This blog has been reprinted from: Peper, E., Lin, I-M, & Harvey, R. (2017). Posture and mood: Implications and applications to therapy. Biofeedback.35(2), 42-48.
Slouched posture is very common and tends to increase access to helpless, hopeless, powerless and depressive thoughts as well as increased head, neck and shoulder pain. Described are five educational and clinical strategies that therapists can incorporate in their practice to encourage an upright/erect posture. These include practices to experience the negative effects of a collapsed posture as compared to an erect posture, watching YouTube video to enhance motivation, electromyography to demonstrate the effect of posture on muscle activity, ergonomic suggestions to optimize posture, the use of a wearable posture biofeedback device, and strategies to keep looking upward. When clients implement these changes, they report a more positive outlook and reduced neck and shoulder discomfort.
Most people slouch without awareness when looking at their cellphone, tablet, or the computer screen (Guan et al., 2016) as shown in Figure 1. Many clients in psychotherapy and in biofeedback or neurofeedback training experience concurrent rumination and depressive thoughts with their physical symptoms. In most therapeutic sessions, clients sit in a comfortable chair, which automatically creates a posterior pelvic tilt and encourages the spine to curve so that the client sits in a slouched position. While at home, they sit on an easy chair or couch, which lets them slouch as they watch TV or surf the web.
Figure 1. (A). Employee working on his laptop. (B). Boy with ADHD being trained with neurofeedback in a clinic. (C). Student looking at cell phone. When people slouch and look at the screen, they tend to slouch and scrunch their neck.
In many cases, the collapsed position also causes people to scrunch their necks, which puts pressure on their necks that may contribute to developing headache or becoming exhausted. Repetitive strain on the neck and cervical spine may trigger a cervical neuromuscular syndrome that involves chronic neck pain, autonomic imbalance and concomitant depression and anxiety (Matsui & Fujimoto, 2011), and may contribute to vertebrobasilar insufficiency –a reduction in the blood supply to the hindbrain through the left and right vertebral arteries and basilar arteries (Kerry, Taylor, Mitchell, McCarthy, & Brew, 2008). From a biomechanical perspective, slouching also places more stress is on the cervical spine, as shown in Figure 2. When the neck compression is relieved, the symptoms decrease (Matsui & Fujimoto, 2011).
Figure 2. The more the head tilts forward, the more stress is placed on the cervical spine. Reproduced by permission from: Hansraj, K. K. (2014). Assessment of stresses in the cervical spine caused by posture and position of the head. Surgical Technology International, 25, 277–279.
Most people are totally unaware of slouching positions and postures until they experience neck, shoulder, and/or back discomfort. Neither clients nor therapists are typically aware that slouching may decrease energy levels and increase the prevalence of negative (hopeless, helpless, powerless, or defeated) memories and thoughts (Peper & Lin, 2012; Peper et al, 2017)
Recommendations for posture awareness and training in treatment/education
The first step in biofeedback training and therapy is to systematically increase awareness and training of posture before attempting further bio/neurofeedback training and/or cognitive behavior therapy. If the client is sitting in a collapsed position in therapy, then it will be much more difficult for them to access positive thoughts, which interferes with further training and effective therapy. For example, research by Tsai, Peper, & Lin (2016) showed that engaging in positive thinking while slouched requires greater mental effort then when sitting erect. Sitting erect and tall contributes to elevated mood and positive thinking. An upright posture supports positive outcomes that may be akin to the beneficial effects of exercise for the treatment of depression (Schuch, Vancampfort, Richards, Rosenbaum, Ward, & Stubbs., 2016).
Most people know that posture affects health; however, they are unaware of how rapidly a slouching posture can impact their physical and mental health. We recommend the following educational and clinical strategies to teach this awareness.
- Practicing activities that raise awareness about a collapsed posture as compared to an erect posture
Guide clients through the practices so that they experience how posture can affect memory recall, physical strength, energy level, and possible triggering of headaches.
A. The effect of collapsed and erect posture on memory recall. Participants reported that it is much easier evoke powerless, hopeless, helpless, and defeated memories when sitting in a collapsed position than when sitting upright. Guide the client through the procedure described in the article, How posture affects memory recall and mood (Peper, Lin, Harvey, and Perez, 2017) and in the blog Posture affects memory recall and mood.
B. The effects of collapsed and erect posture on perceived physical strength. Participants experience much more difficulty in resisting downward pressure at the wrist of an outstretched arm when slouched rather than upright. Guide the client through the exercise described in the article, Increase strength and mood with posture (Peper, Booiman, Lin, & Harvey, 2016) and the blog, Increase strength and mood with posture.
C. The effect of slouching versus skipping on perceived energy levels. Participants experience a significant increase in subjective energy after skipping than walking slouched. Guide the client through the exercises as described in the article, Increase or decrease depression—How body postures influence your energy level (Peper & Lin, 2012).
D. The effect of neck compression to evoke head pressure and headache sensations. In our unpublished study with students and workshop participants, almost all participants who are asked to bring their head forward, then tilt the chin up and at the same time compress the neck (scrunching the neck), report that within thirty seconds they feel a pressure building up in the back of the head or the beginning of a headache. To their surprise, it may take up to 5 to 20 minutes for the discomfort to disappear. Practicing similar awareness activities can be a useful demonstration for clients with dizziness or headaches to experience how posture can increase their symptoms.
- Watching a Youtube video to enhance motivation.
Have clients watch Professor Amy Cuddy’s 2012 TED (Technology, Entertainment, and Design) Talk, Your body language shape who you are, which describes the hormonal changes that occur when adapting a upright power versus collapsed defeated posture.
