Research & Publications

Dr. Peper’s research interests focus on the psychophysiology of healing, illness prevention, voluntary self-regulation, holistic health, healthy computing, respiratory psychophysiology and optimizing health with biofeedback. The following is a list of free down-loadable articles researched and published by Dr. Peper.

New  Publications

Peper, E. (2018 Oct 8). Breathing exercises that help to reduce pain and stress in our lives. Western Edition HP Journal, 10-11.

Gastroesophageal reflux disease (GERD), more commonly known as acid reflux, is a common and chronic disorder that affects 10% and 20% of people in the U.S. and Europe. We propose that tight clothing around the waist and stomach area as well as stress can increase hydraulic pressure on the stomach that pushes the stomach content upward into the esophagus especially during inhalation. When clients wear looser clothing, avoid slouching, and master slower, diaphragmatic abdominal breathing (belly breathing), they may reduce the hydraulic pressure on the stomach as the diaphragm descends.  Two male college student whose acid reflux symptoms significantly decreased illustrates this process.  Discussed are: 1) the important function of breathing which includes enhancing venous and lymph circulation and changing inter-abdominal pressure in the abdomen; 2) abdominal breathing as an early intervention strategy and prevention of acid reflux; and, 3) the importance of transferring breathing/stress management skills into daily life.

Peper, E., Harvey, R., Mason, L., & Lin, I-M. (2018). Do better in math: How your body posture may change stereotype threat response. NeuroRegulation, 5(2), 67-740 Do better in math Published NeuroRegulationpdf

This study investigates posture on mental math performance. The math test was rated significantly more difficult while sitting slouched than while sitting erect. Specifically, Participants with the highest test anxiety, math difficulty and blanking out scores (TAMDBOS) rated the math task significantly more difficult in the slouched position as compared to the erect position. Discussed are processes such as stereotypic threat associated with a “defense reaction” by which posture can affect mental math and inhibit abstract thinking. Moreover, clinicians who work with students who have learning difficulty may improve outcome if they include posture changes.

Peper, E. & Harvey, R. (2018). Digital addiction: increased loneliness, depression, and anxiety. NeuroRegulation. 5(1),3–8doi:10.15540/nr.5.1.3 

Digital addiction is defined by the American Society for Addiction Medicine (ASAM) as well as the American Psychiatric Association (APA) as “… a primary, chronic disease of brain reward, motivation, memory, and related circuitry.  Symptoms of digital addiction such as increased loneliness (also called “phoneliness”), anxiety, and depression were observed in a sample of university undergraduates who completed a survey about smartphone use during and outside of class. Other observations included observations of “iNeck” (poor) posture as well as how multitasking/semitasking was prevalent in the sample. Implications of continued digital addition are discussed.

Peper, E., Mason, L., & Huey, C. (2017). Healing irritable bowel syndrome with diaphragmatic breathing. Biofeedback. 45(4), 83-87. DOI: 10.5298/1081-5937-45.4.04

Irritable bowel syndrome (IBS) affects 7 to 21% of the general population and is a chronic condition. The symptoms usually include abdominal cramping, discomfort or pain, bloating, loose or frequent stools and constipation, and can significantly reduce the quality of life. This case report describes how a 22-year-old woman, who was initially diagnosed with IBS when she was a high school junior, healed herself from IBS with slow abdominal breathing without any therapeutic coaching. She has continued to be symptom-free for the last three years. The article reviews how slower diaphragmatic breathing (abdominal breathing) may reduce symptoms of IBS, explores the possibility that breathing is more than increasing sympathetic/parasympathetic balance, and suggests additional self-care strategies to reduce the symptoms of IBS.

The Effects of Upright and Slumped Postures on the Recall of Positive and Negative Thoughts

This study assessed whether it was easier to generate positive and negative thoughts in either an upright or slumped position. Surface electromyography (sEMG) of zygomaticus major, heart rate, and respiratory rate were assessed across four 1-min counterbalanced conditions of either upright or slumped posture and either positive or negative thought generation. At the end of the study, participants rated which thought was easiest to generate in the two postures. Significantly more participants (92%), indicated it was easiest to generate positive thoughts in the upright position. This study supports the finding that positive thoughts are more easily recalled in the upright posture.

Peper, E. & Aita, J. (2017). Winning the Gold in Weightlifting Using Biofeedback, Imagery and Cognitive Change. Biofeedback, 45(4), 77–82. DOI: 10.5298/1081-5937-45.4.01

Jo Aita, age 46 and weighing 58 kg, set the Masters World Records and Masters Games Records for her age group in Snatch, Clean and Jerk, and Total Olympic weightlifting at the World Masters Games by lifting 71 kg in the Snatch and 86 kg in the Clean and Jerk Olympic lifts. She incorporated biofeedback and visualization training to help optimize her performance. This article summarizes and describes the protocol of breathing and electromyography feedback combined with imagery that contributed to achieving her personal best.

Peper, E. & Harvey, R. (2017). The fallacy of the placebo controlled clinical trials: Are positive outcomes the result indirect treatment side effects? NeuroRegulation. 4(3–4), 102–113.

This paper argues that placebo effects have a larger influence on clinical trial outcomes than purported treatment effects, raising questions about the size of effects currently attributed to clinical treatments. Placebo-controlled clinical trials usually do not include an “active” placebo and thus the clinical outcome could be due to the placebo responses to nontherapeutic side effects of the treatment.  This paper emphasizes exercising caution when interpreting results from clinical trials using pharmaceutical or surgical treatments, discusses possible mechanisms underlying the acceptance of treatment procedures which later have been shown to be ineffective or harmful, and highlights the importance of incorporating active placebo procedures to address any covert treatment side effects induced by placebo response. Finally, the authors suggest that clinical trials of bio/neurofeedback treatments carefully consider the important and consequential influences of placebos when designing studies or interpreting the results of trial outcomes.

Peper, E., Lin, I-M., Harvey, R., & Perez, J. (2017). How posture affects memory recall and mood.  Biofeedback.45 (2), 36-41.

