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Pain Perception, Distraction/Engagement, and Biofeedback

O.J. Sahler, MD


  1. What is Pain?
  2. What is Anxiety?
  3. Why Distraction/Engagement Works
  4. What is Biofeedback?

What is pain?

Unpleasant feeling — sensory or emotional — often caused by intense or damaging stimuli

What does a person do in response to pain?

  • Withdraws from the damaging stimuli
  • Protects a damaged body part while it heals
  • Avoids similar experiences in the future

What is anxiety?

  • Unpleasant state of inner turmoil with nervous or clinging behavior
  • Physical changes include palpitations, tachycardia, hyperventilation, muscle tension, headache, stomach ache
  • Being anxious that pain will escalate can become a self-fulfilling prophecy

How sensory input is transmitted to the brain

Type of Nerve Fiber Information Carried Conduction Speed (mi/hr)
Painful Stimuli
C Pain (sharp, burning) 2 mi/hr
leisurely walk
A-delta Pain (cold, pressure) 60 mi/hr
highway driving
Non-Painful Stimuli
A-alpha Awareness of the environment 200 mi/hr
airplane taking off

Gate Theory


Why Distraction/Engagement Works:

"It's All in Your Head"
"Take Your Mind Off Your Pain"

What is distraction?

  • Something that diverts attention and makes it hard to think or do work
  • Something that amuses or entertains and makes it hard to think about problems (e.g., pain)

What is engagement?

  • Emotional, cognitive, and behavioral connection that exists between a user and a resource

Only a certain amount of information can be carried to the brain at a given time. If most of the afferent nerve fibers are carrying information about the environment (engaged with TV or friends, reading, playing video games), the amount of information about pain that reaches the brain is subthreshold and, therefore not perceived.

Good Medicine

  • Being able to be distracted by or engaged with someone or in something is good medicine
  • Being able to distract/engage yourself is the best medicine

What is biofeedback?

  • Measuring a person's quantifiable physiologic functioning (e.g., heart rate, blood pressure, skin temperature)
  • Conveying that information to the person in real time
  • Raises the person's awareness and conscious control over seemingly unconscious (automatic) physiologic activities

Providing access to physiologic information that was previously considered an automatic response allows the person to gain control of the response and modify it

Biofeedback is particularly useful in controlling/decreasing the stress response by helping a person understand how he/she can superimpose the relaxation response using mind/body self-regulation techniques

Circulatory changes in the stress and relaxation responses


  • Increased blood flow to vital organs (brain, heart, lungs) and the muscles of "fight or flight"
  • Decreased blood flow to non-vital areas (small muscles of the hands and feet)


  • Homeostatic circulation

Biofeedback is probably efficacious for:

  • Alcoholism/substance abuse
  • Arthritis
  • Chronic pain
  • Epilepsy
  • Fecal elimination disorders
  • Insomnia
  • Traumatic brain injury

Biofeedback is efficacious for:

  • Anxiety
  • ADHD
  • Hypertension
  • Migraine, cluster headaches, tension headaches

Biofeedback is efficacious and specific for:

  • Urinary incontinence in females through perineal muscle strengthening

Some believe using biofeedback to manage stress and anxiety could be replaced by simple relaxation training, meditation, and self-hypnosis

In fact, biofeedback is only the use of an external monitor while practicing relaxation (using any method desired)

so the person can see how effective his/her relaxation techniques are and

learn how to strengthen them

Biofeedback Benefits

"When people see that they can produce physiological changes [through] relaxation, this has both motivational and cognitive effects... building a sense of self efficacy and confidence that their actions will lead to benefits."

Powers SW et al JAMA 2012; 310: 2622-30.

Online Resources about Biofeedback


The Association for Applied Psychophysiology and Biofeedback is an international society for mind-body research, health care, and education. The Society publishes a journal with research and opinion articles.


This site from the Mayo Clinic provides a brief overview of various types of biofeedback


This site was produced by Medical News Today and has references to various studies using biofeedback for headache including migraine, ADHD, and PTSD among other conditions.


Seeing a biofeedback specialist who uses computer-based equipment can be expensive, but monitoring physiologic responses does not require sophisticated equipment. This site, from Stressstop.com, lists a variety of inexpensive do-it-yourself "monitors" that can provide information similar to that demonstrated in the video. The most basic type of "thermometer" is called a Biodot®. Remember mood rings? The concept is the same.

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