Adapted from: Peper, E. (2026). Tell me where it hurts. the peper perspective.
https://peperperspective.com/2026/04/24/tell-me-where-it-hurts/

Abstract

In clinical biofeedback practice, healing rarely arises from a single technique but from the integration of self-regulation skills into daily life. When clients combine physiological awareness with slow breathing, imagery, cognitive reframing, and lifestyle shifts, the organism reorganizes toward health. Across cases, reductions in pain, anxiety, and somatic symptoms reflect this pattern of learned regulation. Rachel Zoffness’s Tell Me Where It Hurts articulates a complementary neuroscience-based model: pain is real yet dynamically shaped by brain, body, and context. Education reduces fear and opens the possibility for change. As illustrated by both experimental and clinical stories, perception powerfully modulates pain. When individuals understand and retrain these processes, recovery becomes participatory. This integrative framework offers clinicians and patients practical, evidence-informed pathways to reduce suffering and restore function. After reading the article, I recommend listening to the excellent podcast generated with Google NotebookLM, which thoughtfully expands upon and clarifies the underlying research.

In my biofeedback practice, I’ve repeatedly seen that healing rarely comes from a single technique. It emerges from observation, integration, and practicing and integrating skills in daily life.  When clients learn to combine biofeedback with other strategies to make it their own such as slower, more coherent breathing, guided imagery, shifts in internal dialogue, and practical lifestyle changes, something important happens: the body begins to reorganize itself toward health.

Again and again, clients report meaningful changes. Stress symptoms, headaches, eye problems, neck, shoulder, and back pain decrease or disappear. Gastrointestinal symptoms often fade out. Anxiety loosens its grip. Asthma improves.  Chronic neck, shoulder, and pelvic pain diminish.  These are not isolated outcomes; they reflect a pattern. When people gain the skills to regulate their physiology and reinterpret their internal experience, decrease in symptoms often follow (see the list of articles that describe successful outcomes).

Even though many of my clients benefit, I am continually searching for strategies and approaches that can improve their health and reduce suffering and for materials that I can recommend to them.

Now when I see a client who reports pain or who takes care of someone with pain, the first thing I do is to recommend the book, Tell Me Where It Hurts, by Rachel Zoffness, PhD, a leading pain expert and psychologist. The book offers a clear, science-based framework grounded in modern neuroscience, yet conveyed through compelling human stories. Her work aligns closely with what we observe in biofeedback: pain is not simply a signal from injured tissue. It is an experience shaped by the interaction of body, brain, emotions, beliefs, culture and context.

She makes a crucial point that pain may begin with injury or illness, but it is always modulated by factors such as physiological state, emotional meaning, cognitive interpretation, and social and cultural influences. In other words, pain is real, but it is also dynamic and changeable.

The first step she emphasizes is education. When people understand how pain actually works, fear often decreases. From there, the task becomes identifying what amplifies pain and what reduces it and then systematically strengthening the factors and behaviors and skills that support recovery.

One striking story captures this perfectly: a construction worker jumps from a plank onto what appears to be a 7” nail, which is driven through his boot. He experiences excruciating pain and is rushed to the emergency room. Yet when the boot is removed, the nail is found to have passed cleanly between his toes—there is no tissue damage. The pain was real, but it was driven by perception and expectation. This is not an anomaly; it is a powerful illustration of how the brain constructs pain.

Equally compelling are the recovery stories. Patients with severe chronic pain that continued and got worse after failed surgeries, long-term disability, or even amputation, find relief not through more invasive procedures or medication alone, but through learning how to retrain their nervous system. In many of these cases, even opioids had failed to provide meaningful relief. What made the difference was a shift in understanding, combined with evidence-based self-regulation strategies. They are no longer abstract ideas; they are lived experiences.

The larger message is both simple and profound: pain can change. And when people are given the right framework and tools, they can actively participate in that change. For anyone living with pain, or working professionally with those who do, this book is not just informative. It is practical, empowering, and, in many cases, transformative.

This is the book to read if you have pain or care for someone with pain. It is also the book every therapist who works with people with pain should read and recommend to their clients.