Body posture reflects emotional states, and this study investigates the effect of posture sitting in a slouched or upright position on recall of either negative (hopeless, helpless, powerless, or defeated) memories or positive (empowered or optimistic) memories. In this study, 86% of the students reported that it was easier to recall/access negative memories in the collapsed position than in the erect position, and 87% of the students reported that it was easier to recall/access positive images in the erect position than in the collapsed position. Participants who reported being most depressed over the previous two years reported significantly more recall of negative memories in both the slouched position and erect position. We recommend that therapists teach clients posture awareness and to sit more upright in the office and at home as a strategy to increase positive affect and decrease depression.

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 six 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.

Peper, E. (2017). Enhancing Yoga with Biofeedback. J Yoga & Physio.2(2).

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? 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.

Posture and Health

Peper, E., Booiman, A., Lin, I.M., & Harvey, R. (2016).  Increase strength and mood with posture. Biofeedback, 44(2), 66-72.

Body postures can project nonverbally how a human being feels. Postural changes affect thoughts, emotions, and energy levels, and conversely, energy levels, emotions, and thoughts affect posture. The purpose of this study was to explore how changes in erect or standing body posture affect positive energy levels, emotions, and thoughts. When measured in this study, all but one (98%) of the subjects perceived greater arm strength as they resisted the downward pressure when they stood in an erect posture compared with when they stood in a collapsed/slouched posture. Similarly, testers observed that the subject were much stronger in their ability to resist the downward pressure in the erect versus slouched position. This study points out that psychology and bioneurofeedback training needs to understand how important body posture, movement, and somatic feedback are as part of the therapeutic and teaching process, because changing the posture affects strength and recall of memories, which are important parts of the mind-body equation that underlies health and illness.

Peper, E., Booiman, A., Lin, I.M., & Harvey, R. (2016).  Increase strength and mood with posture. Beweegreden,12(2), 14-17.

Body posture can project non-verbally how we feel (Coulson, 2004; Pitterman & Nowicki, 2004). For example, when standing erect we occupy more space and tend to project power and authority to others and to ourselves (Huang, Galinsky, Gruenfeld, & Guillory, 2010).  More and more in contemporary life we sit collapsed for many hours with our spine in flexion. The authors conclude that an essential part of the holistic approach to health and wellness involves incorporating awareness of body posture, movement and providing some form of somatic feedback as part of the therapeutic and patient education process. Without teaching that a collapsed body posture may impact the healing process, only one half of the mind-body equation that underlies health and illness will be impacted.

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.

This article demonstrated that if you are sitting collapsed, it takes almost twice as long and the brain has to work much significantly harder to access positive memories than when you sit erect. Sitting collapsed facilitates the presence of negative, hopeless, defeating thoughts and memories. While sitting erect and looking upward increases the access to positive thoughts and memories can possibly could decrease depressive thoughts and feelings. Thus clinicians and clients need to be aware of posture and encourage upright posture to promote health.

Educational Model for Self-healing: Eliminating a Chronic Migraine with Electromyography, Autogenic Training, Posture, and Mindfulness

An educational approach is often different from a clinical treatment approach to promote healing. Using an educational approach, 80% of university students who are enrolled in a holistic health course report that both acute and chronic disorders can be ameliorated or eliminated when they engage in daily self-practice of autogenic training, biofeedback self-regulation practices, and/or somatic posture awareness. This process of reducing health problems is illustrated by a case report of a 20-year-old female student who experienced three migraines per week for the past 6 years. After practicing self-regulation and body awareness techniques such as autogenic training, surface electromyography–assisted muscle awareness, diaphragmatic breathing, and postural changes, the frequency of her headaches decreased to zero. At 20-month follow-up, the student continued to be headache free. This type of integrated self-healing educational approach is recommended for students, patients, and anyone who wants to create lasting health changes.

Healthy Computing

Stress Protocol for Assessing Computer-Related Disorders

The information gained from a psychophysiological stress profile when a person works at the computer can be used to assess and prevent repetitive strain injury (RSI)/computerrelated disorders (CRDs). The following protocol offers recommendations for (a) placing sensors, (b) instructing the trainee about tasks, (c) debriefing the trainee after the task, and (d) interpreting physiological indicators concomitant with stress reactions. Suggestions for educational and clinical interventions and biofeedback training based on the stress profile are offered to reduce the risk for RSI/CRD.

If It Is Just Ergonomics, Why Do My Employees Still Hurt?

Two years after his first ergonomic assessment Mark was still suffering.  His employer had followed the recommendations of the ergonomist, yet, with all these changes, Mark continued to complain of severe and chronic neck pain, tingling down his arms, and aching in his forearm. Mark’s story is, unfortunately, a very common one.  Why, after spending so much money and making the ergonomic corrections, do Mark and thousands of other workers still suffer from computer-related disorders? This article offers tips to reduce computer-related discomfort.

Computer-Related Symptoms

When employees develop awareness and acquire the skills to work healthfully at their peak, this alarming epidemic will abate. Using a group-training model that included muscle biofeedback for micro-break training, the SFSU study found that trained employees, as compared to the control group, reported a significant overall reduction in work-related symptoms. This included significant reduction of muscle strain of the head, neck and shoulders, wrists and hands, arms and overall tiredness.

Assessment, Treatment and Prevention of Repetitive Strain Injury (RSI) at the Workstation

This paper reviews the ergonomic and psychosocial factors that affect musculoskeletal disorders at the workstation. Recommendations include suggestions that successful safety and prevention programs need multiple components and that participants should to be trained to control physiological responses with respiration and sEMG biofeedback. All participants should to master these physiological skills just as they learn how to use the computer.

Unique Safety Program Wins Governor’s Award

The Ergonomic Safety Program Team at SFSU was awarded Gov. Schwarzenegger’s Employee Safety Award for its groundbreaking program that helps employees practice healthy computing habits. The program includes many quick tips — from dropping the hands to the lap every 30 seconds to blinking at the end of sentences — which computer users can incorporate into their daily routines.