- Electromyographic (EMG) feedback to demonstrate how posture affects muscle activity.
Record EMG from muscles such as around the cervical spine, trapezius, frontalis, and masseters or beneath the chin (submental lead) to demonstrate that having the head is forward and/or the neck compressed will increase EMG activity, as shown in Figure 3.
Figure 3. Electromyographic recording of the muscle under the chin while alternating between bringing the head forward or holding it back, feeling erect and tall.
The client can then learn awareness of the head and neck position. For example, one client with severe concussion experienced significant increase in head pressure and dizziness when she slouched or looked at a computer screen as well as feeling she would never get better. She then practiced the exercise of alternating her awareness by bringing her head forward and then back, and then bringing her neck back while her chin was down, thereby elongating the neck while she continued to breathe. With her head forward, she would feel her molars touching and with her neck back she felt an increase in space between the molars. When she elongated her neck in an erect position, she felt the pressure draining out of her head and her dizziness and tinnitus significantly decrease.
- Assessing ergonomics to optimize posture.
Change the seated posture of both the therapist and the client during treatment and training. Although people may be aware of their posture, it is much easier to change the external environment so that they automatically sit in a more erect power posture. Possible options include:
A. Seat insert or cushions. Sit in upright chairs that encourage an anterior pelvic tilt by having the seat pan slightly lower in the front than in the back or using a seat insert to facilitate a more erect posture (Schwanbeck, Peper, Booiman, Harvey, & Lin, 2015) as shown in Figure 4.
Figure 4. An example of how posture can be impacted covertly when one sits on a seat insert that rotates the pelvis anteriorly (The seat insert shown in the diagram and used in research is produced by BackJoy™).
B. Back cushion. Place a small pillow or rolled up towel at the kidney level so that the spine is slight arched, instead of sitting collapsed, as shown in Figure 5.
Figure 5. An example of how a small pillow, placed between the back of the chair and the lower back, changes posture from collapsed to erect.
C. Check ergonomic and work site computer use to ensure that the client can sit upright while working at the computer. For some, that means checking their vision if they tend to crane forward and crunch their neck to read the text. For those who work on laptops, it means using either an external keyboard, a monitor, or a laptop stand so the screen is at eye level, as shown in Figure 6.
Figure 6. Posture is collapsed when working on a laptop and can be improved by using an external keyboard and monitor. Reproduced by permission from: Bakker Elkhuizen. (n.d.). Office employees are like professional athletes! (2017).
- Wearable posture biofeedback training device
The wearable biofeedback device, UpRight™, consists of a small sensor placed on the spine and works as an app on the cell phone. After calibration the erect and slouched positions, the posture device gives vibratory feedback each time the participant slouches, as shown in Figure 7.
Figure 7. Illustration of a posture feedback device, UpRight™. It provides vibratory feedback to the wearer to indicate that they are beginning to slouch.
Clinically, we have observed that clients can learn to identify conditions that are associated with slouching, such as feeling tired, thinking depressive/hopeless thoughts or other situations that evoke slouching. When people wear a posture feedback device during the day, they rapidly become aware of these subjective experiences whenever they slouch. The feedback reminds them to sit in an erect position, and they subsequently report an improvement in health (Colombo et al., 2017). For example, a 26-year-old man who works more than 8 hours a day on computer reported, “I have an improved awareness of my posture throughout my day. I also notice that I had less back pain at the end of the day.”
- Integrating posture awareness and position changes throughout the day
After clients have become aware of their posture, additional training included having them observe their posture as well and negative changes in mood, energy level or tension in their neck and head. When they become aware of these changes, they use it as a cue to slightly arch their back and look upward. If possible have the clients look outside at the tops of trees and notice details such as how the leaves and branches move. Looking at the details interrupts any ongoing rumination. At the same time, have them think of an uplifting positive memory. Then have them take another breath, wiggling, and return to the task at hand. Recommend to clients to go outside during breaks and lunchtime to look upward at the trees, the hills, or the clouds. Each time one is distracted, return to appreciate the natural patterns. This mental break concludes by reminding oneself that humans are like trees.
Trees are rooted in the earth and reach upward to the light. Despite the trauma of being buffeted by the storms, they continue to reach upward. Similarly, clouds reflect the natural beauty of the world, and are often visible in the densest city environment. The upward movement reflects our intrinsic resilience and growth. –Erik Peper
Have clients place family photos and art slightly higher on the wall at home so they automatically look upward to see the pictures. A similar strategy can be employed in the office, using art to evoke positive feelings. When clients integrate an erect posture into their daily lives, they experience a more positive outlook and reduced neck and shoulder discomfort.
Compliance with Ethical Standards:
Conflict of Interest: Author Erik Peper has received donations of 15 UpRight posture feedback devices from UpRight (http://www.uprightpose.com/) and 12 BackJoy seat inserts from Backjoy (https://www.backjoy.com) for use in research. Co-authors I-Mei Lin and Richard Harvey declare that they have no conflict of interest.
This report evaluated a convenience sample of a student classroom activity related to posture and the information was anonymous collected. As an evaluation of a classroom activity, this report of findings was exempted from Institutional Review Board oversight
Bakker Elkhuizen. (n.d.). Office employees are like professional athletes! (2017). Retrieved from https://www.bakkerelkhuizen.com/knowledge-center/whitepaper-improving-work-performance-with-insights-from-pro-sports/
Colombo, S., Joy, M., Mason, L., Peper, E., Harvey, R., & Booiman, A. Posture Change Feedback Training and its Effect on Health. Poster presented at the 48th Annual Meeting of the Association for Applied Psychophysiology and Biofeedback, Chicago, IL March, 2017. Abstract published in Applied Psychophysiology and Biofeedback.42(2), 147.
