Many factors influence pain perception, including physical/physiological, behavioral, and psychological/emotional factors. This is illustrated by the description of a four-year-old child receiving a painless vaccination that highlighted the gap between theoretical knowledge of pain management and its practical application. Five key elements for reducing pain perception are explored: exhaling during the painful stimulus, creating a sense of safety, using distraction, reducing anticipation of pain, and understanding the personal meaning of pain. The discussion includes how exhalation activates the parasympathetic nervous system, thereby reducing pain perception, as illustrated by research on a yogi who inserted skewers through his tongue without bleeding or reporting pain. Feeling safe is another component that may reduce pain perception and enhance healing, as demonstrated by research on Sufis who heal rapidly after deliberately inflicting harm, such as pushing a knife through the pectoralis muscle. In addition, the article examines the physiological mechanisms of pain modulation, including the role of baroreceptors and their influence on inflammation and pain signaling. In summary, the article emphasizes the importance of hope, trust, and acceptance, suggesting that mindful breathing, self-healing visualizations, and engagement in meaningful activities may reduce pain and promote healing.

I took my four-year-old daughter to the pediatrician for a vaccination. As the nurse prepared to administer the shot in her upper arm. I instructed my daughter to exhale while breathing, understanding that this technique could influence her perception of pain. Despite my efforts, my daughter did not follow my instructions. At that point, the nurse interjected and said, “Please sit in front of your daughter.” Then, the nurse turned to my daughter and said,“Do you see your father’s curly hair? Do you think you could blow the curls to move them back and forth?” My daughter thought this playful game was fun! As she blew at my hair, the curls moved back and forth while the nurse administered the injection. My daughter was unaware that she had received the shot and felt no pain.

My experience as a father and as a biofeedback practitioner was enlightening; it demonstrated the difference between theoretical knowledge of breathing techniques associated with pain perception and practical applications of clinical skills used by a pediatric nurse practitioner while administering an injection with children. An obvious question raised is what processes are involved in the perception of pain?

There are many factors influencing pain perception, such as physical/physiological, behavioral, and psychological/emotional factors related to the injection as described by St Clair-Jones et al. (2020). Physical and physiological considerations include device type, such as needle gauge size, as well as formulation volume and ingredients (e.g., adjuvants, pH, buffers), fluid viscosity, and temperature as well as possible sensitivity to coincidental exposures associated with an injection (e.g., sensitivity to latex exam gloves or some other irritant in the injection room).

There are overlapping physical and behavior-related moderators that include weight and body fat composition and proclivity toward movements (e.g., activity level or “squirminess”) as well as comorbid factors, such as whether the person has body sensitization due to rheumatoid arthritis and/or fibromyalgia, for example. Other behavioral factors include a clinician selecting the injection site, along with the angle, speed, or duration of the injection. Psychological influences center around patient expectations, including injection anxiety or needle phobia and pain catastrophizing as well as any nocebo effects, such as white-coat hypertension.

Although the physical, behavioral, and psychological categories allow for considering many physical and physiological factors (e.g., product-related factors), behavioral factors (e.g., injection-related behaviors), and psychological factors (e.g., person-related psychological attitudes, beliefs, cognitions, and emotions), this article focuses on a figurative recipe for success associated with the benefits of simple breathing to reduce pain perceptions.

Of the many categories of consideration related to pain perceptions, following are five key“recipe ingredients” that contributed to a relatively painless experience:

1. Exhaling during painful stimuli: Exhaling during a painful stimulus can activate parts of the parasympathetic nervous system leading to promotion of self-healing.

2. Creating a sense of safety: Ensuring that the child feels safe and secure is crucial in managing pain. My lack of worry and concern and the nurse’s gentle and engaging approach created a comforting environment for my daughter.

3. Using distraction: Distraction techniques, such as focusing on the movement of the curls of the hair served to redirect my daughter’s attention away from the anticipated pain.

4. Reducing anticipation of pain: My daughter’s previous visits were always enjoyable, and as a parent, I was not anxious and was looking forward to the pediatrician visit and the helpful advice.

5. Understanding the personal meaning of pain: The approach taken by the nurse allowed the injection to be perceived as a nonevent, thereby minimizing the psychological impact of the pain.