Group Training with Healthy Computing Practices to Prevent RSI

This pilot study investigated whether group training, in which participants become role models and coaches, would reduce discomfort as compared to a non-treatment Control Group.  The program included training in ergonomic principals, psychophysiological awareness and control, sEMG practice at the workstation, and coaching coworkers. This study suggests that employees could possibly improve health and work style patterns based on a holistic training program delivered in a group format followed by individual practice.

From Technostress to Technohealth

Technostress contributes to increasing discomfort and illness at the worksite, especially for those who work at the computer. In this study, a technohealth training program consisting of six weekly, two-hour group sessions consisting of an educational component and practice of muscle tension awareness and control is described. A decrease in symptoms and improvement in positive work habits resulted from participating in the technohealth intervention; participants continue to report benefits from the training program at a two year follow-up.

Stay Healthy at the computer

The majority of employees who work on computers experience discomfort ranging from neck, shoulder, back, and arm pain to eye irritation and exhaustion. A major cause is the holding of chronic and unnecessary muscle tension—tension of which the employee is usually unaware and leads to illness. Research at San Francisco State University have demonstrated with biofeedback that 95% of employees automatically raised their shoulders as well as maintained low-level tension in their forearms while keyboarding and mousing, as well as increased their breathing rates and decreased eye blinking rates. Almost all employees studied thought that their muscles were relaxed when they were sitting correctly at the computer, even though they were tense.

Healthy Computing Email Tips

Healthy computing incorporates optimum work style, ergonomics, mind/body fitness, and positive work setting as a whole while working at the computer. This article suggest integrating eight components improves health, decreases discomfort, and increases performance. The eight components are provided in detail.

Article in Dutch: Een technologische kramp

Improve Health with Movement: There is Life After Five.

Physical fitness promotes health. In most cases about 20 minutes of continued activity is enough to keep in shape and regenerate. The following exercises are developed to reduce discomfort and improve health. Practice them throughout the day, especially before the signals of pain or discomfort occur. Before performing the exercises, read over the General Concepts Underlying the Exercises, and then explore the various movements.

Wireless devices may cause harm, be careful while using mobile phones, tablets or laptops

In less than 20 years, we can no longer imagine a life without these wireless devices and go into a panic when they are missing. We have accepted the new technology and assumed that it is safe. Yet, could this be similar to the early cigarette debates in the tobacco industry? Or the discovery that X rays were dangerous for pregnant women? Or how we were accepting asbestos in our lives? We now know better. This article offers suggestions on how to act now and reduce the exposure to the antenna radiation.

Computer Related Symptoms: A Major Problem for College Students

This survey investigated the frequency of discomfort associated with computer use.The results showed that 96.8 % of subjects reported some discomfort while only 3 subjects reported no discomfort. To prevent illness, learning how to stay healthy at the computer should be the first lesson and an integral part of every computer class — from grade school to university.

Keep Cell Phones and PDAs Away From EMG Sensors and the Human Body to Prevent Electromagnetic Interference Artifacts and Cancer

Cell phones produce electromagnetic interference (EMI), which can cause artifacts in physiological recordings and be misinterpreted by the clinician. This study investigated the possible effect of EMI (electrical artifact) on physiological recordings when cell phones are activated/ringing. To avoid EMI artifacts, clients and therapists should turn off their cell phones when recording physiological signals.  In addition, recent epidemiological studies suggest that long-term intensive cell phone use may increase the risk of gliomas, auditory tumors, and salivary tumors on the side of the head to which the person places the cell phone. Thus, to reduce artifacts and biological harm, the authors recommend keeping the cell phone away from the body and the biofeedback equipment.

The smartphone and iPad/tablet have revolutionized personal computing. iPad/tablets smartphones can now do activities that until recently only computers could do such as e-mailing, browsing the internet, taking notes, playing games, and connecting with social networks. This study explores 1) students use of smartphones and iPad/tablets and 2) physiological patterns associated with smartphones and iPad/tablets use.

Stress Management

Tseng, C., Peper, E., Harvey, R., Yau, C., & Abili, R. (2016). Reducing Acne-Stress and an Integrated Self-Healing Approach. Applied Psychophysiology and Biofeedback. 41(4), 445.

Acne is a very common problem for young people with about 20% of young adults being moderately to severely affected (Bhate & Williams 2012). Some social consequences of facial acne include reduction of feelings of self-worth and self-esteem. An early biofeedback study by Hughes, Brown, Lawlis & Fulton (1983) observed that those participants who continued and generalized the relaxation skills continued to show improvement in facial acne. The current study surveys the frequency of acne and stress among college students and illustrates through a case example how an integrated stress management program can significantly improve acne as well as self-esteem.

Integrated stress management with ‘Make Health Happen: Measuring the impact through a 5-month follow-up.

Awareness of one’s stress reaction coupled with mastery of physiological self-regulation, conscious behavior and attitude changes appear to be useful approaches to mobilize health. This poster provides 1) an overview of a structured 14-session regenerative program, 2) results of the 5-month follow-up email outcome survey, and 3) two case examples to illustrate the process.

Achieving health: A 14-session structured stress management program—Eczema as a case illustration

Stressors and an individual’s stress reaction may act as an initiator, promoter, or co-factor in the development of and recovery from illness (Sapolsky, 1998). Awareness of one’s stress reaction coupled with mastery of physiological reactivity and conscious changes in behavior and attitude appear to be useful self-regulation approaches to mobilize health. We propose that therapists and teachers include a structured educational stress management program to complement their biofeedback and training protocols for enhancing clients’/students’ self-healing potentials. This paper provides an overview of a structured 14-session regenerative program that can be used to guide individuals or groups to practice at home and work. Emphasis is on active participation in one’s own self-healing, which is essential for reducing mental/emotional blocks that may interfere with regeneration.

