• When your nervous system is inflamed and hyper-reactive, lesser levels of stress cause your body to go into flight or fight.
• In contrast, you are able to more easily deal with challenges if you feel safe and calm.
• Four categories of factors influence your baseline physiological state of safety versus threat: 1) sleep 2) diet 3) exercise/activity level 4) childhood programming/ patterns.
• All of these factors are addressed throughout the course, but the initial focus is on getting adequate sleep.

Your nervous system gathers about 20-40 million bits of information per second, and interprets the sum total as safe or threatening. Signals are continuously sent out to adjust the body’s physiology (output) and actions to optimize your function. The reactivity of your nervous system ranges from calm to hypervigilant. These four categories of factors influence the sensitivity of the nervous system.

• Consistently restful sleep is necessary for your brain to refuel and empty waste products.
• Lack of exercise affects your physiology and also your capacity to cope with both mental and physical stress.
• A poor diet is inflammatory.
• Your baseline physiology is also affected by your past. Survival depends on learning what is dangerous and then avoiding it in the future. If you were raised in a chaotic abusive environment, many situations were dangerous or perceived as such. That doesn’t change as you age even when you intellectually know you are safe. So, more scenarios in the present seem threatening with less stress than you might expect.

Although all these variables affecting your nervous system are presented throughout the course, successfully addressing sleep is a high priority. The DOC Journey approaches will be marginally effective if you aren’t getting 7 or 8 hours of restful sleep. Not sleeping is NOT an option. No major decisions regarding your medical care should be made until you feel rested during the day. This is particularly true regarding surgical procedures.

Systematic Approach to Sleep

Insomnia is consistently solvable with a stepwise approach regardless of the level of your pain. The key is focus and persistence. It is a myth that you need less sleep as an adult and at least seven hours of sleep is desirable. Few patients suffering from chronic pain are getting adequate sleep.

Incorporating sleep into the treatment was my first step in conceiving the DOC protocol. I had a new resource that was effective and measurable. My patients’ sense of well-being improved and often other symptoms diminished.

Sleep and pain

I originally thought that people suffering from chronic pain couldn’t sleep because of their pain. But a large study out of Israel demonstrated that lack of sleep induces chronic low back pain, and that the reverse was not true – that pain caused insomnia.¹

Another study documented that consistently poor sleep was a greater predictor of disability than the severity of back pain. Even more interesting was that this was also true for leg pain (sciatica), which surgeons generally feel is an incredibly disabling symptom.²

I treated one businessman who had experienced chronic neck pain for almost two years. There was no specific injury. He continued working as an owner of a small accounting firm, but he was miserable. He had been through multiple courses of physical therapy. I started him on a strong sleep medication, which immediately allowed him to experience restful sleep. I saw him back at two weeks and noted the medication was working well. I was planning on starting aggressive physical therapy on the next visit. When he returned six weeks later, I was surprised that he was pain-free without any other interventions.

Start sleeping – NOW

Most people find a way to sleep using a combination of the suggestions listed below. If you are still struggling after a few weeks, Discuss sleep with your primary care physician. The details of each of these suggestions are outlined in chapter 14 of my book, Back in Control. Please use this as a resource.

Approaches to Insomnia

Self-directed

1. Sleep hygiene – well-known set of principles to optimize sleep.
2. Stress management at bedtime – i.e., don’t read business emails for at least an hour before going to bed.
3. Exercise – Physical conditioning improves sleep, but don’t exercise late in the evening.
4. Expressive writing –  shortens the time it takes to fall asleep.
5. CBT-I –  Cognitive Behavioral Therapy Insomnia is documented to improve sleep. Online resources are readily available.
6. Over-the-counter sleep aids – I do not have specific recommendations. They may be helpful, but should not be used long-term. Alert your physicians if you are using them.

Under the guidance of a physician

1. Prescription Medications – Many stronger medications are effective for treating insomnia. I have observed that if you are suffering from chronic mental and/or physcial pain that you often need a kick-start with strong sleep meds. Once your nervous system quiets down you can and should come from them relatively soon. Using narcotics for sleep is not recommended and creates many additional problems.
2. Diagnosing a sleep disorder – there are over 100 sleep disorders with the most common one being sleep apnea. Sleep apnea is caused from your airway intermittently becoming partially occluded. Oxygen levels drop as you gasp for air. Sleep quality is poor, and daytime sleepness is one of the hallmarks of this disorder. More importantly, your heart is stressed and its function is progressively compromised. It is important to diagnose and treat it if there is any suspicion. Restless Leg Syndrome is another common sleep disorder that is treatable with the correct medications.

Recap

The other factors affect the reactivity of your nervous system, buy a consistently restful night’s sleep is necessary for healing. It must be not only be addressed, but at least partially solved as an early step. Most people improve their sleep with simple self-directed interventions, but you should not hesitate to seek help from your physician.

Questions and considerations

1. Assess your sleep.
   1. How many hours do you sleep per night?
   2. How often do you wake up?
   3. How long does it take for you to fall asleep?
   4. Do you feel rested in the morning?
   5. Do you fall asleep easily during waking hours?
2. Do you notice a difference in your physical and mental symptoms after several nights of restful sleep? What symptoms are worse with poor sleep?
3. From a practical perspective, how can you really enjoy your life if you are tired? Why pursue so many other treatments without covering this base?
4. Temporarily push away the other aspects of your situation and focus on sleep. It is a clear and measurable variable.
5. “I can’t sleep because of my pain.” You have to flip that idea around. Remember, it is lack of sleep that is causing so many problems.

