Chronic pain infiltrates every aspect of life. You have pursued endless treatments with promise of relief and you keep being disappointed. Eventually, you may give up any hope of a cure. Most people aren’t anxious to undergo surgery but if it seems like a definitive solution and what else is there to do? Additionally, surgeons are likely to promise a good outcome. Why wouldn’t you choose that option?

Back pain surgery doesn’t work

Focusing on low back pain, there is a major problem. Fusion surgery for chronic back pain doesn’t work well. The reported success rate is around 25% (1, 2) The data also shows that you can induce or worsen pain after any surgery between 20-60% of the time when operating in the presence of chronic pain. (3) So the chances of making you worse are higher than the chances of success.

Surgery is not a “definitive solution”. It should only be considered for a defined structural problem. That is a lesion that can be defined on an imaging study (MRI, Xray, etc.) with symptoms that match the identified anatomical problem. You can’t fix something you can’t see. LBP is a non-specific symptom and its cause seldom identifiable. I am clear with all of my surgical patients that whatever arm or leg pain I can solve with surgery; it won’t help back or neck pain.

Deal with all the issues

Chronic pain is complex and each human being is unique. There’s a trend in medicine to recommend simplistic solutions to this multi-faceted problem. All the factors that affect pain need to be addressed simultaneously. Almost all treatments offer some benefit but none are effective in isolation. The variables include:

• Sleep
• Stress
• Physical conditioning
• Medications
• Life outlook
• Family relationships

You’re the only one who can solve your pain. It’s critical to take control of your care with the medical profession being the source of your information and guidance. If your mindset is, “I just want my pain to go away” or “Fix me” you have almost no chance of meaningful improvement.

What is happening in modern medicine is disconcerting. Providers are almost all on a volume demand where we are given just a few minutes per patient to figure out what’s going on. It is essentially impossible to understand the whole situation in a busy clinic setting, so we are recommending treatments based on limited information. When you show up in a surgeon’s office, they are going to either recommend surgery or not. A paper out of Baltimore shows that less than 10% of surgeons are assessing the known factors that affect the outcomes of surgery, which leads to predictably poor outcomes. (4)

My wake up call

Several years ago my staff noticed that patients who were taking charge of their own care were going through surgery with less pain, better rehab and more consistent long-term outcomes. Historically, my approach was to aggressively address surgical lesions and have the rehab done later. I felt that a person in chronic pain couldn’t tolerate the additional discomfort of an identified structural problem. Most patients did fairly well but a significant number were worse after a well-performed procedure for severe pathology.

About that time, I had a patient with tightly pinched nerves in his lower back. He had both back and leg pain. I tried to work with him for a few months by addressing the above-mentioned common sense variables. He wasn’t buying it. I was clear that surgery would not help the back pain but could help the leg pain. Sure enough the leg pain did disappear after I took the pressure off of the nerves and stabilized the unstable level with a fusion. I would have thought that relieving the leg pain would have made a big difference in his overall quality of life. However, his back pain became much worse and he became incredibly angry. When I reminded him about our pre-operative conversation about not relieving back pain, he went ballistic.

Then I came across scientific studies showing that operating in the presence of chronic pain can induce pain at the new surgical site. I made a decision then that if a given patient didn’t want to learn about the nature of pain and take responsibility for his or her own care, that I wasn’t the surgeon for them. Why would I offer a procedure in a scenario where the success rate was compromised?

Current protocol – prehab

For patients considering elective surgery, we want them first engaging in their own healing process for at least eight to twelve weeks. I encourage them to engage for as long as needed. Some will participate in prehab activities for several years. We want them to be:

• Getting a restful night’s sleep for at least a couple of months. Lack of sleep will induce chronic pain. (5)
• Actively addressing stress to the point where they feel a noticeable decrease in anxiety and frustration.
  • Am I operating on your pain or anxiety?
• Defining and stabilizing pain medications. At a certain dose, narcotics cause more pain by sensitizing the nervous system.
• Becoming more physically active.
• Educated
  • Understand the neurological nature of chronic pain.
  • Identify whether they have a structural problem that is amenable to surgery? Do they really understand the risks versus benefits?
  • Know that surgery won’t significantly help neck, thoracic or low back pain.
• Looking at harmful habits.
  • Stop smoking for at least six weeks prior to a fusion.
  • Address eating/ weight
  • Address any recreational drugs being used, including excessive alcohol?

