A straightforward decision

I rarely make a surgical decision on the first visit, but his situation seemed so straightforward that I decided to make an exception. He also wanted to proceed quickly, as he was frustrated by his limitations. As I walked out the door to grab the pre-operative letter that describes the details of the fusion, he quietly said, “My son just died a few months ago.” I immediately turned around and sat down with him. His son had died from a massive heart attack. I let him know how sorry I was about his loss, and also told him that I was not comfortable with him making such a major decision in light of the situation. He agreed. I gave him the pre-op letter and asked him to return in a couple of weeks. I gave him a copy of my book, Back in Control, which is an excellent resource for dealing with stress, as well as chronic pain. A week later he called and told me that he really wasn’t into reading my book and just wanted to proceed with surgery. I asked him one more time just to glance through the book, as it does help with post-operative pain and rehab; and I signed him up for surgery.

The pre-op appointment

He came in with his wife for his pre-operative appointment to coordinate the final details around the operation. I wanted be sure that I was on the same page regarding the severity of the pain and his understanding of the procedure. He said, “I am feeling better. I have read some  of your book and think that maybe I should work through some of the issues around my son’s death.” We had a long conversation about the effect this degree of trauma can cause. He asked me if it was OK with me for him to delay his surgery for a while.

I saw him a month later and he had no pain in his back or down his leg. He was fully active and had just re-joined the gym. I asked him what seemed to be the most helpful strategy in resolving his pain. He had continued to read the book. However, I am well-aware that reading my book, or any book, is not going to take away pain. It requires some level of engagement. For him, it was awareness. Just understanding the links between anxiety, anger, trauma, and pain helped him make sense of the different emotions he was trying to process. He was also now talking to his friends about his loss, who were offering a lot of support. His whole demeanor had changed and he was now more concerned about how the situation was affecting his wife.

How do I decide who needs surgery?

It is becoming increasingly unclear to me what severity of pathology requires surgery to solve a given problem. His constriction around his 5^th lumbar nerve root was severe and he had a classic history that matched. Had I done the surgery, his leg pain would have resolved; but not his emotional pain. He now is moving forward, as his emotional pain is being addressed. His back and leg pain are gone. He did not have to undergo the trauma and risks of surgery. He will return to being a productive person and provide emotional support for his wife. Although, not the main reason, there was essentially no cost involved.

“I know when a patient is at risk for a poor outcome”

I have witnessed many stories that are similar to George’s; and I am more diligent in making sure that there not major life stresses occurring while making a final decision regarding surgery. There doesn’t need to be one specific event. More commonly people hit their breaking point from cumulative stress, and they don’t see a way out. Physicians almost uniformly feel that they can detect emotional distress in their patients. As I have been doing spine surgery for so many years, I feel like I am really able to detect patients with anxiety and depression in my clinic. However, research shows that physicians are correct in this regards only 25-43% of the time. It does not matter whether the doctor is a junior resident or senior staff physician. George’s story again reminded me that I cannot figure any of this out either. There is too much going on in the middle of a busy clinic – especially on an initial visit. (1)

Physical versus mental pain

The areas of the brain that interpret physical and emotional distress are located in close proximity to each other. (2) It also seems that there are abnormalities of a given person’s body that are not quite severe enough to cause pain. But when the pain threshold is lowered, in the presence of adversity, these specific areas can become symptomatic. As one of my workout buddies points out, “It is the weak area that lights up.” Prior pain circuits can also be activated.

There are hundreds of research papers documenting the link between anxiety and depression with pain, and poor outcomes with treatment. For many reasons, these factors are not being routinely addressed. The culture of medicine is geared towards performing procedures, and not on talking to you about other options or providing the necessary resources. It is critical that you have done everything possible to calm down your nervous system before you undergo a surgical procedure. In this medical environment, you will have to take on that responsibility.

1. Daubs, M, et al. Clinical impression versus standardized questionnaire: The spinal surgeon’s abilityto assess psychological distress. JBJS (2010); 92; 2878-2883.
2. Hashmi, JA et al. “Shape shifting pain: chronification of back pain shifts brain representation from nociceptive to emotional circuits.” Brain(2013); 136: 2751 – 2768.

The post “My Son Just Died” first appeared on Back in Control.

The post “My Son Just Died” appeared first on Back in Control.

The secretion of survival “flight or fight” hormones such as adrenaline, cortisol and histamines affects every cell in the body, with the potential of creating over thirty physical and mental symptoms. Prolonged exposure has been shown to be at the root of most chronic diseases. One of reasons, as demonstrated in laboratory animal studies, is increased speed of nerve conduction, which intensifies the sensation of pain.(1) From a strict survival perspective, it makes sense: When the situation calls for it, you should be on high alert, in order to defend yourself and whoever else you’re responsible for protecting. But the relentless bombardment of stress hormones takes a toll on your body.