References

1. Agmon M and Galit Armon. “Increased insomnia symptoms predict the onset of back pain among employed adults.” PLOS One (2014); 9: 1-7.
2. Zarrabian MM, et al. “Relationship between sleep, pain, and disability in patients with spinal pathology.” Archives of Physical Medicine and Rehabilitation (2014); 95:1504-1509.

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Prehab

We decided that if the surgical results were so much better, we would have all of our patients engage in at least 8 to 12 weeks of “prehab” before any surgery, regardless of the magnitude. Our protocol included:

• Learning about chronic pain through my book, Back in Control: A Spine Surgeon’s Roadmap Out of Chronic Pain.
• They were sleeping at least six hours a night (often required meds).
• Addressing their stress.
• Engaging in the expressive writing exercises.
• Learning and using active meditation.
• Noting some improvement in their mood and pain.
• Narcotic medications were defined and stabilized.

We encouraged them to return, but we weren’t going to perform surgery without them engaging in a prehab process.. The data shows that not addressing these issues significantly compromises surgical outcomes. (1)

What Happened?

I am enjoying my practice at a level that I could not have imagined. Our patients are doing well and excited about their progress. What I didn’t expect was that so many patients would become pain-free without undergoing surgery I thought they needed. We presented a research paper reporting on a group of patients who’d come in for their final preoperative visit, and their pain was gone. Of course, we canceled the surgery.

What was even more surprising was the severity of the problems. Normally, the diameter of the spinal canal is about 15 mm. I don’t schedule surgery unless the canal is less than 8 mm, and the patient has leg pain. I have one patient who avoided surgery with a four mm canal.

Janet’s Story

The following letter is from a woman whom I saw last summer with a large synovial cyst. This is a problem where a sac of fluid is formed off a facet joint off the back of the spine. It was not only pinching her sciatic nerve, but it was calcified, which means it couldn’t shrink. I immediately offered her a small operation to remove it. The outcome of removing the cyst is predictably positive with few complications. It is one of my favorite procedures. I offered her the prehab process through my book and website. I also thought the pain center would help. I was surprised that she did not immediately take me up on surgery. She never returned to see me, and I received this letter from her about eight months later.

Dear Doctors,

Last summer, an MRI scan revealed a synovial cyst in my back. I had severe pain from cramps in my butt and calf muscles. My family doctor referred me to your office.

I am writing to update you on my status, which is greatly improved. On my initial visit at the Pain Center, the doctor asked me to keep a journal of what I couldn’t do.

What I cannot do because of pain

I cannot get up in the morning in a flash. I need to exercise and stretch my right leg in bed, roll carefully out of bed to ice my butt and calf, do stair-step exercises, and then finally do a 20 to 30 minute “working with pain” meditation. I can’t sit in any chair I want because my butt muscle will spasm. Car seats are hard to sit in. I have to get out at least every 45 minutes to stretch. I was on Gabapentin, Cyclobenzaprine, and Ibuprofen. I followed the Back-in-Control program, writing down my thoughts and beginning to focus on what I wanted to do, including returning to dance class. In early October, I began sleeping in a semi-upright position, with a pillow under my legs, and the cramping began to subside. I also had biofeedback training. By mid-November, I was able to get off all pain medications and start lifting weights again.

I have very occasional twinges in my right butt when sitting or walking, but I am basically pain-free. I am so grateful for the chronic pain management program and extremely grateful that you offered the program rather than immediate surgery on the synovial cyst.

Many, many thanks.

Sincerely,

Janet

Do Surgery Now??

I had forgotten about her case, so I reviewed her MRI scans and was shocked to see the size of the cyst. However, I have been surprised at the severity of the pathology with every surgical patient I have witnessed becoming pain-free without an operation. In fact, in the first edition of my book, I comment that if a patient has a significant structural problem with matching symptoms, surgery should be performed quickly so as to move forward with the comprehensive rehab program. I thought the pain would be too distracting to be able to participate. The opposite scenario occurred in that when I performed surgery in the face of a fired-up nervous system, the pain would frequently be worse. I eventually discovered this problem has been well-documented in the medical literature. (1) Chronic pain can actually be induced or worsened as a complication of any surgical procedure, including painless ones such as a hernia repair. One of the risk factors is pre-existing chronic pain in any part of the body.

I now have dozens of stories similar to Janet’s. There are many times that I do perform urgent surgery for compelling problems. But if there’s any room to have my patient participate in the prehab, that is what we have them do.

Video: Get it Right the First Time

Ask for This Approach!

I’m excited about this turn of events, although it is becoming a little challenging maintaining a surgical practice. The medical literature has clearly documented that this process is effective. Ask your doctor to help you out with setting up your own program. You don’t need a major pain center, as the necessary resources are readily available.

Every surgery has risks, and no one thinks a complication will happen to him or her. I have seen them all. They are unpredictable, and the outcomes can be catastrophic. Also, why would you not want to maximise your odds of success. Do you really need surgery? Be careful!!

Are You Kidding Me?

Perkins FM and Henrik Kehlet. “Chronic Pain as an Outcome of Surgery.” Anesthesiology (2000); 93: 1123-1133.

The post Optimizing (Avoiding) Spine Surgery first appeared on Back in Control.

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Anxiety is the sensation generated when you are in flight or fight. It is a physiological state. When you can’t resolve your anxiety, your body kicks in a stronger neurochemical response and you’ll be anger. Anger and anxiety are the result of stress, not psychological, and a million times stronger than your conscious brain. You have absolutely no control over these reactions. However, you are able to reprogram these responses.

This email was recently sent to me by someone who I have never met and reflects most of the concepts of healing presented in The DOC (Direct your Own Care) course and app.

