Then I read an extensive review on the nociceptive pain system. (1) This is the part of the your nervous system that signals a given stimulus is uncomfortable and evasive action needs to be taken. What I learned is that your brain unconsciously keeps your behavior in a range to avoid injury and you feel pain when this threshold is exceeded. For example, your body continuously is shifting while you sit to avoid skin breakdown. Paralyzed patients lack this protective sensation and pressures sores are an ongoing concern.

It has also been demonstrated that the severity of pain in the presence of arthritis in the shoulder, hip and knee does not correlate with the severity of the joint destruction. In other words, people with complete loss of cartilage often have little pain and others with minimal arthritis will experience severe pain. The pain correlates almost perfectly with the level of stress.

It is important to understand that your brain has to unscramble all sensory input to assess its importance to your survival (not well-being). For example, your eyes have no inherent capacity to see. If you have a stroke of the back part of your brain, you will be blind in spite of having normally functioning eyes. It is called, “occipital blindness.” The same holds true for pain. You cannot feel pain without your brain interpreting the impulses as unpleasant.

Pavlov

One experiment that demonstrates the power of reprogramming is the famous one by Ivan Pavlov, a Russian researcher. Pavlov showed how the brain can be trained, through repetition, to cause certain reactions in certain circumstances. His results corroborate the theories behind the Mind Body Syndrome.

Experiments

Pavlov set up an experiment in which every interaction a dog had with food would involve the sound of a bell. Eventually just the bell sound would cause the dog to salivate, even without food. The sound became its own pleasurable experience.

One of his lesser-known experiments is one where he associated a dog’s interaction with food with an electric shock. With repetition, the dog would look foward to the shock.  “Within a few weeks the dog would actually wag its tail excitedly, salivate, and turn toward the food dish in response to the electricity. It was “paw dependent” in that if the same shock was applied to its other leg, the dog would react violently.”  (2)

Pain and the Brain

It is well documented that patients suffering from chronic pain experience a significant decrease in the actual size of their brain. It is unclear exactly why this occurs, but it is a consistent observation. It makes sense to me that if much of  your brain is stuck in the repetitive thought patterns associated with pain, then the parts of your brain that normally experience close friends, excellent wine, great food, new experiences, etc. are going to atrophy. It has also been shown that the phenomenon is reversible with active interventions such as reprogramming. Chronic pain sucks the life right out of you—including brain cells. Don’t let that process continue!

It appears to me that pain from any source can be re-rerouted. I can not predict who will respond or when. I am fascinated by the human body’s capacity to heal.  I am relentless and I encourage my patients to never give up on themselves.

1. Baliki, M and A Vania Apakarian. Nociception, Pain, Negative Moods, and Behavior Selection. Neuron (2015); 87: 474-486.

2. Brand, Paul. “Pain the Gift that Nobody Wants”. Harper Collins, 1993, p 206.

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.

BF

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Every injured worker should have access to some level of mental health support. I work with a veteran pain psychologist who is wonderful. 90% of her practice is caring for my patients. If she feels it is necessary, she will refer a patient to one of several psychiatrists for medication management.

Chronic Pain and Mental Health

It is unclear, from the psychiatrist’s viewpoint, what constitutes a diagnosable psychiatric disorder. On my intake questionnaire, I have a simple 0 to 10 scale for anxiety, depression, and irritability. Essentially every injured worker that has been out of work for more than six weeks is greater than a 6 out of 10 on at least two of these scales.  What would be my threshold for a formal referral, especially in light of the fact that my state will not pay for an evaluation in a timely manner? What is even more worrisome to me is the patient who puts down a zero for all three. He or she is just a time bomb.

Diagnosis Problems

In the disability literature, there are hundreds of papers linking stress and disability, but there is not a clear-cut definition of anxiety disorder to aid practitioners in diagnosing an injured worker. How bad does a patient’s anxiety have to be in order for it to be diagnosable? What is the definition of a diagnosable mental health disorder in general?  As there is not a concise definition, I am in a continual battle with worker’s comp trying to persuade them to “buy” a psychiatric diagnosis. While the patient is waiting, what are we to do?  Their stress level climbs even higher as they wait for an answer.