Consider driving your car down the freeway at 70 mph in second or third gear, instead of cruising in fourth or fifth. How long do you think your over-extended engine would hold up? The same is true for your body. Not only will you suffer a multitude of physical symptoms manifested by the burden placed on your body; you will be operating with a weakened immune system. For example, a large study found a clear connection between chronic stress and autoimmune disorders such as rheumatoid arthritis, Crohn’s disease, ulcerative colitis, ankylosing spondylitis, and psoriasis, among others. (2) Research results going back fifty years identify chronic stress as a risk factor for frequent and serious illnesses, (3) and a shortened life span. (4)

Factors that Determine the State of Your Nervous System

1. Quality of sleep. Are you getting enough? Lack of sleep compromises every aspect of your treatment, whether it is surgical or non-operative care. Lack of sleep actually causes chronic low back pain.
2. Level of chronic stress. Are you chronically anxious, frustrated, depressed, angry, fearful?
3. Level of situational stress. Are you dealing with an unusually difficult situation in your life, in addition to the problems created by your pain?
4. Physical manifestations. Are you experiencing random symptoms such as rashes, headaches, or tinnitus?
5. Commitment to recovery. Are you open-minded regarding learning about the nature of chronic pain and the principles behind solving it? Are you willing to commit to a long-term program that will resolve your pain and improve the quality of your life? Are you addicted to your pain or using it to your advantage? Believe it or not, people often become addicted to being in pain. One’s medical condition can be powerful weapon, and the unwillingness to let it go is the one greatest obstacle to healing.

Considering these five areas is meant to give you a feel for the state of your nervous system and the extent to which protective (harmful when sustained) stress hormones and inflammatory molecules are coursing through your body. This is crucial information for you to know. A hyper-vigilant nervous system negatively affects not only your pain and your surgical outcomes, but your overall quality of life as well.

Expensive and harmful surgery

I ran across yet another case of a woman in her mid-forties who was experiencing chronic neck pain. Her cervical imaging showed some degeneration at several levels, which has been well-documented to not be a source of neck, thoracic, or low back pain. There was no compression of her spinal cord. She had the following additional symptoms.

• Pain migrating over her whole body
• Skin rashes
• On long-term methadone
• Difficult family situation
• Numbness and tingling in her hands
• Swelling of her fingers
• Generalized weakness
• Depression and anxiety
• Chronic headaches
• Ear pain
• Trouble swallowing
• Dizziness/ lightheadedness
• Had two low back surgeries with ongoing low back pain
• Left flank pain
• Thoracic pain

All of these symptoms are typical of a fired up nervous system and sustained fight or flight physiology. With any number of clinicians who are familiar with approaches to calm down and redirect the nervous symptoms, most, if not all of her issues could have resolved. In fact, we love to see and help these patients, as the outcomes are often so rewarding. Seeing someone without hope come out of The Abyss is inspiring. What we are observing is the body’s capacity to heal itself. But what happened?

Instead, she underwent a five-level fusion through the front of her neck and a five levels through the back her neck. This was performed on a spine that was normal for her age and no neurological deficits. There is nothing in our medical/ surgical training that indicates that this is rational and in fact it says the opposite. Performing surgery in the presence of untreated chronic pain will worsen the pain 40-60% of the time.(5) The data also shows that spine surgeons only address the risk factors for poor outcomes less than 10% of the time.(6)

The billed charges for the operation was over $200,000 and the reimbursement was almost $50,000. This did not include the surgeon’s fee or her ongoing medical care. In contrast, her problems could have been solved with minimal resources and no risk. Patients often completely come out of medical care. She predictably is having ongoing neck pain, is actually doing worse, and is having a hard time holding her head up. She is still experiencing rest  of her symptoms.

You have to take charge of your care

Before you embark on any spine surgery, unless it is an emergency, please look at my book, Do You Really Need Spine Surgery? It breaks down the decision into four quadrants that are easy to identity. Once you understand you situation in this context, the decision will usually become more clear. I am in favor of performing surgery for a clearly defined lesion with matching symptoms. The results are better if you calm down the nervous system before making the final decision. It is what the data says to do. I call it prehab.

Most of you know, I quit my practice to see what I could do to slow down the juggernaut of aggressive surgery on normally ageing spines. It is why I wrote this book and it is for patients and providers alike. Surgeons must be held more accountable. It distresses me that this level of harmful surgery is continuing to increase, and it should not be in your lap to have to take such a large role in the final decision. This type of surgery should never be offered to anyone. Please don’t let it happen to you, your family, friends, or anyone.

References

1. Chen, X et al. “Stress enhances muscle nociceptor activity in the rat.” Neuroscience (2011); 185: 166 – 173.
2. Song, H et al. “Association of stress-related disorders with subsequent autoimmune disease.” Journal of the American Medical Association(2018); 319: 2388 – 2400.
3. Rahe, R et al. “Social stress and illness onset.” Journal of Psychosomatic Research (1964); 8: 35.
4. Torrance, N et al. “Severe chronic pain is associated with increased 10-year mortality: A cohort record linkage study. European Journal of Pain (2010); 14: 380– 386.
5. Perkins FM and Henrik Kehlet. “Chronic Pain as an Outcome of Surgery.” Anesthesiology (2000); 93: 1123-1133.
6. Young AK, et al. “Assessment of presurgical psychological screening in patients undergoing spine surgery.” Journal Spinal Disorders Tech (2014); 27: 76-79.

The post The Impact of Stress on Pain and Decision-Making first appeared on Back in Control.

The post The Impact of Stress on Pain and Decision-Making appeared first on Back in Control.

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.

