But more surprising to me was that not only would they improve, many would experience a nearly complete recovery. Patients who had been disabled for quite a while would have a remarkable resolution of their pain, come off narcotics, and resume an almost normal lifestyle. Frequently the new lifestyle was more active and satisfying than anything they had experienced before. This level of recovery went well beyond both my patients’ and my own expectations.

Changing my practice

When I moved to Sun Valley, ID in 1999, I was in the worst part of my own 15-year ordeal with chronic pain. I was experiencing many physical symptoms, including migraine headaches, thoracic back pain, tinnitus, burning in my feet, and over a dozen of the other known 33 physical symptoms of a stressed nervous system. My practice changed from being that of a complex spine surgeon at a major medical center, to becoming a primary care physician caring for all aspects of a patient’s spine problem. There weren’t many resources, so I orchestrated most of the care.

I had always been diligent in doing what I could to help patients avoid surgery, but I did not understand chronic pain. I applied a surgeon’s mindset to non-operative care. Whatever aspect of the issue arose, my goal was to solve it – and quickly. Eventually, a predictable pattern evolved as well as a structure. As I personally tried this approach, I also began to heal. When I left Sun Valley to return to Seattle in 2003, I had largely broken free from the grip of chronic pain.

The DOC project

 Here is the core of the DOC project:

• Sleep
• Effectively processing stress
• Physical conditioning
• Medication management
• Life outlook
• Education as to the nature of chronic pain and the principles behind the solutions
• Family dynamics

1. The first step that clearly made a significant difference was addressing sleep. Back then, only a small percent of physicians dealt with sleep issues. I took an aggressive approach and would begin with simple “sleep hygiene” issues. But if a patient wasn’t getting adequate sleep within a couple of weeks, I would use different combinations of sleep medications. Most people would respond within six to eight weeks. A significant percent of patients experienced a dramatic improvement in their pain. It wasn’t until years later, that I read a major paper showing that lack of sleep could induce chronic pain. (1)
2. Dealing with stress was the next concept that emerged, which I discovered through expressive writing. I did not have access to a pain psychologist, so I recommended that patients read David Burn’s book, Feeling Good. Many refused to read it or they would read it but not engage in the writing exercises that he strongly recommended. The book presents a program of self-directed cognitive behavioral therapy. His research had shown that 85% of people would respond with an improvement in mood. I liked using the book because patients could immediately engage with it, whereas it would usually take weeks and months to get into a pain psychologist. Then I noticed that the only ones who responded were those who did the recommended writing.
3. The physical conditioning aspect of the DOC process was not a new concept and I did have the privilege of working with superb physical therapists right next door to my office. I was introduced to a high level of evaluation and care. We were also close to an athletic club and working out with resistance training quickly became part of the program. Weight training increases strength, so there is less stress on the body. It also stimulates the release of hormones that enhance your sense of well-being. But it also seems to have a neurological component in that you are on the offensive, taking charge instead of being at the mercy of your pain.
4. Medications are a significant aspect of healing, although eventually most people came off of them as their sleep and pain improved. My approach was the reverse of what is usually done. My sense was that people needed some symptomatic relief in order to engage in the other parts of the DOC process. I would keep patients on the same doses of medications they came in on, including narcotics. All medication discussions were done face-to-face. The goal was to wean down but the patient always had the last say regarding how quickly this would occur. What I did not realize at the time that anxiety is the pain and going to war over medications is counter-productive. With the patient in charge, he or she had control (an antidote to anxiety) and I rarely had a problem with patients coming off of their meds. In fact, as the pain dropped, the side effects increased and they were anxious to stop taking them. I also realized that no one really wants to be dependent on meds. The only criteria I required was that they had to be actively engaged in the other aspects of the DOC process, although I did not have a name for it back then.
5. Life outlook turns out to be maybe the most important aspect of healing although it began accidentally. I had been working hard with a middle-aged woman to help her with her pain and get her back to work. It was a bit of a struggle, but she steadily pulled out of her chronic pain. When it became time to have her return to work, she told me that she never had any intention of returning to work. I became upset and realized that I had never set any goals with her. I began to ask every patient exactly why they were seeing me and what they wanted. What eventually became apparent was that goal setting is a core aspect of stimulating neuroplasticity. Your brain will develop wherever you place your attention. It is similar to learning a new language. You have to decide what you want your life to look like, what you want in it, and then pursue it. Otherwise you are still focused on the problem and not the solution. A corollary aspect of this is forgiveness. You can’t move forward until you can let go.
6. Education about the nature of a problem is essential in any realm before you can solve it. This is particularly true with chronic pain because it is so complex and each individual is unique. The traditional approach to chronic pain is to manage it, not solve it. Random simplistic treatments are used to treat symptoms and not address the core problem of a fired up nervous system and sustained exposure to elevated stress chemical. My book, Back in Control: A Surgeon’s Roadmap Out of Chronic Pain evolved from my need to explain the problem to my patients. Its main role is to provide a context of care and it is helpful to be able to understand why and how different treatments work – or not.
7. The final component regarding family dynamics came about over the last few years of my practice in Seattle. We had known that chronic pain takes a terrible toll on the family. It became clear that a patient could engage in many aspects of the DOC process but the family dynamics would sabotage everything. Conversely, by addressing the family interactions around pain, patients would often experience powerful healing. We began to set up rules around pain in the household. The basic one was that the patient could not discuss their pain with anyone – ever – especially with their family. The corollary was no complaining, giving unasked-for advice, or criticizing. Basically – be nice.