Exhaling During Painful Stimuli

Exhaling during painful stimuli facilitates a reduction in discomfort through several physiological mechanisms. During exhalation, the parasympathetic nervous system is activated, which slows the heart rate and promotes relaxation and regeneration, reduces anxiety, and may counteract the effects of pain (Magnon et al., 2021). Breathing moderation of discomfort is observable through heart rate variability associated with slow resonant breathing patterns, during which heart rate increases with inhalation and decreases with exhalation (Lehrer & Gevirtz, 2014; Steffen et al., 2017). Physiological studies show that slow, resonant breathing at approximately six breaths per minute for adults and a little faster for young children causes the heart rate to increase during inhalation and decrease during exhalation as illustrated in Figure 1.

One can experience how breathing affects discomfort when taking a cold shower under two conditions: As the cold water hits your skin: (a) gasping and holding your breath versus (b) exhaling slowly as the cold water hits you. Most people report that slowly exhaling feels less uncomfortable though they may still prefer a warm shower.

An Exercise for Use During Blood Draws and Medical Procedures: Correlating the Procedure with Inhalation and Exhalation

A simple breathing technique can be used to reduce the experience of pain during a procedure or treatment or during uncomfortable movement postinjury or post-surgery. Physiologically, inhalation tends to increase heart rate and sympathetic activation, whereas exhalation reduces heart rate and increases parasympathetic activity. Often, inhalation increases tension in the body, whereas during exhalation, one tends to relax and let go. The goal is to have the patient practice longer and slower breathing so that a procedure that might be uncomfortable is initiated during the exhalation phase. Applications of long, slow breathing techniques include having blood drawn, insertion of acupuncture needles in tender points, or movement that causes discomfort or pain. Slowly breathing is helpful in reducing many kinds of discomfort and pain perceptions (Jafari et al., 2020; Joseph et al., 2022).

Implementing the technique of exhaling during painful experiences can be deceptively simple yet challenging. When initially practicing this technique, the participants often try too hard by quickly inhaling and exhaling as the pain stimulus occurs. The effective technique involves allowing the abdomen to expand while inhaling and then allowing exhaled air to flow out while simultaneously relaxing the body and smiling slightly and initiating the painful procedure only after about 25% of the air is exhaled.

Some physiological mechanisms that explain how slow breathing influences pain perceptions focus on baroreceptors that are mechanically sensitive to pressure and breathing dynamics. According to Suarez-Roca et al. (2021, p. 29),“Several physiological factors moderate the magnitude and the direction of baroreceptor modulation of pain perception, including (a) resting systolic and diastolic AP [arterial pressure], (b) pain modality and dimension, (c) type of activated vagal afferent, and (d) the presence of a chronic pain condition.”

Selections from a table developed by Suarez-Roca et al. (2021, p. 105) and reordered by the authors describe factors related to baroreceptor sensitivity (BRS) and AP regulation of pain as follows:

1. Parasympathetic efferents exert an anti-inflammatory influence, whereas the sympathetic activity is mostly proinflammatory.

2. Peripherally, baroreflexes indirectly regulate tissue inflammation by modulating parasympathetic and sympathetic outflow. For example, inflammatory mediators activate vagal afferents and trigger the vagal anti-inflammatory reflex that attenuates the production of pronociceptive molecules.

3. Acute baroreceptor stimulation during systole or neck suction reduces experimental pain ratings and pain-evoked electroencephalogram (EEG) potentials in humans.

4. Baroreceptors exert a gating of nociception at brain- stem nuclei and cortical/subcortical structures.

5. Baroreceptors modulate parasympathetic and sympathetic outflow to regulate inflammation and associated pain.

6. Baroreceptor input also modulates the neural activity within cortical and subcortical structures to modulate the different dimensions of pain, such as the cognitive aspects of pain perception, by influencing the neural activity of the anterior insula.

7. Baroreceptors modulate other sensory inputs, including touch, cold, and heat, or noncutaneous senses, vision, and hearing.

8. Chronic pain patients have low BRS.

9. Low BRS allows the development of neuropathic pain in rats.

10. The physiological mechanisms underlying the association between hypoalgesia and increased arterial blood pressure or baroreceptor activation have not been elucidated. However, current evidence suggests central and peripheral mechanisms.

11. Although pain is not always associated with an increase in AP, nociceptive stimuli can increase in AP and heart rate, and the subsequent baroreceptor activation is compensatory negative feedback to avoid an exaggerated cardiovascular response to pain.

12. Orthostatic reduction in AP increases pain perception by hormonal (nonbaroreceptor) mechanisms, such as activation of the renin–angiotensin–aldosterone system and, subsequently, stimulation of angiotensin II type-2 receptors. Peper et al.

13. Both AP levels and pain are under the influence of variations in the gene encoding catechol-O-methyltransferase.

14. At the level of the brainstem, baroreflex input to nucleus tractus solitarius inhibits pronociceptive ON-cells and excites antinociceptive OFF-cells in the rostroventral medial medulla via projection to the lateral parabrachial nucleus, which leads to enhanced descending control of pain transmission within the dorsal spinal cord.