Common links to all chronic illnesses

Chronic mental and physical diseases are caused by common problems occurring at the genomic (DNA) and mitochondrial level (energy generators in each cell). These are the most basic components of evolution and maintaining life. Basic science research has brought this to light in numerous papers. The problem is the lack of communication between these silos of knowledge and clinicians to bring these critical concepts into the clinical domain.

This is short list of symptoms, illnesses, and disease states caused by exposure to chronic stress (threat), which is catabolic (consuming fuel) and inflammatory (attacking tissues). It is the reason that “stress kills.”¹ The variables are the intensity and duration. The sources of threat come in an infinite number of forms and can be real or perceived.

Symptoms

• Anxiety
• Obsessive thought patterns
• Carpal tunnel syndrome
• Migraine headaches
• Tension headaches
• Facial, neck, thoracic, and low back pain
• Pelvic pain
• Irritable bladder syndrome (interstitial nephritis)
• Irritable bowel Syndrome (IBS)
• Migratory skin rashes
• Tingling/burning sensations
• Tinnitus
• Insomnia
• Chronic mental and physical pain

Illnesses

• Fibromyalgia
• Chronic fatigue
• POTS disease (postural orthostatic hypotension)
• Asthma
• Hypertension
• PTSD
• Eating disorders
• Reflex Sympathetic Dystrophy (RSD)
• Temporomandibular joint syndrome (TMJ)

Diseases

• Cardiovascular disease
• Dementia/ Alzheimer’s disease
• Parkinson’s Disease
• Renal failure
• Autoimmune disorders
  • Crohn’s disease, colitis, rheumatoid arthritis, SLE (systemic lupus erythematosus), dermatomyositis, psoriasis, and ankylosing spondylitis
• Early mortality
• AODM
• Metabolic Syndrome
• Obesity (core)
• Major depression/ deaths of despair (suicide)
• Peripheral vascular disease
• Osteoporosis
• Bipolar disorder
• Addiction
• Obsessive compulsive disorder (OCD)
• Schizophrenia
• Cancer – except colon cancer and melnoma

You may be wondering how so many different symptoms and disease states can be linked by a common cause. It is because under sustained heightened threat physiology, each cell and organ system responds in its own unique way and will eventually breakdown.

Each of us is unique

Chronic disease is a complex problem affected and defined by many individual variables. It is not going to be solved by information gained by prospective clinical trials on ill-defined groups of patient. There are several reasons for this problem.

• • Trauma of any sort is connected to a higher chance of experiencing chronic disease.² It is worse when it happens in childhood as it alters the structure of the brain as well as causing long-term elevations of inflammatory markers. However, chronic adult trauma, bullying, or living under societal threats also keeps one in an activated threat state.³

There are at least four patient scenarios that affect one’s capacity to heal.

• Willing to engage – Since the greatest factor predicting a successful outcome is willingness to engage and take responsibility, any clinical study has to begin here. If people can or will engage, will they heal? This seems to consistently play out and we have seen hundreds of patients heal as evidenced by many powerful testimonials. This group must be clearly defined, and then various clinical interventions can be evaluated and refined with ongoing research. The “stages of change” questionnaire is one validated tool to sort this out.⁴
• Emotional inability to engage – This group is one who has suffered so much trauma that they have incurred a significant mental illness and/ or have no capacity to face incredibly unpleasant emotions. They are in a mental survival state. 86% of people in chronic pain referred as an outpatient to a psychiatrist are so frail, they cannot engage.⁵ It is a major reason why traditional psychotherapy is not very effective for treating chronic pain. There are ways to bring this group into a better state.
  • Skilled somatic trauma therapy – training one to feel safe
  • ISTDP – Intermediate Short Term Dynamic Psychotherapy.⁶ This is a specific approach designed to teach people to tolerate unpleasant emotions and also feel safe.
  • Specifically stabilizing their mental health situation.
• Don’t want to engage – Angry/ frustrated – This group is maybe the most challenging in that they are so angry that they will not engage in anything. Anger is a hyper-inflammatory/ metabolic state that causes the neocortex (thinking centers) to be less active and the survival midbrain to become more active. In other words, they cannot think clearly and process new information. They also don’t want to in that anger is destructive, including self-destructive. So, the activated physiology also blocks willingness to engage.
  • There are many approaches to bring them back “online”, but it is unclear what is the best approach for a given person.
• Lack resources – There are other obstacles to learning new skills. They include illiteracy, low educational level, no access to computers or lack skills, low IQ, poor access to care, poverty, chaotic family situation, and anything that causes unrelenting threat (stress).

Treating the individual

• We are not going to be healed from data gleaned from randomized clinical trials on general populations. Each person is “programmed” by their entire past up to this moment and are infinitely unique. It is a little unclear how modern medicine has veered so far away from treating each person individually.
• The complexity of chronic disease, uniqueness of each person and circumstances, and the need to address multiple factors simultaneously makes it impossible to do randomized prospective studies on large ill-defined groups and obtain meaningful data. It simply cannot and will never be done. How can you compare a college professor with someone who is illiterate? The core basis for our “data” is deeply flawed.
• We must think differently, as current approaches are not only ineffective, but they are also making the problem of chronic disease much worse. “Data” has not helped us heal. In fact, physicians, by being more focused on the data (which they may not realize is so flawed) have become more detached from their patients as they continue to administer ineffective care. Many caregivers and patients alike are frustrated by the lack of success and have somewhat given up.
  • Research has shown us solutions for specific symptoms, but it has not helped us deal with the complexity of a person and his or her disease state.
• This quote from Dr. Francis Peabody in 1927⁷ is at the core of the problem.