Improving College Students’ Health-Including Stopping Smoking and Healing Eczema

Many of the health ailments we face today are due to stress (American Psychological Association (2007). According to American Medical Association (Cohen et al, 2007), stress is often a silent killer because it is commonly believed that we cannot do anything about undue stress in our lives. College students equally report high stress levels: a factor that may put them at higher risk for future illness. Thus, teaching students lifelong stress management and self-healing skills as part of a university curriculum would offer students ways to cope with stress and, optimize their health.

There is Hope: Autogenic Biofeedback Training for the Treatment of Psoriasis

Many college students experience stress-related illness, and in one study, 82% of students reported significant improvement in health when they participated in a semester-long stress management program. The factors that contribute to symptom reduction are illustrated by the case report of a 23-year-old male student who had been suffering from psoriasis for the past 5 years, which was not alleviated with medication and traditional medical treatment. Results showed a significant improvement in the clearing of the skin, more positive self-talk, and improved posture. The benefits have been maintained at the 4-month follow-up. Discussed are the training components and procedures along with factors that contributed to the clinical success and that can be applied to numerous other stress-related disorders.

About the methods of Autogenic Therapy

Autogenic Training (AT) is a highly systematized technique designed to generate a state of psychophysiologic reaction relaxation– a state diametrically opposed to that elicited by stress.

I thought I was relaxed

Stiffness, tightness, pain or other muscle discomforts and exhaustion are common experiences for many people who work long hours at the computer or for athletes who push their body physically. Muscle discomfort often limits what they would like to do and, as symptom intensity increases, their discomfort tends to interfere with their work or athletic performances.The teaching examples presented in this chapter illustrate the efficacy of the evidence based SEMG biofeedback approach in the assessment and reduction of dysponesis, or misdirected muscular efforts.

Breathing and Wellness

Peper, E., Mason, L., & Huey, C. (2017). Healing irritable bowel syndrome with diaphragmatic breathing. Biofeedback. 45(4), 83-87. DOI: 10.5298/1081-5937-45.4.04

Irritable bowel syndrome (IBS) affects 7 to 21% of the general population and is a chronic condition. The symptoms usually include abdominal cramping, discomfort or pain, bloating, loose or frequent stools and constipation, and can significantly reduce the quality of life. This case report describes how a 22-year-old woman, who was initially diagnosed with IBS when she was a high school junior, healed herself from IBS with slow abdominal breathing without any therapeutic coaching. She has continued to be symptom-free for the last three years. The article reviews how slower diaphragmatic breathing (abdominal breathing) may reduce symptoms of IBS, explores the possibility that breathing is more than increasing sympathetic/parasympathetic balance, and suggests additional self-care strategies to reduce the symptoms of IBS.

Effortless Diaphragmatic Breathing: Reduce Symptoms of Hyperventilation, Panic and Asthma

The underlying premise of this protocol is if the startle response or alarm reaction is embedded in the performance of an activity which adversely affects the respiratory patterns (e.g. gasping, thoracic breathing, breath holding), then changing the respiratory patterns with effortless diaphragmatic breathing may lead to an improvement in health and performance. This protocol includes an assessment of dysfunctional breathing and training strategies toward effortless breathing.

Taking Control: Strategies to Reduce Hot Flashes and Premenstrual Mood Swings

Women have been troubled by hot flashes and premenstrual syndrome for ages. Hormone replacement therapy, historically the most common treatment for hot flashes, and other pharmacological approaches for pre-menstrual syndrome (PMS) appear now to be harmful and may not produce significant benefits. This paper reports on a model treatment approach based upon the early research of Freedman & Woodward to reduce hot flashes and PMS using biofeedback training of diaphragmatic breathing, relaxation, and respiratory sinus arrhythmia. Successful symptom reduction is contingent upon lowering sympathetic arousal utilizing slow breathing in response to stressors and somatic changes. We strongly recommend that effortless diaphragmatic breathing be taught as the first step to reduce hot flashes and PMS symptoms.

Effect of Breath Patterns on Balance: Breathe Diaphragmatically to Prevent Falling

Balance is crucial in standing and prevention of falling.  While standing, if we stiffen we might increase the occurrence of falling. This stiffening occurs when we tighten and breathe thoracically. Many people tend to hold their breath or breathe thoracically while attempting to balance. This study investigated whether diaphragmatic breathing or thoracic breathing increased or decreased postural sway as measured by Center of Pressure (COP). COP length is indicative of the postural corrections made by the subject while performing the task. Therefore, larger COP lengths mean that more postural corrections are being made and imply less stability.

Teaching Diaphragmatic Breathing to Children

The process of breathing has been linked to consciousness, health, and spirit. Newborns naturally breathe using diaphragmatic breathing. However, by the age of 10, most children use a shallow thoracic breathing pattern, except when in a supine position. Adult literature indicates that patients taught diaphragmatic breathing experience significant decreases in numerous physical and psychophysiological symptoms. There is a paucity of professional or lay literature that addresses the topic of breath training in children. This article describes the use of breath training as a component of biofeedback training and the possible uses of breath training for prevention and intervention of physical and psychophysiological disorders in children. Directions for future research are proposed.

Protocol for the Treatment of Asthma

This paper describes a training protocol to reduce the onset and severity of asthmatic symptoms. The methodology and helpful hints are described for each practice. Most subjects mastered the skills, inhibited their automatic escalation of dysfunctional breathing, and demonstrated the ability to continue to breathe diaphragmatically under a variety of conditions. Although this protocol was used with patients with asthma, it could be adapted as a treatment approach to other disorders (e.g., hyperventilation syndrome, anxiety or panic).

Breathing biofeedback to reduce side effects after a kidney transplant

A 39-year-old kidney transplant female participated in six biofeedback sessions to learn relaxation and enhance control. When she inhaled pentamadine it caused coughing, gagging and increased blood pressure and heart rate. Respiration feedback was recorded with abdominal and thoracic strain gauges. Training included cognitive and physiological breathing self-regulation skill. After training, respiration changed from 27 to 8 breaths per minute with concurrent abdominal movement; heart rate decreased and RSA increased. She was able to take the pentamadine inhalation treatment without evoking discomfort and her blood pressure and heart rate remained normal.

