In 2003, a neurosurgeon performed a laminectomy of his neck. That’s an operation where the lamina or the bone over the back of the spinal cord is removed to relieve pressure. He seemed to improve for a little while. In 2005, his symptoms worsened, and in 2009, he underwent a fusion through the front of his neck between his 5^th and 6^th vertebrae. Again there was a slight improvement but two years later he was in my office with crippling pain throughout his whole body.

Normal studies

As I talked to him, I could see how desperate he was for relief. He also wasn’t sleeping and his anxiety and frustration were a 10/10 on my spine intake questionnaire. I couldn’t find any neurological problems on my physical exam. When I looked at his neck MRI, I could see where the two prior surgeries had been performed, but there were no pinched nerves. The alignment and stability of the vertebrae were also fine. He also had undergone several workups of his brain and the rest of his nervous system. Everything was normal.

When I explained to him that I did not see a structural problem that was amenable to surgery he became understandably upset.  He was stuck on the idea that the prior surgeries had helped and that I was missing something. It didn’t matter what I said or how I explained the situation to him. He wasn’t buying it.

What I didn’t tell him was that I had also looked at his scans he had prior to undergoing each surgery. Telling a patient that they did not really need a prior surgery is a very unproductive, unpleasant interaction; I didn’t see why this patient’s prior surgeries were performed. On the first MRI of his neck, there were no bone spurs and the spinal cord was completely free. There wasn’t a structural problem that could have been corrected by surgery. On the scan before the second operation, there also wasn’t a hint of anything that could be causing any symptoms of any type.

The power of placebo

What’s difficult for patients (and physicians) to realize is that the placebo rate for any medical or surgical treatment is between 25-30% or even higher. The response and improvement is not only real but is powerful. It is the result of your body’s own healing capacity. It is a desired response, and you feel less pain.

The pain-killing effects of a placebo are reversed with Narcan, which is the drug used to reverse the effect of narcotics. There is a part of the frontal lobe of your brain that shuts off pain pathways for short periods of time. Another example is the placebo effect of cardiac medications causes the heart rhythms to actually change. Just because a prior surgery or procedure on normal age-appropriate anatomy might have been temporarily effective is irrelevant. It should have nothing to do with current decision-making. I tell my patients “If I can see it, I can fix it” and  “If I can’t see it, I can’t surgically correct it.” It’s critical to have a specific structural problem with matching symptoms before surgery becomes an option. Surgery: The Ultimate Placebo

I suggested that he take a look at the DOC website and I would be happy to explain the whole program to him in as much detail as needed. He was so angry that I didn’t think I’d hear from him again.

Early engagement

Over the next couple of months, I received a couple of emails and had a telephone conversation that seemed to go pretty well.  He was willing to engage in the DOC protocol and began some of the writing exercises. I had a second phone conversation with him a couple of weeks later that seemed to go even better. He was able to recognize that his thought of me “missing something that needed to be fixed” was an obsessive thinking pattern. I was encouraged and thought that maybe I had been able to break through his “story.”

Time went by and our third and final conversation was dismal. He couldn’t let go of the thought that “something was being missed” and that his seventh cervical vertebra was “out of alignment.” I assured him it was OK. As a surgeon, I am also quite obsessive about not missing problems that I can fix. At this point, it didn’t matter. He’d found a surgeon who was going to fuse his neck.

Injury conviction

Physicians use the term “injury conviction” to describe this phenomenon. It is the relentless pursuit of a cause for your symptoms that is well beyond reason. My concept has changed in that I feel this pattern of thinking becomes its own irrational set of neurological circuits. It is similar to phantom limb pain and my term is “phantom brain pain.” Regardless of whether the original source of pain is there, the symptoms are the same. Rational arguments have absolutely no effect.

Hell

I wrote a post Anxiety and Anger: The Highway to Hell. Unfortunately, if you’re in this pattern, you’re in Hell, and the only way out is through you. The deep tragedy is that if you don’t realize you’re in Hell, you’ll remain there. I never give up, but I have learned to let go when I can’t penetrate that firewall of obsessive thinking. For those of you that have let yourself out this hole, I am open to suggestions as to what gave you the insight to move forward. Awareness is the basis of the entire DOC process and is always the first step.