The letter

Hello David,

I am writing to you on my day off, sun is shining and I am almost ready to go for my walk. I really feel supported by your program and thank you for replying my emails.

 It means a lot to me. I do a bit of reading and learning each day and then move on to the things in life that I need and want to do.

I touched a huge topic and adressed it. I arranged for a meeting with my ex-partner and told him I wanted to have a one on one conversation on how we are raising our son seperately and how this is going. In this conversation I was able to really listen to him and feel the hurt feelings and being uncomfortable. He let me have my moment and I spoke up about my grief and the things that caused my hurt feelings and what I would wish for my son, and also that it was hard for me to forgive him on how things went between us in the past.

It was the first time that I spoke and took this approach. Usually, I complain about him to my boyfriend, whom suggested that I should say these things in a mature way to my ex. Now, I feel like I forgave me and him. Actually, me meeting and speaking up, without the actual need for me to have him change anything made all the difference. But I needed to have the conversation. Only so much you can learn from books. In the playground of real life you are meant to use the things you learn.

It feels that I am moving forward and I am persistent. It is working for me because I am showing up for me everyday and do my writing, eating well, sleeping, and learning.

It is a life-long journey. I am also adressing the relationship between me and my parents. My mom has become ill and she is in her victim role most of the time. Also I am reviewing my role in family dynamics. For me this was also confronting, because stopping complaining and not talking about my pain was a huge step. My therapist friends help me accomplish this.

I have notes on my fridge. I crossed out “try” and the “do” note hangs on my bathroom mirror. Even my son participates with me. He manages to sleep in his own room, which is a huge step for him and for me.

Now I realise that trying to fix yourself is focusing on what you don’t want and you can fail easily. Moving forward and taking small steps to the life you want makes it possible to let them co-exist. Since the pain is needed to get myself moving. This time I am dedicated and for this reason I am making it work. I took control.

And what makes me happy everyday is that I show up for myself and do my work, everyday. This realisation makes it that I feel I can be more persistent and pursue life as I see fit. It is like getting married with myself, for better and for worse.

I will keep you updated. I am so grateful that my friend pointed out your work. Thank you for showing this way and helping people to live the life they want to live. To have hope and knowing that I can succeed with patience, persistance and dedication.

Wishing you well, WT

Summary of her journey

Her letter covers the core of the healing journey. I’ll just list them.

Leg 1 – Beginning the journey – and learn later

• Expressive writing is a major necessary step. It is not the final solution but nothing will really happen without this exercise.
• She stopped complaining
• Sleep improved

Leg 2 – Understanding the healing principles

• She quit trying to fix herself and pursued the life she wanted.
• The two separate but linked parts of healing are letting go and moving forward.
• Hope has been shown to lower inflammatory markers. Being trapped in pain without direction is a dark place and why I call it “The Abyss.”

Leg 3 – Lowering threat physiology – anxiety

• Relaxed enough that her son could be a part of all of this
• An anti-inflammatory diet contributes to lowering threat physiology.

 Leg 4 – Awareness

• She let go of her expectations and agenda and was able to listen
• Your family is the source of your deepest triggers and she took responsibility for her possible role. You can’t change your family, but you can work on yourself.

Leg 5 – Anger processing

• Confronting a given situation head on
• Stopped blaming her ex
• “Try” is the ultimate victim word. “Do” is the opposite. This is a strategy that I learned from my Hoffman process.

Leg 6 – Pursuing your vision

• Consistence and persistence are key – one day at a time.
• Continually trying to fix yourself places your brain on the problem and reinforces your pain.
• As you learn to let go, you can move forward away from your pain circuits. They will “atrophy” from disuse.

Leg 7 – Living life on your terms

• She is executing and moving forward.
• She took control. Nothing will happen until you lean into this. We are somewhat programmed to look outside of ourselves for fixes and also for blame.
• She understands what makes her happy and nurtures that energy.
• Connecting with friends for support and connection is also powerfully anti-inflammatory. Instead of complaining to her friends, they became her support.

One key concept was her statement, “It is like getting married with myself, for better and for worse.” In other words, she connected to every aspect of herself, including her capacity to heal. The DOC Journey is not a self-help program. It is a set of documented tools based on deep medical research and provides a foundation of knowledge that allows you to figure your own way out of The Abyss. You cannot go from pain to pleasure without a sequence and tools.

Then, as you move into the life that you desire, your brain will continue to evolve in the direction of your choice (neuroplasticity), physical and mental symptoms abate, and you’ll thrive and move into a life that you never thought was possible.

Her journey is an example of how you can heal. You will implement your own version of it, and healing is always possible regardless of how long you have been in pain. The choice is yours. Do you want to learn the skill set to move forward and become a professional at living your life?

The post How to Heal – A Patient’s Story first appeared on Back in Control.

The post How to Heal – A Patient’s Story appeared first on Back in Control.

• There is deep basic science research that has revealed the nature of chronic pain and this understanding will allow you to discover your version of a solution. The essence of the problem is sustained exposure to threat and the core of the solution lies in finding safety.
• Create safety by learning skills to:
  • Stimulate neuroplasticity – create and shift to new neurological circuits in your brain.
  • Learn to regulate your body’s neurochemical response to threats (stresses).
• As you learn about chronic pain, it is helpful to simply get started using some of these core tools to “jump start” the healing process.
  • Expressive writing
  • Active meditation
  • Restful sleep
  • No discussing your pain or medical care with others – especially your family

Many years ago, I would spend hours explaining chronic pain to my patients in the office but it was too complicated and it wore me out. That is when I decided to write, Back in Control. Patients would have a better understanding but there was no action. The website, www.backincontrol.com was the action plan and evolved into a self-directed process that allowed hundreds of people to break free from their chronic pain. The DOC Journey is the next rendition of the program. But the healing process begins when you begin to use methods that stimulate your brain to change. During the last few years of my practice I would ask patients to simply begin to learn and use the basic tools as quickly as possible and the rest of the concepts would fall into place. This is the first lesson of The DOC Journey.