15. Chronic hypertension and hypotension are associated with hypoalgesia and hyperalgesia, respectively.

16. The inverse relationship between baroreceptor function and pain is altered by resting systolic and diastolic AP levels, pain modality, type of vagal afferent activated, and the presence of a chronic pain condition.

17. Hypoalgesia occurs in rats following an acute rise in AP and chronic hypertension.

Although there are complex physiological interactions between cardiorespiratory systems, AP and BRS that influence pain perceptions, this report focuses on simpler reminders, such as creating a sense of safety for people as a result of better breathing techniques.

Creating a Sense of Safety

My young daughter did not know what to expect and totally trusted me, and I was relaxed because the purpose was to enhance my daughter’s future health by giving her a vaccination to prevent being sick at a future time. Often, a parent’s anxiety is contagious to the child because expectations and emotional states influence the experience of medical procedures and pain (Sullivan et al., 2021). For my daughter, the nurse’s calm and confident demeanor contributed to a safe and reassuring environment. As a result, she was more engaged in a playful distraction, blowing at my hair, rather than focusing on the impending shot. This observation underscores an important psychological principle: when individuals do not anticipate pain and feel safe, they are more likely to experience surprise rather than distress. Conversely, anticipation of pain can amplify the perception of discomfort.

For instance, many people have experienced heightened anxiety at the dentist, where they may feel the pain of the needle before it is inserted. Anticipation evocates a past memory of pain that triggers a defensive reaction, increasing sympathetic arousal and sharpening awareness of potential danger. By providing the experience of feeling of safety, parents, caretakers, and medical professionals can play a crucial role in reducing the perceived pain of medical interventions.

Using Distraction

It is inherently difficult to attend to two tasks simultaneously; thus, focusing one’s attention on one task often diminishes awareness of pain and other stimuli (Rischer et al., 2020). For instance, when the nurse asked my daughter to see if she could blow hard enough to make the curls move back and forth, this task captured her attention in a fun and multisensory way. She was engaged visually by the movement of the curls, audibly by the sound of the rushing air, physically by the act of exhalation, and cognitively by following the instructions. Additionally, her success in moving the curls reinforced the activity as a positive and enjoyable experience.

In contrast, it is challenging to allow oneself to be distracted when anticipating discomfort as numerous cues can continuously refocus attention on the procedure that may induce pain. This experience is akin to attempting to tickle oneself, which typically fails to elicit laughter due to the predictability and lack of external stimulation. Most of us have experienced how challenging it is to be self-directive and not focus on the sensations during dental procedures as discussed in the overview of music therapy for use in dentistry by Bradt and Teague (2018). The challenges are illustrated by my own experience during a dental cleaning.

I often attempt to distract myself by mentally visualizing the sensation of breathing down my legs while repeating an internal mantra or evoking joyful memories. Despite these efforts, I frequently find myself attending to the sound of the ultrasonic probe and the sensations in my mouth. To manage this distraction more effectively, I find that external interventions, such as listening to music or an engaging audio story through earphones, is more beneficial.

From this perspective, we wish that the dentist could implement an external intervention by collaborating with a massage therapist to provide a simultaneous foot massage during the teeth cleaning. This dual stimulation would offer enough competing sensations to divert attention from the dental procedure to the comfort of the foot massage.

Reducing Anticipation of Pain

A crucial factor in the experience of pain is the anticipation and expectation of discomfort, which is often shaped by previous experiences (Henderson et al., 2020; Reicherts et al., 2017). When encountering a novel experience, we might interpret the sensations as novel rather than painful. Similar phenomena can be observed in young children when they fall or get hurt on the playground. They may initially react with surprise or shock and may look for their caretaker. Depending the reaction of their caregiver, they may begin to cry, or they might cry briefly, stop and resume playing.

Conversely, the anticipation of pain can heighten sensitivity to any stimuli, causing it to be automatically perceived as painful. Anticipatory responses function as a form of mental rehearsal, to which the body responds in a manner similar to the actual experience of pain. For example, Peper et al. (2015) show that, when a pianist imagined playing the piano, her forearm flexor and extensor muscles exhibited slight contractions even though there was no observable movement in her arm and the pianist was unaware of these contractions (see Figure 2).

These kinds of muscle reactions are also visible in sportsmen. For example, while mentally racing a lap on a motorbike, the arm muscles act as if the person is racing in the dust of the circuit (Booiman 2018). The blood flow and blood vessels as monitored by blood volume pulse react even quicker than muscle tension on thoughts and expected (negative) experiences.

