Florence, Italy, 2013

On vacation

We all intellectually know that life is short and somehow we spend a lot of energy avoiding that thought. I was reminded of the frailty of life this week while vacationing in Florence, Italy.

Many of the cobblestone streets are narrow and the sidewalks even narrower. It is also quite crowded. There is a constant negotiating for sidewalk space with other people going with or against you. At the same time I am trying to relax by enjoying the sights. There is some risk to this combination of forces.

The bus

I was standing just behind my wife looking into a shop window. There were people milling both in front and back of me. We were on one of the more narrow streets when suddenly I felt something touch my hair that felt like a light breeze. Then I heard a horn. I looked up and a local bus had passed me traveling around 25 mph. The mirror of the bus was about five feet off of the ground. With the road being so narrow a portion of the mirror was overhanging the sidewalk about a foot when it passed me. It was traveling so fast that it was 20 feet past me before the driver was able to hit the horn and I could look up. I was within a quarter of an inch of my head being slammed to the ground. The good news is that it would have been quick.

I was relating the story to our incredibly gracious Florentine host who wasn’t surprised. “I had a friend of mine was killed in London about 30 years ago after his head was struck by a passing bus mirror.” Then I was talking to another one of our American friends who has lived in Florence since 1979. She told me that it happens frequently, and she has been wary of the possibility since had moved here. Then my son remembered that he had a classmate who was killed at age 18 in London after being hit by a passing bus mirror. None of these stories were reassuring.

On life #6

This incident was my fifth significant close encounter with dying with this one being particularly intense. Being comfortable with death is a skill I am not inclined to learn, although the philosophers point out it’s a necessary part of truly living. The response it fosters in me is gratitude. I have long realized that life is one day (moment) at time and that I am incredibly fortunate in many realms. The first one being that a “bad day” is much better than not having a day at all. I also live in a free country with food on my table and a shelter over my head. We have comforts and opportunities that have never existed in the human experience.

Another benefit, that I never expected was the gift of suffering. I never understood how extreme the experience of being crippled by anxiety and other physical symptoms could be and each patient in pain takes me back to some part of my journey in the Abyss. I came out of it one millimeter at a time. I am incredibly grateful to be able to share my insights with others. Watching them thrive has been rewarding, inspiring and humbling. The capacity of a given person to heal is almost infinite and I am one example.

The Denial of Death

Ernest Becker wrote a famous book, The Denial of Death. His premise that he elaborates on in multiple ways is that the fear of death drives most of human behavior. I agree that avoiding anxiety is the main driving force in that the human body’s primary role is survival and then procreation. Homo sapiens that didn’t pay attention to the environmental cues simply didn’t survive. The current human race represents “survival of the most anxious” and it’s effective. Worrying about death is unique to humans because we have consciousness and it’s the ultimate fear. However, it is just one of an infinite number of other things to be anxious about. But spending your time worrying, including about the inevitable, then it’s much harder to enjoy the gift of life you have been given today. Deeply accepting death is a major step in truly living. Learning to live with anxiety is another one.

Constantly thinking about how to solve your chronic mental and physical pain is, I think, almost a worse situation than worrying about dying. You are living a life that is steeped with misery, being bounced around, not believed, labeled and there doesn’t seem to be any hope of escape. I will never forget reading Viktor Frank’s book, Man’s Search for Meaning, in which he describes his experience in a WWII concentration camp from a psychiatrist’s perspective. He was able to somehow accept his fate while in the camps. What caught my attention was that he felt that the worst part of the ordeal, in spite of extreme physical suffering, was wondering if and when it would end. The effect of chronic pain has been documented to have a similar impact on a person’s life as terminal cancer. (1)

The paradox

The solution to chronic pain is a paradox. It is important to understand the neuroplastic properties of the brain. Your brain changes structure every millisecond by forming new connections, supporting cells, neurons, etc. It will develop in whatever direction you choose. If you spend your time looking for a solution for your pain or constantly discussing it, you are only reinforcing it. If you choose to move forward with or without your pain, paradoxically you can leave it behind. Remaining anxious about things beyond your control will suck your life energy right out of you. Dealing with your inevitable end is an opportunity to accept, process it and move forward.