 The nature of chronic pain (mental and physical) – sustained threat vs. safety

The essence of chronic illness, including chronic pain, is your body’s reaction to sustained stress because it responds with profound elevations of stress hormones, metabolic activity (rate of fuel consumption), and inflammatory markers (destroys invaders and your own tissues). The result is many different disruptive mental and physical symptoms.

The solution lies in learning the tools to create sense of safety, which normalizes your body’s survival fight or flight reaction. Successfully implementing these strategies causes a shift your mood, pain, and other physical symptoms. I am suggesting to dive in and begin using some of these basic foundational strategies right away. Why wait?

Creating Safety

Neuroplasticity is a term that describes your brain’s capacity to change its structure. You can form new connections, grow cells, increase the insulation around the nerves (myelin), and shift from unpleasant to pleasant circuits. Your brain physically changes in shape and structure based on programming.

As you learn strategies to regulate your body’s responses to stress, you have regained control, which creates safety. There are many ways to accomplish this and with repetition the process becomes automatic. It is like an athlete or musician attaining a high-level of skill. It cannot be done by just reading a book.

Let’s begin with these core strategies – Now

• Begin expressive writing. It is the one mandatory step to start. People can improve without doing it, but I have rarely seen people go pain free without engaging in this exercise. It has been documented in over a thousand research papers to be effective in creating significant shifts in multiple organ systems. (1)
• Practice active meditation. This involves placing your attention on a physical sensation for five to ten seconds as often as you can remember. You are switching to neutral or pleasant sensory input which causes less of a reaction in your nervous system. It requires minimal time and effort.
• Adequate sleep is critical. Lack of sleep has been shown to cause chronic pain. (2) With a multi-pronged approach, restful sleep can usually be achieved within 4-6 weeks. Medications may be needed for a few months.
• Never discuss your pain or medical situation with anyone except your medical providers. The solution for chronic pain lies in rewiring your brain around your memorized pain circuits. Your nervous will develop and evolve wherever you place your attention.

Why should this program work?

An important early step is to acknowledge and embrace your skepticism. Why should this DOC Journey work? You have been bounced around, promised relief time and time again, undergone failed interventions, and your pain is worse than ever. There is not any reason to think that this is going to work. I agree. In fact, primate research has shown that you can induce a major depression by repeatedly dashing hope. (3)

Every treatment offered in this program has been well-documented by decades of deep medical research; implement what is already known. I have watched well over 1500 patients break free from chronic pain and not only regain their life but thrive at a level they had never experienced at any point in their lives. It happened by them learning and using this DOC Journey sequence that evolved from my experience coming out of severe chronic pain and discovering what was effective with my patients.

What is not helpful is “believing” in the DOC Journey or David Hanscom, using positive thinking, or affirmations. It is about connecting with your current reality, which is unpleasant enough for you to sign up for this Journey. You are rightfully angry, frustrated, and trapped. It is the starting point. Feeling and knowing where you are at allows you to learn the strategies that allow you change direction. One successful patient commented what you need is a, “suspension of disbelief.”

Anything is possible

The DOC Journey begins with acknowledging doubt, learning awareness, and allowing hope to re-enter. Research has shown that hope and optimism are anti-inflammatory. (4) There is a lot of hope in hearing about other’s successes. I am increasingly convinced you can stimulate your brain to rewire around almost any pain regardless of the source.

I got another reminder when a patient who I never personally treated resolved his pain largely through The DOC Journey approach. He is now in his late 60’s and had experienced severe pain for over 22 years. He lost his marriage and business, ended up addicted to high-dose narcotics and attempted suicide. During this period, he underwent 28 surgeries. He has not only been free from pain for over five years, but he is enthusiastic that he has not felt this good since he was 30 years old. Historically, I would never have thought that this was possible in light of the severity of his trauma.

Please acknowledge your disbelief, embrace it, start with using these basic tools, and you’ll learn as you go. Helping patients emerge from The Abyss of chronic pain has been the most rewarding phase of my career. I am continually inspired by the resiliency of the human spirit and I am honored to be a part of your journey.

Recap of Lesson one – “Let’s Start Now”

Healing your pain requires repetition of tools that simulate your brain to change (neuroplasticity) and calm down your body’s survival response. The sooner you can engage with these strategies, the quicker you can begin to heal. That is why you might as well begin to use them ASAP. You will learn more about the nature of chronic pain and the principles behind solving it in a logical stepwise sequence throughout the rest of the course.

The next lesson will expand on the concept of threat vs safety and then more detailed explanations of these basic tools will be presented as you progress through leg one.

References:

1. Pennebaker JW and JM Smyth. Opening Up by Writing It Down. The Guilford Press, New York, NY, 2016.
2. Agmon M and G Armon. Increased insomnia symptoms predict pain among employed adults. PLoS One (2014);9:e103591. doi:10.1371/journal.pone.0103591
3. Blum D. Love at Goon Park. Perseus Books, New York, NY, 2002.
4. Dantzer R, et al. Resilience and immunity. Brain Behav Immun (2018);74:28-42. doi:10.1016/j.bbi.2018.08.010

The post Let’s Start Now and Learn the Details Later first appeared on Back in Control.

The post Let’s Start Now and Learn the Details Later appeared first on Back in Control.

