a controlled study. Coaches, sport psychologist, or anyone who has had contact with an athlete who does extremely well usually claims that their suggestions were the magic ingredient; however, it could be synchronicity and not due to the actual skills taught. It may be due to unidentified factors or covert factors embedded in the coaching or teaching such as transforming hope and belief.
 Be aware that when people learn to reconnect with their body or learns slow diaphragmatic breathing and allow their lower abdomen to relax and expand, it is possible that past traumatic memories could be released. This release is a healthy process and we usually adapt an Autogenic Therapy/Training perspective by which the person accepts, allows discharge and continues with the task at hand.
“I have had headaches for six years, at first occurring almost every day. When I got put on an antidepressant, they slowed to about 3 times a week (sometimes more) and continued this way until I learned relaxation techniques. I am 20 years old and now headache free. Everyone should have this educational opportunity to heal themselves.” -Melinda, a 20 year old student
Health and wellness is a basic right for all people. When students learn stress management skills which include awareness of stress, progressive muscle relaxation, Autogenic phrases, slower breathing, posture change, transforming internal language, self-healing imagery, the role of diet, exercise embedded within an evolutionary perspective as part of a college class their health often improves. When students systematically applied these self-awareness techniques to address a self-selected illness or health behavior (e.g., eczema, diet, exercise, insomnia, or migraine headaches), 80% reported significant improvement in their health during that semester (Peper et al., 2014b; Tseng, et al., 2016). The semester long program is based upon the practices described in the book, Make Health Happen, (Peper, Gibney, & Holt, 2002).
The benefits often last beyond the semester. Numerous students reported remarkable outcomes at follow-up many months after the class had ended because they had mastered the self-regulation skills and continued to implement these skills into their daily lives. The educational model utilized in holistic health courses is often different from the clinical/treatment model.
Educational approach: I am a student and I have an illness (most of me is healthy and only part of me is sick).
Clinical treatment approach: I am a patient and I am sick (all of me is sick)
Some of the concepts underlying the differences between the educational and the clinical approach are shown in Table 1.
|Educational approach||Clinic/treatment approach|
|Focuses on growth and learning||Focuses on remediation|
|Focuses on what is right||Focuses on what is wrong|
|Focuses on what people can do for themselves||Focuses on how the therapist can help patients|
|Assumes students as being competent||Implies patients are damaged and incompetent|
|Students defined as being competent to master the skills||Patients defined as requiring others to help them|
|Encourages active participation in the healing process||Assumes passive participation in the healing process|
|Students keep logs and write integrative and reflective papers, which encourage insight and awareness||Patients usually do not keep logs nor are asked to reflect at the end of treatment to see which factors contributed to success|
|Students meet in small groups, develop social support and perspective||Patients meet only with practitioners and stay isolated|
|Students experience an increased sense of mastery and empowerment||Patients experience no change or possibly a decrease in sense of mastery|
|Students develop skills and become equal or better than the instructor||Patients are healed, but therapist is always seen as more competent than patient|
|Students can become colleagues and friends with their teachers||Patients cannot become friends of the therapist and thus are always distanced|
Table 1. Comparison of an educational versus clinical/treatment approach
The educational approach focuses on mastering skills and empowerment. As part of the course work, students become more mindful of their health behavior patterns and gradually better able to transform their previously covert harm promoting patterns. This educational approach is illustrated in a case report which describes how a student reduced her chronic migraines.
Case Example: Elimination of Chronic Migraines
Melinda, a 20-year-old female student, experienced four to five chronic migraines per week since age 14. A neurologist had prescribed several medications including Imitrex (used to treat migraines) and Topamax (used to prevent seizures as well as migraine headaches), although they were ineffective in treating her migraines. Nortriptyline (a tricyclic antidepressant) and Excedrin Migraine (which contains caffeine, aspirin, and acetaminophen) reduced the frequency of symptoms to three times per week.
She was enrolled in a university biofeedback class that focused on learning self-regulation and biofeedback skills. All these students were taught the fundamentals of biofeedback and practiced Autogenic Training (AT) every day during the semester (Luthe, 1979; Luthe & Schultz, 1969; Peper & Williams, 1980).
In the class, students practiced with surface electromyography (SEMG) feedback to identify the presence of shoulder muscle overexertion (dysponesis), as well as awareness of minimum muscle tension. Additional practices included hand warming, awareness of thoracic and diaphragmatic breathing, and other biofeedback or somatic awareness approaches. In parallel with awareness of physical sensations, students practiced behavioral awareness such as alternating between a slouching body posture (associated with feeling self-critical and powerless) and an upright body posture (associated with feeling powerful and in control). Psychological awareness was focused on transforming negative thoughts and self-judgments to positive empowering thoughts (Harvey and Peper, 2011; Peper et al., 2014a; Peper et al, 2015). Taken together, students systematically increased awareness of physical, behavioral, and psychological aspects of their reactions to stress.
The major determinant for success is to generalize training at school, home and at work. Each time Melinda felt her shoulders tightening, she learned to relax and release the tension in her shoulders, practiced Autogenic Training with the phrase “my neck and shoulders are heavy.” In addition, whenever she felt her body beginning to slouch or noticed a negative self-critical thought arising in her mind, she shifted her body to an upright empowered posture, and substituted positive thoughts to reduce her cortisol level and increase access to positive thoughts (Carney & Cuddy, 2010; Cuddy, 2012; Tsai, et al., 2016). Postural feedback was also informally given by Melinda’s instructor. Every time the instructor noticed her slouching in class or the hallway, he visually changed his own posture to remind her to be erect.
Melinda’s headaches reduced from between three and five per week before enrolling in the class to zero following the course, as shown in Figure 2. She has learned to shift her posture from slouching to upright and relaxed. In addition, she reported feeling empowered, mentally clear, and her acne cleared up. All medications were eliminated. At a two year follow-up, she reported that since she took the class, she had only few headaches which were triggered by excessive stress.
Figure 2. Frequency of migraine and the implementation of self-practices.
The major factors that contributed to success were:
- Becoming aware of muscle tension through the SEMG feedback. Melinda realized that she had tension when she thought she was relaxed.
- Keeping detailed logs and developing a third person perspective by analyzing her own data and writing a report. A process that encouraged acceptance of self, thereby becoming less judgmental.
- Acquiring a new belief that she could learn to overcome her headaches, facilitated by class lecture and verbal feedback from the instructor.
- Taking active control by becoming aware of the initial negative thoughts or sensations and interrupting the escalating chain of negative thoughts and sensations by shifting the attention to positive empowering thoughts and sensations–a process that integrated mindfulness, acceptance and action. Thus, transforming judgmental thoughts into accepting and positive thoughts.
- Becoming more aware throughout the day, at school and at home, of initial triggers related to body collapse and muscle tension, then changing her body posture and relaxing her shoulders. This awareness was initially developed because the instructor continuously gave feedback whenever she started to slouch in class or when he saw her slouching in the hallways.
- Practicing many, many times during the day. Namely, increasing her ongoing mindfulness of posture, neck, and shoulder tension, and of negative internal dialogue without judgment.
The benefits of this educational approach is captured by Melinda’s summary, “The combined Autogenic biofeedback awareness and skill with the changes in posture helped me remarkably. It improved my self-esteem, empowerment, reduced my stress, and even improved the quality of my skin. It proves the concept that health is a whole system between mind, body, and spirit. When I listen carefully and act on it, my overall well-being is exceptionally improved.”
Carney, D. R., Cuddy, A. J., & Yap, A. J. (2010). Power posing brief nonverbal displays affect neuroendocrine levels and risk tolerance. Psychological Science, 21(10), 1363-1368.