A brush with death also reminds me that the goal of The DOC Journey is to enjoy the day that you’re are in. There is a tendency to look at this process as a stepwise formula with the goal being the end of pain and suffering. That’s the opposite of what actually happens. The “goal ” is to get happy first regardless of your circumstances, including the pain. You’ll then have the energy and passion to move through your mental and physical pain and create the life you desire. The ring of fire

Enjoy your day today

1. Fredheim OM, Kaasa S, Fayers P, Saltnes T, Jordhøy M, Bortchgrevink PC. Chronic non-malignant pain patients report as poor health-related quality of life as palliative cancer patients. Acta Anaesthesiol Scand. 2008;52(1):143-148. 

The post “Dying” Before Living first appeared on Back in Control.

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Awareness

You cannot successfully address any problem without understanding its root cause. But many people in pain stubbornly insist that, “The problem is that I am in pain,” and leave the solution to their health professionals. Unfortunately, the neuroscience research has not worked its way into mainstream care and they don’t understand the problem either. A recent paper that reviewed hundreds of studies stated that “chronic pain is a maladaptive neuropathological disease state.” (1,2,3) You cannot successfully solve a neurological problem with interventions aimed at structural issues. It is just not possible. This approach can’t and doesn’t work. That is why over 1 in 3 American adults are suffering from some level of chronic pain.

The body processes both emotional pain and physical pain by responding with stress hormones? Both kinds of pain are successfully treatable using similar strategies? Given a choice most of my patients would like to eliminate their emotional over their physical pain. Paradoxically, as the emotional pain drops, so does the physical pain. It doesn’t work the other way around.

My friend, Fred Luskin, author of Forgive for Good, pointed out that the human body is designed for survival, not necessarily for quality of life. All stress–real or imagined–is perceived as a threat and triggers your body to secrete adrenaline and cortisol. If you are under constant stress you may not even notice it, but your body will continue to secrete these chemicals that keep you in a continual “fight or flight” mode. You may be so used to being in this state, that it seems normal. The first step in healing is to become aware of your state of mind, life outlook and the effect they have on your body’s chemical balance. You have to understand your current state of being before you can change direction.

Hope

Hope is a critical component for thriving and living a meaningful life.

The observation and experience of core group of physicians and some other health care professionals is that of chronic pain is solvable. However, most physicians view it as a diagnosis to be managed. They simply haven’t been trained in utilizing an effective approach. They are almost as frustrated as their patients because they went into medicine to help people. Most of my patients have been to many providers and undergone multiple treatments without success. Additionally, since no one has provided them a plan should the treatment fail, there does not seem to be any way out.  They feel trapped. The indescribable anger and frustration really crank up their stress chemical output, which increases the pain. How many times can you experience that kind of disappointment and still keep moving forward?

Dr. Viktor Frankl, author of Man’s Search for Meaning, was an Austrian psychiatrist who survived the WWII concentration camps. In his book, Dr. Frankl described how the worst part of the ordeal was not the indescribable physical suffering, but not knowing when if and when it was going to end.

Every week I see huge smiles on the faces of patients who are now pain free after years, sometimes decades, of pain. They cannot express their feeling in words, and I feel privileged that I have been able to provide a framework for them to pull themselves out of the hole. It began with awareness and hope.

Forgiveness

You will not heal while you hold on to anger, no matter how justified your anger might be. In fact, the more legitimate your anger, the harder it is to let it go. How can you move forward while hanging on tightly to the past? There are many resources out there to help you process your anger, and Stage 2 of this website is a solid starting point. The method does not matter as long as it enables you to truly let go. Remember, that to stimulate your brain to develop new pain-free pathways you have to move forward with or without your pain. I highly recommend Dr. Luskin’s book, Forgive for Good. When it entered the DOC program, I began to see many more patients free themselves from their pain. I consider acknowledging and processing anger the “Continental Divide” of chronic pain.

Several studies have shown that the vast majority of people in chronic pain still blame the person or situation that caused their injury. Interestingly, the person they blame the most is themselves. (4) When patients tell me they are not angry I often will ask them how critical they are of themselves. The most important person to let off of the hook is you. Knowing how anger obstructs healing and creates more pain, why do you insist on holding on to it? Is it really worth it?

Pain free after suffering for decades

Iris became pain free after decades of severe chronic pain. She had been on high-dose narcotics and using a walker. Now she is off her meds and walking unassisted.  She wrote me, “The book you have written has saved my life. It is so much more than a book on back pain; it is back in control of my sanity, my depression, my self-worth, and my caring. I had no idea that anger was behind my anxiety and depression.” I have never met her but was able to talk to her a few months later. The key to her healing was awareness and letting go.

Play

Anger and play could not be farther apart. Anger disconnects us from others, from ourselves and from life; while sharing play is the essence of life.

