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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She was a healthy physically active rancher. Her low back pain started in the summer of 2005 after a lifting injury. The pain had become constant and was located throughout most of her back. She was still functioning at a fairly high level, in spite of the pain.

Her prior care

Jean’s care so far had consisted of six visits to physical therapy, and two sets of cortisone injections in her back, none of which had been helpful. She had not been prescribed a ongoing organized treatment plan. On her second visit to a spine surgeon, it was recommended that she undergo a eight-level fusion of her lower back from her 10^ththoracic vertebra to the pelvis. It is a six to eight-hour operation that carries significant risks.

Jean’s x-rays showed that she had a mild curvature of her lower back. Other imaging tests did not reveal any identifiable, structural source of pain. From my perspective as a scoliosis surgeon, I felt her spine was essentially normal for her age.

Instead, I felt that her pain was probably from the muscles and ligaments around the spine. The medical term that we use is myofascial. When an operation geared towards the bones, such a fusion, is done in the presence of mostly soft tissue pain, it rarely works. In addition to the risks, the entire lower back becomes a solid piece of metal and bone. This surgery should only be done if there are no other options. The procedure comes with long-term lifestyle limitations and she was still so active.

At this point, I was perplexed as to why surgery had been recommended when she had done so little rehabilitation. I also didn’t understand why she was continuing to experience such severe ongoing back pain without any obvious cause.

What was missing?

I consulted her spine intake questionnaire to look for clues.

It revealed that she’d had some marital difficulties and had just reconciled with her husband six months earlier. That immediately caught my attention because marital troubles usually indicate significant stress. She then said her job had become much more difficult. Although she worked for the same employer, they had forced her to switch duties without adequate training. She was worried about not only her performance, but also her ability to keep her job – another major problem.

I turned the page. A month before her pain began, her twenty-six-year old son had drowned. I knew that outside stressors played a role in chronic pain, but this factor had never been so powerfully demonstrated. Her case really brought home for me how crucial it was to take a full view of the patient’s life and circumstances, instead of just looking at surgical solutions.

As I sat there stunned, I realized that I needed to do something different. In fact, the whole medical profession needed to do something different. How could a surgeon have recommended a fusion without taking the time to get to know Jean and to hear her circumstances? I have always wondered if she went through with the surgery, but I never heard from her again.

From that moment, some form of structured rehabilitation became my focus with every patient, without exception. I have not taken my eyes off of that vision since that day.

The post My Call to Action first appeared on Back in Control.

The post My Call to Action 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.

Anger

Nonetheless, there are obstacles to becoming pain free. The absolute biggest block that I encountered daily was anger. I honestly didn’t know how to help a patient get past it. He or she becomes irrational. When you are chronically angry, it is your baseline, and you cannot even recognize that you are angry. I personally had no clue that I had any anger issues until I was 50 years old. In fact, one of the first lines to my wife when I first met her was that I was a “good catch” because  I had dealt with all of my anger issues. I am glad that neither of us had any idea that I had not even opened the door to my frustrations, as we never would have made it.

Noncompliant

The problem with anger is that you cannot listen and accurately assess a given situation. The conversation I have with a patient who is noncompliant goes like this. “Doctor, you mean to tell me that there is nothing wrong with my back? I have been in pain for several years and I know that this pain is not in my head. You must be missing something.”

I reply, “The pain you are experiencing is not imaginary pain, nor is it psychological. We know that if we did a functional MRI of your brain right now, the part of your brain that corresponds to your area of pain would light up brightly. All that matters is what is happening in your brain. We also know that the brain can fire spontaneously without an indentifiable source of the pain. I don’t just believe you have pain–I know you are experiencing pain and are frustrated about being trapped.”

I also explain to them that degenerated discs are normal as you age and that there is no correlation between a degenerated disc and back pain. The surgical success of a fusion for LBP is less than 30% with a significant downside of a failed surgery. They then say, “I don’t want surgery. I just want to be fixed and get my life back.” When I reply that we have had very consistent results following the steps outlined in this book, they explode saying, “I don’t want to read a book or anything like this. Just do something to fix my back.” They will then start ranting and often even yelling that no one will help them. Occasionally they will walk out of the room.