The ultimate sacrifice

His book caught my attention in the first chapter when he related the story of his missionary family moving to a remote area of India where no one had ventured because of a deadly type of malaria. Sure enough, his father died relatively soon from it, but his mother spent the rest of her life there serving the medical needs of these people living in incredibly remote area. He went on to become an orthopedic hand surgeon and spent the first years of his practice in India dealing with patients with leprosy. You may know that they routinely develop severe grotesque deformities of their arms and legs. He would perform corrective surgery and kept meticulous records of his approaches both for learning and teaching.

Leprosy

Since the beginning of time, lepers have been treated as outcasts with their limb and facial deformities being nothing short of hideous. After it was figured out that that the leprosy bacteria was the reason for these problems, they still were not treated that well, but at least it wasn’t some type of evil humor or demon possession. Doctors felt that the bacterium directly attacked the tissues and caused the disfigurement.

Dr. Brand figured out that the deformities were not directly caused from the leprosy bacteria, but because the bacteria destroyed sensory nerves and they had lost protective sensation. Your pain system sends signals to the brain, which interprets them to indicate danger any time the limits of a structure or tissue are being challenged that could result in damage. For example, a morsel of food would fall into the cooking fire and the person would reach right into the coals to lift it out. If there was an injury to an ankle, normally you would rest in order to allow it to heal. These people would just keep walking and eventually the joint would disintegrate. A common descriptive term is, “a bag of bones.”

Diabetes

When he returned to the United States from India in the 60’s, he began to notice similarities between his patients with diabetic foot and leg breakdown and his observations of leprosy. There were poorly healing skin ulcerations, infections that would not heal easily, and joints were severely breaking down. Doctors felt that the elevated blood sugars were the cause of the problem. He quickly noted that it was the same problem that existed in lepers; the sensory nerves were being damaged and that they losing protective sensation. It was his pioneering work that led to more aggressive control of blood sugars, protective footwear, healing casts, and patient education to learn ways to protect themselves. He made a huge difference in many people’s lives.

 Congenital indifference to pain

He also described the problems that are created when people are born without a functioning pain system. It is a rare condition called, “congenital indifference to pain.” They have no way of programming their brain as to what might be dangerous or safe. They routinely exceed the limits of their tissues. They don’t even know how to avoid a hot stove. Their lifespan is only about 10-15 years and they die from repeated infections.

Dr. Brand, as a part of his work and research, was given a large government grant to develop a device that would warn people without protective sensation of danger. He devised a tight fitting body sensor suit that would send unpleasant warning signals to the brain when there was potential tissue damage. For example, if a person was using a wrench to tighten a bolt and was pulling too hard, they would receive an unpleasant electrical jolt. The problem was that the person didn’t want to be bothered and would just remove the glove and proceed to damage his or her joints.

The state of your central nervous system

After multiple attempts, everyone gave up. There has never been a solution for someone not having a protective pain system. The problem is that it is incredibly complex system that exists in a delicate balance. Additionally, the final perception of pain is determined by the state of your central nervous system as well as your prior experiences. For example, one night of poor sleep will significantly increase your pain the next day. (2) Consistent lack of sleep actually causes chronic low back pain. (3) Arguing with your spouse instantly increases pain. (4) Running into the bully at school may cause your stomach to churn. This list is infinite. Why would this be the case? Because pain is only pain because your brain says it is so. Your brain is analyzing about 20 million bits of information per second and is programmed to keep you safe and alive. The species of creatures who did not pay attention to environment cues did not survive. Pain is a major part of all of this and is a gift that allows you to safely navigate this planet.

The curse of chronic pain

Chronic pain is not a gift. For many reasons this intricate and balanced pain system is broken. It continues to fire away even when there is no danger. So, now you have a scenario where you are experiencing a sensation that is intended to be so unpleasant that it compels you to take protective action, but you cannot turn it off. It is like a car alarm that won’t turn off except it is incredibly more disruptive. It may be one of the worst experiences of the human existence.  Research has shown that living in chronic pain has a similar impact on a person’s life as experiencing terminal cancer. (5) The problem is that while suffering from chronic pain, you are not being told the nature of the problem, and where is the endpoint? You could argue that it is worse than having terminal cancer.

Fortunately, chronic pain is solvable by first understanding the nature of the problem and then learning approaches to bring the system back into balance. The DOC Journey represents the sequence of many patients who have broken out of the grip of pain. You first have to understand the nature of a problem before you can solve it.

The Journey also begins by embracing your disbelief. You have already tried everything that has been suggested, why would you try this process? Although a positive vision is necessary to move forward, this Journey is not about positive thinking. It is about becoming connected and engaged to what is right in front of you regardless of how pleasant or unpleasant it may be. Then you can move on.

Don’t let the gift of pain that has spun out of control take way from your gift of life. Treat yourself this Holiday by taking  your life back.

1. Yancey, P and Paul Brand. Pain: The Gift Nobody Wants. DIANE Publishing Company (1999).
2. Kahol K, et al. “Effect of fatigue on psychomotor and cognitive skills.” Am Jrn Surg (2008); 195: 195-204.
3. Agmon M and Galit Armon. “Increased insomnia symptoms predict the onset of back pain among employed adults.” PLOS One (2014); 9: 1-7.
4. Burns, JW, et al. Temporal associations between spouse criticism/ hostility and pain among patients with chronic pain: A within-couple daily diary study. Pain (2103); 154: 2715-2721.

The post Pain: the Gift Nobody Wants first appeared on Back in Control.

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I plateaued for about six months but now had some hope. I had always perceived myself as “cool under pressure” and felt that most things weren’t worth getting upset about. I could not have more wrong. What I was highly skilled at was suppressing anger. It exploded and I did not process it well.