Cuddy, A. (2012). Your body language shapes who you are. Technology, Entertainment, and Design (TED) Talk, available at: http://www.ted.com/talks/amy_cuddy_your_body_language_shapes_who_you_are
Harvey, E. & Peper, E. (2011). I thought I was relaxed: The use of SEMG biofeedback for training awareness and control (pp. 144-159). In W. A. Edmonds, & G. Tenenbaum (Eds.), Case studies in applied psychophysiology: Neurofeedback and biofeedback treatments for advances in human performance. West Sussex, UK: Wiley-Blackwell.
Luthe, W. (1979). About the methods of autogenic therapy (pp. 167-186). In E. Peper, S. Ancoli, & M. Quinn, Mind/body integration. New York: Springer.
Luthe, W., & Schultz, J.H. (1969). Autogenic therapy (Vols. 1-6). New York, NY: Grune and Stratton.
Peper, E., Booiman, A., Lin, I-M., & Shaffer, F. (2014a). Making the unaware aware-Surface electromyography to unmask tension and teach awareness. Biofeedback. 42(1), 16-23.
Peper, E., Gibney, K.H. & Holt. C. (2002). Make health happen: Training yourself to create wellness. Dubuque, IA: Kendall-Hunt. ISBN-13: 978-0787293314
Peper, E., Lin, I-M, Harvey, R., Gilbert, M., Gubbala, P., Ratkovich, A., & Fletcher, F. (2014b). Transforming chained behaviors: Case studies of overcoming smoking, eczema and hair pulling (trichotillomania). Biofeedback, 42(4), 154-160.
Peper, E., Nemoto, S., Lin, I-M., & Harvey, R. (2015). Seeing is believing: Biofeedback a tool to enhance motivation for cognitive therapy. Biofeedback, 43(4), 168-172. doi: 10.5298/1081-5937-43.4.03
Peper, E. & Williams, E.A. (1980). Autogenic therapy (pp. 131-137). In: A. C. Hastings, J. Fadiman, & J. S. Gordon (Eds.). Health for the whole person. Boulder: Westview Press.
Tsai, H. Y., Peper, E., & Lin, I. M. (2016). EEG patterns under positive/negative body postures and emotion recall tasks. NeuroRegulation, 3(1), 23-27.
Tseng, C., Abili, R., Peper, E., & Harvey, R. (2016). Reducing acne-stress and an integrated self-healing approach. Poster presented at the 47th Annual Meeting of the Association for Applied Psychophysiology and Biofeedback, Seattle WA, March 9-12, 2016.
 Adapted from: Peper, E., Miceli, B., & Harvey, R. (2016). Educational Model for Self-healing: Eliminating a Chronic Migraine with Electromyography, Autogenic Training, Posture, and Mindfulness. Biofeedback, 44(3), 130–137. https://biofeedbackhealth.files.wordpress.com/2011/01/a-educational-model-for-self-healing-biofeedback.pdf
Sweating, finger temperature, muscle tension, breathing, heart rate, posture and other body signals covertly and overtly display your emotional state. The feedback from these signals can facilitate awareness and control to promote your health. Watch my presentation, The skin you’re in and other signals “Tells” of emotional state, presented at the TransTech-Transformative Technology Conference, Sofia University, Palo Alto, CA, Oct 14, 2016.
Many illness may be prevented or reversed when we life in harmony with our evolutionary origins such as diet, movement, and circadian rhythm. The focus is to teach skills and not pills; since, many medications have long term negative side affects. By applying behavioral life style changes that supports our evolutionary patterns, we may be able to prevent or even reverse numerous illnesses such as epilepsy, eczema, diabetes, Crohn’s disease, allergies, ADHD, depression, anxiety, cancer, stress related symptoms.
Enjoy the wide ranging lecture presented at the 2012 meeting of the International Society for Neurofeedback and Research.
When I allowed my lower abdomen to expand during inhalation without any striving and slightly constrict during exhalation, breathing was effortless. At the end of exhalation, I just paused and then the air flowed in without any effort. I felt profoundly relaxed and safe. With each effortless breath my hurry-up sickness dissipated.
Effortless breathing from a developmental perspective is a whole body process previously described by the works of Elsa Gindler, Charlotte Selver and Bess M. Mensendieck (Brooks, 1986; Bucholtz, 1994; Gilbert 2016, Mensendieck, 1954). These concepts underlie the the research and therapeutic approach of Jan van Dixhoorn (2008, 2014) and is also part of the treatment processes of Mensendieck/Cesar therapists (Profile Mensendeick) . During inhalation the body expands and during exhalation the body contracts. While sitting or standing, during exhalation the abdominal wall contracts and during inhalation the abdominal wall relaxes. This whole body breathing pattern is often absent in clients who tend to lift their chest and do not expand or sometimes even constrict their abdomen when they inhale . Even if their breathing includes some abdominal movement, often only the upper abdomen above the belly button moves while the lower abdomen shows limited or no movement. This may be associated with physical and emotional discomfort such as breathing difficulty, digestive problems, abdominal and pelvic floor pains, back pain, hyper vigilance, and anxiety. (The background, methodology to monitor and train with muscle biofeedback, and pragmatic exercises are described in detail in our recent published article, Peper, E., Booiman, A.C, Lin, I-M, Harvey, R., & Mitose, J. (2016). Abdominal SEMG Feedback for Diaphragmatic Breathing: A Methodological Note. Biofeedback. 44(1), 42-49.)
Some of the major factors that contribute to the absence of abdominal movement during breathing are (Peper et, 2015):
- ‘Designer jean syndrome’ (the modern girdle): The abdomen is constricted by a waist belt, tight pants or slimming underwear such as Spanx and in former days by the corset as shown in Figure 1 (MacHose & Peper, 1991; Peper & Tibbitts, 1994).
- Self-image: The person tends to pull his or her abdomen inward in an attempt to look slim and attractive.
- Defense reaction: The person unknowingly tenses the abdominal wall –a flexor response-in response to perceived threats (e.g., worry, external threat, loud noises, feeling unsafe). Defense reactions are commonly seen in clients with anxiety, panic or phobias.
- Learned disuse: The person covertly learned to inhibit any movement in the abdominal wall to protect themselves from experiencing pain because of prior abdominal injury or surgery (e.g., hernia or cesarean), abdominal pain (e.g., irritable bowel syndrome, dysmenorrhea, vulvodynia, pelvic floor pain, low back pain).
- Inability to engage abdominal muscles because of the lack of muscle tone.
Figure 1. How clothing constricts abdominal movement. Previously it was a corset as shown on the left and now it is Spanx or very tight clothing which restricts the waist.
Whether the lower abdominal muscles are engaged or not (either by chronic tightening or lack of muscle activation), the resultant breathing pattern tends to be more thoracic, shallow, rapid, irregular and punctuated with sighst. Over time participants may not able to activate or relax the lower abdominal muscles during the respiratory cycle. Thus it is no longer involved in whole body movement which can usually be observed in infants and young children.
In our published paper by Peper, E., Booiman, A.C, Lin, I-M, Harvey, R., & Mitose, J. (2016), we describe a methodology to re-establish effortless whole body breathing with the use of surface electromyography (SEMG) recorded from the lower abdominal muscles (external/ internal abdominal oblique and transverse abdominis) and strategies to teach engagement of these lower abdominal muscles. Using this methodology, the participants can once again learn how to activate the lower abdominal muscles to flatten the abdominal wall thereby pushing the diaphragm upward during exhalation. Then, during inhalation they can relax the muscles of the abdominal wall to expand the abdomen and allow the diaphragm to descend as shown in Figure 2.