Disease in man is never exactly the same as disease in an experimental animal, for in man the disease at once affects and is affected by what we call the emotional life. Thus, the physician who attempts to take care of a patient while he neglects this factor is as unscientific as the investigator who neglects to control all the conditions that may affect his experiment.

What we now know is that emotions reflect one’s physiological state and he was well ahead of this time. In 1927, he was concerned with the intrusion of technology into the patient/ physician relationship.

Summary

Big data is harming all of us because it is not granular enough. Not only is the burden of chronic disease continuing to rise, but it is also crippling our society both financially and emotionally. “Mainstream medicine” is not only actively promoting ineffective risky, expensive, and ineffective treatments, we are hurting people that trust us.

Chronic disease is solvable by applying a systematic approach that creates a healing alliance where both the patient and provider can heal. Humans are not data points. The “data-based” foundation of care is deeply flawed. Is it any wonder that the burden of chronic disease continues to crush us financially and emotionally?

It is more important to know what sort of person has a disease than to know what sort of disease a person has. 

              Hippocrates

References

1. Holmes TH, Rahe RH. The Social Readjustment Rating Scale.J Psychosom Res (1967); 11:213–8. doi:1016/0022-3999(67)90010-4
2. Felitti VJ, Anda Rf, Nordenberg D, et al. The relationship of adult health status to childhood abuse and household dysfunction. American Journal of Preventive Medicine (1998); 14:245-258.

3. Takizawa, R, et al. Bullying victimization in childhood predicts inflammation and obesity at mid-life: a five-decade birth cohort study. Psychological Medicine (2015); 45: 2705- 2715.
4. Carr JL, et al. Is the pain stages of change questionnaire (PSOCQ) a useful tool for predicting participation in a self-management programme? BMC Musculoskeletal Disorders (2006); 7:101-108. doi:10.1186/1471-2474-7-101.

5. Abbass Allan. ISTDP in the treatment of chronic pain. Lecture to the Dynamic Healing Discussion Group (4/6/22); from the Halifax ISDTP database. https://drive.google.com/drive/folders/1k9AXx1webG69mKlCGoCU8XeUtNwTTM3q?usp=sharing
6. Abbass Allan, et al. Intensive short-term dynamic psychotherapy to reduce rates of emergency department return visits for patients with medically unexplained symptoms: preliminary evidence from a pre-post intervention study. CJEM (2009); 11:529-34.
7. Peabody FW. The care of the patient. JAMA (1927); 88:877-882.

The post Humans Aren’t Data Points – Modern Medicine is Hurting Us first appeared on Back in Control.

The post Humans Aren’t Data Points – Modern Medicine is Hurting Us appeared first on Back in Control.

• Her pain originally arose from severe arthritis of her hip. Historically, I have approached this is a simple structural problem that is best treated with an artificial hip replacement. What else can be done? Turns out there is plenty.
• She healed herself in spite of medical advice. Taking charge and being persistence are important aspects of healing.
• She recognized that pain is the result of sensory input and that the final signal arises in your brain. Her story is remarkable in how quickly she figured this out and re-routed around her pain circuits.

Here is her letter.

Dear Dr. Hanscom,

I’m really grateful to have a substantial, extended break from my relentless routine of the last few years. I am, finally, getting more than 5-6 hours of sleep…more like 7-8 every night. I do not have the physical demands of my job navigating a huge high school campus. I do not have the weekly organizational demands of coordinating work, shopping, laundry, family, household management, paying bills, home and car maintenance, concern for a parent living alone in another state, as well as concern for grown children and grandchildren…and on and on. Many of us experience the unrelenting demands of daily modern life and its effects can be exhausting.

Her childhood experiences

Reflecting on my life back to my earliest remembered childhood, I realized that I do have the type of personality that wrestles with the double bind of being a perfectionist, people pleaser, fixer, peacemaker, problem solver, responsible “adult” (among other adults who readily relinquish responsibility). I have always set a very high bar for myself. Even the thought of failing sparked a cascade of anxiety and panic. As I child, I was repeatedly reminded that “a job worth doing is a job worth doing well.” Also, “Smile and the world smiles with you, weep and you weep alone,” along with “You’ll get more with honey than you get with vinegar” and “If you can’t say something nice, don’t say anything at all.” (many of those from my Irish Grandmother who drummed them into my mother….sincerely well meaning, who, in turn, reinforced those messages for me.)

Emotions will be expressed–either physically, mentally, or both

Thanks to Dr. Hanscom’s work, I can see relationships between chronic physical conditions such as (Irritable bowel Syndrome) IBS, fainting, panic attacks, acute anxiety… that plagued me throughout childhood and into adulthood, and the messages and beliefs I internalized that were also combined with my innate temperament and personality traits.

My dad suffered from clinical depression and my mother intellectualized her emotions, suppressed negative feelings, and managed the overflow with relentless activity. The more I reflect on the elements of my life and continue to do expressive writing, the more patterns and clues gradually emerge.