MacHose and Peper Effect of clothing on inhationa volume

Diaphragmatic breathing is included as an important component of relaxation training protocols. In the present study, we report on the effectiveness of a simple behavioral technique to illustrate that choices of tight, restraining clothing significantly affect the inhalation volume of the breathing pattern. This study investigates the use of of the incentive inspirometer to observe the effects of tight versus loose clothing on inhalation volume.

Symptom prescription

This study investigates the effects of partial exhalation to feelings of anxiety. In summary, a 70% approach is introduced and described as useful in demonstrating to the client that possible changes in breathing patterns can affect anxiety.

Peper, E., Kawakami, M., Sata, M., Franklin, Y, Gibney, K. H. & Wilson, V.S. (2005). 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

This study explored the physiological correlates of a highly practiced Yoga master while he voluntarily breathed approximately two breaths per minute. Implications for meditation and clinical applications are discussed.

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

Diaphragmatic breathing from a developmental perspective is a whole-body process. During exhalation, the abdominal wall contracts, and during inhalation, the abdominal wall relaxes. This pattern is often absent in many clients who tend to lift their chest when they inhale and do not expand their abdomen. This article describes factors that contribute to the lack of abdominal movement during breathing, as well as a methodology to record the surface electromyography (SEMG) activity from the lower abdominal muscles (external/internal abdominal oblique and transverse abdominis). Strategies are presented to teach clients how to engage the lower abdominal muscles to facilitate effortless breathing. In summary, lower abdominal SEMG feedback is a useful strategy to facilitate complete abdominal involvement during breathing

Peper, E., Lee, S., Harvey, R., & Lin, I-M. (2016). Breathing and math performance: Implication for performance and neurotherapy. NeuroRegulation, 3(4),142–149.

This report of findings describes students’ self-reported difficulty and anxiety during test taking and the effect of deliberate gasping or diaphragmatic breathing on the ability to solve math problems. Students reported a high frequency of blanking out difficulty during exams, and difficulty with math. The students reported significantly more difficulty in solving math problems when gasping than during slow breathing and significantly more anxiety during gasping than during slow breathing when solving math problems. Included are comments to improve study habits, memory consolidation, and how to incorporate somatic feedback of breathing patterns into learning and training within other settings such as during neurotherapy.

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

Abdominal surgery or injury may affect breathing and, if the disturbed breathing pattern is maintained, illness may result, as illustrated by two case examples. This report describes the process of learned avoidance of pain through which abdominal surgery may cause dysfunctional breathing. This clinical note is a reminder to clinicians to ask about abdominal surgery or injury during the intake. In cases in which symptoms occurred months after the abdominal surgery or injury, it may be possible to reduce the symptoms through teaching effortless breathing.

Peper, E., Martinez Aranda, P., & Moss, D. Vulvodynia Treated Successfully with Breathing Biofeedback and Integrated Stress Reduction

Millions of women experience substantial pain and suffering from vulvodynia, which is pain around the entrance to the vagina (vulva). A common treatment is surgical removal of the tissue (vestibulectomy). This case report describes the detailed process of a holistic biofeedback-based intervention that successfully resolved the vulvodynia in a 23-year-old woman. The four-session treatment interventions included teaching diaphragmatic breathing to transform shallow thoracic breathing into slower diaphragmatic breathing. Treatment transformed her feeling of powerlessness, a belief that there was nothing she could do, into empowerment and a hope that she could reduce her symptoms and optimize her health. After 6 weeks, she once again could initiate and enjoy intercourse and has been symptom free during the 8 month follow-up.

The “Duhhh Factor”

Patients can learn self-regulation skills and biofeedback-assisted relaxation in the office, yet fail to show symptomatic improvement. In many cases, the individual is perpetuating behavior in the workplace or elsewhere that hinders healing and symptom reduction, or exacerbates their complaints. A brief case example of a 25-year-old male with repetitive motion injury from computer use serves to illustrate the problem. The biofeedback practitioners used cognitive reframing and humor to assist the patient to accept work and ‘‘workstyle’’ changes facilitating symptom reduction.

Peper, E., Kawakami, M., Sata, M. & Wilson, V.S. (2005). The physiological correlates of body piercing by a yoga master: Control of pain and bleeding. Subtle Energies & Energy Medicine Journal. 14(3), 223-237.

A Yogi master was psychophysiologically monitored while he pierced his neck and tongue with skewers to demonstrate control of pain and bleeding. The Yogi reported no pain during piercing and no bleeding was observed. This demonstration suggests a finding of conscious self-regulation, as opposed to disassociation, for controlling attention and responsiveness to painful stimuli. It could be hypothesized that clients with chronic pain could be taught how to control pain using the mind/body in a similar manner.

Sufi piercing: Dutch article by Booiman, A., Peper, E., Saleh, S., Collura, T., & Hall. H.

Personal Enhancement

Athletes are different

Biofeedback and neurofeedback training procedures are often different for athletes than for clinical patients. Athletes come to improve performance whereas patients come to reduce symptoms. This article outlines factors that distinguish work with athletes from work with clinical patients. The training process with athletes is illustrated through a case example of a young tennis player who mastered control of his anger.

Peper, E. (2016). Increase energy. Western Edition. April, pp4.

Offers background and self-care practices of changing internal dialogue and identifying energy gains and energy drains to increase subjective energy.

Increase Productivity, Decrease Procrastination, and Increase Energy

Procrastination, self-blame, and unproductive behavior are widespread problems in student populations and in human beings generally. The authors present a framework, called Transforming Failure into Success, which is utilized in undergraduate classes and based on self-observation, self-acceptance, and mental rehearsal of positive changes. They provide instructions and guidelines for positive mental rehearsal. The students in the intervention group showed significant improvements in reducing procrastination, improving productivity, and increasing energy.