All of these issues affect outcomes. It is not a complete list but it does address the core problems.

What happened?

After implementing a prehab process for all my elective cases, I lost a significant part of my practice. Many patients would see another surgeon, bypass prehab and undergo surgery. But what happened to my practice was unexpected. Not only was I consistently seeing better outcomes, but dozens of patients with severe pathology were cancelling surgery. Their pain had dropped to the point where it was not worth it to them to undergo surgery with its attendant risks.

These outcomes were entirely unexpected. I had no idea how powerful prehab activities could be! It is incredibly rewarding to see a patient become free of pain without exposing him or her to the risks of surgery. I have done surgery for long enough that I am well-aware of the fact there is no such thing as, “simple surgery.” Complications and poor outcomes are always unanticipated and no one (both surgeons and patients) thinks it will happen to them. It’s also enjoyable to see the patients consistently do well when I do perform the operation.

One important caution – this article is not relevant if you are experiencing neurological compromise such as acute leg or arm weakness, loss of balance or bowel and bladder control. There are situations where emergent or urgent surgery is warranted.

Juan

I had an older gentleman who was having difficulty walking because his legs hurt and felt rubbery from tightly pinched nerves in his lower back. I wanted to quickly recommend a laminectomy to decompress these nerves and he would have done well. He also couldn’t read English and I thought the chances of him successfully engaging in the DOC process (prehab activities) were limited. I held the line and he began to use the Back in Control website tools utilizing the Google translator. He kept holding off on doing surgery. He came in six months later for what I thought would be his final visit before deciding on surgery. When I asked him if he was ready for surgery, he started laughing. “What are you talking about? I am walking as far as I want and am out dancing a couple of times a week. My leg pain is gone.”

Variations of his story happen several times every week. If someone decides to deeply engage in the healing process, it is almost always just a matter of time before they succeed. It’s the length of time, which is unpredictable.

Spine surgery is risky and I would even argue dangerous. One of my former fellows was devastated recently when a young patient died from a blood clot to his lungs after an elective operation. The surgery had taken seven hours but had gone extremely well. I have seen many unexpected severe complications in my own patients. The decision to undergo surgery is a serious one. Every other possible option should be actively pursued. If your surgeon is not assessing or having someone else look at all the above-mentioned prehab factors, then it is your responsibility to challenge him or her. If there is not a specific identifiable structural problem, the decision for surgery needs to come off of the table. Chronic pain is solvable and surgery when it is appropriate can contribute to a successful outcome. It should never be performed without assessing an addressing all of the factors affecting your pain.

Video: Get it Right the First Time

1. Carragee EJ, et al. “A Gold Standard Evaluation of the ‘Discogenic Pain’ Diag­nosis as Determined by Provocative Discography.” Spine (2006) 31:2115-2123.
2. Franklin GM, et al. “Outcomes of lumbar fusion in Washington state workers’ compensation.” Spine (2994); 19: 1897–1903; discussion 190
3. Perkins FM and Henrik Kehlet. “Chronic Pain as an Outcome of Surgery.” Anesthesiology (2000); 93: 1123-1133.
4. Young AK, et al. “Assessment of presurgical psychological screening in patients undergoing spine surgery.” Journal Spinal Disorders Tech (2014); 27: 76-79.
5. Agmon M and Galit Armon. “Increased insomnia symptoms predict the onset of back pain among employed adults.” PLOS One (2014); 9: 1-7.

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As in the past, joining me will be my wife, Babs Yohai, who is a professional dancer; and my daughter Jasmine Yohi-Rifkin, a dancer and choreographer with an MA in psychology. Both will present effective somatic, movement, and expressive arts tools that participants can use after the workshop.

This year, also joining me will be special guest Bernie Siegel, MD, best-selling author, retired pediatric and general surgeon, and founder of Exceptional Cancer Patients (ECaP—a form of group therapy for cancer patients). Bernie has written prolifically about healing and many other topics that address life’s challenges. You may know two of his most prominent books, The Art of Healing and Love, Medicine and Miracles. Over the last couple of years Bernie has inspired me with his wisdom and accomplishments. He will join us live via Skype on Saturday afternoon.

While Bernie and I use different approaches, we both share the conviction that the key to healing is connecting with our own capacity to heal ourselves. I use neuroscience to support the principles in my book, Back in Control; but the science also supports Bernie’s concepts. It will be exciting and insightful to have Bernie talk about his approach and how our two bodies of work intersect.

