Pain thresholds

You can also stimulate pain by visualizing the circumstances that caused it or by just imagining it. You will hurt. (1) There is a well-known story in the pain world of a construction worker presenting to the emergency room in screaming pain after he shot himself in the foot through his work boot with a nail gun. The picture is impressive with the nail penetrating though from top to bottom. When they took his boot off the nail had passed between his toes and hadn’t caused any tissue injury. He wasn’t a wimp. When your brain senses danger and tells you to feel pain, you will feel it.

Why can a prize fighter or NFL football player take the punishment to the body at the level that they do? One fraction of the impact to any one of the rest of us, would create unimaginable pain. In that situation during the heat of battle, it would be more dangerous for “survival” to feel the pain. They are occasionally experiencing pain during the match, but not much.

Here is a small article I just ran across demonstrating how the brain can misinterpret sensory input. It is the answer from a teacher being asked the question, “What are some of your favorite ‘ice breaker’ exercises for students when starting a new school year?

“Smell the Peppermint”

My Psychology teacher put a jar of Peppermint Extract on the desk in the front of the room and removed the top.

“Raise your hand when you can smell the Peppermint.”

Sitting in the back row, it took me some time, and as I watched other hands being raised around me I started wondering if my nose wasn’t working properly. But then I caught the strong smell of Peppermint, and dutifully raised my hand.

At this point almost all hands were raised, and the teacher picked up the bottle and drank the entire contents to the expected gasps from the students.

“It’s only water.”

The “Power of Suggestion” lesson is one of the most amazing learning experiences I have ever had in a classroom.

To this day, I can still remember smelling the Peppermint.

Doc Brown, MA Education, Point Loma Nazarene University (1986)

“Seeing red”

Dr. Lorimer Moseley is a neuroscientist from Australia and has done much research on pain perception. One of his experiments involved placing an uncomfortable (safe) cold probe on the forearms of volunteers. Then measured the time they could tolerate the discomfort while they were looking at a red light or a blue one. They had a much lower capacity to keep the probe on their skin when looking at the red light. Their eyes had already registered some level of danger just by seeing red. Not only does the brain decide when a given stimulus is painful or not, it takes all sensory cues into account. Pain is not pain until your brain says it is so.

There is no separation of the mind and body. One cannot exist without the other. It is a unit. It is your whole body that is perceiving input and experiencing pain regardless of the source.

1. Yarnes, B, et al. Emotional Awareness and Expression Therapy (EAET)Achieves Greater Pain Reduction than Cognitive Behavioral  Therapy (CBT) in Older Adults with Chronic Musculoskeletal Pain: A Preliminary Randomized Comparison Trial. Pai Medicine, Oxford Press, 2020, manuscript.

The post Smell the Peppermint–Safe or Unsafe first appeared on Back in Control.

The post Smell the Peppermint–Safe or Unsafe appeared first on Back in Control.

The first book was based on my personal experience and observing the successes with my patients. A great deal of new neuroscience research has since been published, which both supports my treatment approach and explains the reason for its success. Reading the neuroscience literature has deepened my understanding of how the process works. On a personal note, I also developed severe arthritis in both of my knees. About six months into my ordeal I realized that I had developed chronic pain. I re-engaged with these tools and have experienced a marked improvement in my symptoms.

Here are some of the concepts that I have learned through the literature and observation:

• Emotional pain and physical pain are processed in the brain in a similar manner and are equivalent entities. (1) They both cause the secretion of adrenaline and cortisol. When you feel anxiety you are simply feeling the this hormonal surge. Therefore, anxiety is a chemical reaction to sensory input and is not primarily a psychological issue. The Neurophysiologic Basis of Chronic Pain Most patients, given a choice of getting rid of their physical pain versus mental pain would rather get rid of their emotional pain. Fortunately, as anxiety drops, adrenaline and cortisol levels decrease and the physical pain will diminish. Stress chemicals increase nerve conduction and pain by 30 – 40%. (2) Anxiety, anger and adrenaline