Guan, X., Fan, G., Chen, Z., Zeng, Y., Zhang, H., Hu, A., … He, S. (2016). Gender difference in mobile phone use and the impact of digital device exposure on neck posture. Ergonomics, 59(11), 1453–1461.
Kerry, R., Taylor, A.J., Mitchell, J., McCarthy, C., & Brew, J. (2008). Manual therapy and cervical arterial dysfunction, directions for the future: A clinical perspective. Journal of Manual & Manipulative Therapy, 16(1), 39–48.
Schuch, F. B., Vancampfort, D., Richards, J., Rosenbaum, S., Ward, P. B., & Stubbs, B. (2016). Exercise as a treatment for depression: A meta-analysis adjusting for publication bias. Journal of Psychiatric Research, 77, 42–51.
We thank Frank Andrasik for his constructive comments.
This blog has been reprinted from: Peper, E., Lin, I-M., Harvey, R., & Perez, J. (2017). How posture affects memory recall and mood. Biofeedback, 45 (2), 36-41.
When I sat collapsed looking down, negative memories flooded me and I found it difficult to shift and think of positive memories. While sitting erect, I found it easier to think of positive memories. -Student participant
The link between posture and mood is embedded in idiomatic phrases such as walking tall, standing proud, and an upstanding citizen, versus collapsed, defeated, or in a slump–Language suggests that posture and mood/emotions are connected. Slumped posture is commonly observed in depression (Canales et al., 2010; Michalak et al., 2009) and adapting an upright posture increases positive affect, reduces fatigue, and increases energy in people with mild to moderate depression (Wilkes et al., 2017; Peper & Lin, 2012).
This blog describes in detail our research study that demonstrated how posture affects memory recall (Peper et al, 2017). Our findings may explain why depression is increasing the more people use cell phones. More importantly, learning posture awareness and siting more upright at home and in the office may be an effective somatic self-healing strategy to increase positive affect and decrease depression.
Most psychotherapies tend to focus on the mind component of the body-mind relationship. On the other hand, exercise and posture focus on the body component of the mind/emotion/body relationship. Physical activity in general has been demonstrated to improve mood and exercise has been successfully used to treat depression with lower recidivism rates than pharmaceuticals such as sertraline (Zoloft) (Babyak et al., 2000). Although the role of exercise as a treatment strategy for depression has been accepted, the role of posture is not commonly included in cognitive behavior therapy (CBT) or biofeedback or neurofeedback therapy.
The link between posture, emotions and cognition to counter symptoms of depression and low energy have been suggested by Wilkes et al. (2017) and Peper and Lin (2012), . Peper and Lin (2012) demonstrated that if people tried skipping rather than walking in a slouched posture, subjective energy after the exercise was significantly higher. Among the participants who had reported the highest level of depression during the last two years, there was a significant decrease of subjective energy when they walked in slouched position as compared to those who reported a low level of depression. Earlier, Wilson and Peper (2004) demonstrated that in a collapsed posture, students more easily accessed hopeless, powerless, defeated and other negative memories as compared to memories accessed in an upright position. More recently, Tsai, Peper, and Lin (2016) showed that when participants sat in a collapsed position, evoking positive thoughts required more “brain activation” (i.e. greater mental effort) compared to that required when walking in an upright position.
Even hormone levels also appear to change in a collapsed posture (Carney, Cuddy, & Yap, 2010). For example, two minutes of standing in a collapsed position significantly decreased testosterone and increased cortisol as compared to a ‘power posture,’ which significantly increased testosterone and decreased cortisol while standing. As Professor Amy Cuddy pointed out in herTechnology, Entertainment and Design (TED) talk, “By changing posture, you not only present yourself differently to the world around you, you actually change your hormones” (Cuddy, 2012). Although there appears to be controversy about the results of this study, the overall findings match mammalian behavior of dominance and submission. From my perspective, the concepts underlying Cuddy’s TED talk are correct and are reconfirmed in our research on the effect of posture. For more detail about the controversy, see the article by Susan Dominusin in the New York Times, “When the revolution came for Amy Cuddy,”, and Amy Cuddy’s response (Dominus, 2017;Singal and Dahl, 2016).
The purpose of our study is to expand on our observations with more than 3,000 students and workshop participants. We observed that body posture and position affects recall of emotional memory. Moreover, a history of self-described depression appears to affect the recall of either positive or negative memories.
Subjects: 216 college students (65 males; 142 females; 9 undeclared), average age: 24.6 years (SD = 7.6) participated in a regularly planned classroom demonstration regarding the relationship between posture and mood. As an evaluation of a classroom activity, this report of findings was exempted from Institutional Review Board oversight.
While sitting in a class, students filled out a short, anonymous questionnaire, which asked them to rate their history of depression over the last two years, their level of depression and energy at this moment, and how easy it was for them to change their moods and energy level (on a scale from 1–10). The students also rated the extent they became emotionally absorbed or “captured” by their positive or negative memory recall. Half of the students were asked to rate how they sat in front of their computer, tablet, or mobile device on a scale from 1 (sitting upright) to 10 (completely slouched).
Two different sitting postures were clearly defined for participants: slouched/collapsed and erect/upright as shown in Figure 1. To assume the collapsed position, they were asked to slouch and look down while slightly rounding the back. For the erect position, they were asked to sit upright with a slight arch in their back, while looking upward.