I don’t know how many more tests and surgeries he’ll undergo over the next 30 years. The personal cost to him and society will be enormous.

What’s puzzling is that if any of the surgeons who’d chosen to operate on this man’s essentially normal anatomy were examined by a board examiner about their indications for his surgeries, they’d be failed immediately for giving a “dangerous answer.” It’s our medical responsibility to you to not offer risky procedures that have been documented to be ineffective.

Video: “Get it Right the First Time”

The post How Many More Neck Surgeries? first appeared on Back in Control.

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Anger

It is my observation that the whole system of care ignores the most significant factor that contributes to the development of chronic pain—anger. Anger is universal and part of the human experience. Some argue for the necessity of anger. In any case, it is not going away any time soon. Anger provides a useful survival mechanism. When you are threatened and feel anxiety, you will take evasive or avoidance action. When that ability to escape is lost, you will become angry, which increases your body’s physical reaction and mental focus to solve the problem.

Control

The antidote to anxiety is control.

Loss of control = anger.

The current disability system strips the worker of control. Additionally, at least in Washington State, the injured worker is at the mercy of a medically unsophisticated claims examiner. That examiner has final say in everything. As “enlightened” as I am, I cannot discuss a case with an examiner for more than a few minutes before I feel like I am losing my mind. I cannot imagine having my well being, as well as my livelihood, at the mercy of this system.

Dealing with the Anger

It will not matter what systems are designed to “incentivize” workers to return to work, unless this core issue of anger is addressed. You don’t have to incentivize any living creature to jump out of a cage. You just have to the door. Anger not only traps workers so they cannot fully engage in their care, but it also robs them of the ability or motivation to become engaged.

Although anger can be a useful survival mechanism, it is usually destructive to you and everyone around you.  Your anger imposes its own will on the immediate surroundings, and you lose all ability to rationally interact with your environment. The consequences are often disastrous. The most well designed programs are not going to be effective unless the wall of anger can be penetrated.

Anger and Frustration with Workers Compensation 

The post Anger and Workers’ Comp Webinar first appeared on Back in Control.

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“Not much I can do”

I prepared to walk out the door and have her referred to a primary care physician. He or she could offer some basic care such as medications and physical therapy. But I did not know a way to have this quickly done, and she seemed like she was in a crisis. I turned around and walked back into the room realizing that at least her husband spoke some English. I spent about 20 minutes explaining the relationship between pain and the central nervous system’s response to it and gave them a copy of my book. I asked both of them to at least engage in the expressive writing.

Surprisingly, she and her husband returned. She could walk and conversed with me through the interpreter. Her whole body still hurt but she felt a little better. Her husband had not really engaged in reading the book. I was encouraged by the little progress, but I felt that if I was going to teach her anything about chronic pain, it was going to have to be done by me in the office through the interpreter. I spent about a half an hour going through the relationship between pain, anxiety, and anger. I again asked the husband to assist her in learning and translating the concepts. I also requested that she further commit to writing down her thoughts and immediately destroy them.

It was anxiety

They returned two weeks later and her pain was markedly improved. As I talked to her it became crystal clear that she was being tormented by extreme anxiety. She stood in the opposite corner of the room with her arms wrapped around herself and her whole body was quivering with fear. They had decided to move their family back to Puerto Rico so she could be with her mother. I realized that this was the last chance to turn this around.

I explained to her that although she might have a temporary decrease in her anxiety, she was not going to completely outrun it by being around her family. It was fine to move back home if that was what she wanted to do. If it was to escape anxiety, I felt that was a bad idea and it would follow her. I became very blunt with her and her husband about the whole situation. He needed to engage. She needed to address her anxiety as its own issue and commit to the writing process. I re-explained some of the central nervous system concepts. I was fairly sure they were headed back to Puerto Rico.