These findings underscore how anticipatory responses can mirror actual physical experiences, providing insights into how anticipation and expectancy can modify pain perception (Henderson et al., 2020). Understanding these mechanisms allows for the development of interventions aimed at managing pain through the modification of expec- tations and the introduction of distraction techniques.

The Personal Meaning of Pain (Adapted from Peper, 2015)

The personal meaning of pain is a complex construct that varies significantly based on context and individual perception. For example, consider the case of a heart attack. Initially, the person might experience chest pain and dismiss it, which can be attributed to societal norms by which people are conditioned to ignore pain. However, once the pain is assumed or diagnosed to be a heart attack, the same pain may become terrifying as it may signify the potential for life-threatening consequences. Following bypass surgery, the pain might actually be worse, but it is now reframed positively as a sign of the surgery’s success and a symbol of hope for survival. Thus, the meaning of pain evolves from one of fear to one of reassurance and recovery.

This notion that pain is defined by the context in which it occurs is crucial (Carlino et al., 2014). For instance, childbirth, despite being intensely painful, is understood within the context of a natural and temporary process that leads to the birth of a child. This perception is often reinforced nonverbally by a supportive midwife or doula. It may be helpful if the midwife or doula has given birth herself. Without words, she communicates that “this is an experience that you can transcend, just as I did.” Psychologically/ emotionally, the pain serves a higher purpose, to deliver a child into the world, which may also make the pain more bearable. There is a reward, namely, the child. More importantly, doula guidance in perinatal care is associated with positive delivery outcomes, including reduced cesarean sections, premature deliveries, and length of labor (Sobczak et al., 2023).

To further illustrate this concept, Peper et al. (2006) and Kakigi et al. (2005) physiologically monitored the experiences of a Japanese yogi who performed voluntary body piercing with unsterilized skewers as depicted in Figure 3 (Peper, 2015).

See the videorecording of the tongue-piercing study recorded November 11, 2000, at the annual Biofeedback Society Meeting of California in Monterey at https:// youtu.be/f7hafkUuoU4 (Peper & Gunkelman, 2007).

Despite the visual discomfort of seeing this procedure, physiological data from pulse, EEG, and breathing patterns reveal that the yogi did not experience pain. During the piercing, his heart rate was elevated, his electrodermal activity was low and unresponsive, and his EEG showed predominant alpha waves, indicating a state of focused meditation rather than pain. This study suggests that conscious self-regulation, rather than dissociation, can be employed to control attention and responsiveness to painful stimuli and possibly benefit individuals with chronic pain (Peper et al., 2005).

During a ceremonial practice, a similar phenomenon was observed among Sufi initiates in Amman, Jordan. These individuals, led by Sheikh Mohammed Abdul Kareem Kasnazani, took part in a ceremony that involved drumming and chanting and a piercing demonstration with unsterilized skewers (typically in the face, neck, arms, or chest). As did the Japanese yogi, participants exhibited no experience of pain and healed quickly as shown in Figure 4.

See the videorecording of the actual piercing study organized by Erik Peper and Howard Hall with Thomas Collora recording the quantitative electroencephalography (qEEG) at the 2013 Annual Scientific Meeting of the Association for Applied Psychophysiology and Biofeedback in Portland, Oregon (Collura et al., 2014; Peper & Hall, 2013), at https://www.youtube.com/watch?v¼56nLZyG87oc.

What Factors Decrease the Experience of Pain and Promote Rapid Healing with the Absence of Bleeding?

In the case of the Sufis, they framed their experience as a normal, spiritual phenomenon that occurs in a setting of religious faith and total trust in their spiritual leader (Hall, 2011). The Sufis reported that they had permission and support from their master, Sheikh Mohammed Abdul Kareem Kasnazani. Thus, they felt totally safe and protected; they had no doubt they could experience the piercing with reasonable composure and that their bodies would totally heal. Even if pain occurred, it was not to be feared, but was part of the process. The experience may be modulated by the psychological context of the group, the drumming, and the chanting. The phenomenon was not simply a matter of belief; they knew that healing would occur because they had seen it many times in the past. The knowledge that healing would occur rapidly was transmitted as a felt sense in the group that this is possible and following the expected normal pattern.

The most impressive finding was that the physiology markers (heart rate, skin conductance, and breathing) were normal, there was no notable change (Booiman et al., 2015; Peper & Hall, 2013), and the qEEG indicated the inhibition of pain (Collura et al., 2014).