The DOC process provides a framework for you to organize your thinking around your pain, figure out your individual set of issues, and pursue your own journey. I have watched hundreds of patients break free from the deep Abyss of pain. There is no beginning or end point, as you will learn tools that will help you deal with day-to-day stresses. As your anxiety drops, pain decreases and creativity and joy returns. Helping people out of pain has become the most rewarding and enjoyable phase of my career.

One story

A few years ago, I began to work with a woman in her 30’s, who had been experiencing severe anxiety when she was ten and developed widespread pain over most of her body. She continued to push forward, in spite it all. She was a talented musician but had to put a hold on it because of her pain. Her life became progressively smaller as she kept pursuing different treatments without any success.

She began to work with me on the DOC process, beginning with expressive writing and learning about pain. Sleep was a major problem and it took months to bring that under control. However, a few weeks after she began writing, she noticed an improvement in her anxiety. She also had access to a somatic therapist who was able to help her relax. Over a period of six months, her anxiety dropped dramatically, her pain resolved, she came off all medications, and she is re-engaged with her music career. She can’t express in words how happy she is to be not only free from chronic pain and anxiety, but also that she is thriving.

1. Agmon, M and G Armon. “Increased insomnia symptoms predict the onset of back painamong employed adults.” PLoS ONE (2014); 9(8): e103591. doi: 10.1371/ journal.pone.0103591.

The post Evolution of the DOC Project first appeared on Back in Control.

The post Evolution of the DOC Project appeared first on Back in Control.

I was introduced to this concept in the 1980’s by Dr. Bernie Siegel’s book, Love, Medicine and Miracles. He reviews some of literature that links stress with disease and also relates many stories of patients with terminal cancer who beat the disease. He formed a non-profit group, ECaP (Exceptional Cancer Patients). These miracles happened in the presence of widespread disease without any hope of survival. Although this has been witnessed for decades, he asked the question, “Why?” It is not just a lucky occurrence. Remarkable healing stories – Dr. Bernie Siegel

The destructive power of anger

The same principles hold true for the healing that occurs in the DOC process. It is not a series of steps that you undertake and you are free of pain. It is a framework that organizes your thinking and clears the air so you can figure out your own next steps. Somewhere in the midst of quieting down, my patients unconsciously connect with the core of who they are and allow themselves to heal.

Being trapped causes frustration and anger. Anger disconnects you in almost every direction and adversely alters your body’s chemistry so all of your cells (organs) are bathed in stress chemicals. Some things that trap us are:

• Our thoughts
• Anxiety
• Unpleasant work environment
• Abusive home situation
• Uncomfortable/ painful physical sensations
• Too little money
• Not being able to meet basic daily obligations – always behind
• Random medical treatments

Most of these problems are not solvable, so as your legitimate frustrations continue, so will the chemical assault on your body. You cannot connect with your body’s capacity to heal in this adverse physiological environment. You can   train yourself to alter this primitive survival response.

Placebo

Placebo is a term that has been incorrectly presented to both doctors and patients. It is felt that if a patient responds to a placebo, then there clearly must not be a problem. Really? It has been shown and continues to be demonstrated that almost every medical treatment has a significant placebo component – even in the presence of the active ingredient of the drug. Also, the more invasive the treatment the more powerful the placebo effect. In other words, an injection is stronger than a pill, and a surgical procedure has even a greater placebo effect.