Zoffness, R. (2026). Tell me where it hurts. Grand Central. https://www.amazon.com/Tell-Me-Where-Hurts-Science/dp/1538758148/

I recommend listening to the excellent podcast generated with Google NotebookLM, which thoughtfully expands upon and clarifies the underlying research. https://peperperspective.com/wp-content/uploads/2026/04/why_your_brain_constructs_physical_pain.m4a

The following blog has a link to a superb podcast featuring Rachel Zoffness. https://peperperspective.com/2022/02/20/when-you-have-pain-listen-to-this-first/

Examples of Integrated Biofeedback Outcomes

Peper, E (2015). Pain as a Contextual Experience. Townsend Letter–The Examiner of Alternative Medicine, 388, 63-66. https://townsendletter.com/peper-contextual-pain-09-11-15/

Peper, E, Booiman, A and Harvey, R  (2025a). Pain-There is Hope. Biofeedback, 53(1), 1-9. http://doi.org/10.5298/1081-5937-53.01.16 Also, republished in Townsend Letter–Innovative Health Perspectives. https://townsendletter.com/pain-there-is-hope/

Peper, E, Chen, S, Heinz, N and Harvey, R (2023). Hope for menstrual cramps (dysmenorrhea) with breathing.  Biofeedback, 51(2), 44–51. https://doi.org/10.5298/1081-5937-51.2.04

Peper, E and Cohen, T (2017). Inhale to breathe away pelvic floor pain and enjoy intercourse. Biofeedback, 45(1), 21–24. https://doi.org/10.5298/1081-5937-45.1.04

Peper, E, Cosby, J and Almendras, M (2022a). Healing chronic back pain. NeuroRegulation, 9(3), 164–172. https://doi.org/10.15540/nr.9.3.164

Peper, E, Covell, A and Matzembacker, N (2021). How a chronic headache condition became resolved with one session of breathing and posture coaching. NeuroRegulation, 8(4), 194–197. https://doi.org/10.15540/nr.8.4.194

Peper, E and Harvey, R (2008). From technostress to technohealth.  Japanese Journal of Biofeedback Research, 35(2), 107-114. https://www.jstage.jst.go.jp/article/jjbf/35/2/35_KJ00005060045/_pdf

Peper, E, Harvey, R, Chen, S and Heinz, N (2025b). Practicing diaphragmatic breathing reduces menstrual symptoms both during in-person and synchronous online teaching. Applied Psychophysiology and Biofeedback. https://do.org/10.1007/s10484-025-09745-7   

Peper, E, Harvey, R, Cuellar, Y and Membrila, C (2022b). Reduce anxiety. NeuroRegulation, 9(2), 91–97. https://doi.org/10.15540/nr.9.2.91 

Peper, E, Martinez Aranda, P and Moss, E (2015). Vulvodynia treated successfully with breathing biofeedback and integrated stress reduction: A case report. Biofeedback. 43(2), 103-109. https://doi.org/10.5298/1081-5937-43.2.04

Peper, E, Mason, L, Harvey, R, Wolski, L and Torres, J (2020). Can acid reflux be reduced by breathing? Townsend Letter–The Examiner of Alternative Medicine, 445/446, 44-47. https://www.townsendletter.com/article/445-6-acid-reflux-reduced-by-breathing/

Peper, E, Oded, Y and Harvey, R (2024). Quick somatic rescue techniques when stressed. Biofeedback, 52(1), 18–26. https://doi.org/10.5298/982312

Peper, E and Tibbitts, V  (2003). Protocol for the treatment of asthma.  In:  Zheng, Y. (ed).  Clinical Practice of Biofeedback. Beijing:  High Education Press (HEP). 163-176. ISBN 7-04-011420-8 https://biofeedbackhealth.org/wp-content/uploads/2011/01/protocol-for-asthma-treatemtn2001-china.pdfPeper, E and Yirmiyahu, D (2023). Transforming a “bad eye” to an “amazing eye”: a case report and protocol. Townsend Letter–The Examiner of Alternative Medicine, Saturday, July 29, 2023 https://townsendletter.com/transforming-a-bad-eye-to-an-amazing-eye-a-case-report-and-protocol/