Figure 2. Correspondence between respiratory strain gauge changes and SEMG activity during breathing. When the person exhales, the lower abdominal SEMG activity increases and when the person inhales the SEMG decreases.
The published article discusses the factors that contribute to the breathing dysregulation and includes guidelines for using SEMG abdominal recording. It describes in detail–with illustrations–numerous practices such as tactile awareness of the lower abdomen, active movements such as pelvic rocking and cats and dogs exercises that people can practice to facilitate lower abdominal breathing. One of these practices, Sensing the lower abdomen during breathing, is developed and described by Annette Booiman, Mensendieck therapist
Sensing the lower abdomen during breathing
The person place their hands below their belly button with the outer edge of hands resting on the groin. During inhalation, they practice bringing their lower abdomen/belly into their hands so that the person can feel the lower abdomen expanding. During exhalation, they pull their lower abdomen inward and away from their palms as shown in Figure 3.
Figure 3. Hands placed below the belly button to sense the movement of the lower abdomen.
Lower abdominal SEMG feedback is useful in retraining breathing for people with depression, rehabilitation after pregnancy, abdomen or chest surgery (e.g., Cesarean surgery, hernia, or appendectomy operations), anxiety, hyperventilation, stress-related disorders, difficulty to become pregnant or maintain pregnancy, pelvic floor problems, headache, low back pain, and lung diseases. As one participant reported:
“Biofeedback might be the single thing that helped me the most. When I began to focus on breathing, I realized that it was almost impossible for me since my body was so tightened. However, I am getting much better at breathing diaphragmatically because I practice every day. This has helped my body and it relaxes my muscles, which in turn help reduce the vulvar pain.”
Van Dixhoorn, J. (2014). Indirect approaches to breathing dysregulation. In: Chaitow, L., Gilbert, C., & Morrison, D. (2014). Recognizing and treating breathing disorders pp. 155-161). Elsevier Health Sciences.
Gilbert, C. (2016). Working with breathing , some early influences. Paper presented at the 47th Annual Meeting of the Association for Applied Psychophysiology and Biofeedback, Seattle WA, March 9-12, 2016.
2. .I thank Annette Booiman for her constructive feedback in writing this blog.
Can abdominal surgery cause epilepsy, panic and anxiety and be reversed with breathing biofeedback?*Posted: March 5, 2016
“I had colon surgery six months ago. Although I made no connection to my anxiety, it just started to increase and I became fearful and I could not breathe. The asthma medication did not help. Learning effortless diaphragmatic breathing and learning to expand my abdomen during inhalation allowed me to breathe comfortably without panic and anxiety—I could breathe again.” (72 year old woman)
“One year after my appendectomy, I started to have twelve seizures a day. After practicing effortless diaphragmatic breathing and changing my lifestyle, I am now seizure-free.” (24 year old male college student)
One of the hidden long term costs of surgery and injury is covert learned disuse. Learned disuse occurs when a person inhibits using a part of their body to avoid pain and compensates by using other muscle patterns to perform the movements (Taub et al, 2006). This compensation to avoid discomfort creates a new habit pattern. However, the new habit pattern often induces functional impairment and creates the stage for future problems.
Many people have experienced changing their gait while walking after severely twisting their ankle or breaking their leg. While walking, the person will automatically compensate and avoid putting weight on the foot of the injured leg or ankle. These compensations may even leads to shoulder stiffness and pain in the opposite shoulder from the injured leg. Even after the injury has healed, the person may continue to move in the newly learned compensated gait pattern. In most cases, the person is totally unaware that his/her gait has changed. These new patterns may place extra strain on the hip and back and could become a hidden factor in developing hip pain and other chronic symptoms.
Similarly, some women who have given birth develop urinary stress incontinence when older. This occurred because they unknowingly avoided tightening their pelvic floor muscles after delivery because it hurt to tighten the stretched or torn tissue. Even after the tissue was healed, the women may no longer use their pelvic floor muscles appropriately. With the use of pelvic floor muscle biofeedback, many women with stress incontinence can rapidly learn to become aware of the inhibited/forgotten muscle patterns (learned disuse) and regain functional control in nine sessions of training (Burgio et al., 1998; Dannecker et al., 2005). The process of learned disuse is the result of single trial learning to avoid pain. Many of us as children have experienced this process when we touched a hot stove—afterwards we tended to avoid touching the stove even when it was cold.
Often injury will resolve/cure the specific problem. It may not undo the covert newly learned dysfunctional patterns which could contribute to future iatrogenic problems or illnesses (treatment induced illness). These iatrogenic illnesses are treated as a new illness without recognizing that they were the result of functional adaptations to avoid pain and discomfort in the recovery phase of the initial illness.
Surgery creates instability at the incision site and neighboring areas, so our bodies look for the path of least resistance and the best place to stabilize to avoid pain. (Adapted from Evan Osar, DC).
After successful surgical recovery do not assume you are healed!
Yes, you may be cured of the specific illness or injury; however, the seeds for future illness may be sown. Be sure that after injury or surgery, especially if it includes pain, you learn to inhibit the dysfunctional patterns and re-establish the functional patterns once you have recovered from the acute illness. This process is described in the two cases studies in which abdominal surgeries appeared to contribute to the development of anxiety and uncontrolled epilepsy.
How abdominal surgery can have serious, long-term effect on changing breathing patterns and contributing to the development of chronic illness.
When recovering from surgery or injury to the abdomen, it is instinctual for people to protect themselves and reduce pain by reducing the movement around the incision. They tend to breathe more shallowly as not to create discomfort or disrupt the healing process (e.g., open a stitch or staple. Prolonged shallow breathing over the long term may result in people experiencing hyperventilation induced panic symptoms or worse. This process is described in detail in our recent article, Did You Ask about Abdominal Surgery or Injury? A Learned Disuse Risk Factor for Breathing Dysfunction (Peper et al., 2015). The article describes two cases studies in which abdominal surgeries led to breathing dysfunction and ultimately chronic, serious illnesses.
Reducing epileptic seizures from 12 per week to 0 and reducing panic and anxiety
A routine appendectomy caused a 24-year-old male to develop rapid, shallow breathing that initiated a series of up to 12 seizures per week beginning a year after surgery. After four sessions of breathing retraining and incorporating lifestyle changes over a period of three months his uncontrolled seizures decreased to zero and is now seizure free. In the second example, a 39-year-old woman developed anxiety, insomnia, and panic attacks after her second kidney transplant probably due to shallow rapid breathing only in her chest. With biofeedback, she learned to change her breathing patterns from 25 breaths per minute without any abdominal movement to 8 breathes a minute with significant abdominal movement. Through generalization of the learned breathing skills, she was able to achieve control in situations where she normally felt out of control. As she practiced this skill her symptoms were significantly reduced and stated:
“What makes biofeedback so terrific in day-to-day situations is that I can do it at any time as long as I can concentrate. When I feel I can’t concentrate, I focus on counting and working with my diaphragm muscles; then my concentration returns. Because of the repetitive nature of biofeedback, my diaphragm muscles swing into action as soon as I started counting. When I first started, I had to focus on those muscles to get them to react. Getting in the car, I find myself starting these techniques almost immediately. Biofeedback training is wonderful because you learn techniques that can make challenging situations more manageable. For me, the best approach to any situation is to be calm and have peace of mind. I now have one more way to help me achieve this.” (From: Peper et al, 2001).
The commonality between these two participants was that neither realized that they were bracing the abdomen and were breathing rapidly and shallowly in the chest. I highly recommend that anyone who has experienced abdominal insults or surgery observe their breathing patterns and relearn effortless breathing/diaphragmatically breathing instead of shallow, rapid chest breathing often punctuated with breath holding and sighs.