Depression, Movement, and Energy Level

My energy slowly drained and I became more sleepy the
longer the lecture lasted; however, when the instructor
guided us through a few physical movements, my energy and
mood significantly increased. I can pay much more attention.

Training Strategies for Concentration

In summary, concentration is the ability to direct one’s full attention to appropriate cues in the present task instead of being controlled by irrelevant external or internal stimuli. Most top athletes have developed their own mental strategies for doing this. These strategies are often perceived as a component of natural athletic ability. In fact, they are not totally innate; they are skills that athletes acquire through regular practice of attention control training. The consistent control over one’s attentional focus before and during competition can be improved through practice, just as any difficult physical skill is learned.

A Teaching Strategy for Successful Hand Warming

This essay outlines a successful approach used in groups to elicit rapid peripheral warming as a strategy to encourage learning and personal beliefs. It is an useful tool to demonstrate to an audience to the value of a biofeedback approach to mobilize health. Through this educational/clinical strategy, almost all participants experience an increase in hand temperature.

Enhancing Therapeutic Success: Some Observations from Mr. Kawakami

Looking at the commonalities between factors that are associated with therapeutic success and those associated with the personal and healing skill of Mr. Kawakami, we suggest options for the reader to explore.

The ‘Aha’ Experience with Somatics: Demonstrating Mind and Body Unity

An ‘Aha’ experience can change one’s belief system, lead to increased awareness and a greater sense of control, and enhance confidence and competence. The ‘aha’ process usually includes getting ‘stuck’ before attaining mental relaxation, an accepting attitude and then, resolution or insight. Because it is felt instead of explained, the ‘aha’ experience is often evoked through Somatic activities, such as lemon imagery, airplane movement, threading a needle, arm lift by a partner, or Feldenkrais foot movement. Participants shift from belief to knowing when they feel/experience an expanded awareness of the mind-body interconnectedness.

Optimize Performance in Daily Life: Improving Physical Fitness and Health at the Worksite

Muscle pain is the primary cause of discomfort for more than 30% of patients who visit their primary physicians with severe pain. These pains are often caused by dysponesis which is unaware misdirected muscle efforts not necessary for task performances.  Dysponesis can be identified with surface electromyographic (SEMG) feedback. The benefits of using SEMG to reduce dysponesis through awareness and training are illustrated by two clinical case examples. SEMG is a useful clinical tool to assess, monitor, provide feedback to the therapist and client, document muscle dysponesis, and teach clients awareness and voluntary control to reduce their dysponesis and improve health.

Better Balance, Fewer Falls

Falls are a primary cause of injury, especially as we get older. Reduce the risk of falling– and the bone fractures that can result–with exercises that improve balance, strength and coordination.

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.

Many people are unaware of muscle tension when performing tasks. This often results in fatigue due to excessive energy expenditure—a process that has been labeled as dysponesis or dysponetic muscle activity. This study investigated whether college students were aware of their neck and back muscle tensions while performing a simple task of bending forward and touching their toes. We recommend that SEMG training be used to enhance awareness and reduce dysponesis during yoga, stretching, and other physical activities.

Electroencephalography feedback (EEG) 

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.

This article demonstrated that if you are sitting collapsed, it takes almost twice as long and the brain has to work much significantly harder to access positive memories than when you sit erect. Sitting collapsed facilitates the presence of negative, hopeless, defeating thoughts and memories. While sitting erect and looking upward increases the access to positive thoughts and memories can possibly could decrease depressive thoughts and feelings. Thus clinicians and clients need to be aware of posture and encourage upright posture to promote health.

Reduction of efferent motor commands during alpha feedback

Subjects who received EEG Alpha feedback recorded from two homologous scalp areas (central-temporal) were trained to have ON-OFF control over the left and right sides. The partial success in demonstrating localized control suggests that subjects may be trained for very specific control. Applications to medicine and altered states of consciousness are discussed.

Healing and Therapeutic Touch

Fields and their clinical implications-Part I

Fields and their clinical implications-Part II 

Fields and their clinical implications_Part III: Anger and how it affects human interactions. 

Fields and their clinical implications Part IV: Depression from the energetic perspective: Etiological underpinnings 

Fields and their clinical implications Part V: Depression from the energetic perspective: Treatment strategies 

Fields and their clinical implications Part VI: The pain process and strategies for pain reduction 

You are whole through touch: Dora Kunz and Therapeutic Touch 

Therapeutic Touch is a method which involves the concept of energy fields in regard to health. This method owes much to Dora Kunz for its beginning. In conclusion, the healing experience is a mutual experience in which the practitioner can go outward and the patient may become more open. The processes illustrated in this article can be applied nonmechanistically in a creative manner to enhance healing efficacy.

Towards the end of suffering: The contributions of integrating mind, body and spirit by Mr. Kawakami

In a world where there are wars, hatred, religion persecution, unspeakable suffering, illness, premature death and demagogues appealing to the baser instincts of people, it is an honor to know a teacher who’s life is dedicated to nurturing the nobler instincts of people.

Clinical Approaches

Shaffer, F., Combatalade, D., & Peper, E. (2016). A Guide to Cleaner Skin Temperature Recordings and More Versatile Use of Your Thermistor.

Valid peripheral temperature measurements ensure the integrity of client assessment and biofeedback training. Accurate measurements require understanding of the signal and potential influences on measurement fidelity, and developing bulletproof monitoring procedures. In addition to their use in temperature biofeedback, thermistors can assist heart rate variability biofeedback practice and monitor breathing when a respirometer is not available.  In summary, skilled temperature monitoring requires familiarity with clean signals, normal values, and understanding of the factors that can affect signals. As with all biofeedback modalities, visual inspection of the raw signal is essential to ensuring measurement fidelity.  While clinicians primarily use thermistors to monitor peripheral temperature during thermal biofeedback, they can provide valuable information during HRVB practice and detect respiration when a respirometer is not available.