I first had to admit that I had a lot of anger, but since “I was right”, I didn’t perceive it was a problem. So, I wasn’t progressing much and my life continued to disintegrate. Over about six months, I was finally able to learn some basic anger concepts and skills and began to rebuild my existence. What I did not expect is that my all of my physical symptoms began to improve and six months later, they had all but disappeared. I was shocked and still did not understand the role of sustained anger and elevated stress hormones/ cytokines causing inflammation.

From reactive to creative

Many people get to this spot of a dramatic turnaround and stop the journey, which is fine. They are excited, as am I, and they usually continue to do well. However, I also think that they have missed the best part. Instead of having to fight your way out of The Abyss, you have the opportunity to further connect to who you are, move forward from your center in a powerful way, and experience life at a level you never knew was possible. That is what this phase, Expanding Your Horizon is about.

The healing journey is based on connecting to your own capacity to heal, learning tools to optimize your body’s chemistry, feeling safe, and then creating the life that you want. As you move towards your idea of what you want your life to look like, you’ll be shifting off the pain circuits and nurturing ones that bring you pleasure and satisfaction. As you move into regaining your life perspective, connecting with your passions, play, and giving back, you’ll be spending much less time reinforcing your pain circuits and thrive.

Here are the areas to address that will enable you to experience the best part of your journey:

• Sleep – still the cornerstone
• Effectively processing stress – Life never stops coming at us
• Physical conditioning – is simply one of the best ways to feel better
• Medication management – a thoughtful approach will simplify this aspect of your care.
• Life outlook – is one of the most critical aspects of your journey. You have to know where you want to go to get there. How you do it is also important.
• A deeper understanding of chronic pain – will allow you to be innovative in dealing with it and allow you to have more control of your care.
• Family dynamics – turned out to be maybe the most powerful force in holding people back, but when addressed with a structured approach was remarkably helpful in healing – for the patient and the whole family.

Moving forward

Addressing sleep was the first step in the evolution of the DOC process. Twenty years ago, only a small percent of physicians dealt with sleep issues. I took an aggressive approach and would begin with “sleep hygiene” measures. But if a patient wasn’t responding within a couple of weeks, I would use combinations of sleep medications. Most people would respond within six to eight weeks. A significant percent of patients experienced a dramatic improvement in their pain. It wasn’t until years later, that I read a major paper showing that lack of sleep could induce chronic pain. (2) Unfortunately, it is still common to have major risky interventions done or recommended before sleep is addressed.

Processing stress became inherent in my practice as I worked with patients dealing with the problems created by being in chronic pain. I had experienced a lot of benefit with the book, Feeling Good, as I mentioned above and I had my patients use it. I quickly noticed that the only ones who responded were those who did the recommended writing. Other stress management approaches emerged over time. I eventually learned that stress is not the problem, as much as your reaction to it.

Addressing Physical Factors is basic to musculoskeletal care.

• Physical therapy must be tailored to a patient’s specific needs.
• Aerobic conditioning has long been documented to improve pain.
• Weight training not only increases strength but also stimulates the release of hormones that enhance your sense of well-being. It also seems to have a neurological component in that you are on the offensive, taking charge instead of being at the mercy of your pain.
• Nutrition is critical. For example, an anti-inflammatory diet can quickly lower your pain. Intermittent fasting consistently lowers inflammation.
• Bone health – osteoporosis (low bone density) creates havoc with the quality of your life and is both preventable and treatable.

Medication management is critical. You need symptomatic relief to give you “the space” to learn and implement the tools to heal. They will become much less important as your pain resolves and no one really wants to be dependent on medications. They are expensive and a hassle.

My approach was the reverse of what is usually done. I would keep patients on the same medications, including narcotics. Medication discussions were always face-to-face. Although, the goal was to wean down, the patient always had the last say regarding how quickly this would occur. Anxiety is the pain and going to war over medications is counter-productive. With the patient in charge, he or she had control (an antidote to anxiety) and I rarely had a problem with patients coming off of their meds. In fact, as the pain dropped, the side effects increased and they were anxious to stop taking them. The only criteria I required was that they had to be actively engaged in the other aspects of the structured care approach.

Life outlook is one the most important aspects of healing. Goal setting is a core aspect of stimulating neuroplasticity. Your brain will develop wherever you place your attention. It is similar to learning a new language. You have to decide what you want your life to look like, what you want in it, and then pursue it. Otherwise you are still focused on the problem and not the solution. A corollary aspect of this is forgiveness. You can’t move forward until you can let go.

Awareness of the nature of chronic pain is important because it is so complex and each individual is unique. The traditional approach is to manage it, not solve it. Random simplistic treatments are used to treat symptoms and not address the core problem of a fired up nervous system and sustained exposure to elevated stress chemicals. The DOC process is a framework that allows you break down pain as it relates to you into its components. It allows you to address all of them simultaneously. It is this multi-pronged approach that is what is so effective in successfully treating chronic pain.

The final component regarding family dynamics came about over the last few years of my practice in Seattle. We had known that chronic pain takes a terrible toll on the family. It became clear that a patient could engage in many aspects of the DOC process but the family dynamics would sabotage everything. Conversely, by addressing the family interactions around pain, patients would often experience powerful healing. We began to set up rules around pain in the household. The basic one was that the patient could not discuss their pain with anyone – ever – especially with their family. The corollary was no complaining, giving unasked-for advice, or criticizing. Basically – be nice.

From reactive to creative

Don’t stop now when you are really just beginning. It is a triumph to be out of The Abyss, but there is much more to life than just surviving. Most people have been fighting the pain for so long that they have forgotten what it is like to relax and enjoy it.