Figure 1. Sitting in a collapsed position and upright position (photo by Jana Asenbrennerova). Reprinted by permission from Gorter and Peper (2011).
After experiencing both postures, half the students sat in the collapsed position while the other half sat in the upright position. While in this position, they were asked to recall/evoke as many hopeless, helpless, powerless, or defeated memories as possible, one after the other, for 30 seconds.
After 30 seconds they were reminded to keep their same position and let go of thinking negative memories. They were then asked to recall/evoke only positive, optimistic, or empowering memories for 30 seconds.
They were then asked to switch positions. Those who were collapsed switched to sitting erect, and those who were erect switched to sitting collapsed. Then they were again asked to recall/evoke as many hopeless, helpless, powerless, or defeated memories as possible one after the other for 30 seconds. After 30 seconds they were reminded to keep their same position and again let go of thinking of negative memories. They were then asked to recall/evoke only positive, optimistic, or empowering memories for 30 seconds, while still retaining the second posture.
They then rated their subjective experience in recalling negative or positive memories and the degree to which they were absorbed or captured by the memories in each position, and in which position it was easier to recall positive or negative experiences.
86% of the participants reported that it was easier to recall/access negative memories in the collapsed position than in the erect position, which was significantly different as determined by one-way ANOVA (F(1,430)=110.193, p < 0.01) and 87% of participants reported that it was easier to recall/access positive images in the erect position than in the collapsed position, which was significantly different as determined by one-way ANOVA (F(1,430)=173.861, p < 0.01) as shown in Figure 2.
Figure 2. Percent of respondents who reported that it was easier to recall positive or negative memories in an upright or slouched posture.
The difficulty or ease of recalling negative or positive memories varied depending on position as shown in Figure 3.
Figure 3. The relative subjective rating in the ease or difficulty of recalling negative and positive memories in collapsed and upright positions.
The participants with a high level of depression over the last two years (top 23% of participants who scored 7 or higher on the scale of 1–10) reported that it was significantly more difficult to change their mood from negative to positive (t(110) = 4.08, p < 0.01) than was reported by those with a low level of depression (lowest 29% of the participants who scored 3 or less on the scale of 1–10). It was significantly easier for more depressed students to recall/evoke negative memories in the collapsed posture (t(109) = 2.55, p = 0.01) and in the upright posture (t(110) = 2.41, p ≦0.05 he) and no significant difference in recalling positive memories in either posture, as shown in Figure 4.
Figure 4. Differences is in memory access for participants with a history of least or most depression.
For all participants, there was a significant correlation (r = 0.4) between subjective energy level and ease with which they could change from negative to positive mood. There were no significance differences for gender in all measures except that males reported a significantly higher energy level than females (M = 5.5, SD = 3.0 and M = 4.7, SD = 3.8, respectively; t(203) = 2.78, p < 0.01).
A subset of students also had rated their posture when sitting in front of a computer or using a digital device (tablet or cell phone) on a scale from 1 (upright) to 10 (completely slouched). The students with the highest levels of depression over the last two years reporting slouching significantly more than those with the lowest level of depression over the last two years (M = 6.4, SD = 3.5 and M = 4.6, SD = 2.6; t(46) = 3.5, p < 0.01).
There were no other order effects except of accessing fewer negative memories in the collapsed posture after accessing positive memories in the erect posture (t(159)=2.7, p < 0.01). Approximately half of the students who also rated being “captured” by their positive or negative memories were significantly more captured by the negative memories in the collapsed posture than in the erect posture (t(197) = 6.8, p < 0.01) and were significantly more captured by positive memories in the erect posture than the collapsed posture (t(197) = 7.6, p < 0.01), as shown in Figure 5.
Figure 5. Subjective rating of being captured by negative and positive memories depending upon position.
Posture significantly influenced access to negative and positive memory recall and confirms the report by Wilson and Peper (2004). The collapsed/slouched position was associated with significantly easier access to negative memories. This is a useful clinical observation because ruminating on negative memories tends to decrease subjective energy and increase depressive feelings (Michi et al., 2015). When working with clients to change their cognition, especially in the treatment of depression, the posture may affect the outcome. Thus, therapists should consider posture retraining as a clinical intervention. This would include teaching clients to change their posture in the office and at home as a strategy to optimize access to positive memories and thereby reduce access or fixation on negative memories. Thus if one is in a negative mood, then slouching could maintain this negative mood while changing body posture to an erect posture, would make it easier to shift moods.
Physiologically, an erect body posture allows participants to breathe more diaphragmatically because the diaphragm has more space for descent. It is easier for participants to learn slower breathing and increased heart rate variability while sitting erect as compared to collapsed, as shown in Figure 6 (Mason et al., 2017).
Figure 6. Effect of posture on respiratory breathing pattern and heart rate variability.
The collapsed position also tends to increase neck and shoulder symptoms This position is often observed in people who work at the computer or are constantly looking at their cell phone—a position sometimes labeled as the i-Neck.
Implication for therapy
In most biofeedback and neurofeedback training sessions, posture is not assessed and clients sit in a comfortable chair, which automatically causes a slouched position. Similarly, at home, most clients sit on an easy chair or couch, which lets them slouch as they watch TV or surf the web. Finally, most people slouch when looking at their cellphone, tablet, or the computer screen (Guan et al., 2016). They usually only become aware of slouching when they experience neck, shoulder, or back discomfort.