Hip arthritis pain resolved

I had been diagnosed with “severe bone on bone osteoarthritis” in my left hip 10 months ago. I had such severe pain starting last May, that I had an ultrasound on my hip and then after seeing a series of doctors (having to wait 2-3 months between appts) had a hip xray which definitely showed the damage in my hip. I was told, by my Doctor, that the hip could send pain down the thigh to the knee but that pain below the knee was probably due to the L4L5 nerve compression that was revealed by my MRI. These diagnostic tests confirmed my condition was much worse than I had believed. After 16 weeks of various treatments and physical therapy I was advised to get a hip replacement. I was 61 and was really not keen on that idea and decided to wait a bit and see if it improved. By December, after doing stretches and mild strengthening exercises, my hip stopped hurting. It has been pain free for more than 4 months. I don’t think I miraculously grew new cartilage! It just does not hurt.

Pain from her brain

Now, fast forward to the past 3 weeks when, intermittently, I started to experience severe throbbing, aching, and burning pain in my left leg. The pain I was experiencing would migrate from the top of my left foot, hover around the ankle, sometimes jump to the side of the leg just below the knee….occasionally jump to the thigh and then zip back down to the ankle. The pain was a 10/10 and it woke me at night for hours. I was quite frustrated, angry really because I know that my foot, ankle and knee are fine. There is no structural damage or deterioration in those parts and I’ve had no prior issues. I completely committed to the belief that these symptoms were coming from somewhere in my brain that was generating pain due to some unconscious impulses to which I had no access with my rational prefrontal cortex.

She healed herself

I followed Dr. Hanscom’s prescription of expressive writing, reminding myself often that I am fine and safe, continuing to move, stretch, and maintain a mild exercise regimen, along with meditation. One night I woke with severe pain and my immediate impulse was to get up and take Aleve for the pain, but instead, I practiced breathing, relaxation, and focused attention instead, on the right leg which was completely pain free. Within 15 minutes the pain began to decrease and I was able to doze off. When I woke I was pain free. The following day the pain returned….I repeated the same routine and continued the writing. by the fifth day, I experienced no pain in the left leg. I found this experience very illuminating because the pain commands attention, but the more attention it gets, the greater the intensity.

Classic symptoms

This is a phenomenal insight and it allows a whole new way to frame this kind of migratory, fluctuating, recurring pain. I realized, as well, that I was repressing feelings of anger, frustration, overwhelm, and chronic stress over the need to excel constantly, without granting myself rest and reward time. I felt frustration and hopelessness as I had spent way too much time and effort in the past years pursuing various “therapies” without appreciable results. I would be encouraged by very temporary relief and then disappointed when symptoms soon returned and the cycle would repeat.

I now react to pain in my body without anxiety and fear but rather with understanding that I have, inadvertently, reinforced neural circuits for years by focusing on the pain. I can now practice responding rather than reacting when existing neural circuits are triggered. This has reduced my fear and anxiety from the sensation of pain. I am able to move my focus elsewhere, calm my nervous system with breathing or active meditation, and reduce my chemical stress response. This immediately reduces the pain sensation, sometimes eliminating it.

As I explore more of Dr. Hanscom’s website and began the DOC program, I feel empowered rather than vulnerable. I finally feel like I am regaining control over my outcomes and can work towards reclaiming my autonomy without depending on others to “fix me.” The result is I no longer feel resigned to pain. I am hopeful again.

My perspective

I originally thought that an obvious source of pain, such as her severe hip arthritis, just had to be fixed. The research shows that there is little correlation between the severity of hip, knee, or shoulder arthritis and pain. (1) Often people with severe arthritis have no pain, and patients with a lot of pain have minimal or no arthritis. The pain was more correlated with stress. How can this be? Under threat, mental or physical, your body is full of hormones that fire up your nervous system, which increases nerve conduction. You will feel more pain. Pain is also a significant source of stress.

I have now seen over 100 patients who I felt needed spinal surgery because there nerves were pinched so tightly. They cancelled the operation when their pain resolved from structured rehab before surgery. I had few resources to help, so I helped them through the DOC process they implemented from the book and website. I also had some of them see excellent pain physicians that used a similar approach. My team was wonderful in providing skilled and compassionate guidance and support. It was mostly self-directed process. We became disciplined in following established medical recommendations to address all the factors that portend a poor outcomes for at least eight weeks prior to surgery and that is when patients began to cancel their operations. If surgery was performed, the outcomes were more predictably positive.

Before you make any elective surgical decisions to relieve pain, please take the time to understand chronic pain. A failed surgery of any kind can destroy your life.

1. Bedson, J and Peter Croft. The discordance between clinical and radiographic knee osteoarthritis: A systematic search and summary of the literature.BMC Musculoskeletal Disorders (2008);  9:116.

The post Never Too Late for Hope first appeared on Back in Control.

The post Never Too Late for Hope appeared first on Back in Control.

Hey David,

I was hoping I could ask you a surgery question. I know you do a lot of revisions.

