Mark Owens’ Story

This is a video that we shot of Mark Owens, who wrote the Forward of my book. I’d like to give you some additional background to his story, both from his and my perspective. He is a PhD scientist who has spent his life addressing environmental issues. At age 29, driving a battered 3rd-hand Land Rover, he and his wife found their way into some of the most remote reaches of the Kalahari Desert of Botswana, and later, the Luangwa Valley of Zambia. There they conducted wildlife research on lions, elephants, hyenas and migrating antelope, and established model programs to protect these animals from commercial poachers while raising the living standards of indigenous people. After 23 years, he accomplished his vision, and his work still continues on through the structure he put into place and the local people he trained to carry it on. His story is reflected in his books, Cry of the Kalahari, The Eye of The Elephant, and Secrets of the Savanna .

Back in Idaho after more than two decades, he purchased and restored a large piece of land and its wetland in Idaho as a wildlife preserve for wolves, grizzlies and other wildlife. He also reversed much of the environmental damage done by indiscriminate ranching and logging practices. His commitment to making the world a better place is remarkable.

The horse accident, as he related in the Forward of my book, occurred while searching for grizzles on his ranch in the Cabinet Mountains of Montana, and his injuries were severe. A fractured spine represents severe trauma, but it isn’t nearly as painful as a crushed chest wall. After the surgery, he developed severe chronic pain for over nine years. Why?

My perspective 

Here are some points that I want to add to his remarkable story of healing.

Although this was a major injury, the usual post-operative course for a fractured spine is moderate to severe pain for a couple of weeks and then it usually resolves in about six weeks. From a surgeon’s perspective, he was the “ideal surgical candidate.” He was extremely motivated to get better, which is true for almost everyone in pain. However, there were a few details that were missed, and no one asked him the right questions.

First, he was under a large amount of stress. He left Africa after corrupt government officials and poachers had plotted his assassination for the third time.  And in Idaho, hunters and ranchers resented his conservation efforts on behalf of predators that they perceived as a threat to their domestic stock. Under less stress, it’s unlikely he would have developed such severe chronic pain. He’s really tough. Few people on this planet would have attempted what he accomplished in Africa.

Second, after he developed chronic pain from the first operation, a second one was performed to address degeneration at the lumbar 2-3 level just below his prior thoracic surgery. The surgeons performed a fusion with a known success rate of less than 30% for disc degeration. It has been well-documented that disc degeneration is not considered a source of pain.

Additionally, it has also been demonstrated that performing surgery in the presence of ongoing chronic pain of any kind, can induce pain at the new surgical site or worsen the pain at the surgical region. (1) His pain become dramatically worse.

Third, several surgeons had recommended surgically breaking his spine in two, re-aligning it and fusing him from his neck to his pelvis. One surgeon referred to the procedure as the “Blue Plate Special.” If a one-level fusion had made him worse, what do you think a 12-hour procedure with a high complication rate would have done to him? From my perspective, the decision not to recommend surgery was easy. His spine showed disc degeneration that was normal for his age. There was nothing to operate on.

Fourth, although he was not without some hope, he was quite skeptical and he didn’t really believe me that his pain was solvable, with or without surgery. The DOC project is not about believing in it or not. It is simply a framework that allows the patient to more clearly and readily sort out his or her scenario, and find a solution. The principles are universal and hold true regardless of how you feel about them. The key is to engage and move forward.

Fifth, his healing was dramatic, which many of my patients find discouraging because they don’t have an immediate response. Most people don’t, and I have observed that the process generally begins to create change over three to four months. Maybe one out of twenty people experience such a rapid response. The key is persistence.

Sixth, there are over 1000 research papers that document the effectiveness of expressive writing. (2) There is no debate that it improves mood, performance and lessens over 30 possible physical symptoms. The issue is how and why it works. Conversely, there is little evidence that a spine fusion is a solution for back pain. The success rate is less than 30% at two-year follow up and has never been compared to carefully structured non-operative care, such as the DOC program. (3) Unfortunately, insurances don’t cover most of the treatments that have been demonstrated to work.

Finally, his life wasn’t perfectly pain free after the initial healing. Unpleasant circumstances will cause your body to be full of stress chemicals, which increases the speed of nerve conduction and increases pain. (4) We worked through several major flare-ups together and eventually he acquired the skills to pull out of these flares on his own.

We have become close friends and we now support each other. Not only is he doing well over four years later, he’s thriving. The cost of healing was negligible for him and society. The risk was zero. I feel privileged that I was able to give back what I learned through my own ordeal with chronic pain. Watching people connect with their own healing capacity continues to be a remarkable experience.