Better

Two weeks later they returned. She and her husband were both smiling. Her pain and anxiety were much better. They were not moving to Puerto Rico and were excited about how the situation was turning around. Her husband was more engaged and she had pursued her expressive writing with a vengeance. It had been extremely helpful. Her husband’s comment was, “I have my wife back.”

I have no illusions that she is yet home free. Recovery is not a straight-line endeavor.  But she now had tools and more importantly—hope. Her problem was not chronic pain; it was anxiety. I did not order any tests. I prescribed some medications for sleep and pain. I spent about two hours of my time talking to her. She engaged in the simple but powerful tool of expressive writing and has a high probability of continued improvement.

Back in action

What is this worth? There are two adults and two children in this family who have a higher chance of being contributing members of society. There is less family stress, which improves the behavior of the children, who are going to school with your children. The wife has a better chance of being an effective mother and getting back into the workforce. Minimal medical resources were expended and less will probably be spent in the future.

Four lives affected. Minimal medical resources expended. With her severe language barrier, writing down her anxieties was her only choice of tools. This occurred relatively early in my presenting the DOC process to my patients. I did not anticipate this outcome. Treating chronic pain has become one of the most rewarding parts of my practice.

BF

The post Freed by a Pen first appeared on Back in Control.

The post Freed by a Pen appeared first on Back in Control.

Crystal could not walk for more than half of a block without having to sit down. As she had been this way for several years, she was becoming increasingly weaker. She was very unhappy at the prospect of losing her independence, in addition to experiencing a lot of discomfort. Understandably, her anxiety was through the roof.

The Surgery

I performed a three-level laminectomy on her at L2-3, L3-4, and L4-5. This procedure removes the narrowing around the nerves, and about 70% of the time, patients are able to walk without pain. It takes a while for the strength and endurance to return. Unfortunately, most patients don’t engage in the rehab enough to experience the full benefit of their surgery. As she was so frail, my optimism for Crystal was tempered. I knew her leg pain would improve, but probably not her strength.  She also just did not seem like the person who would engage in a full rehab program.  I never give up though, so I talked to her about the DOC project and told her about my website.

Post-Op

The surgery went well and Crystal’s legs felt better. During our first phone appointment, she began to ask a lot of questions about the website and had begun the writing exercises.  She was slightly encouraged, and I was pleasantly surprised. The talk evolved into a somewhat extended conversation about the central nervous system and conditioning. It is difficult to make the effort to exercise when a person has a lot of anxiety.  To see a full recovery, I ask all of my patients to workout with weights three to five hours per week.  She was interested in getting completely involved in the process.

One month after the surgery, she was sleeping better, and felt her anxiety dissipating. She would go out for small walks every now and then. I encouraged her to join a gym. I really did not expect her to go.

Her Outcome

When I talked to her a few months ago, she was a different person. Her voice was energized. She had joined a gym and was working out four or five times a week. She felt a dramatic increase in her strength and endurance. Her anxiety was down by 80-90%.  She was going out with her friends and socializing. She was ecstatic.

I asked her to write a follow up letter about her experience, which is about a year from her surgery.

Crystal’s Letter

Dear Dr. Hanscom,

How nice it is to feel better!

It’s great to be able to do some of the things again that I used to do. I am doing everything that I have been asked to do. I am working out in the gym every week. I am also working through all of the stages of the web site. All of the books have been interesting and helpful.

My friends tell me how good I look. They say that they no longer see the look of pain in my face.

I feel like I have my life back.

Sincerely,

Crystal

Move Forward

I have kept in touch with Crystal and we talk every three months. Seven years later, she is still working out in the gym, and her strength and endurance have continued to improve. She is active in the community with a nice circle of friends. This in sharp contrast to when I first met her and she was lying around her house, at the mercy of her pain.

The tools on this website are self-directed. My observation is that there is no question of “if” you’ll better, but only a question of “when.” The decisive factor is a patient’s willingness to engage. It is stories like Crystal’s that keep me moving forward with this project.

