I had joined a prominent orthopedic group in town and was the fourth spine surgeon. We were all determined to create a major spine center in Seattle. I worked long hours with a high level of energy.  It was also an era where we had just started placing screws directly into the vertebrae to immobilize them. This technique offered a higher chance of obtaining a solid fusion. I was enthusiastic about my ability to obtain a solid fusion. If someone had back pain for more than six months, I would order a discogram, which is a test where dye is injected into the disc under x-ray control. If the injection simulates the patient’s usual pain, it is considered a positive test. Based on that test, I would then offer them a fusion that would remove the pain generator.

I was also quite diligent trying all types of non-operative care during this time. One approach I used was aggressively immobilizing the spine with a semi-rigid brace for three or four months while simultaneously work on conditioning in the gym. The idea was that if a fusion was going to work, why not try something to immobilize the spine that is less invasive. I had a lot of success with the bracing. Nonetheless, I performed many spine fusions for low back pain and I thought that the success rate would be over 90%. It is a big operation. I felt bad if I couldn’t offer my patient a fusion. Some patients would do extremely well. However, many if not most, would have some improvement in pain but still remain disabled. It wasn’t clear to me what variables would predict a good outcome.

One evening in the fall of 1987, I heard a knock on my door. A gentleman by the name of Stan Herring introduced himself.  He said he was a physiatrist who specialized in spine care and would like to have me work with him as his surgeon. He had to explain to me that a physiatrist is a rehabilitation physician. The philosophy is to take whatever physical limitations that exist and maximize the patients’ function. I had not heard of this concept before and it sounded interesting.

I began to spend a half a day a week in his office. It quickly became clear that this was a different world of spine care than I had been exposed to. He knew which physical therapists he wanted to work with, and knew what they did and why. He worked with a pain psychologist. His office practiced a much more complete approach to the pain problem. When his patients required surgery, the results were consistently better. My role in this practice became that of talking many patients out of surgery until they had really engaged in the rehab process. Once I explained the magnitude of the surgery in detail, they would usually proceed with their rehab and most patients seemed to do well without the surgery.

I became better at selecting my patients for low back pain surgery but was still frustrated by the unpredictability of the outcomes. It was not until 1994, eight years into my practice, that I stopped performing fusions for low back pain. The data out of Washington Workers Comp showed that the return to work rate one year after surgery was only 15%. It was half the rate of those who had not undergone surgery. (1) Meanwhile, I descended into my own ordeal with chronic pain and I didn’t emerge from it for over 13 years. Slowly, the current DOC process evolved about ten years later. It took me a long time to figure out what was going on and now the last five years of neuroscience research has revealed the answers to solving chronic pain. Surgery is occasionally needed but is never the definitive answer in isolation. It is also never indicated for chronic LBP and degenerative disc disease.

I am one of the few spine surgeons who has aggressively been on both sides of this fence of using surgery as a solution for non-specific low back pain and now successfully helping patients heal without the risk of an operation. It has been quite a journey.

1. Franklin GM, et al. Outcome of lumbar fusion in Washington State Workers’ Compensation. Spine (1994); 19:1897–1903.

The post My Early Surgical Philosophy first appeared on Back in Control.

The post My Early Surgical Philosophy appeared first on Back in Control.

You have to sleep

I began to address sleep in my patients after I moved to Sun Valley in 1999, If it were an acute problem such as a ruptured disc, I would use sleeping medications in addition to pain medications. It was much easier for my patients to wait out the pain until the disc healed if they could sleep. In chronic pain, the results were consistent. Over two to four weeks, my patient’s mood and coping mechanisms would improve.  If they did not get to sleep, I would aggressively keep switching meds until sleep was attained.  Not sleeping was not an option. None of the rest of the DOC program will work without sleep.

I had one businessman that had experienced chronic neck pain for almost two years. There was no specific injury. He continued work as an owner of a small accounting firm but was miserable. He had been through multiple courses of physical therapy. I started him on a strong sleep medication, which immediately allowed him to sleep a full night. I saw him back at two weeks to check on how the medication was working. I was planning on starting aggressive physical therapy six weeks later. When he came back for his eight-week visit, I was surprised to find he was pain-free after being in pain for over two years.

Incorporating sleep into my treatment of pain was my first step in conceiving the DOC protocol. I felt I had a whole new weapon that was effective and yet simple. There is always some improvement in their sense of well-being if not also their pain.

Patients will argue with me that it is impossible to sleep with the pain. There are few situations where the right combination of medications cannot be found to yield a consistent good night’s sleep in spite of the pain.

BF

The post Early Sleep Concepts first appeared on Back in Control.

The post Early Sleep Concepts appeared first on Back in Control.