Forward to Back in Control

1. Perkins FM and Henrik Kehlet. Chronic Pain as an. Outcome of Surgery. Anesthesiology (2000); 93:1123-33.
2. Smyth JM and James Pennebaker. Exploring the boundary conditions of expressive writing: In search of the right recipe. Br Jrn of Health Psychology (2008); 13:1-7.
3. Carragee EJ, et al, A gold standard evaluation of the “Discogenic Pain” diagnosis as determined by provocative discography. Spine (2006); 18:2115-2123.
4. Chen X, et al. “Stress enhances muscle nociceptor activity in the rat.” Neuroscience (2011); 185: 166–173.

The post Avoided a 12-hour Spine Fusion and is Free from Chronic Pain first appeared on Back in Control.

The post Avoided a 12-hour Spine Fusion and is Free from Chronic Pain appeared first on Back in Control.

It’s Donna, a former patient. I just wanted to write and tell you some good news regarding my back situation. You were right about forgiveness as well as the emotional aspects of back pain–at least in my case.

After following the physiological recommendations and taking the various classes you suggested, I read your book and began my own journey of forgiveness with the help of my church.

I continued to get stronger and feel better as I progressed through the various stages. However, the nerve pain continued to remain. It would crop up for no apparent reason and take me out. The final step to my healing process was a worship night at my church and prayers of healing. I was able to release all the guilt and shame I had been holding onto unbeknownst to me. I had received prayers, love and unconditional acceptance in return from the prayer team.

With all that said, the bottom line is, I am out of pain!! It has attempted to return but I am able to pray it away and remind myself of the healing that took place and it goes away. There is a huge element of emotional healing involved, as you have stated. I thought you might be interested in hearing another success story.

Thank you again for all of your insight, wisdom and help! It is truly amazing to wake up pain free!

Gratefully Yours, Donna

Meet Donna

Imagine getting a letter like this from a patient you had worked with for a couple of years and then lost touch with after she moved away. Her success story is enough to write about in and of itself; but her case also changed the way I think about chronic pain.

Donna was an extremely pleasant, positive, and physically fit aerobics instructor and single mother of three teenagers. She came to me for a second opinion regarding a proposed spine fusion. It was going to be her sixth spine operation in seven years. She began to experience lower back pain (LBP) around the year 2000, without any obvious inciting event.

Before coming to see me, she had undergone the following procedures:

2002    Two-level lumbar spine fusion from L4 to S1, with marginal results

2003    Spinal hardware removed

• • L5-S1 (lowest level) had not healed
  • Weak area repaired, but it did not help

2007    Neurostimulator placed into spine (two trials placed), which helped for about a year

 When she first came to see me in 2009, Donna was unable to work because of the following condition:

• • Disabling LBP and leg pain
  • L5-S1 fusion still had not healed
  • Arthritic facet joints (joints along the back of the spinal column that link the vertebrae)
  • Lumbar 3-4 disc, just above the two-level lumbar 4 to the sacrum fusion broken down to the extent that the vertebrae were “bone on bone” (However, her spine was stable at this level in that the vertebrae did not move when she leaned forwards and backwards, and there were no pinched nerves.)

Donna’s Journey

Because her condition was stable, and because there is little if any correlation between degenerative disc disease and back pain, I recommended no more surgery for her. As bad as her L3-4 disc looked, I did not feel it was the source of her pain. Besides, if L3-4 was fused, there was a strong chance she would not improve—L2-3 could break down quickly; and over five or ten years she might need a fusion up to her thoracic spine. With a fusion that high, you can no longer twist; and Donna was, after all, an aerobics instructor, and needed that flexibility.

Instead, I suggested that Donna apply the treatment outlined in the DOC process, and I referred her to a non-operative physician to help her along. She took my advice and aggressively pursued every part of the DOC program. She addressed sleep and stress, avoided pain medications, attended wellness classes, and resumed workouts at the gym. She consciously chose to move forward with her life in spite of her pain.

But she did not improve very much. I don’t think I’ve ever seen a patient work so hard at getting better with so little improvement. Because of her spine pathology, I still questioned whether I should offer her more surgery; but by that time she had decided to recover without any more surgical procedures. After a couple of years she moved to another state, and we lost touch.

Then, a couple of years later, around 2011, her letter came. At the time I was surprised at her degree of pain relief. But today I have seen this level of recovery occur consistently in many patients who fully engage the DOC process. In my experience, the most consistent predictor of success has been truly letting go of anger, including that caused by the chronic pain experience. True forgiveness is not just an intellectual exercise. While I have seen many patients improve before they let all the anger go, none become pain-free until they cross that line.  I call it the “Continental Divide” of chronic pain.  Remember, although you have legitimate and understandable reasons for your frustrations, your anger will still hurt you.