“Better Not Look Down”

The post A New Life at 72 first appeared on Back in Control.

The post A New Life at 72 appeared first on Back in Control.

I talk about how anxiety and stress can lead to certain obsessive tendencies. Some of the tools from the DOCC project are laid out, specifically those that can help break down the circuits that fuel anxious and stressful thoughts and behaviors.

For more, see Your Demons are Robots.

BF

The post Video: Anxiety and It’s Demons first appeared on Back in Control.

The post Video: Anxiety and It’s Demons appeared first on Back in Control.

As these family patterns are so familiar it is anxiety-producing to change or even think about changing them. Your family feels the same way. All parties involved have a vested interest in having you remain unchanged – regardless of how miserable you might be. “Misery loves company” is not a joke.

Paraplegic

I have a patient who became paraplegic after spine surgery at an outside institution.  He has had multiple medical problems associated with his paraplegis in addition to suffering chronic pain in his back and legs.  Working through the phases of the DOC project has resulted in a significant decrease in pain. Unexpectedly, his bipolar disorder of over 40 years disappeared and he was able to discontinue his medications. The key was addressing his deep anger. The transformation was dramatic. He felt happier in a wheelchair than when he was bipolar and walking.

“I don’t want to see you”

I had been seeing him monthly for several years. We had entered the goal-setting phase of his rehab. He was interested in interacting with other people who are wheelchair-bound.  This fall, he was able to purchase a laptop computer and start pursuing his dream.  Then he called my assistant and told us that he was not going to be seeing me anymore. My first response was to wonder what I had done to upset him. He had truly been an inspirational person, so I gave him a call to ask why he no longer wanted to see me.

Thanksgiving

What happened was this: his family from the East joined him for Thanksgiving; instead of being excited and supportive of his transformation, they destroyed him. They told him that there was no use in reaching out to other paraplegics. They also reminded him that he had been diagnosed with a bipolar disorder since he was 12 years old and told him that the disorder is incurable. Finally, the family instructed the patient to stop seeing me.

The family environment that contributed to him becoming bipolar was now focused on keeping him that way. His deep changes were upsetting to his family because there was a major redefinition of roles taking place. He had been the sick one. If he could create this depth of insight and healing, why couldn’t they do the same?

When he was in his own familiar patterns, which were based on anger, he could not see his anger or their anger. Today he saw it as clear as day. He had not been chronically angry for over a year and was moving forward quickly. To now see the people you love live in anger was extremely distressing.

Family Patterns

Family patterns are passed down from generation to generation.  From birth to age 12, your family environment is “downloaded” into your brain. It is your database for the rest of your life and also your frame of reference. What are your patterns? Are you being held back by your own patterns that you cannot recognize? Are you unconsciously making sure that the people close to you maintain a certain familiarity, even though it may be destructive?  Do you have control issues?  Do you feel controlled?

Wake up. Your life will not improve until you become aware of your behavioral patterns and the impact they have on those around you.  If you are chronically angry, you cannot see anything clearly, and like me, you may not even be aware you have any issues with anger.

I had a great discussion with that patient and he continued to see me for about six months. The phase of breaking free of his family patterns was challenging. In order to break free, he had to first recognize that he was trapped. He was undertaking a significant step, one that I’ve talked about before in “ Anger: The Continental Divide.” Personally, I had never understood how strongly these family patterns could hold you down. I thought his family would have been ecstatic. He was happy for the first time in his life. His family was not.

Back into the abyss

I am rewriting this story after about a year. For about six months his mood and pain were great and rehab was moving forward. The anger returned for reasons that are unclear. He was never completely the same after that Thanksgiving holiday. He did quit seeing me, his anger consumed him. His pain returned and his mood turned black. I don’t know all of the issues that pulled him back into the abyss but his family was a significant part of of it.

What effect is your family having on your journey? Are they your cheerleaders – or not?

The crab bucket

The post Breaking Loose – NOT first appeared on Back in Control.