It is important that medical practitioners and post-operative surgery patients recognize the common covert learned disuse patters such as shifting to shallow breathing to avoid pain. The sooner these patterns are identified and unlearned, the less likely will the person develop future iatrogenic illnesses. Biofeedback is an excellent tool to help identify and retrain these patterns and teach patients how to reestablish healthy/natural body patterns.
The full text of the article see: “Did You Ask About Abdominal Surgery or Injury? A Learned Disuse Risk Factor for Breathing Dysfunction,”
Burgio, K. L., Locher, J. L., Goode, P. S., Hardin, J. M., McDowell, B. J., Dombrowski, M., & Candib, D. (1998). Behavioral vs drug treatment for urge urinary incontinence in older women: a randomized controlled trial. Jama, 280(23), 1995-2000.
Dannecker, C., Wolf, V., Raab, R., Hepp, H., & Anthuber, C. (2005). EMG-biofeedback assisted pelvic floor muscle training is an effective therapy of stress urinary or mixed incontinence: a 7-year experience with 390 patients. Archives of Gynecology and Obstetrics, 273(2), 93-97.
Osar, E. (2016). http://www.fitnesseducationseminars.com/
Peper, E., Castillo, J., & Gibney, K. H. (2001, September). Breathing biofeedback to reduce side effects after a kidney transplant. In Applied Psychophysiology and Biofeedback (Vol. 26, No. 3, pp. 241-241). 233 Spring St., New York, NY 10013 USA: Kluwer Academic/Plenum Publ.
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. DOI: 10.5298/1081-5937-43.4.06
Taub, E., Uswatte, G., Mark, V. W., Morris, D. M. (2006). The learned nonuse phenomenon: Implications for rehabilitation. Europa Medicophysica, 42(3), 241-256.
My arm did not move and yet the muscle tension from my forearm increased when I mentally rehearsed playing the piano. I did not notice anything. It really made me aware how my thoughts affect my body. –25 year old woman psychologist
Therapists and educators can demonstrate the mind/body interaction with physiological monitoring to change their clients’ illness beliefs and demonstrate how ruminating thoughts may affect mental and physical health (Peper, Shumay, Moss, & Sztembis, 2013). When clients see how their body’s physiological responses are affected by thoughts and emotions, they gain a perspective that allows them to KNOW that thoughts affect body—the objective physiological evidence is indisputable.
The concept that thoughts affect the body has been described by many researchers. For example, Whatmore and Kohli (1975) used the term “Representing efforts,” which are the efforts we bring forth within our self during thinking, remembering, anticipating, daydreaming and worrying. Similarly, Green, Green and Walters (1970, p.3) described a process of thoughts influencing human physiological reactions as the Psycho-physiological principle, where “every change in the physiological state is accompanied by an appropriate change in the mental-emotional state, conscious or unconscious, and conversely, every change in the mental-emotional state, conscious or unconscious, is accompanied by an appropriate change in the physiological state.”
The mind/body connection can be demonstrated through recording physiological signals. For example, when a volunteer had her skin conductance (SC) level monitored, and then another person was asked in the group to give the volunteer a kiss, there was an increase in skin conductance response just after the instruction was given even though the person did not actually kiss the volunteer. The volunteer was responding to the instructions that a kiss might occur, as shown in Figure 1.
Figure 1. The effect on SC level of hearing the instruction that someone will give her a kiss
For educators and psychotherapists, biofeedback can be used to demonstrate the connection between positive or negative mental rehearsal, thoughts or visualization or recalling memories and physiological responses. This process can be demonstrated with surface electromyography (SEMG) recorded from muscles that become activated when the person mentally rehearses a task as illustrated in the following case example.
The participant was a 25 year old female psychologist who had practiced playing the piano for more than 16 years. Muscle activity was recorded from her right forearm extensor muscles and displayed on a large screen so that other group participants could observe. The physiological data and video recording of the volunteer were simultaneously recorded. The volunteer was asked to relax, imagine playing a musical piece, relax, and again imagine playing a musical piece and relax.
Results. Each time she imagined playing the piano, the forearm extensor muscle tension increased, even though there was no observed finger and forearm movements, as shown in Figure 2.
Figure 2. The covert SEMG increase in forearm SEMG as the participant imagined playing the piano.
After the recording, the session was replayed so she could see herself and her movements on the screen simultaneously with the SEMG signal. She reported being totally unaware that she had activated her forearm muscles and, was totally surprised when she saw the recording of the SEMG activity while her forearm appeared to stay in a relaxed position.
Discussion.The physiological monitoring demonstrated that her body responded to here thoughts and imagtes. In the case example, the arm muscle tension increased in tension when she mentally rehearsed playing the piano. This participant like most other people was unaware that her body reacted.If the thought of piano playing increased forearm tension,what would thoughts of anger, resentment, hopelessness, kindness or love do to the body. This concrete physiological demonstration illustrated that changing your thoughts changes your physiology. .
Once the person is aware how thoughts affect their body, it may motivate the person to become aware and change their cognitions. They can now understand that interrupting negative ruminations and behavior patterns and rehearsing new behavior patterns, their health can be improved. We strongly recommend that cognitive behavioral therapists, educators, psychologists, and other therapeutic practitioners include biofeedback monitoring for demonstrating the links between cognitions and physiological reactions.
After such a demonstration, the therapist may point out that what happens in the office setting is likely the identical process that occurs when a person worries, has negative cognitions, continuously reviews personal failures, or makes judgmental statements such as “I should not have done ________.”
When individuals think a negative statement such as “I should not have…………”, they are mentally rehearsing what they should not do and are unintentionally strengthening the negative behavior even more. Instead, whenever people becomes aware of the beginning of the negative cognitions, they can learn to stop and transform their negative cognitions to positive cognitions. In this way they can rehearse what they would want to do instead of what they do not want to do (Peper, Gibney, & Holt, 2002).
The more you rehearse what you want to achieve, the more likely it is to occur. This strategy is useful to change clients’ illness beliefs and motivate them to transform their cognitions from what they do not want to what they want to do. In addition, it offers cognitive behavior therapists documented evidence—the biofeedback recording provides the data which is necessary for evidence based medicine.
Between stimulus and response there is a space. In that space is our power to choose our response. In our response lies our growth and our freedom.
–Victor E. Frankle
* Adapted from: Peper, E., Nemoto, S., Lin, I-M., & Harvey, R. (2015). Seeing is believing: Biofeedback a tool to enhance motivation for cognitive therapy. Biofeedback, 43(4), 168-172. DOI: 10.5298/1081-5937-43.4.03
Green, E.E., Green, A.M., & Walters, E.D. (1970). Voluntary control of internal states: Psychological and physiological. Journal of Transpersonal Psychology, 11, 1-26.
Peper, E., Gibney, K.H., & Holt. C. (2002). Make health happen: Training yourself to create wellness. Dubuque, IA: Kendall-Hunt.
Peper, E., Shumay, D. M., Moss, D. & Sztembis, R. (2013). The Power of Words, Biofeedback, and Somatic Feedback to Impact Illness Beliefs. Somatics .XVII(1), 4-8.
Whatmore, G.B., & Kohli, D. R. (1975). The physiopathology and treatment of functional disorders: Including anxiety states and depression and the role of biofeedback training. New York: Grune and Stratton, Inc.