A Case

I saw a patient a few months ago who is a young mother. I have known her for years.  She developed quite severe axial back pain. We had a short but direct conversation about stress and pain. She came in a couple weeks later with her back pain feeling moderately improved but seemed upset. I had a little extra time to talk to her. She started out by saying that she had separated from her husband and was having a hard time finding a job and a place to live. I knew that he had not been working and she was home with two young children. It turns out that he had been regularly beating her. It happened enough that her children felt afraid of her if she yelled at them, but the physical abuse that occurred in front of them seemed OK. If you met her, you would be more than upset. She is one of the nicest people you could meet. Under no criteria would she have a diagnosable psychiatric condition. She really did not know what direction to go. Her mother was helping out the best she could. I emailed my pain psychologist and although she had no funds, she was able to be helped out. On top of that, her husband has chronic pain from failed back surgery.

Stress Management

Every person from elementary school on should be taught stress management and mental health skills. I feel the one factor that determines one’s success in life is the ability to process and handle stress. Even basic stress management tools are extremely helpful.

Support

Every injured worker needs to have access to at a group or organization that teaches these type of skills and offers other support. Individual referrals to psychologists can be figured out more easily in this setting. Losing a job in a capitalistic society is a disaster.  It is bad enough if you are single; it is much worse if you are the breadwinner of a family. Even the thought of being in this situation is mentally crippling.

Labels

A major concern and obstacle to accessing mental health support is our tendency to label people. Injured workers quickly become labeled. This is particularly true if they make the mistake of complaining too loudly or expressing their frustration. They become “difficult” and “manipulative.”  If their stress becomes higher, they may have more pain and ask for more meds. This gets them labeled “drug seekers.”  The list of labels goes on. If a patient is labeled as “anxious” or “depressed,” they are often put on antidepressants and their anxiety is considered “addressed.”  If after a few months they are still depressed, then they might be referred to a psychiatrist or psychologist. By this time, months have passed and often the lives of patients have unraveled.

The Patient is a Person

The patient’s whole life, including her mental life, must be acknowledged from the minute she is injured. Every person that comes in contact with her makes a difference. Even the acknowledgment of her suffering is important.

I made a comment a few weeks ago to David Tauben, who is the head of the University of Washington pain center, and David Elaimy, my surgical performance coach, that they should put on a mini-seminar, “Enjoying the Management of Your Chronic Pain Patients.”  A major part of the enjoyment of being a physician is addressing the whole patient and making the correct diagnosis. If I had just sent the young mother I mentioned above to physical therapy for neck pain, it would not have been helpful. Thanks to the DOCC Project methods, she will be able to get her life back on track and have the tools to live a much more fulfulling life.

BF

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There was a discussion last year that led to a document called “The Five E’s of Chronic Pain.”   They are:

• Empathy
• Evaluation
• Education
• Encouragement
• Engagement

All of these are geared towards enabling and motivating the patient to take charge of his or own care.

One E that I want to emphasize in particular is education   it’s critical for several reasons.  If a given patient is willing to immerse him or herself in learning about all of the variables that affect his or her pain, the chances of them eventually improving is extremely high.

Conversely, if they are not willing to read, listen, and learn, then they cannot and will not get better.  They must be willing to take on that responsibility.  Otherwise they are choosing to remain in a victim role and will remain angry.  It is also difficult to work with them, which also makes progress unlikely.  I think it is important for those working in chronic pain to set personal boundaries while still “keeping the door open.”  If you are attached to getting that resistant patient better in spite of their wishes, you might get yourself into a very unhappy, energy-draining situation.  You need to let them go.

I just put on a mini-seminar called “Enjoying the Management of Your Chronic Pain Patients.”  Once a given patient decides to fully engage, it is like opening the door of a caged wild animal.  You cannot stop them from regaining their life.  It does not matter how long they have been in pain. Working with these patients has become the most rewarding and enjoyable part of my practice.