There’s a guy who came to me in early 2014. He could not sit, lie down, walk or do anything to get relief from terrible pain. I referred him to a colleague who is a McKenzie certified therapist (emphasizing extension of the spine). He couldn’t help him. The guy just didn’t know how to get through the system and I think his physician handled his case, from what I can tell, poorly. He was about a month from his onset when he first came to see me and he hadn’t even had an MRI. Anyway he wound up having a two level fusion right out of the gate. Are You Kidding Me? Not a microdiscectomy; straight to fusion for an L4/5 paracentral herniation (this is a bulging disc and probably not the source of pain). A year later he’s worse off than he was before the surgery and that’s saying a lot. Video: Get it Right the First Time

His surgeon keeps turfing him back to physical therapy because he just doesn’t know what to do with him but we can’t help him.

Other than the fact that he’s still in such bad shape how do you know when a revision is appropriate? As we know, you can always find someone willing to operate. I was talking with a patient the other day who seemed really down and when I asked her she said her daughter was going to have another back surgery. Number eleven!!! “The Pit of Despair”

This guy is only 32 years old and he lives every day in terrible pain. We just don’t know what to tell him other than we can’t help him. It’s so scary. What I’m going through is a mild nuisance compared to what this guy faces every single day. And I made it to 55 before my “problems” began.

Hope you’re well. I began doing some Qigong everyday a week or so ago. I think it’s been good for my mind. Best regards, Mike

My reply

Hi Mike, The data shows that when you perform surgery in the presence of chronic pain that there is a significant chance that you can induce chronic pain at the new surgical site.(1) Of course you can also make the pain worse at the site of the pain. You already know my thoughts about spine fusions. They simply do not work for LBP. I see this scenario every week and is maybe the biggest driving force in pursuing the DOC project. He is a classic person who would respond to the tools in Back in Control, but often patients are so angry that they are not open to anything. I have learned to simply let go hopefully they are open in the future. If he would be willing to read the book AND begin the expressive writing I would be happy to talk to him. Otherwise, I have learned that my conversation is not productive. Physical therapy is helpful, but as you know, is best combined with treating the other factors that affect pain. I am personally re-engaging with the writing/ active meditation at a much higher level along with the gym and a better diet. My knees are finally turning the corner. It has been very humbling and enlightening experience. I am glad to hear you are moving forward. Let me know if I can be of some specific help. Best regards, David

Mike’s unsettling answer

I’ll give it a shot. I’ve thought about it in the past but I just don’t know if he’ll go for it. When I first met him I had all kinds of alarm bells going off, as did my colleague Henry, about how the whole process was unfolding for this guy. And we both told him so.  But he just did the passive patient thing and allowed himself to be carried by the currents of a very unplanned plan of care that he had no capable point person guiding him on.

But at this point what’s he got to lose? As I say about so many of the changes I’ve undergone in my approach to all this; “There are no atheists in a foxhole”.

This whole process has been such a, I don’t know what to call it – a revelation to me. After becoming a physical therapist I became aware there are a lot of people living in chronic, unsolved pain out there. But once you’ve walked a mile in their shoes the numbers of people out there living like this guy becomes staggering and frightening. Like most people I always felt so bad about the people who died young but never really considered people who lived with pain every day. I would have a fleeting thought of “glad that’s not me” and would dread them turning up on my schedule because they made me feel so helpless. My god – the self-centeredness of that mindset. These people made me feel helpless.

I’ve come to believe that in many ways the guy who dies of cancer at age 32 is better off than this guy who, at age 32, has to live the rest of his life in the kind of pain he faces every day. And everything that goes with it: the economic insecurity of trying to live on a monthly disability check, the loneliness of not being able to take part in a life like the other members of his cohort lead, the horrible boredom of being unable to work, have a career and to be so limited physically.

The way I’ve come to feel about it now often makes me think of your remark about how the “certain inalienable rights” to which we are all entitled fell one short in not including a right to live without pain.

Speaking of which I’m really glad to hear your knees are getting better. Mike

Basic human needs

First, not being in pain is a basic human need along with food, air, water, etc. When any of these needs are unmet the human body’s reaction will be intense. Maslow’s Omission

Abraham Maslow was a prominent psychologist who chose to look at the reasons why people thrived in life. He developed a well-known “hierarchy of needs” that he presented as stacked rows shaped in a pyramid. The bottom row includes: air, food, water, sex, excretion, and sleep. The top of the pyramid is, “self-actualization. It is difficult if not impossible to progress up the pyramid until lower needs are met. One need that he did not mention was, “not being in pain.” It is my feeling that it is one of the basic needs that belongs on the bottom row. Your reaction of feeling trapped and angry is completely justified when they are unmet. That is why becoming pain free requires multiple strategies. You cannot just will yourself out of it with positive thinking or mind over matter. Your Personal Brain Scanner

Secondly, I have also felt that chronic pain can be worse than having a terminal illness. I clearly recall the intensity of my feelings when I did not have any hope the pain might end or when that might be. Being in constant mental or physical pain is one of life’s most difficult stressors. It’s paradoxical that a beautifully designed system intended to protect you can also cause so much grief. The crushing aspect of chronic pain is that there appears to be no escape or an end in sight.

The feeling of being trapped was familiar to Viktor Frankel, a famous Jewish psychiatrist who survived WWII concentration camps. He wrote a classic book, Man’s Search for Meaning. It is striking that in spite of the extreme physical hardships Frankel endured, for him the most difficult part of the ordeal was not knowing if and when it was going to end—which is similar if not identical to what patients in chronic pain experience.”

