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.

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

For more, see The Myth of Self Esteem.

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

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

I talk about how anxiety and stress can lead to certain obsessive tendencies. Some of the tools from the DOCC project are laid out, specifically those that can help break down the circuits that fuel anxious and stressful thoughts and behaviors.

For more, see Your Demons are Robots.

BF

The post Video: Anxiety and It’s Demons first appeared on Back in Control.

The post Video: Anxiety and It’s Demons appeared first on Back in Control.

I discuss how anger is the turbocharger that keeps anxiety both covered up and fired up. Until you turn off anger you won’t be able to get a handle on your anxiety or your pain.

The post Video 15/19: Anger Fueled Anxiety-“The Highway to Hell” first appeared on Back in Control.

The post Video 15/19: Anger Fueled Anxiety-“The Highway to Hell” appeared first on Back in Control.

BF

The post Video 14/19: Chronic Pain: Pain Free is Not Only Possible, it’s Probable. first appeared on Back in Control.

The post Video 14/19: Chronic Pain: Pain Free is Not Only Possible, it’s Probable. appeared first on Back in Control.

Normally aging discs

As you age, the discs between your vertebrae lose water content and become stiffer. That is a normal part aging.  You lose flexibility. Over age 50 most people have degeneration of at least one disc. There is no evidence that supports the idea that a degenerated disc causes pain. (1)

At age 32, I underwent a disc excision for a ruptured disc followed by a second operation two weeks later for a deep wound infection. My three lowest discs are completely degenerated and collapsed. Other than an occasional muscle strain from my terrible golf swing, I do not experience back pain. I saw patients weekly with “terrible looking spines” and sciatica from pinched nerves. However, most of them had no back pain. The upshot is that most spine fusions for LBP are performed on normal spines for a given person’s age.  The results are poor. There is less than a 30% chance of long-term success. (2)

If there is an identifiable structural problem with a matching pattern of pain, the success rate of surgery is much higher. These are the only situations that I will perform surgery. An example would be a bone spur pinching the 5^th lumbar nerve root while there is pain down the side of the patient’s leg. In this case, there is a strong correlation between the structural description and the pain. This pattern of pain usually disappears after surgically removing the spur.

Mouth pain vs. a cavity

I frequently compare spine surgery with dentistry. Generally a dentist can specifically identify the structural problem causing your pain.  It might be a cavity that has gone down to the root.  The chance that your dentist can solve this problem with a filling, root canal, crown, etc. is essentially 100%.

What if you went to your dentist with “mouth pain,” but the source of the pain could not be identified?  This is also a common occurrence. The pain may emanate from the sinuses, be caused by TMJ, or can even be a “neurophysiological” symptom. What would be the chance of success if your dentist started doing procedures without seeing which tooth was the source of the pain? It would be almost zero.

Fusions for back pain

Currently there are hundreds of thousands of spine fusions being performed annually for “back pain.” Often, they are based on injections into the discs called discograms that have been shown to be unreliable. Or they are based on MRI’s showing “degenerative changes.” We know bone spurs, arthritis, and degenerated discs do not correlate well with back pain. Yet major structural bony interventions are being performed with the surgical world not being able to accurately diagnose the source of the pain. Many surgeons feel somewhat compelled to perform the surgery because it is the “last resort.”

Fusions not only are ineffective in relieving back pain, but the downside risk of complications and breakdown of the spine often creates serious problems. There is even a medical term called “Failed Back Syndrome”. What is not well-known is the extent of the destruction caused on these patients’ lives. I discuss this outcome in the appendix of my books, Back in Control and in Do You Really Need Spine Surgery? Take Control with a Spine Surgeon’s Advice. Many of these situations were catastrophic.

Surgery is not the “definitive” answer for lower back pain. It is usually the wrong answer!!!

1. Boden, SD et al. “Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects: A prospective investigation.” Journal of Bone and Joint Surgery(1990); 72: 403 – 8.
2. Carragee, EJ et al. “A Gold Standard Evaluation of the ‘Discogenic Pain’ Diag­nosis as Determined by Provocative Discography.”Spine(2006) 31: 2115 – 2123.

The post Back Pain vs. Mouth Pain first appeared on Back in Control.

The post Back Pain vs. Mouth Pain appeared first on Back in Control.

I discuss how the brain becomes more sensitive to pain with repetition. I also introduce the first 3 “E’s” of the 5 “E’s” of chronic pain as well as the evolution of pain. The 5 “E’s” are Empathy, Evaluation, Education, Encouragement and Engagement. For more on this, check out Sensitization of the Nervous System.

BF

The post Video: Your Brain Becomes Sensitized first appeared on Back in Control.

The post Video: Your Brain Becomes Sensitized appeared first on Back in Control.

Our medical culture is geared toward concrete solutions.  This is particularly true when you, the patient, have finally made up your mind to even see a surgeon and waited for some time to get an appointment.  I realize that most of the time you are there to discuss the “definitive” solution of surgery.  It is a major step.  As soon as I mention that surgery is not a viable alternative, many patients become very upset. Then, when I begin to explain the various aspects of the pain experience, it is almost impossible for them to really hear me.  You have been in pain for a long time and you just want your life back—now.

As reported by the Institute of Medicine, the elephant in the room is this: 116 million people living in United States suffer from chronic pain.  Whatever is being done to treat chronic pain, it’s not working.

Lisa was able to work past her initial frustration with me over a couple of weeks.  It became quickly apparent to me that she was an extremely organized, competent businesswoman who was able to grasp many of the smaller details of the DOCC process very quickly.  She asked me many pointed questions.  She also realized that her frustration with the many aspects of her situation was a major block to engaging in her journey back to health.  Accepting things she could not control was going to be one of her first steps.  In the course of the conversation, she came up with a notable quote she gave me permission to share with you.

“Every problem is a solution waiting to happen.”

-Lisa

BF

The post Problems are Opportunities first appeared on Back in Control.

The post Problems are Opportunities appeared first on Back in Control.