Today and what I have learned

Today I am more aware of the mind-body connection than I was when I first saw Donna eight years ago. I now regard emotional pain and physical pain as equivalent, in that they are processed in a similar part of the brain and with the same chemical responses. It appears that anxiety is the pain. As anxiety-produced adrenaline drops, nerve conduction slows down, and you feel less physical pain. Knowing this today, I can understand outcomes for patients like Donna, who became pain-free without additional surgery, even with her significant spine pathology. Her case also taught me:

1. Patience is critical for both physician and patient. I had given up—not on Donna but on the idea that the DOC concepts were going to help her. I learned that I can never predict who will respond or when the tools will kick in.
2. No matter where the pain originates or how severe the pathology might appear, relief is possible, if not probable, without surgery. That is not to say that the DOC process is 100% successful, nor do I feel that I have discovered a magic program. But I feel that the structure it imposes does allow patients to organize their thinking so as to connect with their own capacity to heal.
3. A caring community is powerful. Most patients in chronic pain isolate themselves, giving them more time to think about their pain, allowing the pain pathways to become deeply imbedded. Reconnecting with family, friends and society is a significant factor in moving away from pain pathways.

The final stage of the DOC process is “Expanding Your Consciousness.” The ultimate solution for solving pain is regaining your life perspective, regardless of the form it takes.

Never give up–ever!

The post Healing With Support from her Community first appeared on Back in Control.

The post Healing With Support from her Community appeared first on Back in Control.

His tests and treatment were as follows:

• His lumbar MRI showed disc degeneration at every level but no instability.
• He had crippling anxiety including fairly frequent panic attacks.
• He was open to psychological care.
• I engaged him a structured rehab program, but essentially every request we made for biofeedback, psychological intervention, mindfulness/meditation, and back school was denied by Worker’s Comp—over and over again.
• I somewhat kept him on his feet by seeing him back every couple of weeks for about six months. We kept requesting care.  Even personal phone calls to his claims examiner were of no avail.

I referred him to a pain specialist that I have teamed up with, and he continued with a similar program but again with no support from Workers’ Comp.

• The patient still complained of severe crippling anxiety and was somewhat desperate for mental health care.
• I am not currently his treating physician but last week my colleague emailed me and asked me to re-evaluate him.
• It has been recommended to him that he have a two-level lumbar fusion for his degenerated discs.  My friend begged him not to pursue it.
• The patient is anxious, frustrated, and does not want to talk to me or anyone else.  He is now intent on pursuing surgery.

So look at this situation.

• We know that chronic pain increases anxiety and frustration, which exacerbates pain.
• Psychosocial stress is a better predictor of outcome than the surgical pathology.
• The return-to-work rate at one year from a lumbar fusion for low back pain in the State of WA is 15%.
• The patient has documented severe untreated anxiety.
• In addition to his baseline anxiety, interacting with the Worker’s Comp system has pushed him almost into a rage.
• The state still will not pay for any mental health resources
• They will pay for an operation that will cost them between 50-75 thousand dollars and has a re-operation rate between 15-20% within the first twelve months of the index operation.
• If he does not undergo surgery, his claim will be closed and he does not have the emotional capacity to compete in the work force.

I have no ability to intervene, as I am no longer his treating physician.  I realize that “this is not my problem.”  That is correct.  It is not my problem; it belongs to all of us.

Does anyone have any suggestions?

BF

The post It Really is Upside Down first appeared on Back in Control.

The post It Really is Upside Down appeared first on Back in Control.

I then spent the last year developing The DOC (Direct your Own Care) Journey. It is a self-directed program that reflects the successful efforts of many patients in breaking free from chronic pain. It has become a more clear process and people are healing more quickly with minimal resources and risk.

“You have degenerative disc disease.”

I regularly saw patients who’d been told that they had “arthritis, bulging discs, herniated discs, bone on bone, ruptured discs or degenerated discs”. They were terrified that they would become increasingly disabled and needed to be especially protective of their spines. Surgeons could be aggressive in pointing out how their lifestyle might become quite limited or they might end up in a wheelchair without surgery.

We know that if you view any body part as “damaged”, you’ll tend to focus on it and the sensations from that area become magnified. Then the next logical step in thinking your spine is “a disaster” is to be worried about becoming paralyzed and again surgeons will often state this. None of this is true. We generally don’t know the exact source of neck/thoracic/back pain (axial pain) most of the time. But we actually do know that the discs between the vertebrae are not the source of chronic pain.

Discs lose water content and become stiffer as we age. Since MRI scans are dependent on the signals created by water, less hydration means less signal and a darker disc on scan. That’s it. That is all it means. It doesn’t mean it’s a source of pain. A more accurate term for this condition would be “normally aging discs” instead of “degenerative disc disease.” It’s not a disease.