The post Breaking Loose – NOT appeared first on Back in Control.

BF

The post Video 14/19: Chronic Pain: Pain Free is Not Only Possible, it’s Probable. first appeared on Back in Control.

The post Video 14/19: Chronic Pain: Pain Free is Not Only Possible, it’s Probable. appeared first on Back in Control.

Our brain has neurological circuits that can become memorized. In this video I discuss phantom pain, which is more the rule than the exception with amputations. This factor is a significant problem with any chronic pain situation.

The post Video: Memorizing the Circuits: Phantom Pain first appeared on Back in Control.

The post Video: Memorizing the Circuits: Phantom Pain appeared first on Back in Control.

I am on a much-needed vacation this week in Italy.  From 1980 until 1990, my wife lived in Florence.  We have many friends in Italy we like to visit as much as we can.  It is a unique opportunity for me in that she is fluent in Italian and we are able to spend time in our friends’ homes in the heart of Tuscany.  There is nothing quite like sitting down to a home-cooked Italian meal overlooking a beautiful valley.

Last night was one of those evenings.  Our friends not only put us up in their apartment, they had us over to dinner with several other friends.  The conversation drifted towards medical care.  One of the guests had experienced some medical problems of a moderate nature that required several physician visits and a couple of procedures.  He said that the aspect of his care that most struck him was that at no point during his care did anyone from the receptionist to the doctor ask him how he was doing.  Additionally, when he was asked some detailed questions about his condition, he was asked if he was a doctor.  When he replied that he was not, he was told that he had been informed enough and that he should not ask so many questions.  You might imagine his frustration.

I have witnessed a lot of success with the DOCC protocol, but it has become increasingly clear that the protocol is just a framework. It helps organize both the physician’s and patient’s thinking about chronic pain and therefore makes it much easier to create a treatment plan.  It is the patient who organizes and implements the plan. The physician is more in the role of a “coach” as well as being continually aware that there might be a potential structural problem.

About a year ago, I was talking to the pain psychologist I work with about what we were doing that seemed to be more helpful to our patients than either of us had historically observed.  She kept insisting that I was the factor that made the difference.  I was sure it was the DOCC protocol and the work she does.  After more and more positive results, I finally agreed that I played a major role in their recovery.  To clarify, I don’t believe that I have a special gift or am the world’s best doctor.  I simply stay committed to my work with the patient.  With increased attention over the last couple of years, I have seen more patients who had been in pain for decades become pain free.

Through my numerous difficult experiences, I have had many layers of my own personal labels stripped off.  Physicians, especially surgeons, are perfectionists.  It gives us an early competitive edge in high school and college.  It is somehow held up as a virtue by our medical culture and demanded by society.  Unfortunately, it is a complete disaster with regards to our ability to connect with our patients.  By definition a perfectionist is continually judging himself or herself by an unattainable standard.  As I have labeled myself, I have labeled others around me.  As it has been my reality for over 50 years I had no clue that this process was taking place.  I recently wrote an article, “The Cry of Chronic Pain—No One is Listening.”  The essence of the article is that once you have a label of a “chronic pain patient” placed on you, the world, including you, feels that it is just “something you have to live with” and your care becomes essentially palliative care.

I recognize that labeling is universal but it is not constructive.  I am aware that I label people constantly. As I work to become aware of the label I am placing, I am able to eventually see who you truly are.  You are a whole person.  Neither you nor I are the labels we place on each other.

The energy for your healing journey comes from you, not me.  What I contribute is that I am able to see you as a whole person and you are somehow able to remember that part of you that is really you.  When that part of you “wakes up,” there is no stopping you.  You are your own oasis in the middle of the desert.  I cannot ever tell who will engage or when.  The DOCC project is just a rough framework and every journey is completely different.  I am continually energized and inspired by the incredible obstacles you overcome to return to a rich, pain free life.

I recognize that essentially all physicians are compassionate.  Many physicians have figured out this journey and most have not had to experience burnout to learn it.  I am continually humbled by numerous examples of deep compassion by my colleagues.