Adapted from: Martinez Aranda, P. & Peper, E. (2015). The healing of vulvodynia from a client’s perspective. https://biofeedbackhealth.files.wordpress.com/2011/01/a-healing-of-vulvodynia-from-the-client-perspective-2015-06-15.pdf
It’s been a little over a year since I began practicing biofeedback and visualization strategies to overcome vulvodynia. Today, I feel whole, healed, and hopeful. I learned that through controlled and conscious breathing, I could unleash the potential to heal myself from chronic pain. Overcoming pain did not happen overnight; but rather, it was a process where I had to create and maintain healthy lifestyle habits and meditation. Not only am I thankful for having learned strategies to overcome chronic pain, but for acquiring skills that will improve my health for the rest of my life. –-24 year old woman who successfully resolved vulvodynia
Pelvic floor pain can be debilitating, and it is surprisingly common, affecting 10 to 25% of American women. Pelvic floor pain has numerous causes and names. It can be labeled as vulvar vestibulitis, an inflammation of vulvar tissue, interstitial cystitis (chronic pain or tenderness in the bladder), or even lingering or episodic hip, back, or abdominal pain. Chronic pain concentrated at the entrance to the vagina (vulva), is known as vulvodynia. It is commonly under-diagnosed, often inadequately treated, and can go on for months and years (Reed et al., 2007; Mayo Clinic, 2014). The discomfort can be so severe that sitting is uncomfortable and intercourse is impossible because of the extreme pain. The pain can be overwhelming and destructive of the patient’s life. As the participant reported,
I visited a vulvar specialist and he gave me drugs, which did not ease the discomfort. He mentioned surgical removal of the affected tissue as the most effective cure (vestibulectomy). I cried immediately upon leaving the physician’s office. Even though he is an expert on the subject, I felt like I had no psychological support. I was on Gabapentin to reduce pain, and it made me very depressed. I thought to myself: Is my life, as I know it, over?
Physically, I was in pain every single day. Sometimes it was a raging burning sensation, while other times it was more of an uncomfortable sensation. I could not wear my skinny jeans anymore or ride a bike. I became very depressed. I cried most days because I felt old and hopeless instead of feeling like a vibrant 23-year-old woman. The physical pain, combined with my negative feelings, affected my relationship with my boyfriend. We were unable to have sex at all, and because of my depressed status, we could not engage in any kind of fun. (For more details, read the published case report,Vulvodynia treated successfully with breathing biofeedback and integrated stress reduction: A case report).
The four-session holistic biofeedback interventions to successfully resolved vulvodynia included teaching diaphragmatic breathing to transform shallow thoracic breathing into slower diaphragmatic breathing, transforming feelings of powerlessness and hopelessness to empowerment and transforming her beliefs that she could reduce her symptoms and optimize her health. The interventions also incorporated self-healing imagery and posture-changing exercises. The posture changes consisted of developing awareness of the onset of moving into a collapsed posture and use this awareness to shift to an erect/empowered postures (Carney, Cuddy, & Yap, 2010; Peper, 2014; Peper, Booiman, Lin, & Harvey, in press). Finally, this case report build upon the seminal of electromyographic feedback protocol developed by Dr. Howard Glazer (Glazer & Hacad, 2015) and the integrated relaxation protocol developed Dr. David Wise (Wise & Anderson, 2007).
Through initial biofeedback monitoring of the lower abdominal muscle activity, chest, and abdomen breathing patterns, the participant observed that when she felt discomfort or was fearful, her lower abdomen muscles tended to tighten. After learning how to sense this tightness, she was able to remind herself to breathe lower and slower, relax the abdominal wall during inhalation and sit or stand in an erect power posture.
The self-mastery approach for healing is based upon a functional as compared to a structural perspective. The structural perspective implies that the problem can only be fixed by changing the physical structure such as with surgery or medications. The functional perspective assumes that if you can learn to change your dysfunctional psychophysiological patterns the disorder may disappear.
The functional approach assumed that an irritation of the vestibular area might have caused the participant to tighten her lower abdomen and pelvic floor muscles reflexively in a covert defense reaction. In addition, ongoing worry and catastrophic thinking (“I must have surgery, it will never go away, I can never have sex again, my boyfriend will leave me”) also triggered the defense reaction—further tightening of her lower abdomen and pelvic area, shallow breathing, and concurrent increases in sympathetic nervous activation—which together activated the trigger points that lead to increased chronic pain (Banks et al, 1998).
When the participant experienced a sensation or thought/worried about the pain, her body responded in a defense reaction by breathing in her chest and tightening the lower abdominal area as monitored with biofeedback. Anticipation of being monitored increased her shoulder tension, recalling the stressful memory increased lower abdominal muscle tension (pulling in the abdomen for protection), and the breathing became shallow and rapid as shown in Figure 1.
Figure 1. Physiological recording of pre-stressor relaxation, the recall of a fearful driving experience, and a post-stressor relaxation. The scalene to trapezius SEMG increased in anticipation while she recalled the experience, and then initially did not relax (from Peper, Martinez Aranda, & Moss, 2015).
This defense pattern became a conditioned response—initiating intercourse or being touched in the affected area caused the participant to tense and freeze up. She was unaware of these automatic protective patterns, which only worsened her chronic pain.
During the four sessions of training, the participant learned to reverse and interrupt the habitual defense reaction. For example, as she became aware of her breathing patterns she reported,
It was amazing to see on the computer screen the difference between my regular breathing pattern and my diaphragmatic breathing pattern. I could not believe I had been breathing that horribly my whole life, or at least, for who knows how long. My first instinct was to feel sorry for myself. Then, rather than practicing negative patterns and thoughts, I felt happy because I was learning how to breathe properly. My pain decreased from an 8 to alternating between a 0 and 3.
The mastery of slower and lower abdominal breathing within a holistic perspective resulted in the successful resolution of her vulvodynia. An essential component of the training included allowing the participant to feel safe, and creating hope by enabling her to experience a decrease in discomfort while doing a specific practice, and assisting her to master skills to promote self-healing. Instead of feeling powerless and believing that the only resolution was the removal of the affected area (vestibulectomy). The integrated biofeedback protocol offered skill mastery training, to promote self-healing through diaphragmatic breathing, somatic postural changes, reframing internal language, and healing imagery as part of a common sense holistic health approach.
For more details about the case report, download the published study, Peper, E., Martinez Aranda, P., & Moss, E. (2015). Vulvodynia treated successfully with breathing biofeedback and integrated stress reduction: A case report. Biofeedback. 43(2), 103-109.
The participant also wrote up her subjective experience of the integrated biofeedback process in the paper, Martinez Aranda & Peper (2015). Healing of vulvodynia from the client perspective. In this paper she articulated her understanding and experiences in resolving vulvodynia which sheds light on the internal processes that are so often skipped over in published reports.
At the five year follow-up on May 29, 2019, she wrote:
“I am doing very well, and I am very healthy. The vulvodynia symptoms have never come back. It migrated to my stomach a couple of years after, and I still have a sensitive stomach. My stomach has gotten much, much better, though. I don’t really have random pain anymore, now I just have to be watchful and careful of my diet and my exercise, which are all great things!”
