In 2003, a neurosurgeon performed a laminectomy of his neck. That’s an operation where the lamina or the bone over the back of the spinal cord is removed to relieve pressure. He seemed to improve for a little while. In 2005, his symptoms worsened, and in 2009, he underwent a fusion through the front of his neck between his 5^th and 6^th vertebrae. Again there was a slight improvement but two years later he was in my office with crippling pain throughout his whole body.

Normal studies

As I talked to him, I could see how desperate he was for relief. He also wasn’t sleeping and his anxiety and frustration were a 10/10 on my spine intake questionnaire. I couldn’t find any neurological problems on my physical exam. When I looked at his neck MRI, I could see where the two prior surgeries had been performed, but there were no pinched nerves. The alignment and stability of the vertebrae were also fine. He also had undergone several workups of his brain and the rest of his nervous system. Everything was normal.

When I explained to him that I did not see a structural problem that was amenable to surgery he became understandably upset.  He was stuck on the idea that the prior surgeries had helped and that I was missing something. It didn’t matter what I said or how I explained the situation to him. He wasn’t buying it.

What I didn’t tell him was that I had also looked at his scans he had prior to undergoing each surgery. Telling a patient that they did not really need a prior surgery is a very unproductive, unpleasant interaction; I didn’t see why this patient’s prior surgeries were performed. On the first MRI of his neck, there were no bone spurs and the spinal cord was completely free. There wasn’t a structural problem that could have been corrected by surgery. On the scan before the second operation, there also wasn’t a hint of anything that could be causing any symptoms of any type.

The power of placebo

What’s difficult for patients (and physicians) to realize is that the placebo rate for any medical or surgical treatment is between 25-30% or even higher. The response and improvement is not only real but is powerful. It is the result of your body’s own healing capacity. It is a desired response, and you feel less pain.

The pain-killing effects of a placebo are reversed with Narcan, which is the drug used to reverse the effect of narcotics. There is a part of the frontal lobe of your brain that shuts off pain pathways for short periods of time. Another example is the placebo effect of cardiac medications causes the heart rhythms to actually change. Just because a prior surgery or procedure on normal age-appropriate anatomy might have been temporarily effective is irrelevant. It should have nothing to do with current decision-making. I tell my patients “If I can see it, I can fix it” and  “If I can’t see it, I can’t surgically correct it.” It’s critical to have a specific structural problem with matching symptoms before surgery becomes an option. Surgery: The Ultimate Placebo

I suggested that he take a look at the DOC website and I would be happy to explain the whole program to him in as much detail as needed. He was so angry that I didn’t think I’d hear from him again.

Early engagement

Over the next couple of months, I received a couple of emails and had a telephone conversation that seemed to go pretty well.  He was willing to engage in the DOC protocol and began some of the writing exercises. I had a second phone conversation with him a couple of weeks later that seemed to go even better. He was able to recognize that his thought of me “missing something that needed to be fixed” was an obsessive thinking pattern. I was encouraged and thought that maybe I had been able to break through his “story.”

Time went by and our third and final conversation was dismal. He couldn’t let go of the thought that “something was being missed” and that his seventh cervical vertebra was “out of alignment.” I assured him it was OK. As a surgeon, I am also quite obsessive about not missing problems that I can fix. At this point, it didn’t matter. He’d found a surgeon who was going to fuse his neck.

Injury conviction

Physicians use the term “injury conviction” to describe this phenomenon. It is the relentless pursuit of a cause for your symptoms that is well beyond reason. My concept has changed in that I feel this pattern of thinking becomes its own irrational set of neurological circuits. It is similar to phantom limb pain and my term is “phantom brain pain.” Regardless of whether the original source of pain is there, the symptoms are the same. Rational arguments have absolutely no effect.

Hell

I wrote a post Anxiety and Anger: The Highway to Hell. Unfortunately, if you’re in this pattern, you’re in Hell, and the only way out is through you. The deep tragedy is that if you don’t realize you’re in Hell, you’ll remain there. I never give up, but I have learned to let go when I can’t penetrate that firewall of obsessive thinking. For those of you that have let yourself out this hole, I am open to suggestions as to what gave you the insight to move forward. Awareness is the basis of the entire DOC process and is always the first step.

I don’t know how many more tests and surgeries he’ll undergo over the next 30 years. The personal cost to him and society will be enormous.

What’s puzzling is that if any of the surgeons who’d chosen to operate on this man’s essentially normal anatomy were examined by a board examiner about their indications for his surgeries, they’d be failed immediately for giving a “dangerous answer.” It’s our medical responsibility to you to not offer risky procedures that have been documented to be ineffective.

Video: “Get it Right the First Time”

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I plateaued for about six months but now had some hope. I had always perceived myself as “cool under pressure” and felt that most things weren’t worth getting upset about. I could not have more wrong. What I was highly skilled at was suppressing anger. It exploded and I did not process it well.