Clients and therapists are usually not aware that a slouched posture may decrease the client’s energy level and increase the prevalence of a negative mood. Thus, we recommend that therapists incorporate posture awareness and training to optimize access to positive imagery and increase energy.
Babyak, M., Blumenthal, J. A., Herman, S., Khatri, P., Doraiswamy, M., Moore, K., … Krishnan, K. R. (2000). Exercise treatment for major depression: maintenance of therapeutic benefit at 10 months. Psychosomatic Medicine, 62(5), 633–638.
Canales, J. Z., Cordas, T. A., Fiquer, J. T., Cavalcante, A. F., & Moreno, R. A. (2010). Posture and body image in individuals with major depressive disorder: A controlled study. Revista brasileira de psiquiatria, 32(4), 375–380.
Guan, X., Fan, G., Chen, Z., Zeng, Y., Zhang, H., Hu, A., … He, S. (2016). Gender difference in mobile phone use and the impact of digital device exposure on neck posture. Ergonomics, 59(11), 1453–1461.
Mason, L., Joy, M., Peper, E., & Harvey, R, A. (2017). Posture Matters. Poster presented at the 48th Annual Meeting of the Association for Applied Psychophysiology and Biofeedback, Chicago, IL March, 2017. Abstract published in Applied Psychophysiology and Biofeedback, 42(2), 148.
Michalak, J., Troje, N. F., Fischer, J., Vollmar, P., Heidenreich, T., & Schulte, D. (2009). Embodiment of sadness and depression: Gait patterns associated with dysphoric mood. Psychosomatic Medicine, 71(5), 580–587.
Michl, L. C., McLaughlin, K. A., Shepherd, K., & Nolen-Hoeksema, S. (2013). Rumination as a mechanism linking stressful life events to symptoms of depression and anxiety: Longitudinal evidence in early adolescents and adults. Journal of Abnormal Psychology, 122(2), 339.
Wilkes, C., Kydd, R., Sagar, M., & Broadbent, E. (2017). Upright posture improves affect and fatigue in people with depressive symptoms. Journal of Behavior Therapy and Experimental Psychiatry, 54, 143–149.
We thank Frank Andrasik for his constructive comments.
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:
Sedentary behavior is the new norm as most jobs do not require active movement. Sitting in a car instead of walking, standing on the escalator instead of walking up the stairs, using an electric mixer instead of whipping the eggs by hand, sending a text instead of getting up and talking to a co-worker in the next cubicle, buying online instead of walking to the brick and mortar store, watching TV shows, streaming movies, or playing computer games instead of socializing with actual friends, are all examples how the technological revolution has transformed our lives. The result is sitting disease which we belief can mitigate by daily exercise.
The research data is very clear– exercise does not totally reverse the health risks of sitting. In the NIH-AARP Diet and Health Study, researchers Matthews and colleagues (Matthews et al, 2012) completed an 8.5 year follow up on 240,819 adults (aged 50–71 year) who at the beginning baseline surveys did not report any cancer, cardiovascular disease, or respiratory disease.
The 8.5 year outcome data showed that the time spent in sedentary behaviors such as sitting and watching TV was positively correlated with an increased illness and death rates as shown in Figure 1. More disturbing, moderate vigorous exercises does not totally reverse the health risks of sitting and watching television (Matthews et al, 2012).
Figure 1. The more you sit the higher the risk of mortality even if you if you attempt to mitigate the effect with moderate vigorous exercise (Matthews et al, 2012). From: https://www.washingtonpost.com/apps/g/page/national/the-health-hazards-of-sitting/750/
The harmful impact of sedentary behavior and simple ways to improve health have been superbly described and illustrated by Bonnie Berkowitz and Patterson Clark (2014), in their January 20, 2014, Washington Post article, The health hazards of sitting, Their one page poster should be posted on the office walls and given to all clients. http://www.washingtonpost.com/wp-srv/special/health/sitting/Sitting.pdf
As they point out, sitting disease increases the risk of heart disease, diabetes, colon cancer, muscle degeneration especially weaker abdominal muscles and gluteus muscles, back pain and reduced hip flexibility, poor circulation in the legs which may cause edema in the ankles and deep vein thrombosis, osteoporosis, strained neck, shoulder and back pain. The effects are not only physical. Sitting reduces subjective energy level and attention as our brain becomes more and more sleepy.
The solution is both very simple and challenging. To reduce the risks, do less sedentary behavior and sitting and do more physical movement during the day. Continuously interrupt sitting with standing and movement. After sitting at the computer for 30 minutes, get up and move. Even skipping in place for 30 seconds, significantly will increase your energy and mood (Peper and Lin, 2012). There are many ways to remind and support yourself and others to move. For example, use reminder programs on the computer such as StretchBreakTM to remind you to get up and stretch. Employees who do episode movements, report fewer symptoms and have more energy (Peper & Harvey, 2008). As one of the employees state after implementing the break program, “There is life after five.” Meaning he was no longer exhausted when he finished work.
Although challenging, wean yourself away from the addicting digital screen and being a couch potato at home. At those moments when you feel drained and all you want to do is veg out by watching another TV series, go for a walk. After walking for 20 minutes, in most cases your energy will have returned and your low mood has been transformed to see new positive option. Plan the walks with neighbors and friends who provide the motivation to pull you out of your funk and go out.