Banks, S. L., Jacobs, D. W., Gevirtz, R., & Hubbard, D. R. (1998). Effects of autogenic relaxation training on electromyographic activity in active myofascial trigger points. Journal of Musculoskeletal Pain, 6(4), 23-32. https://www.researchgate.net/profile/David_Hubbard/publication/232035243_Effects_of_Autogenic_Relaxation_Training_on_Electromyographic_Activity_in_Active_Myofascial_Trigger_Points/links/5434864a0cf2dc341daf4377.pdf
Carney, D. R., Cuddy, A. J., & Yap, A. J. (2010). Power posing brief nonverbal displays affect neuroendocrine levels and risk tolerance. Psychological Science, 21(10), 1363-1368. Available from: https://www0.gsb.columbia.edu/mygsb/faculty/research/pubfiles/4679/power.poses_.PS_.2010.pdf
Glazer, H. & Hacad, C.R. (2015). The Glazer Protocol: Evidence-Based Medicine Pelvic Floor Muscle (PFM) Surface Electromyography (SEMG). Biofeedback, 40(2), 75-79. http://www.aapb-biofeedback.com/doi/abs/10.5298/1081-5937-40.2.4
Martinez Aranda, P. & Peper, E. (2015). Healing of vulvodynia from the client perspective. Available from: https://biofeedbackhealth.files.wordpress.com/2011/01/a-healing-of-vulvodynia-from-the-client-perspective-2015-06-15.pdf
Mayo Clinic (2014). Diseases and conditions: Vulvodynia. Available at http://www.mayoclinic.org/diseases-conditions/vulvodynia/basics/definition/con-20020326
Peper, E. (2014). Increasing strength and mood by changing posture and sitting habits. Western Edition, pp.10, 12. Available from: http://thewesternedition.com/admin/files/magazines/WE-July-2014.pdf
Peper, E., Booiman, A., Lin, I, M.,& Harvey, R. (in press). Increase strength and mood with posture. Biofeedback.
Peper, E., Martinez Aranda, P., & Moss, E. (2015). Vulvodynia treated successfully with breathing biofeedback and integrated stress reduction: A case report. Biofeedback. 43(2), 103-109. Available from: https://biofeedbackhealth.files.wordpress.com/2011/01/a-vulvodynia-treated-with-biofeedback-published.pdf
Reed, B. D., Haefner, H. K., Sen, A., & Gorenflo, D. W. (2008). Vulvodynia incidence and remission rates among adult women: a 2-year follow-up study. Obstetrics & Gynecology, 112(2, Part 1), 231-237. http://journals.lww.com/greenjournal/Abstract/2008/08000/Vulvodynia_Incidence_and_Remission_Rates_Among.6.aspx
Wise, D., & Anderson, R. U. (2006). A headache in the pelvis: A new understanding and treatment for prostatitis and chronic pelvic pain syndromes. Occidental, CA: National Center for Pelvic Pain Research.http://www.pelvicpainhelp.com/books/
After the first week to my astonishment, I have fewer hot flashes and they bother me less. Each time I feel the warmth coming, I breathe out slowly and gently. To my surprise they are less intense and are much less frequent. I keep breathing slowly throughout the day. This is quite a surprise because I was referred for biofeedback training because of headaches that occurred after getting a large electrical shock. After 5 sessions my headaches have decreased and I can control them, and my hot flashes have decreased from 3-4 per day to 1-2 per week. -50 year old client
After students in my Holistic Health class at San Francisco State University practiced slower diaphragmatic breathing and begun to change their dysfunctional shallow breathing, gasping, sighing, and breath holding to diaphragmatic breathing. A number of the older female students students reported that their hot flashes decreased. Some of the younger female students reported that their menstrual cramps and discomfort were reduced by 80 to 90% when they laid down and breathed slower and lower into their abdomen.
The recent study in JAMA reported that many women continue to experience menopausal triggered hot flashes for up to 14 years. Although the article described the frequency and possible factors that were associated with the prolonged hot flashes, it did not offer helpful solutions.Yet, there is hope besides hormone replacement therapy (HRT) for women who suffer from hot flashes during menopause. The general accepted hypothesis that the drop in estrogen triggers hot flashes is incomplete. If lowering of estrogen was the main culprit then all older post-menopausal women should have more and more hot flashes–they do not! And, all women going through menopause should suffer; however, 20% of women go through menopause without much discomfort and very few hot flashes.
Another understanding of the dynamics of hot flashes is that the decrease in estrogen accentuates the sympathetic/ parasympathetic imbalances that probably already existed. Then any increase in sympathetic activation can trigger a hot flash. In many cases the triggers are events and thoughts that trigger a stress response, emotional responses such as anger, anxiety, or worry, increase caffeine intake and especially shallow chest breathing punctuated with sighs. Approximately 80% of American women tend to breathe thoracically often punctuated with sighs and these women are more likely to experience hot flashes. On the other hand, the 20% of women who habitually breathe diaphragmatically tend to have fewer and less intense hot flashes and often go through menopause without any discomfort. In the superb study Drs. Freedman and Woodward (1992), taught women who experience hot flashes to breathe slowly and diaphragmatically which increased their heart rate variability as an indicator of sympathetic/parasympathetic balance and most importantly it reduced the the frequency and intensity of hot flashes by 50%.
Test the breathing connection if you experience hot flashes
Take a breath into your chest and rapidly exhale with a sigh. Repeat this quickly five times. In most cases, one minute later you will experience the beginning sensations of a hot flash. Similarly, when you practice slow diaphragmatic breathing throughout the day and interrupt every gasp, breath holding moment, sigh or shallow chest breathing with slower diaphragmatic breathing, you will experience a significant reduction in hot flashes.
Although this breathing approach has been well documented, many people are unaware of this simple behavioral approach unlike the common recommendation for the hormone replacement therapies (HRT) to ameliorate menopausal symptoms. This is not surprising since pharmaceutical companies spent nearly five billion dollars per year in direct to consumer advertising for drugs and very little money is spent on advertising behavioral treatments. There is no profit for pharmaceutical companies teaching effortless diaphragmatic breathing unlike prescribing HRTs. In addition, teaching and practicing diaphragmatic breathing takes skill training and practice time–time which is not reimbursable by third party payers.
For more information, research data and breathing skills to reduce hot flash intensity, see our article which is reprinted below.
Gibney, H.K. & Peper, E. (2003). Taking control: Strategies to reduce hot flashes and premenstrual mood swings. Biofeedback, 31(3), 20-24.
Taking control: Strategies to reduce hot flashes and premenstrual mood swings*
Erik Peper, Ph.D**., and Katherine H. Gibney
San Francisco State University
After the first week to my astonishment, I have fewer hot flashes and they bother me less. Each time I feel the warmth coming, I breathe out slowly and gently. To my surprise they are less intense and are much less frequent. I keep breathing slowly throughout the day. This is quite a surprise because I was referred for biofeedback training because of headaches that occurred after getting a large electrical shock. After 5 sessions my headaches have decreased and I can control them, and my hot flashes have decreased from 3-4 per day to 1-2 per week. -50 year old client
For the first time in years, I experienced control over my premenstrual mood swings. Each time I could feel myself reacting, I relaxed, did my autogenic training and breathing. I exhaled. It brought me back to center and calmness. -26 year old student
Women have been troubled by hot flashes and premenstrual syndrome for ages. Hormone replacement therapy, historically the most common treatment for hot flashes, and other pharmacological approaches for pre-menstrual syndrome (PMS) appear now to be harmful and may not produce significant benefits. This paper reports on a model treatment approach based upon the early research of Freedman & Woodward to reduce hot flashes and PMS using biofeedback training of diaphragmatic breathing, relaxation, and respiratory sinus arrhythmia. Successful symptom reduction is contingent upon lowering sympathetic arousal utilizing slow breathing in response to stressors and somatic changes. We strongly recommend that effortless diaphragmatic breathing be taught as the first step to reduce hot flashes and PMS symptoms.
A long and uncomfortable history
Women have been troubled by hot flashes and premenstrual syndrome for ages. Hot flashes often result in red faces, sweating bodies, and noticeable and embarrassing discomfort. They come in the middle of meetings, in the middle of the night, and in the middle of romantic interludes. Premenstrual syndrome also arrives without notice, bringing such symptoms as severe mood swings, anger, crying, and depression.