Finally, it is now well-documented in many research studies that not working is bad for your mental and physical health – really bad. (2) The human body is designed for survival and does not perform well when not challenged. Additionally it has been demonstrated that working and having a sense of purpose actually slows down the aging process at the cellular level.

Phantom Brain Pain

If you are reading this post with complete disdain for all of these ideas please understand you are experiencing one of the symptoms of a stressed and over-adrenalized nervous system – obsessive thought patterns. I call it “phantom brain pain.” Similar to phantom limb pain these spinning circuits don’t stop and are unpleasant. It appears that Mike’s patient may be in this situation.

It is also well-documented that your brain physically shrinks in the presence of chronic pain and fortunately re-expands with successful treatment. (3) Adrenaline may be a factor in that it diminishes the blood flow to your brain. This phenomenon affects your perceptions and reasoning. Anxiety, Anger and Adrenaline

Between a decreased brain mass, diminished brain blood flow, obsessive thought patterns that seem like your reality, and anxiety you may not have the mental capacity to process new concepts.  You also may not really want to heal and/or you just want to be fixed. The only chance you have is to begin to engage in some basic tools to break up these irrational thought patterns. It is well documented that writing down your actual thoughts has an effect on doing this. I call it, “mechanical meditation.” Write Your Way Out of Pain

My plea to you is simply pick up a pen or pencil and start spewing out any of your thoughts on paper and immediately tear them up. It can and will break through these circuits. Just do it.

1. Perkins, FM and H Kehlet. Chronic pain as an outcome of surgery. Anesthesiology (2000); 93: 1123-1133.
2. Waddell, G and Kim Burton. Is Work Good for Your Health and Well-Being? The Stationary Office, Norwich, UK, 2006.
3. Seminowicz DA, et al. Effective treatment of chronic low back pain in humans reverses abnormal brain anatomy and function. The Journal of Neurosci­ence (2011); 31: 7540-7550.

The post When will the Pain Stop? first appeared on Back in Control.

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In the first edition of my book, Back in Control, my advice was that if you had a surgical problem, get the surgery done quickly and engage in the rehab process after you recovered from the operation. I had felt that people in pain could not tolerated the extra burden created from a structural problem. I also thought that surgically correcting severe pathology would relieve the pain to the point that people would be compelled to move forward with their lives. However, I had many patients continue to do poorly in spite of a well-performed indicated operation. I was perplexed and could not predict when this would happen.

Inducing more pain

But I wasn’t aware of the research that shows there is a 40–60% chance of inducing chronic pain as a complication of any surgery if you operate in the presence of untreated chronic pain in any part of the body. It can become a permanent problem 5-10% of the time. (1) Chronic pain as a complication of surgery is not a well-known concept. If I had a neurological complication rate of 5%, I would not have remained in practice for long. This occurs even if the procedure goes well.

My staff pointed out that our patients that had gone through a structured rehab program prior to a procedure were doing much better, and we made a team decision to not perform surgery unless a given patient was sleeping, working on stabilizing medications, experiencing improvement in his or her anxiety/ depression and willing to deal with anger issues. We called the program, “prehab”, and asked our patients to fully engage for at least 8-12 weeks. When we considered major deformity surgery, the prehab might take up to a year.

Many patients did choose to go elsewhere, but the ones who stuck with it, consistently did better and frequently patients with significant structural anatomic problems cancelled surgery because their symptoms had improved or resolved. This turn of events was completely unexpected. It appears that as the nervous system calmed down that the pain threshold was elevated.

Four patients

I saw four patients within a two-week span that I had an almost the same conversation with regards to their decision to undergo surgery. All were professional men between the ages of 45-65. They had leg pain originating from an identifiable problem in their spine. The pain was severe enough that each wanted to have surgery, but they were all at least an 8 out of 10 on the anxiety scale and were sleeping poorly. Their stresses included seriously ill children, loss of jobs, marital problems, etc. and none of them were coping that well.

Can you live with your anxiety?

They were familiar with the DOC project but had not engaged with the concepts at a meaningful level. They were coming back for their second and third visits. Finally, I asked each of them the same question, “What would it be like if I could surgically solve the pain in your leg, but the anxiety you are experiencing would continue to progress over the next 30 to 40 years?” Their eyes widened with a panicked look and every one replied, “That would not be OK. I couldn’t live like this.” Each of them also grabbed his leg and asked, “Won’t getting rid of this pain alleviate my anxiety?” My answer was “No.”

Anxiety is a sensation generated by the body’s chemical response to a mental or physical threat. It is a deeply unpleasant sensation, and the intent is for you to take evasive action and survive. Although surgically removing the spur and pain will relieve the pain and some anxiety, it doesn’t come close to solving it. The essence of lowering anxiety is training your body to secrete less stress hormones.

The quest

I told them that although I would love to get rid of their leg pain with surgery, my bigger concern was their severe anxiety and possibly chronic pain. I recalled my 15-year battle with pain and anxiety. I was on an endless quest to find the one answer that would give me relief; especially for the anxiety. I also remembered the intensity of that need. At that moment I realized that each of these patients felt that by getting rid of the pain they could lessen or solve their anxiety.