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

Cognitive behavior therapy (CBT) as applied by behavioral scientists includes strategies for changing negative cognitions that contribute to depression and anxiety. Biofeedback is a useful strategy to demonstrate to clients the mind (cognitive, psychological) to body (physiological) interaction. For example, a cognitive, psychological reaction to a stimuli results in a physiological effects as illustrated by changes in skin conductance or muscle tension. A case example is used to demonstrate an anticipatory psychophysiological response resulting in covert activity of the forearm as a client simply imagines playing the piano.

Porges, S. & Peper, E. When Not Saying NO Does Not Mean Yes:
Psychophysiological Factors Involved in Date Rape

To understand how a woman who does not want to be a willing sexual partner can at times acquiesce and not fight the date rape predator, the neurobiology of our responses to threat needs to be understood. Under situations of extreme threat, instead of responding just to danger signals with only the options to fight or flee, we also retain in our nervous system a primitive immobilization response that may reflexively be expressed when our body detects life threat. The polyvagal theory proposed by Stephen Porges may explain why many rape victims do not actively resist. This discussion of the polyvagal theory supports the recently passed California law (Senate Bill 967) that requires the governing boards of California postsecondary institutions (colleges and universities) to adopt procedures and protocols requiring students to obtain ‘‘affirmative, unambiguous, and conscious decision by each participant to engage in mutually agreed-upon sexual activity.’’                                                                                             
Transforming Chained Behavior

The authors describe the format of a holistic health class provided to undergraduates at San Francisco State University in California. The class initially emphasizes self-monitoring and record keeping to enhance the students’ self-awareness of negative emotions, symptomatic behaviors, and other ‘‘chained behaviors’’ leading to various problems, such as smoking or eczema. The students cultivate a variety of positive self-care behaviors and selfregulation skills, such as mindfulness, relaxation skills, visualization techniques, and seeking social support. Finally, they learn to substitute these self-care practices for the negative emotions and behaviors, in the moments of emerging awareness, thus interrupting the ‘‘chain of behaviors’’ leading to problems. The authors provide case narratives of three students implementing this program to address personal illnesses or problems (smoking, eczema, and trichotillomania).

Clinical Tip: Relax and Relax More

Sit comfortably. Raise your shoulders, hold, relax . . . relax more. What did you experience? If you are like most people, you noted that the second instruction to relax more, you may have felt your shoulders dropping even more and relaxed even deeper. Thus, we recommend that practitioners teaching relaxation instruct their clients after tightening a muscle, such as lifting the shoulder, to repeat the relaxation instruction at least twice so that the muscle can totally relax before it is reactivated.

Support Healthy Brain Development: Implications for Attention Deficit/ Hyperactivity Disorder

Neglecting and disregarding our evolutionary background during infant, toddler and childhood stages of development may contribute to the increase in diagnosis and treatment of attention deficit/hyperactivity disorder (ADD/ADHD). To optimize healthy brain development, the following factors need to be supported:1) Breast feed children at least for one year and concurrently introduce new foods slowly after 6 or 8 months to reduce the risk of developing food allergies; 2) Respect the importance of face-to-face contact to provide safety, develop empathy and nurture social connection; 3) Provide routine and ongoing parental attention and support circadian rhythms; 4) Integrate vision with touch and movement by encouraging motor development such as crawling, playing in nature, and physical movement that occurs while playing games instead sitting and being entertained by smartphones, computers, tablets or TV screens; and 5) Provide face-to-face reassurance when overwhelmed with rapidly changing visual and auditory stimuli. Health implications of new digital devices are discussed.

Pain as a contextual experience in Townsend Letter-The Examiner of Alternative medicine

Pain is not simply a neurological or biological experience, it occurs in context. Major lessons include the need for clients to feel totally safe and accepted, with components of the experience including trust, hope, and faith.

Single-Session Treatment of Hip Pain: Factors Underlying the Healing Process

“After experiencing your guided exercises on the gym floor, I slept comfortably and without any pain for the first time in four years. This morning when I went grocery shopping, I could walk straight with a normal stride and again without pain. I feel great.”  -Paul Maassen

The rapid successful resolution of pain described above occurred as the result of a spontaneous teaching moment with a person in the gym. This success is not just a case of magical/spontaneous healing but of the integration of multiple factors that promote healing and underlie somatic awareness practices and successful biofeedback training. In this clinical note, we describe 1) how the educational treatment began, 2) the educational/clinical coaching sequence, and 3) factors that therapists may want to consider in their treatment.

Falls and hip fractures are not inevitable: A return to nature

Falls and hip fractures may not be inevitable, however, at prevent time they account for a significant portion of morbidity and contribute significantly to mortality in the elderly. This paper offers an evolutionary perspective with the concept of learned disuse as one of the major factors contributing to falls and hip fractures. The concepts are illustrated through experiential exercises. These exercises can be used both diagnostically and as preventive/educational approaches. Pragmatic recommendations are provided to reduce the risk of falls and improve strength and balance.

Exercise or Play? Medicine of Fun

Patients often equate biofeedback training homework to mandatory activities, which are often viewed as one more thing to do. Changing the perception from that of work to fun can encourage laughter and joy and help overcome a chronic pain pattern all necessary for healing. This paper encourages therapists to explore utilizing childhood activities and paradoxical movement to help patients release tension patterns and improve range of motion. A strong emphasis is placed on linking diaphragmatic breathing to movement.

Healing a Shoulder Injury

This case report describes an indirect approach incorporating diaphragmatic breathing, imagery, role rehearsal and surface electromyographic (SEMG) feedback to successfully reduce pain and increase left shoulder mobility in a 23 year old woman with a left pectoralis muscle injury from a skiing accident. It demonstrates how direct biofeedback or therapeutic interventions may be counterproductive and indirect approaches guided by SEMG activity may facilitate clinical success. Discussed are specific concepts, rationales and strategies employed that guided the successful therapeutic intervention. This article offers a case description with process and outcome comments from the client’s and therapist’s perspectives. It is offered as a model to increase therapeutic efficacy when an initial biofeedback intervention appears not to work.