If you take the word, reactive and move the “c” to the front, you have the word creative. If you can “c” first, you have some space to look at your options and create your reality.

1. Burns D. Feeling Good. Avon Books, New York, 1999.
2. Agmon M and G Armon. “Increased insomnia symptoms predict the onset of back pain among employed adults.” PLOS One (2014); 8: e103591. pp 1-7.

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Searching for an answer

A few years ago I had a great deal of stress that landed in my neck and I couldn’t find any relief anywhere for more than 18 months. I saw many professionals – spine surgeons (no structural issue); chiropractor (looked like chronic whiplash symptoms), occupational therapist (recommended diet changes, flats, exercises, saunas, massages) and physical therapist (heat treatments, TENS treatment, exercises, massage) and nothing was working. In fact, when I went to the chiropractor he snapped my neck without asking or explaining prior to doing it and I felt an electric like shock feeling go through my back. For the next 10-12 months, I now had not only neck pain but a deep ache going down both arms. My sleep was disrupted, I was tearful, struggling with focus at work and I didn’t want to do anything.

Omega workshop

I shared my struggle with Dr. Fred Luskin, who shared Dr. Hanscom’s book, Back in Control, with me. I started to implement some of his suggestions with the first being focusing on improving my sleep. I attended the Omega training shortly after and learned more about the impact of stress and the mind-body connection. I saw others improving before my eyes and yet I found myself being miserable. I could hardly sit through the classes and was edgy and irritable but determined to learn.

It took another few months but by addressing the stress, improving my sleep, and taking glucosamine I have been pain-free for a number of years. What is even better than that is that when I feel the neck muscles tightening from either stress or behaviors (too much computer work), I can focus on getting good sleep, anti-inflammatory diet, add the glucosamine back in and now avoid major relapses. In fact, once I recovered I have never reached the same level of pain again.

Moving on

I have been so impressed with Dr. Hanscom’s work and insights into the mind-body connection that I have been focusing my PhD studies in Mind Body medicine on chronic pain and stress management. I now share the tools that I have learned and the Back In Control book with every client I work with who struggles with chronic pain.

I will be forever grateful to Dr. Luskin who led me to Dr. Hanscom and Dr. Hanscom for putting his understanding out to the world. As I have heard him say many times, “If you calm the system down surgery may no longer be necessary. If surgery is necessary, calming the system down before the surgery has much better outcomes.” Prehab

Thank you Dr. Hanscom for looking out for the greater good and not the bottom dollar. Hospitals and pharmaceuticals would prefer pain management but the DOC (Direct your Own Care) can significantly reduce pain and in some cases even cure without all the negative side effects.

How many more neck surgeries?

Omega 2018 workshop

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The post Chronic Neck Pain Gone – DOC Prevents Relapse appeared first on Back in Control.

• Adequate sleep is a necessary requirement for healing.
• Insomnia is a cause of chronic pain, and it is not the other way around.
• It is almost always possible to experience a consistently good night’s sleep using a combination of approaches.
• Do not undergo any major invasive interventions until you have solved this issue.

Insufficient sleep is a major factor that compromises one’s coping capacity and increases pain. It is consistently solvable with a stepwise approach regardless of the level of your pain. The outcomes of the various treatments are easily assessed. The key is focus and persistence. It is a myth that you need less sleep as an adult and at least seven hours of sleep is the desired amount. Few patients suffering from chronic pain are getting adequate sleep.

Incorporating sleep into the treatment of pain was my first step in conceiving the DOC protocol. I felt I had a whole new weapon that was effective and yet simple. There was always some improvement in their sense of well-being if not also their pain.

 Sleep and pain

I had originally thought that people in chronic pain could not sleep because of their pain. But a large study out of Israel showed that it is lack of sleep that induces chronic low back pain. It also demonstrated that the reverse was not true – that pain caused insomnia.¹

Another study documented that lack of sleep was a bigger predictor of becoming disabled than the severity of back pain. Even more interesting to me was that this was also true for leg pain (sciatica), which surgeons generally feel is the most disabling problem.²

Successfully addressing insomnia is the highest priority. The DOC Journey will be marginally effective if you aren’t getting 7 or 8 hours of restful sleep. Not sleeping is NOT an option. No major decisions regarding your spine care should be made until you feel rested during the day. This is particularly true regarding spine surgery.

I had one businessman that had experienced chronic neck pain for almost two years. There was no specific injury. He continued to work as an owner of a small accounting firm but was miserable. He had been through multiple courses of physical therapy. I started him on a strong sleep medication, which immediately allowed him to sleep a full night. I saw him back at two weeks to check on how the medication was working. I was planning on starting aggressive physical therapy six weeks later. When he came back for his eight-week visit, I was surprised to find he was pain-free after being in pain for over two years.

Start sleeping – NOW

There are many ways to get a good night’s sleep. Most people can figure out a solution using a combination of the self-directed suggestions below. If you are still struggling after a few weeks, you should discuss it with your primary care physician. The details of each of these suggestions are outlined in the next lesson, which is the sleep chapter of my book, Back in Control. Please use this a reference to devise your own approach.

Approaches to Insomnia – self-directed

1. Sleep hygiene – well-known set of principles to optimize sleep.
2. Stress management at bedtime – i.e., don’t read business emails while you are trying to fall asleep.
3. Exercise – It is not helpful to exercise late in the evening, but overall physical conditioning improves sleep.
4. Expressive writing – has been shown to help decrease the time it takes to fall asleep.
5. CBT-I – stands for Cognitive Behavioral Therapy Insomnia. There are online resources that may be helpful in addressing some of the anxiety around trying to get a good night’s sleep.
6. Over the counter sleep aids – I do not have specific recommendations and they should not be used long-term. You also should make your physicians aware that you are using them.