You do stiffen up as you age

A less flexible spine doesn’t correlate with a painful spine. There have been multiple studies done in the cervical, thoracic, and lumbar spine demonstrating that there is little correlation between a degenerated, herniated, bulging, or ruptured disc and back pain. (1) For example, if you randomly study 100 people who have NEVER experienced significant low back pain, by age 50, the majority of them have bone spurs, herniated or ruptured discs, disc bulges, or “degenerative disc disease”. By age 65, it approaches 100%.

There was a study done in the 1950’s that showed that after a disc operation, the chance of having low back pain after surgery was less if there was more degeneration of the disc and therefore less motion.

I encountered this scenario daily in clinic. Patients came to me with severe leg pain from a pinched nerve and had no back pain. Yet the x-rays and MRI scan often show that the spine has severe arthritis, degeneration or ruptured discs. I have personally undergone two low back surgeries and my three lower discs are severely degenerated on MRI. Nonetheless, it is my right arthritic knee and hip that slows me down, not low back pain.

Severe degeneration and no LBP

I evaluated an active middle-aged woman with extreme pain down the side of her left leg every time she stood up or walked. She had no pain with sitting or lying down. She was an avid cyclist, runner, and worked out at the gym regularly. She had narrowing around her fifth lumbar nerve root as it exited out of the side of her spine. Every time she stood up, the fifth nerve was tightly pinched. Her spine was one of the worst looking spines I have ever seen in any person of any age. Every disc was completely collapsed and each vertebrae was bone against bone. There was also a moderate amount of curvature (scoliosis). She had absolutely no back pain. She had never had significant back pain. I performed a one level fusion at L5-S1, which relieved the pressure on the nerve. The fusion prevented the opening around her 5th nerve from collapsing when she stood up. Her leg pain is gone and she has been back to full activities for over ten years.

This example is extreme only in the severity of the degeneration of the discs. I see patients routinely who present with severe degeneration of their spines and have only leg or arm symptoms from pinched nerves.

Structural versus non-structural

If you can’t specifically localize the source of pain, it would be considered a non-structural problem. Axia pain almost always considered non-structural since the pain is widespread and there isn’t a reliable method to identify the “pain generator”. Surgery is helpful only for structural problems, when the offending lesion can be identified and the symptoms closely match.

One analogy is that of going to the dentist with a painful cavity. The source of the pain is obvious. By having the tooth repaired or pulled, the problem is solved. But if you present to the dentist with mouth pain and can’t identify the source, you have to be much more careful. Random procedures in your mouth probably won’t solve the pain, since there are so many possibilities. Doing back fusions is about as successful. Most of the discs in the lower back have some degeneration. Even if you thought one of them might be the source of pain, how do you know which one it is? More invasive testing, such as injecting dye into the disc, hasn’t worked out well either.

Stiffer

I recall a Golf Digest article many years ago showing a famous golfer’s swing during his first years on the PGA tour compared to 20 years later. Early in his career he had a beautiful “C” shape of his lower back at the completion of his swing. Twenty years later, his lower back was almost straight throughout all the phases of his swing. None of us are as flexible in our 60’s as we were in our 20’s.

Discs can be the cause of pain in the initial acute phase of an injury. This often occurs in the presence of a relatively normally hydrated disc that has more motion than a degenerated disc. (2) It’s felt that the ring around the perimeter of the disc is partially torn and there’s an irritation of the nerve fibers in the ring that can be quite uncomfortable. Before my first back operation, I would experience severe episodic bouts of low back pain. After the rupture of my L5-S1 disc relieved the internal pressure on the pain fibers in the ring, my back pain disappeared.

Even though discs may cause acute neck/ thoracic/low back pain, they are not the source of chronic axial pain. Chronic pain in any location in the body becomes a neurological issue after six to twelve months. (3)

There are hundreds of thousands of spine fusions being performed annually in the US on degenerated discs for axial pain. The results are predictably poor and people are often worse. (4, 5) Be careful. A spine fusion is a major intervention. You might be making the decision to have surgery performed on a structure that is completely normal for your age. How can that possibly be a good idea? Challenge your surgeon.

References:

1. Jensen MC, et al. Magnetic resonance imaging of the lumbar spine in people without back pain. NEJM (1994); 331:69-73.
2. Weber, Henrik. Lumbar disc herniation: A controlled prospective study with ten years of observation. Spine (1983);8:131-140.
3. Hashmi, JA et al. Shape shifting pain: Chronification of back pain shifts brain representation from nociceptive to emotional circuits. Brain (2013); 136: 2751 – 2768.

4. Perkins, FM and H Kehlet. “Chronic pain as an outcome of surgery: A Review of Predictive Factors.” Anesthesiology (2000); 93: 1123 – 1133.

5. Carragee, EJ et al. A Gold Standard Evaluation of the ‘Discogenic Pain’ Diagnosis as Determined by Provocative Discography. Spine (2006) 31: 2115 – 2123.

Listen to the Back in Control Radio podcast Degenerative Disc Disease Isn’t a Disease

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