Hormone replacement therapy (HRT) was the most common treatment for hot flashes for decades. However, recent randomized controlled trials show that the benefits of HRT are less than previously thought and the risks—especially of invasive breast cancer, coronary artery disease, dementia, stroke and venous thromboembolism—are greater (Humphries & Gill, 2003; Shumaker, et al, 2003; Wassertheil-Smoller, et al, 2003). In addition, there is no evidence of increased quality of life improvements (general health, vitality, mental health, depressive symptoms, or sexual satisfaction) as claimed for HRT (Hays et al, 2003).
“As a result of recent studies, we know that hormone therapy should not be used to prevent heart disease. These studies also report an increased risk of heart attack, stroke, breast cancer, blood clots, and dementia…” -Wyeth Pharmaceuticals (2003)
Because of the increased long-term risk and lack of benefit, many physicians are weaning women off HRT at a time when the largest population of maturing women in history (‘baby boomers’) is entering menopausal years. The desire to find a reliable remedy for hot flashes is on the front burner of many researchers’ minds, not to mention the minds of women suffering from these ‘uncontrollable’ power surges. Yet, many women are becoming increasingly leery of the view that menopause is an illness. There is a rising demand to find a natural remedy for this natural stage in women’s health and development.
For younger women a similar dilemma occurs when they seek treatment of discomfort associated with their menstrual cycle. Is premenstrual syndrome (PMS) just a natural variation in energy and mood levels? Or, are women expected to adapt to a masculine based environment that requires them to override the natural tendency to perform in rhythm with their own psychophysiological states? Instead of perceiving menstruation as a natural occurrence in which one has different moods and/or energy levels, women in our society are required to perform at the status quo, which may contribute to PMS. The feelings and mood changes are quickly labeled as pathology that can only be treated with medication.
Traditionally, premenstrual syndrome is treated with pharmaceuticals, such as birth control pills or Danazol. Although medications may alleviate some symptoms, many women experience unpleasant side effects, such as bloating or acne, and still experience a variety of PMS symptoms. Many cannot tolerate the medications. Thus, millions of women (and families) suffer monthly bouts of ‘uncontrollable’ PMS symptoms
For both hot flashes and PMS the biomedical model tends to frame the symptoms as a “structural biological problem.” Namely, the pathology occurs because the body is either lacking in, or has an excess of, some hormone. All that needs to be done is either augment or suppress hormones/symptoms with some form of drug. Recently, for example, medicine has turned to antidepressant medications to address menopausal hot flashes (Stearns, Beebe, Iyengar, & Dube, 2003).
The biomedical model, however, is only one perspective. The opposite perspective is that the dysfunction occurs because of how we use ourselves. Use in this sense means our thoughts, emotions and body patterns. As we use ourselves, we change our physiology and, thereby, may affect and slowly change the predisposing and maintaining factors that contribute to our dysfunction. By changing our use, we may reduce the constraints that limit the expression of the self-healing potential that is intrinsic in each person.
The intrinsic power of self-healing is easily observed when we cut our finger. Without the individual having to do anything, the small cut bleeds, clotting begin and tissue healing is activated. Obviously, we can interfere with the healing process, such as when we scrape the scab, rub dirt in the wound, reduce blood flow to the tissue or feel anxious or afraid. Conversely, cleaning the wound, increasing blood flow to the area, and feeling “safe” and relaxed can promote healing. Healing is a dynamic process in which both structure and use continuously affect each other. It is highly likely that menopausal hot flashes and PMS mood swings are equally an interaction of the biological structure (hormone levels) and the use factor (sympathetic/parasympathetic activation).
Uncontrollable or overly aroused?
Are the hot flashes and PMS mood swings really ‘uncontrollable?’ From a physiological perspective, hot flashes are increased by sympathetic arousal. When the sympathetic system is activated, whether by medication or by emotions, hot flashes increase and similarly, when sympathetic activity decreases hot flashes decrease. Equally, PMS, with its strong mood swings, is aggravated by sympathetic arousal. There are many self-management approaches that can be mastered to change and reduce sympathetic arousal, such as breathing, meditation, behavioral cognitive therapy, and relaxation.
Breathing patterns are closely associated with hot flashes. During sleep, a sigh generally occurs one minute before a hot flash as reported by Freedman and Woodward (1992). Women who habitually breathe thoracically (in the chest) report much more discomfort and hot flashes than women who habitually breathe diaphragmatically. Freedman, Woodward, Brown, Javaid, and Pandey (1995) and Freedman and Woodward (1992) found that hot flash rates during menopause decreased in women who practiced slower breathing for two weeks. In their studies, the control groups received alpha electroencephalographic feedback and did not benefit from a reduction of hot flashes. Those who received training in paced breathing reduced the frequency of their hot flashes by 50% when they practiced slower breathing. This data suggest that the slower breathing has a significant effect on the sympathetic and parasympathetic balance.
Women with PMS appear similarly able to reduce their discomfort. An early study utilizing Autogenic Training (AT) combined with an emphasis on warming the lower abdomen resulted in women noting improvement in dysfunctional bleeding (Luthe & Schultz, 1969, pp. 144-148). Using a similar approach, Mathew, Claghorn, Largen, and Dobbins (1979) and Dewit (1981) found that biofeedback temperature training was helpful in reducing PMS symptoms.. A later study by Goodale, Domar, and Benson (1990) found that women with severe PMS symptoms who practiced the relaxation response reported a 58% improvement in overall symptomatology as compared to a 27.2% improvement for the reading control group and a 17.0% improvement for the charting group.
Teaching control and achieving results
Teaching women to breathe effortlessly can lead to positive results and an enhanced sense of control. By effortless breathing, the authors refer to their approach to breath training, which involves a slow, comfortable respiration, larger volume of air exchange, and a reliance upon action of the muscles of the diaphragm rather than the chest (Peper, 1990). For more instructions see the recent blog, A breath of fresh air: Improve health with breathing.
Slowing breathing helps to limit the sighs common to rapid thoracic breathing—sighs that often precede menopausal hot flashes. Effortless breathing is associated with stress reduction—stress and mood swings are common concerns of women suffering from PMS. In a pilot study Bier, Kazarian, Peper, and Gibney (2003) at San Francisco State University (SFSU) observed that when the subject practiced diaphragmatic breathing throughout the month, combined with Autogenic Training, her premenstrual psychological symptoms (anger, depressed mood, crying) and premenstrual responses to stressors were significantly reduced as shown in Figure 1.
Figure 1. Student’s Individual Subjective Rating in Response to PMS Symptoms.
In another pilot study at SFSU, Frobish, Peper, and Gibney (2003) trained a volunteer who suffered from frequent hot flashes to breathe diaphragmatically. The training goals included modifying breathing patterns, producing a Respiratory Sinus Arrhythmia (RSA), and peripheral hand warming. RSA refers to a pattern of slow, regular breathing during which variations in heart rate enter into a synchrony with the respiration. Each inspiration is accompanied by an increase in heart rate, and each expiration is accompanied by a decrease in heart rate (with some phase differences depending on the rate of breathing). The presence of the RSA pattern is an indication of optimal balance between sympathetic and parasympathetic nervous activity.
During the 11-day study period, the subject charted the occurrence of hot flashes and noted a significant decrease by day 5. However, on the evening of day 7 she sprained her ankle and experienced a dramatic increase in hot flashes on day 8. Once the subject recognized her stress response, she focused more on breathing and was able to reduce the flashes as shown in Figure 2.
Figure 2. Subjective rating of intensity, frequency and bothersomeness of hot flashes. The increase in hot flashes coincided with increased frustration about an ankle injury.