NH, BF

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BF

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

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I am on a much-needed vacation this week in Italy.  From 1980 until 1990, my wife lived in Florence.  We have many friends in Italy we like to visit as much as we can.  It is a unique opportunity for me in that she is fluent in Italian and we are able to spend time in our friends’ homes in the heart of Tuscany.  There is nothing quite like sitting down to a home-cooked Italian meal overlooking a beautiful valley.

Last night was one of those evenings.  Our friends not only put us up in their apartment, they had us over to dinner with several other friends.  The conversation drifted towards medical care.  One of the guests had experienced some medical problems of a moderate nature that required several physician visits and a couple of procedures.  He said that the aspect of his care that most struck him was that at no point during his care did anyone from the receptionist to the doctor ask him how he was doing.  Additionally, when he was asked some detailed questions about his condition, he was asked if he was a doctor.  When he replied that he was not, he was told that he had been informed enough and that he should not ask so many questions.  You might imagine his frustration.

I have witnessed a lot of success with the DOCC protocol, but it has become increasingly clear that the protocol is just a framework. It helps organize both the physician’s and patient’s thinking about chronic pain and therefore makes it much easier to create a treatment plan.  It is the patient who organizes and implements the plan. The physician is more in the role of a “coach” as well as being continually aware that there might be a potential structural problem.

About a year ago, I was talking to the pain psychologist I work with about what we were doing that seemed to be more helpful to our patients than either of us had historically observed.  She kept insisting that I was the factor that made the difference.  I was sure it was the DOCC protocol and the work she does.  After more and more positive results, I finally agreed that I played a major role in their recovery.  To clarify, I don’t believe that I have a special gift or am the world’s best doctor.  I simply stay committed to my work with the patient.  With increased attention over the last couple of years, I have seen more patients who had been in pain for decades become pain free.

Through my numerous difficult experiences, I have had many layers of my own personal labels stripped off.  Physicians, especially surgeons, are perfectionists.  It gives us an early competitive edge in high school and college.  It is somehow held up as a virtue by our medical culture and demanded by society.  Unfortunately, it is a complete disaster with regards to our ability to connect with our patients.  By definition a perfectionist is continually judging himself or herself by an unattainable standard.  As I have labeled myself, I have labeled others around me.  As it has been my reality for over 50 years I had no clue that this process was taking place.  I recently wrote an article, “The Cry of Chronic Pain—No One is Listening.”  The essence of the article is that once you have a label of a “chronic pain patient” placed on you, the world, including you, feels that it is just “something you have to live with” and your care becomes essentially palliative care.

I recognize that labeling is universal but it is not constructive.  I am aware that I label people constantly. As I work to become aware of the label I am placing, I am able to eventually see who you truly are.  You are a whole person.  Neither you nor I are the labels we place on each other.

The energy for your healing journey comes from you, not me.  What I contribute is that I am able to see you as a whole person and you are somehow able to remember that part of you that is really you.  When that part of you “wakes up,” there is no stopping you.  You are your own oasis in the middle of the desert.  I cannot ever tell who will engage or when.  The DOCC project is just a rough framework and every journey is completely different.  I am continually energized and inspired by the incredible obstacles you overcome to return to a rich, pain free life.

I recognize that essentially all physicians are compassionate.  Many physicians have figured out this journey and most have not had to experience burnout to learn it.  I am continually humbled by numerous examples of deep compassion by my colleagues.

I always thought I was compassionate. I was very well intentioned and always gave every patient my best shot.  However, the physician burnout rate is around 50% and we truly have a life full of more stress than you can imagine.  If you are just trying to survive, there is only so much you can give.  Additionally we have no resources or tools to help us out.  The safety net is a concrete floor.  It has been shown in several studies that it is during the third year of medical school that compassion takes a dive.

I am not writing this post for you to begin looking for a physician who is compassionate.  It is not a bad idea, but it is not necessary for you to heal.  Remember this process is about you taking full responsibility for every aspect of your care and your life.  You don’t need me.  You don’t need the DOCC project.  You just need to connect with that part of yourself that is whole and wants to thrive. The person who you need to experience compassion from is you. Use whatever means you have at your disposal to figure this out.  It will probably take some outside help but there are multiple resources. Quit trying to “figure all of this out” and just go.