Berkowitz, B. & Clark, P. (Jan 20, 2014). The health hazard of sitting. The Washington Post. Retrieved July 29, 2017.https://www.washingtonpost.com/apps/g/page/national/the-health-hazards-of-sitting/750/
Matthews, C. E., George, S. M., Moore, S. C., Bowles, H. R., Blair, A., Park, Y., … Schatzkin, A. (2012). Amount of time spent in sedentary behaviors and cause-specific mortality in US adults. The American Journal of Clinical Nutrition, 95(2), 437–445. http://doi.org/10.3945/ajcn.111.019620
“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
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/
The next time you’re feeling sad and depressed, pay close attention to your posture. According to cognitive scientists, you’ll likely be slumped over with your neck and shoulders curved forward and head looking down.
While it’s true that you’re sitting this way because you’re sad, it’s also true that you’re sad because you’re sitting this way. This philosophy, known as embodied cognition, is the idea that the relationship between our mind and body runs both ways, meaning our mind influences the way our body reacts, but the form of our body also triggers our mind.
In large part due to Amy Cuddy’s widly popular 2012 TED talk, most of us know that two minutes of “power poses” a day can change how we feel about ourselves. This isn’t just about displaying confidence to others around; this is about actually changing your hormones—increased levels of testosterone and decreased levels of cortisol, or the stress hormone, in the brain.
“The brain has an area that reflects confidence, but once that area is triggered it doesn’t matter exactly how it’s triggered,” says Richard Petty, professor of psychology at Ohio State University. “It can be difficult to distinguish real confidence from confidence that comes from just standing up straight … these things go both ways just like happiness leads to smiling, but also smiling leads to happiness.”
When it comes to posture, Petty explains that the way we ultimately feel has a lot to do with the associations we have with being taller. For example, if you take two people and you put one on a chair that’s above the other person, the one that’s looking down will feel more powerful because “we have all these associations” with height and power that “gets triggered automatically when certain movements are made,” he says. The function of your body posture tells your brain that you’re powerful, which, in turn, affects your attitude.
In a 2009 study published in the European Journal of Social Psychology, Petty along with other researchers instructed 71 college students to either “sit up straight” and “push out [their] chest” or “sit slouched forward” with their “face looking at [their] knees.” While holding their assigned posture, the students were asked to list either three positive or negative personal traits they thought would contribute to their future job satisfaction and professional performance. Afterward, the students were asked to take a survey where they rated themselves on how well they thought they would perform as a future professional.
The researchers found that how the students rated themselves depended on the posture they kept when they wrote the positive or negative traits. Those who were in the upright position believed in the positive and negative traits they wrote down while those in the slouched over position weren’t convinced of their positive or negative traits. In other words, when the students were in the upright, confident position, they trusted their own thoughts whether those thoughts were positive or negative. On the other hand, when the students sat in a powerless position, they didn’t trust anything they wrote down whether it was positive or negative.
However, those in the upright position likely had an easier time thinking of “empowering, positive” traits about themselves to write down while those in the slouched over position probably had an easier time recalling “hopeless, helpless, powerless, and negative” feelings, according to Erik Peper, professor of Holistic Health at San Francisco State University.
In a series of experiments, Peper found that sitting in a collapsed, helpless position makes it easier for negative thoughts and memories to appear while sitting in an upright, powerful position makes it easier to have empowering thoughts and memories.
“Emotions and thoughts affect our posture and energy levels; conversely, posture and energy affect our emotions and thoughts,” says one of Peper’s studies from 2012, and two minutes of skipping versus walking in a slouched position can make a significant difference on our energy levels. Like Cuddy, Peper’s research finds that it only takes two minutes to change your hormones, meaning you can basically change the chemistry in your brain while waiting for your food to heat up in the microwave.
Since posture affects our mood and thoughts so much, the increase of collapsed sitting and walking—from sitting in front of our computer to looking down at our smartphones—may very much have an effect on the rise of depression in recent years. Peper and his team of researchers suggest that posture is a significant contributor to decreased energy levels and depression. Slouching is also known to result in frequent headaches and neck and shoulder pains.
With so much research proving the influence posture has on our mind, Peper suggests hanging photos of people you love slightly higher on the wall or above your desk so that you have to look up. Also, adjust your rear view mirror slightly higher so that you have to sit up taller while driving. If you need reminders, Petty advises setting reminders on your phone, computer, or even a Post-It note. When you do have negative thoughts, instead of validating them by slumping over or bending your head, Petty says that you should write them down on a piece of paper, then throw that piece of paper away in the trash.
“People who throw those negative thoughts into the trash can are less affected by them then people who had the same thoughts but symbolically put them in their pocket,” he says. “It’s this idea that it’s not what we think that’s important; it’s how much we trust what we think.”
Reprinted by permission from Vivian Giang
It is impossible to belief that that only a few years ago there were no cell phones.
When I go home, I purposely put the phone away so that I can be present with my children.
I just wonder if the cell phone’s electromagnetic radiation could do harm?
Cell phone use is ubiquitous since information is only a key press or voice command away. Students spend about many hours a day looking and texting on a cell phone and experience exhaustion and neck and shoulder discomfort (Peper et al, 2013). Constant use may also have unexpected consequences: Increased stress on the cervical spine and increased risk for brain cancer.
Increased cervical spine stress
As we look at the screen, text messages or touch the screen for more information, we almost always bend our head down to look down. This head forward position increases cervical compression and stress. The more the head bends down to look, the more the stress in the neck increases as the muscles have to work much harder that hold the head up. In a superb analysis Dr. Kennth Hansraj, Chief of Spine Surgery 0f New York Spine Surgery & Rehabilitation Medicine, showed that stress on the cervical spine increases from 10-12 lbs when the head is in its upright position to 60 lbs when looking down.
