Winning the Gold in weight lifting-Using biofeedback, imagery and cognitive change

Erik Peper [1], [2]  and Jo Aita

“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[3].  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.

Fig2.initial assessment

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.

Fig3 role playing

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.[1]

Fig4mental rehearsal with emg

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. Fig5 iron arm imagery

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.


Cumming, J., Hall, C., & Shambrook, C. (2004). The influence of an imagery workshop on athletes’ use of imageryAthletic insight6(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

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.

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

Wilson, V. & Peper, E. (2011). Athletes are different: Factors that differentiate biofeedback/neurofeedback for sport versus clinical practice. Biofeedback, 39(1), 27-30.


[1] 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:; web:; blog:

[2] We thank Dr. Sue Wilson for her helpful and constructive feedback.

[3] 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.

[4] 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.

Education versus treatment for self-healing: Eliminating a headache[1]

“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. figure3

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:

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.

[1] 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.


Your body “tells” of your emotional state

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.


Evolutionary approach to return to health

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.

Allow natural breathing with abdominal muscle biofeedback [1, 2]

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, 1986Bucholtz, 1994; Gilbert 2016, Mensendieck, 1954). These concepts underlie the the research and therapeutic approach of  Jan van Dixhoorn (20082014) 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):

  1. ‘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, 1991Peper & Tibbitts, 1994).
  1. Self-image: The person tends to pull his or her abdomen inward in an attempt to look slim and attractive.
  2. 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.
  3. 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).
  4. Inability to engage abdominal muscles because of the lack of muscle tone.

corset and spanxFigure 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.

Fig 3 EMG and respFigure 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.

Fig 6 Hand poistion low ab

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.”


Brooks, C. V. W. (1986). Sensory Awareness: Rediscovery of Experiencing Through the Workshops of Charlotte Selver. Felix Morrow Pub.

Buchholz, I. (1994). Breathing, voice, and movement therapy: Applications to breathing disorders. Biofeedback and Self-regulation, 19(2), 141-153.

Mensendieck, B.M. (1954). Look better, feel better.  Pymble, NSW, Australia: HarperCollins.

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.

Peper, E., Martinez Aranda, P., & Moss, D. (2015). Vulvodynia treated successfully with breathing biofeedback and integrated stress reduction: A case report. Biofeedback.43(2), 103-109.

Peper, E., & Tibbetts, V. (1994). Effortless diaphragmatic breathing. Physical Therapy Products6(2), 67-71.

Profile Mensendieck remedial therapy. Dutch Mensendieck Remedial Therapists Association Vereniging van Oefentherapeuten Cesar en Mensendieck (VvOCM)

van Dixhoorn, J. (2008). Whole body breathing. Biofeedback. 3I(2), 54-58

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.

1.  Adapted from: Peper, E., Booiman, A., Lin, I-M, Harvey, R., & Mitose, J. (2016). Abdominal SEMG Feedback for Diaphragmatic Breathing: A Methodological Note. Biofeedback. 44(1), 42-49. 

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?*

“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,”

*Adapted from: Biofeedback Helps to Control 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).

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.


Seeing is believing*

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

*This blog was adapted from: Peper, E., Nemoto, S., Lin, I-M., & Harvey, R. (2015).

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.

Fig 1 SCL kiss

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.

Fig 2 Piano Mental rehearsal white

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.