Play is an essential aspect of child development. It is how we learn to constructively interact with others. Play areas of the brain are powerful and permanent circuits present in every human being; but they can get buried in the hubbub of daily life and the distraction of chronic pain. They’re present even in someone who did not develop an overabundance of them in childhood. But although play exists in all of us, they must be nurtured by making conscious choices to play. You do not need to continue to live your life in anger.

About ten years ago, I made a conscious decision to re-inhabit my play pathways when I chose to enjoy my day regardless of the circumstances. I am not always successful; but I committed to re-engaging with these circuits as quickly as possible when I wandered off course. Eventually, the labels “work” and “play” have merged into one. Play for me is curiosity, gratitude, awareness, letting go and simply deciding to enjoy and appreciate what I am doing at the moment.

Three of the principle methods for eliminating chronic pain are: 1) “de-adrenalizing” the nervous system, which slows the speed of nerve conduction and decreases the level of pain; 2) building new circuits that circumvent the embedded pain ones; and 3) shifting to new and more functional areas of my brain.  Play does all of this.

Omega Workshop

I didn’t realize how powerful play pathways were until a five-day workshop I facilitated at the Omega Institute in Rhinebeck, New York. Fred Luskin worked with us during the forgiveness portion, and my wife and daughter helped us play together. Feeling safe and relaxed, we began to laugh. Many attendees went pain free within five days and have remained that way. Even I did not expect such a powerful outcome. The Cup Song

My book presents a robust framework to help you organize your thinking about pain. Using awareness, hope, forgiveness and play will allow you to discover your own way out. Give it a go. Those of us physicians who use some version of this approach feel strongly that the majority of our patients will significantly improve or free themselves from the grip of pain.

1. Davis KD and M Moayedi. “Central mechanisms of pain revealed through functional and structural MRI.” Journal of Neuroimmune Pharmacology (2013); 8: 518–534.

2. Baliki MN and A Vania Apkarian. “Nociception, pain, negative moods, and behavior selection.” Neuron (2015); 87: 474-491.

3. Tracey I and MC Bushnell. “How neuroimaging studies have challenged us to rethink: Is chronic pain a disease?” The Journal of Pain (2009); 10, 1113–1120.

4. Eccleston C, et al. “Patients’ and professionals’ understandings of the causes of chronic pain: blame, responsibility and identity protection.” Social Science & Medicine (1997); 45: 699–709.

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The post Awareness, Hope, Forgiveness and Play first appeared on Back in Control.

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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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A Surgery gone wrong

He underwent ear surgery when he was 19 years-old. The surgeon had slipped and perforated his eardrum. He initially had a lot of pain that resolved over several months but he ended up with significant ringing in his ear. He spent years being frustrated at the endless ringing and also at the surgeon who had caused him so much suffering. His quality of life wasn’t close to where he wanted it, particularly at such a young age.

Tinnitus resolved

As the interview progressed, it was clear that he knew much more about the DOC principles than most. Yet he had not been exposed to the concepts. I began to ask him a couple of questions, since he indicated that the tinnitus was no longer a problem.

He realized that the energy he was expending being angry was a waste  of time. There was nothing he could do about it. He made a decision to accept his ringing and in an odd way “made friends” with it. Although it was not his intention to get rid of it, over the next few years the ringing stopped. He only occasionally experiences it.

You can’t “fix” yourself

One of the intents of the DOC project is to create a nervous system shift from fired up circuits to more pleasurable areas. The more you fight and try to “fix” your symptoms the stronger they will become since your nervous system will develop wherever you place your attention. You will also become worn out similar to an insect being trapped in a spider web. As he quit reacting to the signal from his ears his nervous system shifted. Eventually his brain become less sensitized and he experienced relief.

Embracing Adversity

He went a step further and somehow embraced his tinnitus. Viktor Frankl tells a similar, more intense story. His book is titled Man’s Search for Meaning. He was a Jewish psychiatrist who survived the concentration camps but lost several immediate family members. Somehow in the midst of indescribable suffering he felt it was important not only to find one’s purpose in life, but also to find meaning in suffering. He was able to accomplish this while in the camps. Many, if not most, survivors did not do that well after the camps. They understandably had severe PTSD. I have had many patients tell of their parents’ lives after the ordeal and it is often dismal. Viktor Frankl not only survived, he thrived and went on to a prestigious academic career.

Remember that in the big picture of life stress is not the problem. It’s how you choose to react to it. It’s only by letting go, and possibly embracing your adversities, will you be able to move past your pain into a full and rich life. What is your choice?

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