Anger is an absolute block to moving on

This is a frequent scenario. I would estimate that at least 50% of my patients fall somewhere in this part of the spectrum. They are noncompliant actually not by choice. I realize that chronic pain causes anger, but It is this anger that is also a complete block to engagement in effective treatment. Anger is destructive and it is multi-directional. It is particlurlarly self-destructive. You also have a strong sense of “being right” when you are angry and an even stronger sense of everyone else “being wrong.” I honestly do not know what to do to break this mind set.  I have tried everything from being confrontive to being incredibly patient. Nothing has worked. In fact, I have found that the longer I spend trying to convince someone to engage, the angrier they become. Angry people become upset when trying to be convinced to give it up. They just cannot hear me.

Address Your Anger

If you are angry or living in one of the above disguises of anger, be careful. You are trapped. You are truly stuck, and no one can even throw you a lifeline. What you cannot see is the havoc you are wreaking on those around you and onto yourself. I do not know how best to quell the anger rooted in chronic pain. I am open to suggestions.

The post Anger-The Absolute Block first appeared on Back in Control.

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Every injured worker should have access to some level of mental health support. I work with a veteran pain psychologist who is wonderful. 90% of her practice is caring for my patients. If she feels it is necessary, she will refer a patient to one of several psychiatrists for medication management.

Chronic Pain and Mental Health

It is unclear, from the psychiatrist’s viewpoint, what constitutes a diagnosable psychiatric disorder. On my intake questionnaire, I have a simple 0 to 10 scale for anxiety, depression, and irritability. Essentially every injured worker that has been out of work for more than six weeks is greater than a 6 out of 10 on at least two of these scales.  What would be my threshold for a formal referral, especially in light of the fact that my state will not pay for an evaluation in a timely manner? What is even more worrisome to me is the patient who puts down a zero for all three. He or she is just a time bomb.

Diagnosis Problems

In the disability literature, there are hundreds of papers linking stress and disability, but there is not a clear-cut definition of anxiety disorder to aid practitioners in diagnosing an injured worker. How bad does a patient’s anxiety have to be in order for it to be diagnosable? What is the definition of a diagnosable mental health disorder in general?  As there is not a concise definition, I am in a continual battle with worker’s comp trying to persuade them to “buy” a psychiatric diagnosis. While the patient is waiting, what are we to do?  Their stress level climbs even higher as they wait for an answer.

A Case

I saw a patient a few months ago who is a young mother. I have known her for years.  She developed quite severe axial back pain. We had a short but direct conversation about stress and pain. She came in a couple weeks later with her back pain feeling moderately improved but seemed upset. I had a little extra time to talk to her. She started out by saying that she had separated from her husband and was having a hard time finding a job and a place to live. I knew that he had not been working and she was home with two young children. It turns out that he had been regularly beating her. It happened enough that her children felt afraid of her if she yelled at them, but the physical abuse that occurred in front of them seemed OK. If you met her, you would be more than upset. She is one of the nicest people you could meet. Under no criteria would she have a diagnosable psychiatric condition. She really did not know what direction to go. Her mother was helping out the best she could. I emailed my pain psychologist and although she had no funds, she was able to be helped out. On top of that, her husband has chronic pain from failed back surgery.

Stress Management

Every person from elementary school on should be taught stress management and mental health skills. I feel the one factor that determines one’s success in life is the ability to process and handle stress. Even basic stress management tools are extremely helpful.

Support

Every injured worker needs to have access to at a group or organization that teaches these type of skills and offers other support. Individual referrals to psychologists can be figured out more easily in this setting. Losing a job in a capitalistic society is a disaster.  It is bad enough if you are single; it is much worse if you are the breadwinner of a family. Even the thought of being in this situation is mentally crippling.

Labels

A major concern and obstacle to accessing mental health support is our tendency to label people. Injured workers quickly become labeled. This is particularly true if they make the mistake of complaining too loudly or expressing their frustration. They become “difficult” and “manipulative.”  If their stress becomes higher, they may have more pain and ask for more meds. This gets them labeled “drug seekers.”  The list of labels goes on. If a patient is labeled as “anxious” or “depressed,” they are often put on antidepressants and their anxiety is considered “addressed.”  If after a few months they are still depressed, then they might be referred to a psychiatrist or psychologist. By this time, months have passed and often the lives of patients have unraveled.