Our clinical experience confirms the SFSU pilot studies and the previously referenced research by Freedman and Woodward (1992) and Freedman et al. (1995). When arousal is lowered and breathing is effortless, women are better able to cope with stress and report a reduction in symptoms. Habitual rapid thoracic breathing tends to increase arousal while slower breathing, especially slower exhalation, tends to relax and reduce arousal. Learning and then applying effortless breathing reduces excessive sympathetic arousal. It also interrupts the cycle of cognitive activation, anxiety, and somatic arousal. The anticipation and frustration at having hot flashes becomes the cue to shift attention and “breathe slower and lower.” This process stops the cognitively mediated self-activation.
Successful self-regulation and the return to health begin with cognitive reframing: We are not only a genetic biological fixed (deficient) structure but also a dynamic changing system in which all parts (thoughts, emotions, behavior, diet, stress, and physiology) affect and are effected by each other. Within this dynamic changing system, there is an opportunity to implement and practice behaviors and life patterns that promote health.
Learning Diaphragmatic Breathing with and without Biofeedback
Although there are many strategies to modify respiration, biofeedback monitoring combined with respiration training is very useful as it provides real-time feedback. Chest and abdominal movement are recorded with strain gauges and heart rate can be monitored either by an electrocardiogram (EKG) or by a photoplethysmograph sensor on a finger or thumb. Peripheral temperature and electrodermal activity (EDA) biofeedback are also helpful in training. The training focuses on teaching effortless diaphragmatic breathing and encouraging the participant to practice many times during the day, especially when becoming aware of the first sensations of discomfort.
Learning and integrating effortless diaphragmatic breathing into daily life is one of the biofeedback strategies that has been successfully used as a primary or adjunctive/complementary tool for the reversal of disorders such as hypertension, migraine headaches, repetitive strain injury, pain, asthma and anxiety (Schwartz & Andrasik, 2003), as well as hot flashes and PMS.
The biofeedback monitoring provides the trainer with a valuable tool to:
- Observe & identify: Dysfunctional rapid thoracic breathing patterns, especially in response to stressors, are clearly displayed in real-time feedback.
- Demonstrate & train: The physiological feedback display helps the person see that she is breathing rapidly and shallowly in her chest with episodic sighs. Coaching with feedback helps her to change her breathing pattern to one that promotes a more balanced homeostasis.
- Motivate, persuade and change beliefs: The person observes her breathing patterns change concurrently with a felt shift in physiology, such as a decrease in irritability, or an increase in peripheral temperature, or a reduction in the incidence of hot flushes. Thus, she has a confirmation of the importance of breathing diaphragmatically.
In addition, we suggest exercises that integrate verbal and kinesthetic instructions, such as the following: “Exhale gently,” and “Breathe down your leg with a partner.”
Imagine that you are holding a baby. Now with your shoulders relaxed, inhale gently so that your abdomen widens. Then as you exhale, purse your lips and very gently and softly blow over the baby’s hair. Allow your abdomen to narrow when exhaling. Blow so softly that the baby’s hair barely moves. At the same time, imagine that you can allow your breath to flow down and through your legs. Continue imagining that you are gently blowing on the baby’s hair while feeling your breath flowing down your legs. Keep blowing very softly and continuously.
Practice exhaling like this the moment that you feel any sensation associated with hot flashes or PMS symptoms. Smile sweetly as you exhale.
Breathe Down Your Legs with a Partner
Sit or lie comfortably with your feet a shoulder width apart. As you exhale softly whisper the sound “Haaaaa….” Or, very gently press your tongue to your pallet and exhale while making a very soft hissing sound.
Have your partner touch the side of your thighs. As you exhale have your partner stroke down your thighs to your feet and beyond, stroking in rhythm with your exhalation. Do not rush. Apply gentle pressure with the stroking. Do this for four or five breaths.
Now, continue breathing as you imagine your breath flowing through your legs and out your feet.
During the day remember the feeling of your breath flowing downward through your legs and out your feet as you exhale.
Learning Strategies in Biofeedback Assisted Breath Training
Common learning strategies that are associated with the more successful amelioration of hot flashes and PMS include:
- Master effortless diaphragmatic breathing, and concurrently increase respiratory sinus arrhythmia (RSA). Instead of breathing rapidly, such as at 18 breaths per minute, the person learns to breathe effortlessly and slowly (about 6 to 8 breaths per minute). This slower breathing and increased RSA is an indication of sympathetic-parasympathetic balance as shown in Figure 3.
- Practice slow effortless diaphragmatic breathing many times during the day and, especially in response to stressors.
- Use the physical or emotional sensations of a hot flash or mood alteration as the cue to exhale, let go of anxiety, breathe diaphragmatically and relax.
- Reframe thoughts by accepting the physiological processes of menstruation or menopause, and refocus the mind on positive thoughts, and breathing rhythmically.
- Change one’s lifestyle and allow personal schedules to flow in better balance with individual, dynamic energy levels. Figure 3. Physiological Recordings of a Participant with PMS. This subject learned effortless diaphragmatic breathing by the fifth session and experienced a significant decrease in symptoms.
Generalizing skills and interrupting the pattern
The limits of self-regulation are unknown, often held back only by the practitioner’s and participant’s beliefs. Biofeedback is a powerful self-regulation tool for individuals to observe and modify their covert physiological reactions. Other skills that augment diaphragmatic breathing are Quieting Reflex (Stroebel, 1982), Autogenic Training (Schultz & Luthe, 1969), and mindfulness training (Kabat-Zinn, 1990). In all skill learning, generalization is a fundamental factor underlying successful training. Integrating the learned psychophysiological skills into daily life can significantly improve health—especially in anticipation of and response to stress. The anticipated stress can be a physical, cognitive or social trigger, or merely the felt onset of a symptom.
As the person learns and applies effortless breathing to daily activities, she becomes more aware of factors that affect her breathing. She also experiences an increased sense of control: She can now take action (a slow effortless breath) in moments when she previously felt powerless. The biofeedback-mastered skill interrupts the evoked frustrations and irritations associated with an embarrassing history of hot flashes or mood swings. Instead of continuing with the automatic self-talk, such as “Damn, I am getting hot, why doesn’t it just stop?” (language fueling sympathetic arousal), she can take a relaxing breath in response to the internal sensations, stop the escalating negative self-talk and allows more acceptance—a process reducing sympathetic arousal.
In summary, effortless breathing appears to be a non-invasive behavioral strategy to reduce hot flashes and PMS symptoms. Practicing effortless diaphragmatic breathing contributes to a sense of control, supports a healthier homeostasis, reduces symptoms, and avoids the negative drug side effects. We strongly recommend that effortless diaphragmatic breathing be taught as the first step to reduce hot flashes and PMS symptoms.
I feel so much cooler. I can’t believe that my hand temperature went up. I actually feel calmer and can’t even feel the threat of a hot flash. Maybe this breathing does work! –Menopausal patient after initial training in diaphragmatic breathing
Bier, M., Kazarian, D., Peper, E., & Gibney, K. (2003). Reducing the severity of PMS symptoms with diaphragmatic breathing, autogenic training and biofeedback. Unpublished report.
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*We thank Candy Frobish, Mary Bier and Dalainya Kazarian for their helpful contributions to this research.
**For communications contact: Erik Peper, Ph.D., Institute for Holistic Healing Studies, San Francisco State University, 1600 Holloway Avenue, San Francisco, CA 94132; Tel: (415) 338 7683; Email: firstname.lastname@example.org; website: http://www.biofeedbackhealth.org; blog: http://www.peperperspective.come