It is actually the opposite scenario. As your anxiety resolves, it is common for pain to abate. Crippling anxiety is a solvable problem with the correct approach. That usually doesn’t include surgery. Also, after a failed surgery, another level of hope has been taken away.

Can you live with your leg pain?

Then I asked each of them that if I could resolve their anxiety but they would have to live with their leg pain, what would that be like? Although not completely happy about the scenario, they thought they could deal with it. It was more palatable than experiencing no improvement in their fear.

“No” to surgery

These patients didn’t want to jump to surgery and wanted to give the DOC program a try. Within six to twelve weeks their pain disappeared or subsided to the level where they weren’t even considering surgery. Although I know pain and anxiety are linked circuits, I had never realized that for many patients the pain relief they were asking for was really for peace of mind.

Conversely, I’ve had many patients over the years undergo a successful surgery for a severe structural problem with no improvement or worsening of their pain. Now I understand. “Neurons that fire together wire together.” Pain, anxiety, and anger are tightly intertwined. As long as the anxiety/anger pathways are fired up, they will keep the pain circuits firing.

Surgery may or may not help your arm or leg pain. It rarely solves neck or back pain. It really doesn’t work for anxiety. What relief are you asking your surgeon for?

Listen to the Back in Control Radio podcast Am I Operating on Your Pain or Anxiety?

1. Ballantyne J, et. al . Chronic Pain after Surgery or Injury. IASP (2011); 1-5.

The post Am I Operating on Your Pain or Anxiety? first appeared on Back in Control.

The post Am I Operating on Your Pain or Anxiety? appeared first on Back in Control.

What next?

He elected to go ahead with surgery. He improved for a couple of months and the pain returned except that it was worse. He then underwent a second operation about six months later that did not help and in fact worsened his pain. He asked me again what I thought he should do next. About six weeks before I talked to him he had fired everyone and stopped everything. No more doctors, medications, or surgery. Within a week of making that decision his pain disappeared. He had taken complete charge of his care.

What makes his story more interesting was that when I looked at the MRI scan done after his second operation the bone spur was still there. The surgeon had missed it. He had worked on the middle part of his spine freeing up the 1^st sacral nerve root, not the L5 nerve root. He had needed to remove the bone spur out to the side of the spinal canal, not the middle. He should still have been in pain.

Both L5 nerves pinched

I treated another woman a couple of years ago who had pain down both of her legs in the pattern of the L5 nerve root. She had resisted the DOC project for a long time. She decided to undergo surgery to free up both of the L5 nerve roots. She did have significant spurring touching both of the nerves. When she made the decision to have the operation she also finally engaged in the DOC project. When she came in for her pre-operative visit her leg symptoms disappeared. I cancelled her surgery.

They Both Had Structural Problems

In both of these cases there were structural problems with matching symptoms. In the first case, if the L5 nerve root had been correctly freed up his pain would have disappeared after the first operation or the second operation. As the bone spur was never removed it now was clear that he could have gotten the same improvement without any surgery. With the second case she would have also done well with surgery. Both of them solved their own problem with engagement and taking charge. That is why my book is titled, “Back in Control.” Every patient I have seen get better has taken full responsibility for their pain and care.

Raising the Pain Threshold

When your nervous system calms down utilizing Neurophysiologic Disorder principles the threshold for sensing pain is raised. I am sure that the structural lesions in their spines are still firing pain impulses to the brain. It is just that they are now below the elevated pain threshold and are not interpreted as pain.

What did they do? They both took charge of their problem. They took control, which instantly decreases anxiety. That, in and of itself, is a major step in calming down the nervous system. Their pain did not just decrease; it disappeared. In the future there is a chance that the symptoms will re-appear under a certain level of outside stress. I am now used to having my patients go through the steps that originally calmed them down and the symptoms will reliably disappear. Remember that pain circuits are permanent. I also reassured them that if the symptoms don’t diminish I could always perform an operation.

Why Not Just Do the Surgery?

You might be asking, “Why not do the operation and then they would not have to worry about it in the future?” There are a several reasons. First, even with a successful operation it is common for pain pathways to get fired up under stress, even if there is not a recurrence of the structural problem. Second, even the simplest operation has risks. I could write a book of simple operations going bad. Third, with spine surgery you always cause the formation of scar tissue that can be permanently irritating. You are just better off avoiding surgery if at all possible. Video: “Get it Right the First Time”

The Change in My Thinking

I witnessed over one hundred cases similar to these two. It has caused me to change my thinking about the timing and role of surgery. I use to think that surgery was always required in the presence of a structural problem. My conversation with my patients would be, “Let’s get the surgery done and we’ll work through the rehab later. You cannot rehab a structural problem.” Now my discussion is, “I am happy to perform your surgery but I have seen patients go to pain free even in the presence of a structural problem. If we can calm down your nervous system your post-operative pain will be less and easier to control.” We now have decided that we will not perform elective surgery until a given patient has been involved in addressing his or pain in a structured manner for at least 8 to 12 weeks. Our outcomes have been much more consistent.

I am a surgeon. My thinking around the DOC project is continually evolving. The idea that a person could raise their pain threshold enough to avoid surgery simply by taking complete charge of their decision-making has been surprising to me.

“My Son Just Died”

The post Avoid Surgery by Raising the Pain Threshold first appeared on Back in Control.

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