The Patient is a Person

The patient’s whole life, including her mental life, must be acknowledged from the minute she is injured. Every person that comes in contact with her makes a difference. Even the acknowledgment of her suffering is important.

I made a comment a few weeks ago to David Tauben, who is the head of the University of Washington pain center, and David Elaimy, my surgical performance coach, that they should put on a mini-seminar, “Enjoying the Management of Your Chronic Pain Patients.”  A major part of the enjoyment of being a physician is addressing the whole patient and making the correct diagnosis. If I had just sent the young mother I mentioned above to physical therapy for neck pain, it would not have been helpful. Thanks to the DOCC Project methods, she will be able to get her life back on track and have the tools to live a much more fulfulling life.

BF

The post Everyone Needs Support first appeared on Back in Control.

The post Everyone Needs Support appeared first on Back in Control.

Abraham Maslow

Abraham Maslow (1908-1970) was a brilliant professor of psychology. He founded a branch of psychology known as “Humanistic Psychology,” which focuses more on psychological virtues or excellences rather than on psychological disorders. Maslow is best known for his conceptualization of “man’s hierarchy of needs.” This hierarchy is usually represented as a pyramid, which is depicted above. Maslow thought that meeting one’s basic needs in the lower part of the hierarchy was necessary before progressing to the needs at the top. He also recognized that getting to the very top of the pyramid, what he called self-actualizing–flourishing as a human being, was not commonly attained.

Basic Human Needs

The most basic needs are physiological:

• Air
• Food
• Water
• Sleep
• Sex

According to Maslow, it is impossible to progress up the pyramid if you cannot obtain air, food, water, sleep, and sex.

Where is Pain?

A thought struck me as I looked at his hierarchy: where is the need to be free from pain? I believe this need belongs on the bottom row. Any time a basic human need is not met, anxiety quickly results. If the basic need remains unmet, then the anxiety will progress to anger, disrupting your quality of life and compromising your ability to function. When you are in pain, your body will flood you with anxiety in an attempt to protect itself from harm. (I talk more about the relationship between pain and anxiety in “Your Hand Stuck Over the Stove.”)

Will you have the wherewithal to progress up the hierarchy of needs when you are consumed by pain? You won’t. I believe it is impossible to flourish as a human being without first absolving yourself of your pain. Maslow simply missed including this basic need in his paradigm.

A.H. Maslow, A Theory of Human Motivation, Psychological Review 50(4) (1943):370-96.

The post Maslow’s Miss first appeared on Back in Control.

The post Maslow’s Miss appeared first on Back in Control.

Self esteem involves endless judgment of comparing yourself to others around you. I discuss the negative impact that this concept has on us.

For more, see The Myth of Self Esteem.

The post Video: The Myth of Self Esteem first appeared on Back in Control.

The post Video: The Myth of Self Esteem 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.

There was a discussion last year that led to a document called “The Five E’s of Chronic Pain.”   They are:

• Empathy
• Evaluation
• Education
• Encouragement
• Engagement

All of these are geared towards enabling and motivating the patient to take charge of his or own care.

One E that I want to emphasize in particular is education   it’s critical for several reasons.  If a given patient is willing to immerse him or herself in learning about all of the variables that affect his or her pain, the chances of them eventually improving is extremely high.

Conversely, if they are not willing to read, listen, and learn, then they cannot and will not get better.  They must be willing to take on that responsibility.  Otherwise they are choosing to remain in a victim role and will remain angry.  It is also difficult to work with them, which also makes progress unlikely.  I think it is important for those working in chronic pain to set personal boundaries while still “keeping the door open.”  If you are attached to getting that resistant patient better in spite of their wishes, you might get yourself into a very unhappy, energy-draining situation.  You need to let them go.

I just put on a mini-seminar called “Enjoying the Management of Your Chronic Pain Patients.”  Once a given patient decides to fully engage, it is like opening the door of a caged wild animal.  You cannot stop them from regaining their life.  It does not matter how long they have been in pain. Working with these patients has become the most rewarding and enjoyable part of my practice.

NH, BF

The post The “Five E’s” of Chronic Pain first appeared on Back in Control.