Figure 1. Stress on the cervical spine as related to posture. (From: Hansraj, K. K. (2014). Assessment of stresses in the cervical spine caused by posture and position of the head. Surgical technology international, 25, 277-279.)
Looking down for a short time period is no problem; however, many of us look down for extended periods. This slouched collapsed position is becoming the more dominant position. A body posture which tends to decrease energy, and increase hopeless, helpless, powerless thoughts (Wilson & Peper, 2004; Peper & Lin, 2012). The long term effects of this habitual collapsed position are not know–one can expect more neck and back problems and increase in lower energy levels.
increased risk for brain cancer and inactive sperm and lower sperm count
Cell phone use not only affect posture, the cell phone radio-frequency electromagnetic radiation by which the cell phone communicates to the tower may negatively affect biological tissue. It would not be surprising that electromagnetic radiation could be harmful; since, it is identical to the frequencies used in your microwave ovens to cook food. The recent research by Drs Michael Carlberg and Lennart Hardell of the Department of Oncology, University Hospital, Örebro, Sweden, found that long term cell phone use is associated by an increased risk of developing malignant glioma (brain cancers) with the largest risk observed in people who used the cell phone before the age of 20. In addition, men who habitually carry the cell phone in a holster or in their pocket were more likely to have inactive or less mobile sperm as well as a lower sperm count.
What can you do:
Keep an upright posture and when using a cell phone or tablet. Every few minutes stretch, look up and reach upward with your hands to the sky.
Enjoy the cartoon video clip, Smartphone Ergonomics – Safe Tips – Mobile or Smart Phone Use while Driving, Traveling on the Move.
Agarwal, A., Singh, A., Hamada, A., & Kesari, K. (2011). Cell phones and male infertility: a review of recent innovations in technology and consequences. International braz j urol, 37(4), 432-454. http://www.isdbweb.org/documents/file/1685_8.pdf
Carlberg, M., & Hardell, L. (2014). Decreased Survival of Glioma Patients with Astrocytoma Grade IV (Glioblastoma Multiforme) Associated with Long-Term Use of Mobile and Cordless Phones. International journal of environmental research and public health, 11(10), 10790-10805. http://www.mdpi.com/1660-4601/11/10/10790/htm
De Iuliis, G. N., Newey, R. J., King, B. V., & Aitken, R. J. (2009). Mobile phone radiation induces reactive oxygen species production and DNA damage in human spermatozoa in vitro. PloS one, 4(7), e6446.
Hansraj, K. K. (2014). Assessment of stresses in the cervical spine caused by posture and position of the head. Surgical technology international, 25, 277-279.
Peper, E. & Lin, I-M. (2012). Increase or decrease depression-How body postures influence your energy level. Biofeedback, 40 (3), 126-130.
Peper, E., Waderich, K., Harvey, R., & Sutter, S. (2013). The Psychophysiology of Contemporary Information Technologies Tablets and Smartphones Can Be a Pain in the Neck. In Applied Psychophysiology and Biofeedback, 38(3), 219.
Wilson, V.E. and Peper, E. (2004). The Effects of upright and slumped postures on the generation of positive and negative thoughts. Applied Psychophysiology and Biofeedback.29 (3), 189-195.
“Reasonable people adapt themselves to the world; unreasonable people persist in trying to adapt the world to themselves. Therefore all progress depends on unreasonable people.”
–Paraphrased from Bernard Shaw
Having the right equipment and work environment will reduce injury and improve performance. This is true for athletes as well as for people using computers, laptops, tablets and smartphones. We look down and curve our upper spine to read the tablet, crane our heads forward to read the screen, lift our shoulders, arms and hands up to the laptop keyboard to enter data, and we bend our heads down and squint to read the smartphone—all occurring without awareness (Straker et al, 2008; Asunda, Odell, Luce, & Dennerlein, 2010; Peper et al, 2014). We are captured by the devices and stay immobilized until we hurt. At the end of the work day, we are often exhausted and experience neck and shoulder stiffness, arm pain and eye fatigue. This stress immobility syndrome is the twenty first century reward for digital immigrants and natives.
We hurt because we fit ourselves to the environment instead of changing the environment to fit us. The predominant slouched position even affects our mood and strength (Peper and Lin, 2012). Experience how your strength decreases when you slouch and look downward as compared when you sit tall with your spine lengthened at your laptop, tablet or phone. You will need a partner to do this practice as shown in Figure 1.
Sit in your slouched position while looking down and extend your arm to the side. Have your partner stand behind you and gently press downward on your upper arm near your wrist while you attempt to resist the pressure. Now relax and let your arms hang along the side of your body. Now sit upright in a tall position with your spine lengthening while looking straight ahead. Again extend your arm and gently have your gently press downward on your upper arm near your wrist while you attempt to resist the pressure.
You probably experienced significantly more strength resisting the downward pressure when sitting erect and tall than when sitting collapsed as we discovered in our study at San Francisco State University in with students as shown in figure 2.
Figure 2. Change in perceived strength resisting a downward pressure on the extended arm while sitting. Reproduced by permission from Schwanbeck, R., Peper, E., Booiman, A., Harvey, R., and Lin, I-M. (in press).
Increase your power and take charge! Arrange your laptop, computer and tablet so it fits you. This usually means changing your home and office chairs and desks; since, they have been manufactured for the average person. Just like the average coach airplane seat – it is uncomfortable for most people. As my colleague Annette Booiman who is a Mensendiek practitioner has pointed out, “An incorrectly adjusted chair or table height will force you to work in a dysfunctional body position while an appropriately adjusted chair or table height offers you the opportunity to work in a healthy position.”