The percent of people that respond to a given treatment with a placebo effect ranges from 20 to 50% and it is consistent. I am not aware of any study that shows that the placebo effect is absent. Harnessing and  this placebo effect is what you desire. It is specific, powerful and does not have side effects or risks. There is nothing more impressive than having your immune system rally and wipe out a given cancer. All that doctors can do is to kill cells with drugs and radiation and hopefully the cancer cells are destroyed first. Occasionally surgery can completely remove it, but never in these terminal cases. The newer generation of treatments is focused more on targeting only the cancer cells.

The warts on my hands

I had a remarkable experience with my body’s healing powers in my 20’s. You can read about it in detail but after suffering with five to ten warts on both of my hands for over 10 years this disappeared forever within a week after a dermatologist told me to rub fresh Aloe Vera leaves over them. Then he told me that he thought it was a long-shot but it would work, “Because I think it is just a placebo.” I was extremely upset and angry and I can still feel what happened inside me that day. I remember feeling that “I am done with this” and I felt a deep shift occur in the middle of my body. I rubbed the Aloe Vera on my warts for a couple of times and then threw the stems out. Two weeks later I had new hands. I cannot adequately encapsulate this experience in words. It has been shown that even when patients know they are receiving a placebo it is still often effective. (2)

The drug of choice

Placebo is the drug of choice for any disease state, including chronic pain. You must get out of your own way and allow your body heal. Connecting to your own healing capacity does not carry risks or cause harm.

Unfortunately, many medical procedures do have significant risks and cause damage, even when there are no complications. I had to directly or indirectly deal with almost all of them including, stroke, blindness, paralysis and death. Addressing bad outcomes was one of  the most difficult aspects of being a surgeon. This is especially true when you wonder if you could have possibly avoided the procedure, or did my patient really understand the implications of his or her decision? There are conflicting reports but it appears that there are over 150,000 deaths annually from medical errors, which would make it the third leading cause of death behind heart disease and cancer.

One mechanism of action of placebo is that it engages the same brain mechanisms that release the body’s endorphins (natural pain killers) and ‎cannabinoids (active ingredient in marijuana). Interestingly, researchers can block the pain-killing placebo effect with a drug that blocks narcotics called naloxone.

Treatments without risk

A 2012 study recently came to my attention where lidocaine patches for LBP were compared with just the patches. It is extremely interesting in that 50% of the patients responded in both groups. Does the paper show that patients really did not have pain? “No!” It demonstrates that the healing response is stimulated by the patch. Does that mean we should be prescribing patches without the lidocaine? “No!” The risk of Lidocaine on the patch is essentially zero and adds minimal cost. A 50% response rate is excellent. (1)

It doesn’t even matter if the patients know that the “drug” is a placebo. Another “open label” placebo medication study showed a large reduction in chronic low back pain compared to the usual treatment. The mechanism of action of this effect is unclear and it does not require deception to be effective. Somehow the act of taking the pill stimulates the body’s capacity to heal. (2)

When patients heal at some point during the DOC process there is no way of knowing what aspect of it was effective and it doesn’t matter. You have connected with your body’s ability to heal and without a downside.

Heal yourself

Understand that each and every person has the capacity to access his or her own body’s ability to heal. We have observed that the vast majority of patients who engage will not only improve but thrive. Unfortunately, the anger that fires up so many symptoms is also the obstacle that blocks engagement. The major factor that portends a good outcome is willingness to be open to new ideas and then pursue them. Or, as one successful patient pointed out, “It requires a suspension of disbelief.”

1. Hashmi, JA, et al. Lidocaine patch (5%) is not more potent then placebo in treating chronic back pain when tested in a randomized double blind placebo controlled brain imaging study. Molecular Pain (2012); 8:29-30.
2. Carvalho C, et al. Open-label placebo treatment in chronic low back pain: a randomized controlled trial. Pain (2016); vol 0: 1-7.

The post Harnessing the Body’s Healing Power first appeared on Back in Control.

The post Harnessing the Body’s Healing Power 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.

Consider the following:

Thoughts are the mental link to the environment that allows you to assess your situation second by second in order to make choices that allow you to first survive and then thrive. If our thoughts are pleasant our bodies will secrete chemicals such as oxytocin, growth hormone and dopamine that create a sense of relaxation and well-being.