Under the guidance of a physician

1. Prescription Medications – There are many medications that are effective in dealing with insomnia. I have observed that if you are suffering from chronic pain that you often need a kick-start with strong sleep meds. Once your nervous system quiets down you can and should come from them relatively soon. Using narcotics for sleep is not recommended and creates many additional problems.
2. Diagnosing a sleep disorder – there are over 100 sleep disorders with the most common one being sleep apnea. In sleep apnea your airway intermittently becomes occluded while sleeping and you are gasping for air. Sleep quality is poor, and you are tired the next day. More importantly it has an adverse effect on your heart. If simple measures are not working, it is important to diagnose and treat this. Restless Leg Syndrome is another common sleep disorder that is treatable with the correct medications.

Recap

A consistently restful night’s sleep is necessary for healing from chronic mental or physical pain. Insomnia causes chronic LBP and must be addressed as the first step of healing. It is generally solvable regardless of the level of your pain. Most people can improve their sleep with simple self-directed interventions, but you should not hesitate to seek help from your physician.

Use the sleep chapter from my book, Back in Control, as a reference. Read it carefully and implement the steps that are doable for you. As you layer on additional strategies, you will find a way to sleep.

References

1. Agmon M and Galit Armon. “Increased insomnia symptoms predict the onset of back pain among employed adults.” PLOS One (2014); 9: 1-7.
2. Zarrabian MM, et al. “Relationship between sleep, pain, and disability in patients with spinal pathology.” Archives of Physical Medicine and Rehabilitation (2014); 95:1504-1509.

The post Systematic Approach to Sleep first appeared on Back in Control.

The post Systematic Approach to Sleep appeared first on Back in Control.

The problem is that even an ideal system will never be able to respond to the needs of a given patient quickly enough to really make a large-scale difference.  Not only are there problems navigating through all of the various parts of the worker’s comp system, these patients’ personal lives are often a disaster.  I don’t know if many of them are still even on their feet.

The more effective strategy is to give patients the tools to deal with stress.  They can often navigate their way relatively quickly through the process.  The tools also make a difference in their personal life and their families will become their support system instead of targets for their frustrations.  Conversely, without any personal support, their anger will cause them to disengage from reason and the opposite effect occurs.

It’s true that, where I practice, 80% of injured workers do well with minimal intervention.  But we don’t know which injured workers will become one of the 5% that consumes 84% of the medical resources in the state of Washington. Even the simplest injury creates additional stress on a given worker.  It is the luck of the draw whether they end up with a physician and employer that can create a smooth process.  It is unpredictable what provider or circumstance will set off the cascade of extreme disability. The idea of being pro-active in a claim is 20 years ahead of its time. It has been incredibly frustrating watching employers, in the face of overwhelming data, still not want to engage in any type of innovative process.

The category of mental health strategies described are the one’s we have been routinely using.  My concept is to “calm down” the nervous system, which has consistently decreased my patient’s perception of pain.  However, I always start with sleep.  None of the tools are effective without sleep.

I think the roundtable could develop a laundry list of strategies that could be ferreted out and implemented.  This is a group that has the power to change some things and I would challenge us to get focused.

I did become incredibly discouraged last night thinking about national politics.  Regardless of your political leanings, jobs are disappearing.  No matter how skilled you are with these stress management tools, none of them are going to negate not being able to put food on the table for yourself or your family.

BF

The post Arm the Worker first appeared on Back in Control.

The post Arm the Worker appeared first on Back in Control.

Most patients with chronic pain sleep poorly and are tired during daylight hours. They often feel pain more keenly at night when they have fewer distractions. Without restful sleep, one’s quality of life is compromised and day-to-day stress and pain are difficult to handle. The actual intensity of the pain increases.

In 1997, I started to incorporate sleep treatment into my practice. If a patient had an acute problem such as a ruptured disc, I would use sleep medications in addition to pain medications. It was much easier for my patients to wait it out until the disc healed if they were able to sleep. Whenever chronic pain was involved, the results were consistent: over the course of two to four weeks, my patient’s mood and coping mechanisms would improve with consistent sleep. If they did not get to sleep, I would aggressively keep switching meds until we found the right treatment. Not sleeping was not an option. I was able to get most of my patients to sleep reasonably well within four to six weeks.

Sleep is the highest priority

The first step in the DOC program is to get at least a month of adequate restful sleep. It is an integral part of calming down the nervous system. The program isn’t effective unless you are rested. Many adults think they can get by on less than eight hours of sleep, but consider 7 hours a minimum. Most people, especially with chronic pain, do not get a full night’s sleep.

There was one study done in which female volunteers were measured in terms of the quality of their Stage V sleep, also called REM sleep, for a period of time. This is the stage where the most dreaming takes place. It was discovered that the less amount (and poorer quality) of REM sleep, the higher the sensitivity to pain. (1)

It is my first obligation to simply get my patients to sleep. Patients argue with me that it is impossible to sleep with the pain. However, there are few situations where the right combination of medications cannot be found to yield a consistent good night’s sleep in spite of the pain. If your physician is not addressing your insomnia, insist that he or she does. It is one of the first responsibilities you must take on to pursue your pathway to a better quality of life.

1. Karaman S, et al. Prevalence of sleep disturbance in chronic pain. European Review for Medical and Pharmacological Sciences (2014); 18: 2475-2481.

The post Sleep first appeared on Back in Control.

The post Sleep appeared first on Back in Control.