Sources of pain

With pain in any part of the body, there are potentially three components of the problem:

• Structural problems – identifiable problems with matching symptoms
• Non-structural issues – soft tissues such as ligaments, discs, fascia, etc. that cannot be seen on a test
• The central nervous system is always a factor and can independently create symptoms

The first step is for your physician and you to get a clear idea about whether there is possible structural problem that should be surgically addressed. If there is a correctable problem, then you need to decide whether you pain is severe enough to undergo surgical intervention. If it is, then we have discovered that it is critical to spend a few months optimizing the outcome by normalizing sleep, decreasing anxiety, stabilizing meds, etc. We call this “prehab” or rehab before surgery. If the pain is not severe enough to warrant the risk of surgery or the problem is not structural, then surgery is off the table.

Overview

The DOC program is organized around the following variables:

• Education
• Sleep
• Stress management
• Medications
• Goal setting/vocational issues
• Physical conditioning/ rehabilitation
• Family dynamics

The central nervous system

You might notice that the first five of the categories, either directly or indirectly, affect the central nervous system. Improving sleep will decrease the perception of pain and improve your sense of well-being. Stress is an obvious issue regarding the central nervous system. Everyone has stress and most of us have a lot of it without ever being taught effective stress-management skills. The additional stress of chronic pain is a major problem. Medications are used to decrease the pain on a short-term basis to help improve function. Education and goal setting will decrease your anxiety and frustration.

Physical considerations

Rehabilitation of the soft tissues and general care of your physical health is an important step. However, it is necessary to first calm down the central nervous system before they can be adequately addressed. Otherwise, when painful soft tissues are aggressively manipulated, there will be an exaggerated pain response. What exactly is done within each category is not as important as having ALL of the categories successfully defined and treated. Fighting a forest fire-your pain

You will already have been through many of the treatments that will be described. However, it is the self-directed structured combination of these variables that will make an impact on your pain and quality of life.

The post DOC – A Framework of Care first appeared on Back in Control.

The post DOC – A Framework of Care appeared first on Back in Control.

Dr. Schubiner is a pain physician practicing in Detroit, MI. He approaches pain from a whole body perspective. I consider him one of my major mentors and was the one who unlocked the door to cause of all my unexplained symptoms. I asked him to explain how he conceptualizes the source of pain. The next few paragraphs are his concepts.

Three Sources

• Structural – visible lesion with matching symptoms
• Non-structural – not visible on a test
• Nervous system – when pain is caused by a nerve pathway, there is no tissue damage; there is no lesion. Instead, areas of the brain are activated, creating pain and/or causing nerves to fire, which produces tension in muscles or reactions in visceral organs.

So there is direct tissue damage/ inflamation and nerve pathways.  As the tissue damage category includes structural and non-structural injuries. His classification yields three possiblities:

Source of Pain

• Tissues
  • Structural
  • Non-structural (not visible)
• Nervous system
  • Neurophysiologic Disorder (NPD)—direct triggering of nerve pathways

Circuits are always laid down

It’s important to remember that in all three of the above scenarios, the nervous system is laying down pain circuits. Although they may be “turned off” at some point, they are permanently imbedded in your brain and can be “woken up” in the future at any time. That’s why the central nervous system must be addressed in every patient every time. (See “Unlearning Riding Your Bicycle” for more on programming).

Neuroplasticity

Dr. Schubiner presented recent neurological research demonstrating that the brain has the capacity of neuroplasticity, or the ability to create new nerve pathways in response to life events.

• For example, when you learn to play the piano or swing a golf club, your brain cells develop a new pathway that is connected to your body.
• These pathways consist of millions of nerve cells. The more that pathway is activated or practiced, the stronger it becomes.
• What most doctors do not know is that chronic pain can be caused by this type of learned pathway.
• Pain can occur even when there’s no tissue damage in the body, such as a tumor, a fracture, or an infection.
• A learned pathway can and will cause real, physical pain.

Mental pain = physical pain

In fact, recent research has shown that the brain can create pain that is identical to the pain of a physical injury. (Pitt study)

• We have also learned that an emotional insult is processed in the same way in the brain as a physical injury. (Kross)
• We now know that stressful life events and our emotional reactions to them can cause pain that can be severe. The term for this phenomenon is “triggered”.
• Treating this type of pain with pain medications, injections or surgery is usually not effective, thus leaving the patient extremely frustrated and depressed.
• However, when the true cause of the pain is recognized, these pathways can be reversed by any program that utilizes neurological approaches, including this DOC program.

The post 1 – Three Sources of Chronic Pain first appeared on Back in Control.

The post 1 – Three Sources of Chronic Pain appeared first on Back in Control.