I always thought I was compassionate. I was very well intentioned and always gave every patient my best shot.  However, the physician burnout rate is around 50% and we truly have a life full of more stress than you can imagine.  If you are just trying to survive, there is only so much you can give.  Additionally we have no resources or tools to help us out.  The safety net is a concrete floor.  It has been shown in several studies that it is during the third year of medical school that compassion takes a dive.

I am not writing this post for you to begin looking for a physician who is compassionate.  It is not a bad idea, but it is not necessary for you to heal.  Remember this process is about you taking full responsibility for every aspect of your care and your life.  You don’t need me.  You don’t need the DOCC project.  You just need to connect with that part of yourself that is whole and wants to thrive. The person who you need to experience compassion from is you. Use whatever means you have at your disposal to figure this out.  It will probably take some outside help but there are multiple resources. Quit trying to “figure all of this out” and just go.

NH, BF

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“Happy”

We all want to become better, happier people, and we work pretty hard at it. The marketing world keeps reminding us that we are not even close to our potential and holds up endless images of perfection that reinforce that idea. The solution advertising offers is a better appearance, more friends, accomplishments, public recognition, power, etc. We are programmed into being defined by external factors.

Additionally, self-help resources are everywhere. There are seminars, healers, books, lectures, and retreats, much of which can be helpful. The message is “if I had more of  ‘___________’ I would be a happier person.”  This includes wisdom, the tools on this web site, less pain, etc.

What we really mean when we say that we want to be happy is that we would like to experience less anxiety.

The “Abyss”

Many, if not most, of my patients would test out just fine on a psychological test. But chronic pain will still take you down anyway. It creates extreme anxiety and frustration. I define “The Abyss” as:

Anxiety x Anger x Time

The Abyss represents an unspeakably dark area of your brain. My patients can’t express it with words. I spent over seven years in a severe burnout. My experience also included chronic pain in several areas of my body. I experienced an intense burning sensation in both of my feet, tinnitus, multiple areas of tendonitis, migraine headaches and crushing right-sided chest pain.I didn’t know why I was having all of these symptoms and all the testing was normal. I eventually lost all hope. I “pre-tested” every millimeter of the pathway outlined on this website, mostly by trying multiple approaches that didn’t work. Suffering from chronic pain is far removed from happiness.

 Paradoxes

• The DOC process is paradoxical. The harder you try to get enough of the tools to “fix” yourself the less likely you are to be successful in becoming pain free (or happy). It is critical to understand that you have to enjoy your day with the idea that your pain or your life circumstances may never improve. In other words you must learn to enjoy life with what you have—NOW!
• If you are waiting for more wisdom, more re-programming tools, more money, a nicer spouse, better-behaved kids, or less pain before you can fully engage in your life, it’s never going to happen. It is life’s ultimate paradox. The harder you try to “fix” your life and yourself, the less likely you are to enjoy it.
• We also forget how illogical it is to think that all of the variables in our lives are going to align so well that we are going to finally be fulfilled. And if it could happen, how long do you think it would last?  Think how much energy we spend trying to control so much. Yet, we don’t give up trying.

The Reverse Paradox

Then there is the other side of the paradox. The more you can enjoy your day in light of your current life circumstances; you will then possess more energy and creativity to create a life that you desire. The Eye of the Storm

An Exercise

I often do an exercise with my patients. I look at my watch and point out that the time is X and you have Y number of hours left in the day. I ask them to make a decision to enjoy the next number of hours regardless of their circumstances, including the pain. A major key to solving your pain is to step fully into the life you want, with or without the pain.

When I was in the middle of my own intense burnout about 10 years ago, I had to make ongoing decisions to just enjoy the next 15 minutes. I’m serious. I had to make a conscious effort every 15 to 30 minutes.

My ongoing challenge to myself and to my patients is, “Enjoy your day—today.”

Listen to the Back in Control Radio podcast Enjoy Your Day – Today

The post Enjoy Your Day-Today first appeared on Back in Control.

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