Become the unreasonable person and fit the world so that you are comfortable while using digital devices. There are solutions! Take responsibility and adjust your posture to a healthy one–it will make your life so much more energetic. Sit on your sit bones (ischial tuberosities) as if they are the feet of your pelvis and feel your spine lengthening as you sit tall. Alternatively, stand while working and adjust the desk height for your size. Regardless of whether you sit or stand while working, take many breaks to interrupt your immobilized posture. Install a software program on computer to remind you to take breaks and watch the YouTube clips on cartoon ergonomics for working at the computer.
Implement the following common sense ergonomic guidelines:
For working at a computer sit in a chair with your feet on the floor, the elbows bend at 90 degrees with the hands, wrists, and forearms are straight, in-line and roughly parallel to the floor so that the hands can be on the keyboard while the top of monitor is at eye brow level as shown in Figure 3.
Figure 3. Optimum position to sit at a computer work station. From: http://bmarthur.files.wordpress.com/2009/03/good-posture-how-to-sit-at-a-desk.png
For working with a laptop you will always compromise body position. If the screen is at eye level, you have to bring your arms and hands up to the keyboard, or, more commonly, you will look down at the screen while at the same time raising your hands to reach the keyboard. The solution is to use an external keyboard so that the keyboard can be at your waist position and the laptop screen eye level as shown in Figure 4.
Figure 4. Optimum position to sit while using a laptop. From: http://www.winwin-tech.com/uploadfile/cke/images/6.jpg
For working with tablets and smart phones you have little choice. You either look down or reach up to touch the screen. As much as possible tilt and raise the tablet so that you do not have slouch to see the screen.
If you observe that you slouch and collapse while working, invest in an adjustable desk that you can raise or lower for your optimum height. An adjustable height desk such as the unDesk offers the opportunity to change work position from sitting to standing as shown in Figure 5.
Figure 5. Example of a height adjustable desk (the unDesk) that can be used for sitting and standing.
Although office chairs can give support, we often slouch in them. While at home we use any chair that is available—again encouraging slouching. Reduce the slouching by sitting on a seat insert such as a BackJoy® which tends to let you sit more erect and in a more powerful and energizing position see Figure 6.
Finally, whether or not you can change your environment, take many, many short movement breaks– wiggle, stretch, get up and walk–to interrupt the muscle tension and allow yourself to regenerate. To remind yourself to take breaks while being captured by your work, install a reminder program on your computer such as Stretchbreak that pops up on the screen and guides you through short stretches to regenerate.
Cartoon videos on ergonomics: https://peperperspective.com/2014/09/30/cartoon-ergonomics-for-working-at-the-computer-and-laptop/
Healthy computing tips: http://biofeedbackhealth.files.wordpress.com/2013/01/health-computing-email-tips.pdf
Seat insert such as BackJoy®: http://www.backjoy.com/sit/
Height adjustable desk such as The unDesk: http://www.theundesk.com/
Interrupt computer program such as Stretchbreak: http://www.paratec.com
Asundi, K., Odell, D., Luce, A., & Dennerlein, J. T. (2010). Notebook computer use on a desk, lap and lap support: Effects on posture, performance and comfort. Ergonomics, 53(1), 74-82.
Peper, E., & Lin, I. M. (2012). Increase or decrease depression-How body postures influence your energy level. Biofeedback, 40 (3), 126-130.
Peper, E., Booiman, A., Lin, I-M., & Shaffer, F. Making the Unaware Aware-Surface Electromyography to Unmask Tension and Teach Awareness. Biofeedback, 2(1), 16-23.
Schwanbeck, R., Peper, E., Booiman, A., Harvey, R., and Lin, I-M. Posture changes with a seat insert: Changes in strength and implications for breathing and HRV. Poster submitted for the 46th Annual Meeting of the Association for Applied Psychophysiology and Biofeedback.
Straker, L. M., Coleman, J., Skoss, R., Maslen, B. A., Burgess-Limerick, R., & Pollock, C. M. (2008). A comparison of posture and muscle activity during tablet computer, desktop computer and paper use by young children. Ergonomics, 51(4), 540-555.
* Adapted from: Peper, E. (in press). Become the unreasonable person: Adjust your world to fit you! Western Edition and Schwanbeck, R., Peper, E., Booiman, A., Harvey, R., and Lin, I-M. (in press). Posture changes with a seat insert: Changes in strength and implications for breathing and HRV.
I finally bought a separate keyboard and a small stand for my laptop so that the screen is at eye level and my shoulders are relaxed while typing at the keyboard. To my surprise, my neck and shoulder tightness and pain disappeared and I am much less exhausted.
How we sit and work at the computer significantly affects our health and productivity. Ergonomics is the science that offers guidelines on how to adjust your workspace and equipment to suit your individual needs. It is just like choosing appropriate shoes–Ever try jogging in high heels? The same process applies to the furniture and equipment you use when computing.
When people arrange their work setting according to good ergonomic principles and incorporate a healthy computing work style numerous disorders (e.g., fatigue, vision discomfort, head, neck, back, shoulder, arm or hand pain) may be prevented (Peper et al, 2004). For pragmatic tips to stay health at the computer see Erik Peper’s Health Computer Email Tips. Enjoy the following superb video cartoons uploaded by Stephen Walker on YouTube that summarize the basic guidelines for computer, laptop and cell phones use at work, home, or while traveling.
Adult or Child Laptop Use at Home, Work or Classroom
Healthy use of laptops anywhere.
Mobile or Smart Phone Use while Driving, Traveling or on the Move.