Conversely, if you feel stressed then your thoughts will create a chemical environment consisting of adrenaline, cortisol and other hormones that create a sense of insecurity and dread. You will be motivated to control you or the situation to alleviate these feelings of anxiety. If you cannot escape or solve it, you will feel trapped and angry. If you are in a constant hyper-vigilant state, then your body will be continually on overdrive. It is like driving your car 70 mph down the freeway in second or third gear. It will break down much sooner than if you were in 5th gear and cruising.  Anxiety, Anger and Adrenaline

I am aware that life is not easy. Very few people can live their lives on “cruise.” Additionally, avoiding stress also becomes its own stress. You cannot run from your thoughts, which can torment you regardless of your environment. In fact, when I was in the most severe period of my Obsessive Compulsive Disorder (OCD) my mental distress was worse when I was less busy. OCD, BTW, is manifested by intrusive thoughts and extreme anxiety. Some day I will write about my battle with it in more detail but the only metaphor I can use to describe the experience is “having a hot branding iron on my brain”. The misery being in that hell of unrelenting anxiety is indescribable. OCD is no fun and not funny – extreme mental pain

Control

One of the main antidotes to anxiety is control. When you lose control your body will kick in more adrenaline to physically help you solve the problem. For example, if you were physically fighting someone for food to feed your family, the adrenaline boost would up your odds of winning. Unfortunately, just thoughts of danger can create the same chemical response even when there is no physical threat. Now you are in trouble because you have no way of physically solving the problem and there is not an endpoint.

Neurophysiologic Disorder (NPD)

There are many terms to describe the physical consequences of sustained levels of stress chemicals in your body. Some of them include Mind Body Syndrome (MBS), Tension Myositis Syndrome (TMS), Central Sensitization Syndrome (CSS), and Stress Illness Disorder. The term I have chosen is “Neurophysiologic Disorder” (NPD). Your thoughts are the neurologic input to your nervous system that creates a physiological response. We are programmed to gravitate towards the reward chemicals and avoid the stress ones. Within a pretty wide range we are able to conduct our lives in a functional and enjoyable manner – except when we can’t. There are solutions to the problem, which are the focus of my book. However, consider the effects of not addressing it.

These next few paragraphs were part of a proposal to address the effects of high ACE (Adverse Childhood Experiences) scores beginning in elementary school that are directly linked to your responses to stress.  Aced Out

Effects of Untreated NPD and Anxiety

There are several ways that untreated Neurophysiologic Disorder (NPD) manifests itself. Remember that the main focus of the school project is to deal with the lifelong impact of adverse childhood events. The worse the ACE load, the higher will be the anxiety a child brings into the classroom. The devastating impact on mental and physical health of a high ACE score is well documented. This does not even take into account the power struggle that occurs amongst these students to deal with unrelenting anxiety. Bullying, at the moment, is not even counted in the ACE score.

First, NPD can directly cause over 33 different physical symptoms. Medicine is focused on treating symptoms instead of the root cause of a fired up nervous system. Many of these conditions will begin in childhood, such as migraine headaches, insomnia, anxiety, eating disorders, stomach pain, etc. My Battle with NPD

Second, anxiety is the result of sensory input also that drives anger. One common cause of anger is loss of control. When you lose your ability to control your anxiety the anger will become intense. Anger is always destructive, including self-destructive. Although it may not become manifested during school years, it eventually results in complete disregard for personal health. This is an addition to the symptoms directly caused by the MBS. My observation is that complete neglect of your health is akin to a “slow suicide.”

Third, anger is abusive. Chronic pain creates and indescribable depth of frustration. When you are angry, it is all about you. It is a survival response and you lose awareness of the needs around you. Lack of awareness is the essence of abuse. Families of patients in chronic pain become the targets of this deep anger, and hence the cycle of adverse childhood events continues. There is a high chance that these children will act out their frustrations at school. Also, their parents have modeled anger as the normal way of dealing with adversity. Pain = anger = abuse

Unrelenting anxiety/anger cause profound physical effects on your body. Another week I will present the data regarding mental health and life span. It is not a pretty picture.

Your Unconscious Brain

I am aware that no one intellectually wants to be sick or unhealthy. The solution lies in addressing pre-programmed behavioral patterns that are part of the unconscious brain. The unconscious brain is much more powerful than the conscious brain. Your conscious brain energies manifesting as “good intentions” or “will power” have no chance of solving the problem. You must utilize strategies that stimulate your brain to rewire. You cannot “fix” yourself because your attention is still on you. Solving the Unsolvable

The DOC project is a framework intended for you to organize your thinking in a manner to connect with your own body’s capacity to heal. Your unconscious brain will resist this process to the max. Just sit down with Stage 1 on this website and start the therapeutic writing as described in Step 2. Your brain will begin to change and you will be able to move forward.

So my feeling is the mental health is the highest priority. Your body’s chemistry is optimized, you are able to enjoy your life with your family and friends, and your capacity and motivation to care for your health will be higher.

Why are New Year’s resolutions so hard to keep?

The post Mental or physical health – Which is more Critical? first appeared on Back in Control.

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