I first had to admit that I had a lot of anger, but since “I was right”, I didn’t perceive it was a problem. So, I wasn’t progressing much and my life continued to disintegrate. Over about six months, I was finally able to learn some basic anger concepts and skills and began to rebuild my existence. What I did not expect is that my all of my physical symptoms began to improve and six months later, they had all but disappeared. I was shocked and still did not understand the role of sustained anger and elevated stress hormones/ cytokines causing inflammation.

From reactive to creative

Many people get to this spot of a dramatic turnaround and stop the journey, which is fine. They are excited, as am I, and they usually continue to do well. However, I also think that they have missed the best part. Instead of having to fight your way out of The Abyss, you have the opportunity to further connect to who you are, move forward from your center in a powerful way, and experience life at a level you never knew was possible. That is what this phase, Expanding Your Horizon is about.

The healing journey is based on connecting to your own capacity to heal, learning tools to optimize your body’s chemistry, feeling safe, and then creating the life that you want. As you move towards your idea of what you want your life to look like, you’ll be shifting off the pain circuits and nurturing ones that bring you pleasure and satisfaction. As you move into regaining your life perspective, connecting with your passions, play, and giving back, you’ll be spending much less time reinforcing your pain circuits and thrive.

Here are the areas to address that will enable you to experience the best part of your journey:

• Sleep – still the cornerstone
• Effectively processing stress – Life never stops coming at us
• Physical conditioning – is simply one of the best ways to feel better
• Medication management – a thoughtful approach will simplify this aspect of your care.
• Life outlook – is one of the most critical aspects of your journey. You have to know where you want to go to get there. How you do it is also important.
• A deeper understanding of chronic pain – will allow you to be innovative in dealing with it and allow you to have more control of your care.
• Family dynamics – turned out to be maybe the most powerful force in holding people back, but when addressed with a structured approach was remarkably helpful in healing – for the patient and the whole family.

Moving forward

Addressing sleep was the first step in the evolution of the DOC process. Twenty years ago, only a small percent of physicians dealt with sleep issues. I took an aggressive approach and would begin with “sleep hygiene” measures. But if a patient wasn’t responding within a couple of weeks, I would use 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. (2) Unfortunately, it is still common to have major risky interventions done or recommended before sleep is addressed.

Processing stress became inherent in my practice as I worked with patients dealing with the problems created by being in chronic pain. I had experienced a lot of benefit with the book, Feeling Good, as I mentioned above and I had my patients use it. I quickly noticed that the only ones who responded were those who did the recommended writing. Other stress management approaches emerged over time. I eventually learned that stress is not the problem, as much as your reaction to it.

Addressing Physical Factors is basic to musculoskeletal care.

• Physical therapy must be tailored to a patient’s specific needs.
• Aerobic conditioning has long been documented to improve pain.
• Weight training not only increases strength but also stimulates the release of hormones that enhance your sense of well-being. 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.
• Nutrition is critical. For example, an anti-inflammatory diet can quickly lower your pain. Intermittent fasting consistently lowers inflammation.
• Bone health – osteoporosis (low bone density) creates havoc with the quality of your life and is both preventable and treatable.

Medication management is critical. You need symptomatic relief to give you “the space” to learn and implement the tools to heal. They will become much less important as your pain resolves and no one really wants to be dependent on medications. They are expensive and a hassle.

My approach was the reverse of what is usually done. I would keep patients on the same medications, including narcotics. Medication discussions were always face-to-face. Although, the goal was to wean down, the patient always had the last say regarding how quickly this would occur. 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. The only criteria I required was that they had to be actively engaged in the other aspects of the structured care approach.

Life outlook is one the most important aspects of healing. 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.

Awareness of the nature of chronic pain is important because it is so complex and each individual is unique. The traditional approach 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 chemicals. The DOC process is a framework that allows you break down pain as it relates to you into its components. It allows you to address all of them simultaneously. It is this multi-pronged approach that is what is so effective in successfully treating chronic pain.

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.

From reactive to creative

Don’t stop now when you are really just beginning. It is a triumph to be out of The Abyss, but there is much more to life than just surviving. Most people have been fighting the pain for so long that they have forgotten what it is like to relax and enjoy it.

If you take the word, reactive and move the “c” to the front, you have the word creative. If you can “c” first, you have some space to look at your options and create your reality.

1. Burns D. Feeling Good. Avon Books, New York, 1999.
2. Agmon M and G Armon. “Increased insomnia symptoms predict the onset of back pain among employed adults.” PLOS One (2014); 8: e103591. pp 1-7.

The post Expanding Your Horizon–Your New Life first appeared on Back in Control.

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