• In the first edition, I was emphatic that surgery for a structural problem should be performed more quickly since people in chronic pain don’t tolerate additional pain. My experience and the literature do not support that idea. If you operate in the presence of a fired up nervous system, the pain will frequently worsen and often dramatically. I now have all of my elective spine surgery patients engage in the tools outlined in Back in Control for at least 8 to 12 weeks. Surgical outcomes have been more consistent with less pain after surgery and a faster rehab. I also am no longer seeing some of the dramatic failures from a well-done surgery like I saw in the past. The name for this preoperative rehab process is “prehab”. Video: Get it Right the First Time

• What has been the most surprising turn of events is that during the prehab process I have witnessed dozens of patients become pain free that have severe pathology with matching symptoms. I had scheduled each of them for surgery and they cancelled it because their pain dramatically decreased. They did not want or need surgery. I now realize that you can calm down and reprogram your nervous system any way that you want with consistent practice of these tools. It has been rewarding seeing patients become free of pain without the cost or risk of surgery. Avoiding surgery by raising the pain threshold

• I have changed the name of the DOCC (Defined Organized Comprehensive Care) project to the DOC (Direct your Own Care). My book is not a formula. It is a framework that breaks down chronic pain into its component parts and my patients find their own personal solutions. I have watched hundreds of patients become pain free with this largely self-directed process. If someone does not want to engage in these concepts, whether or not they use my book, they cannot and will not get better. The one factor that predicts a good outcome is being truly open to learning and using your personalized version of the tools. DOC-A framework of care

• Research shows that the writing and ripping up exercise does not have to express just negative thoughts. Writing down any thoughts and feelings, either positive or negative is effective. Expressive writing is still the foundation of the DOC project. (3) Write and don’t stop

• These concepts apply to pain from any source in any part of the body. Interestingly, as the process depends on decreasing adrenaline, pain in multiple body areas will disappear about the same time.

John

I had a middle-aged patient who had suffered a significant fracture of the middle part of his back. His spine was bent forward almost 45 degrees. However, since it was just at one level he was able to compensate and was still balanced with his head centered over his pelvis. I would have quickly recommended surgery for it for ten years ago. Then I found out he had been suffering from severe anxiety since he was ten years-old and sleeping poorly. I put him through the prehab process, which included expressive writing, active meditation, normalizing his sleep and getting him more physically active.

He was initially unhappy with me delaying surgery, which would have corrected the deformity. However, the medical literature is clear that surgical outcomes are compromised without the above-mentioned issues being treated. He came back a few times asking for the surgery but was not really engaging in the project. I finally said, “Look, you are welcome to find another surgeon, but I am not going to put you through surgery until these problems are least partially solved.”

He came in a few weeks later with a huge smile on his face. His pain was gone and his anxiety was beginning to decrease. He was sleeping much better and his whole personality was transformed. I will admit that I thought he was going to get his surgery done elsewhere. I am still endlessly surprised and fascinated when my patients come out of their pain pathways, although we witness it every week.

New format

The new edition is organized around following format:

• Section One – The Evolution of Chronic Pain
• Sections Two – The Principles Behind the Solution
• Section Three – The Roadmap Out of Chronic Pain
• Section Four – Continuing Your Journey

I am excited about the new edition. I have learned how to clearly present these concepts, since I have a better grasp of these principles. I am seeing a higher percent of people engaging and improving. This edition reflects that experience as well as the recent advances in neuroscience that support it. I am looking forward to seeing how this whole process unfolds and this new edition is the next step in my journey.

Am I operating on your pain or anxiety?

1. Eisenberger N. “The neural bases of social pain: Evidence for shared representations with physical pain.” Psychosom Med (2012); 74: 126-135.

2. Chen X, et al. “Stress enhances muscle nociceptor activity in the rat.” Neuroscience (2011); 185: 166-173.

3. Smyth JM and James Pennebaker. “Exploring the boundary conditions of expressive writing: In search of the right recipe.” British Journal of Health Psychology (2008); 13: 1-7.

The post Back in Control – Second Edition first appeared on Back in Control.

The post Back in Control – Second Edition 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.

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