Clinical Implications

These observations underscore that the context of pain— whether through personal meaning, spiritual belief, or communal support—can significantly alter its perception and management. This concept is also reflected in clinical settings, where a lack of diagnosis or acknowledgment of pain can exacerbate suffering. An isolated individual, alone at night with the physical sensation of pain, may find the pain tremendously stressful, which tends to intensify the experience. In this situation, there are concerns about the future: “It may get worse, it will not go away, I’m going to die from this, maybe I’ll die alone,” and the worry continues.

If one can let go of these thoughts, breathe through the pain, relax the muscles, and experience a feeling of hope, the pain is often reduced. On the other hand, focusing on the pain may intensify it. On the other hand, the meaning of pain implies survival or hope as sometimes is observed in injured soldiers. In context of the hospital setting:“I have survived, and I am safe.”

What are the implications of these experiences in clinical settings in which the patient is in constant pain and yet has not received an accurate diagnosis, or in cases in which the patient has a diagnosis, such as fibromyalgia, but treatment has not reduced the pain significantly? Experiencing pain or illness that goes undiagnosed and/or that is not acknowledged may increase the level of stress and tension, which can contribute to more pain and discomfort. As long as we are resentful/angry/resigned to the pain or especially to the event that we believe has caused the pain, the pain often increases. Another way to phrase this is that chronic sympathetic arousal increases the sensitivity to pain and reduces healing potential (Kyle & McNeil, 2014). Acknowledgement means having an accurate diagnosis, validating that the pain experience is legitimate and that it is not psychosomatic (imagined) because that simply makes the experience of pain worse. Once the patient has a more accurate diagnosis, treatment may be possible.

When one has constant, chronic, or unrelenting pain, this evokes hopelessness, and the patient is more likely to get depressed (Meda et al., 2022; Sheng et al., 2017). The question is what can be done? The first step for the patients is to acknowledge to themselves that it does not mean the situation is unsolvable. It is important to focus on other options for diagnosis and treatment and take one’s own lead in the healing/recovery process. We have observed that a creative activity that uses the signals of pain to evoke images and thoughts to promote healing may reduce pain (Peper et al., 2022). Pain awareness may be reduced when the person initiates actions that contribute to improving the well-being of others.

Overall, pain appears to decrease when a person accepts without resignation what has happened or is happening. A useful practice that may change the pain experience is to do an appreciation practice. Namely, appreciate what that part of the body has done for you and how so often in the past you may have abused it. For example, if you experience hip pain, each time you are aware of the pain, thank the hip for all the work it has done for you in the past and how often you may have neglected it. Keep thanking it for how it has supported you.

Pain often increases when the person is resentful or wished that what has happened had not happened (Burns et al., 2011). If the person can accept where they are and focus on the new opportunities and new goals the person can achieve, pain may still occur; however, the quality is different. Focus on what you can do and not on what you cannot do. See Janine Shepherd’s (2012) empowering TED talk, “A broken body isn’t a broken person.”

Conclusion

The primary lessons from studying the yogi and the Sufis are the concepts that a sense of safety, acceptance, and purpose can transform the experience of pain. Expressing confidence in a patient’s recovery prospects places the focus on their ability to recover. Incorporating these elements into clinical care may offer new avenues for addressing chronic pain and improving patient outcomes (Booiman & Peper, 2021).

We propose that the first step is to create an atmo- sphere of hope, trust, and safety and to emphasize the improvements made (even small ones). Then, master effortless breathing to increase slow diaphragmatic breathing and teach clients somato-cognitive techniques to refocus their attention during painful stimuli (mindfulness) (Pelletier & Peper, 1977; Peper et al., 2022). Using the slow breathing as the overlearned response facilitates recovery and regeneration following the painful situation. To develop mastery and be able to apply it under stressful situations requires training and over-learning. Yoga masters overlearned these skills with many years of meditation. With mastery, patients may learn to abort the escalating cycle of pain, worry, exhaustion, more pain, and hopelessness by shifting their attention and psychophysiological responses. In clinical practice, strategies such as hypnotic induction, multisensory distraction, self-healing visualizations, and mindfulness techniques can be employed to manage pain. A foundational principle is that healing is promoted when the participant feels safe and accepted, experiences suffering without blame, and looks forward to life with meaning and purpose.

Acknowledgment

We thank Mitsumasa Kawakami, Sheikh Mohammed Abdul Kareem Kasnazani, and Safaa Saleh for their generous participation in this research, and I thank our research colleagues Thomas Collura, Howard Hall, and Jay Gunkelman for their support and collaboration.

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