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Visualization techniques have been used in the athletic and performing arts world for many years. There have been numerous studies demonstrating the effectiveness of these methods. Detailed focused visualization is an effect method of Reprogramming.

Holt and Nick

My son, Nick, is a mogul skier. He is an excellent skier and has come close to making it all the way to the top. He and his best friend Holt have engaged in performance training, which utilizes skills involving both awareness and visualization. They have not only elevated their performances, but they have also been able to handle the stress of the inevitable failures that are inherent in the sport.

Video: Holt’s US 2007 moguls championship run

US Mogul Championships – 2007

In March of 2007, our family was watching the competition for the US National Championship in moguls. My son, Nick, had had a bad day and did not make the finals. Everyone, including Holt was upset. Nick had been talked into trying a trick he hadn’t mastered and just couldn’t pull it off in the heat of the national championship. Holt had a great run and had qualified 2^nd. The top skier on the US ski team had qualified third. The top twelve skiers out of a field of fifty get a second run. There is no carry-over of points from the first run.

It was around 4:00 in the afternoon by the time the final run was winding down. The sun was low and the light was flat. Flat light makes it much harder to see the shapes of the moguls. The top US ski team skier took his run and it was almost flawless. He had a giant score at 27.2 out of a possible score of 30. Usually a score above 26.5 has a high chance of being the winning run. Holt was the next skier. We all were wishing him the best but just hoped that he would have a good run and possibly finish second or third. He came out and scored a 27.6 to win the US championship. We were ecstatic and dumbfounded. It was an incredible run under any circumstances, but almost impossible to pull off under that kind of pressure.

How did he pull it off?

At that point, I did not have that clear of an understanding of the reprogramming process. I could not understand how it was different from positive thinking. I spent the next day picking Holt’s brain, asking how he was able to perform so well under those circumstances. Here’s what he told me. It is first of all critical for the performer to acknowledge the anxiety that is associated with the upcoming performance.

Holt was extremely anxious and he knew that the score he had to beat was high. However, instead of suppressing his anxiety he stuck with it and experienced it. He then concentrated on the feel of the breeze on his face and the edges of the skis on the snow. When his mind would wander off into the potential negative story of how he might fail, he’d  pull himself back into the current sensations that were immediately around him. By doing this, he’d made a choice to detach, effectively saying, “I am not going to be controlled by these thoughts and emotions.” Next he visualized the first few turns and was then able to just ski his run. He also had been practicing these techniques the whole season.

In the past, Holt said his prior strategy would have been to suppress his negative emotions. It would have fallen under the category of  positive thinking: “Don’t’ worry about the other skier’s score.” “Don’t’ be nervous.”  “I can do it.” However, the energy spent on suppressing negative emotions would have taken away from the energy and focus he needed to perform. He instead chose an alternate neurological pathway that was the one he needed to maximize his performance.

The tools

He inadvertently used the sequence of 1) awareness, 2) detachment, and 3) reprogramming to optimize his chances of laying down a winning run.  He was aware of the score of the prior skier and also his level of anxiety. Instead of suppressing he engaged his fears and separated from them. He used “active mediation” and visualization as reprogramming tool. As he felt the breeze and the listened to the sound of the snow under his skis he was connecting himself to the current moment. Reprogramming through visualization is a powerful method: you completely play out the event in your head so that it’s the only program that’s playing. It’s important to mentally experience the smallest detail from beginning to end.

The power of visualization was demonstrated in a study done with volunteers learning to play the piano. The researchers set it up so that two different groups were learning to play a simple scale. One group was taught the skill with an actual piano. The other group was taught by visualizing themselves playing the scale. When they were randomly tested on their ability to do the scale, the results were the same. The experiment was done again with volunteers who were basketball players. One team was asked to learn a play on the court, while the others merely visualized the play. Again, when they were tested, the results were similar.

The tools are the same for dealing with chronic pain. It is critical to become aware of all of the variables that affect your pain, including fear. There are many ways of detaching from your pain as well as an infinite number of possibilities to move forward. Can you connect with your day? Are you able to visualize a productive and fulfilling life? The stakes are much higher than a national championship.

The post Visualization – Holt’s Winning Run first appeared on Back in Control.

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