Over the years that I’ve been offering this workshop, its format has evolved by applying four tools that address chronic pain: awareness, hope, forgiveness, and play.

Awareness

In order to solve a problem, it helps to understand it. For example, it is useful to know that stress created from a physical or emotional source elicits an automatic survival response, which includes the release of stress hormones such as adrenaline and cortisol. Anxiety is the feeling elicited from these chemicals. The first step in solving your pain is to recognize this link. This and other neurophysiological aspects of pain are discussed in chapter one of Back in Control; and we recommend that participants read it before attending, to get the most out of the workshop.

Dr. Siegel advises us to be aware of the role pain plays in our lives, and what it can teach us to help us heal. I strongly encourage you to read The Art of Healing. Bernie has many great stories, and I’m excited to hear what he will be teaching us at the workshop.

Hope

Many people in pain lose hope and find themselves in a downward spiral of despair. I was in that abyss for over fifteen years and became an “epiphany addict,” on a desperate quest to find “the” answer. As a physician, I had access to every known solution, but not one of them brought relief. 2002 found me utterly hopeless and attempting suicide.

Like most of the medical profession, I was looking at chronic pain as something to be managed, and found little success in treating it. Once I finally discovered the mind-body connection, which has been supported in neurophysiological research, I learned that a combination of treatments was the answer. Now I have not only my own, but scores of success stories to share at the workshop. With the correct treatment process, solving pain is not only possible—it’s probable. Chronic pain is curable.

Forgiveness

Most patients find it extremely difficult to forgive the person or situation that caused their pain. The more legitimate one’s anger, the more difficult it is to let it go. Typically, people are most angry with themselves. But as long as you hold on to anger, you hold on to chronic pain, no matter whom you are angry with. As travelers of the same neurological pathways, anger and pain sensations are tightly linked.

You must be willing to deeply forgive not only others, but yourself—down to your deepest wrongs. You may improve by using other tools in the DOC process; but you will not become pain-free until you completely forgive. Many people in pain are addicted to the power of anger and pain, and refuse to give it up. They not only choose to continue to suffer but also make the lives of those close to them miserable. If you are one of those people, this workshop is not for you.

Play

The one goal I had when I began holding Omega workshops was that people just be with each other and share some experiences. Almost all my patients had become socially isolated, which gave them more time to obsess about their pain. I thought, after they learned and practiced some effective tools, they would go home, put them to use, and then start to experience an improvement. But one of the biggest surprises was how quickly chronic pain disappeared during the workshop. After suffering for years, many participants became pain-free during those few days.

In the workshops we create a structured environment where participants feel safe to share. As participants relaxed, a sense of play crept into the group and their pain began to abate. When this first happened it was totally unexpected! But it might have had something to do with our prohibition against complaining or discussing their pain or medical treatments during the workshop.

When participants returned home and re-encountered familiar triggers, pain typically re-appeared. But with new tools to process these emotional agitators, eventually the participants did well. One of my mentors, the coach for the University of Washington women’s golf team who, by using many of these concepts, advanced them to the national championships in 2016, taught me, “Adversity is a chance to practice your tools.”

Success Story: Deb

Deb was a social worker in her mid-forties when she attended our first Omega workshop in 2013. She had experienced severe, unrelenting neck pain for over four years, and tried all the traditional treatments without success. She was studying chronic pain for her PhD dissertation, thinking that it would help her solve her own pain. Deb did not fully participate in the workshop, missing a couple of key sharing sessions and staying off-campus with her boyfriend. When her condition did not improve, I assumed that was just the way it was going to be. But about ten months later she became completely pain free. Why? Deb attributes her remarkable recovery to stopping physical therapy, adopting an anti-inflammatory diet, getting better quality sleep, practicing expressive writing, and focusing on forgiveness. Not only is she free of pain; she has brought the DOC tools into her community and set up a non-profit housing project. She is a delightful, energetic, contributing member of her community.

Awareness prepares you for change.

Hope is the energy needed to begin the climb out the Abyss.

Forgiveness eradicates anger and its poisons.

Play connects you with others and transcends pain.

Step into your new life.

The post Omega 2017: Awareness, Hope, Forgiveness and Play first appeared on Back in Control.

The post Omega 2017: Awareness, Hope, Forgiveness and Play appeared first on Back in Control.