Healing of Vulvodynia from the Client perspective 2015-06-15

This article discusses one individuals healing of Vulvodynia from the client perspective. The participant’s interpretation of what she experienced and her perception for reasons for success, including triggers for illness and triggers for healing are discussed.

Making the Unaware Aware-Surface Electromyography to Unmask Tension and Teach Awareness

Poor awareness of covert low-level muscle tension and poor ergonomics can result in chronic muscle bracing and the development of clinical symptoms. This article introduces a simple exercise to teach awareness and control of residual muscle contraction, presents evidence of its effectiveness, and concludes with a case study in which it contributed to the treatment of severe pelvic girdle pain.

The Power of Words, Biofeedback, and Somatic Feedback to Impact Illness Beliefs

The article explores the use of words, biofeedback and somatic feedback as tools to change illness beliefs. These tools can make patients aware of the mind-body connection, illustrating how thoughts and emotions can affect their body.

Treating Prostate Cancer with Immune Therapy Using the GorterModel

Clinical research on prostate cancer treatment has shown that watchful waiting and healthier lifestyle frequently leads to an improved clinical outcome. Encouraging outcomes with newer treatments suggest that supporting and enhancing the body’s own immune capabilities offer significant promise in the fight against prostate cancer. This article outlines a protocol of immune therapies developed by Robert Gorter, MD, PhD, founder and director of the Medical Center Cologne, in Cologne, Germany, which provides integrative cancer treatment.

Experience the Mind-Body Connection: A Metaphor for Immune Competence

Feeling overwhelmed, hopeless, and powerless are common feelings especially when sick. We often forget that evoking or ruminating on negative thoughts decreases our energy level and strength. This change in strength can be used as a metaphor for immune competence. In many cases caretakers of a family member with Alzheimer disease or a disabled child have reduced immune competence. For many of these care takers, life feels like being on a treadmill with no end in sight. Just recalling or ruminating on a hopeless, helpless, powerless memory causes our energy to drop. Experience the change in energy and physical strength when you shift your thoughts in the following exercise taken from our book, Fighting Cancer-A Nontoxic Approach to Treatment (Gorter and Peper, 2011).

Current Applications of Biofeedback to Physical Medicine and Rehabilitation

Clinical biofeedback has a 35 year history of developing applications to disorders in physical medicine and rehabilitation. The authors summarize the paradigm of biofeedback, discuss its mechanisms, and review current protocols for the treatment of asthma, epilepsy, fibromyalgia, headache, myofascial pain disorders, repetitive strain disorders, and urinary incontinence. Biofeedback interventions are compatible with and often augment the therapeutic effects of conventional medical, pharmacologic and manual interventions. Biofeedback offers evidence-based alternative therapies for a variety of common disorders in rehabilitation.

Place Yourself in Your Client’s Shoes with Biofeedback to Promote Healing

Applied psychophysiology appears useful to uncover whether the external persona represents the internal physical and emotional experience.  Observing the ongoing physiological changes within an individual can be helpful to guide the clinical interventions and can be used by the therapist to uncover ongoing psychological and emotional processes, describe and help label the subjective experience, offer a physiological rationale for the illness process, and offer interventions to promote healing.  Speaking for the client, utilizing a YES set and reframing may increase rapport and allow the client to feel understood—a process, which may induce symptom relief and relaxation.

How to do Clinical Biofeedback in Psychosomatic Medicine

Biofeedback interventions, based on the psychophysiological principle that thoughts, emotions, and body interact, affecting each other, have been shown to be powerful clinical tools for use in psychosomatic medicine settings and primary care settings where 75% of patients may present with symptoms of unknown causes. This paper describes both overt and covert factors supporting successful biofeedback training. This case illustrates that clinical biofeedback is more than just attaching sensors or having the person mechanically practice some prescribed behavior.

Biofeedback: An Evidence Based Approach in Clinical Practice

Clinical biofeedback procedures are highly effective ameliorating a variety of symptoms that range from urinary incontinence to hypertension as well as assess a person’s somatic awareness by making the invisible visible. The paper reviews the biofeedback process and some psychosomatic applications. This process is illustrated through the description of a single session with a patient who experienced severe gastrointestinal distress and insomnia.

Thermal biofeedback training in children with headache 

Two young girls with a history of headaches were trained with autogenic training phrases and with thermal biofeedback training. Both girls rapidly learned to control their peripheral temperature in two training sessions while practicing for 3 weeks at home and school; both have been symptom free (without medication) for the last 6 months. This learning process may foster a shift in health attitudes from helplessness to self-responsibility.

An holistic merger of biofeedback and family therapy 

This article is a positive consideration of the integration of self-regulation skills (biofeedback and autogenic training), and family therapy in order to create a holistic approach which includes the individual, the family, the social network and the belief system within which one lives.

Biofeedback History: An Alternative View

The tapestry of biofeedback history has been woven from many independent threads. Some contributors started with much vigor and nurtured others, and then they faded away. Yet they seeded ideas that the next generation rediscovered as their own. Others blossomed and disappeared, whereas still others have continued to actively nurture the field. Interest in biofeedback has waxed and waned in response to the historical forces of technology, social culture, beliefs, and economics.

The Future of Biofeedback

Biofeedback is increasingly valuable in the search for a deeper and more detailed understanding of the min/body connection.  It is called upon in wider applications in research and clinical practices to help us redefine ourselves and achieve health. Providing us with an objective reflection of our inner states and access to “hidden” information about how we react, it is a uniquely effective tool for learning control through self-regulation.  Biofeedback is invaluable for self-awareness, self-development, teaching and therapeutic approaches.

Acknowledgements

Erik Peper is Recognized for his Research

The San Francisco State University professor is internationally recognized for his research in biofeedback and self-regulation, and he’s recently done studies on physiological reactions to cell phone use.