NH, BF

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Aching Back? Why Surgery Is Not Indicated for Lower Back Pain, Case In Point, July 201.  (Reproduced with permission from Case In Point.)

BF

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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.

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BF

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I have argued for 25 years that a claims examiner should not be in charge of a given case.  The caseload for a given examiner used to be 400-600 workers.  Even if you had an occupational medicine physician in each claims examiner’s chair, she could not manage the claim.  I would hope the ratios were better, but even if it were 200-300 claims per examiner, the responsiveness would not be even close to the workers’ needs.  Each worker’s ENTIRE LIFE depends on an overloaded examiner.

Many claims examiners seem to have the mandate to “be tough” and move the claim through as quickly as possible.  I assume that the vast majority of examiners are initially motivated to provide the best service possible to the patient.  However, after dealing with angry workers on a regular basis, it is difficult not to develop a “thick skin.”  What that attitude does is make the claimant angry, and everything grinds to a halt.  I have to spend a lot of time just calming down my patient (and myself).  In the end, the “labeling” of workers as anything less than a “human being caught in the quagmire of a huge system” is counter-productive.  There has always been an obvious dividing line between workers with a benevolent claims examiner and those with a hard-liner.

I understand from the claims examiner’s perspective that it is important to move a claim through quickly.  However, claims tend to be dealt with more quickly when the relationship of the examiner to the worker is one of an ally helping navigate the worker through the maze of worker’s comp.

Additionally, there is a high turnover rate amongst claims examiners.   It takes several weeks for the new examiner just to get through his or her stack of claims, during which time patient anxiety goes through the roof.  How would any of us feel to have our middle school teacher changed halfway through the year and then find that her replacement has no idea who any of us are or what are needs are?

The level of medical training a claims examiner has is minimal. The claims examiners do not have enough medical training to make thoughtful medical decisions.  Currently, even if your surgical approval company approves a given surgery, I often have to still argue with the examiner about getting the surgery performed.  An insane phrase I here all too often: “The final word rests with the claims examiner.”

Many examiners do develop a valuable perspective in recognizing outliers and dangerous medical care.  However, that perspective is not uniform, and I cannot quantify what percent have that kind of experience.  I do know that many examiners are new and do not have that perspective.  There is too much variability to put so much responsibility into this position. Even if I could clone myself and sit in every claims examiner’s chair, I could not competently make the best medical decisions for that given patient.  Medical care cannot be delivered at that distance.  The examiners are in a “no win” situation.

I am also well aware of the “rumor mill” amongst the claims examiners.  Certain physicians are labeled and care is delayed.  Different treatment philosophies get picked up within the system.  Their own concepts of the human body and medical care enter the medical decisions.  When confronted, they will ask for an IME, which delays all care for at least 4-6 weeks.  They then use the IME recommendations as a template for the care of the patient.  The IME physician spends just a few minutes with the patient and their attitude is not one of providing the optimum care for the patient.  I understand that there is a need for IME’s, but that need is not to influence ongoing medical care.  With that “authority,” the claims examiner often makes everything even more difficult for the physician and the patient.

Meanwhile, I try to help “calm down” the patient, as the circumstances are extremely adverse from our perspective, and the patient’s pain and tolerance to the pain is completely out of whack.  As the final nail in the coffin, I usually cannot persuade worker’s comp, which has wreaked havoc on my patient’s life, to approve any mental health services.

I disagree with comments about the ideal system not being able to respond to the needs of a given patient.  Payments of modest financial incentives can and will change physician behavior.  But no system can respond to the complexity of an injured worker’s life and specific needs.  Each one of us becomes incredibly frustrated just dealing with airlines trying to make changes to a travel itinerary. Imagine having you’re medical treatment plan being altered against your wishes. These claims examiners are dealing with these workers entire life, including their ability to put food on the table.  My point is that any system cannot respond to the specific complexity of a given claim.  The better solution is to give the workers the tools to navigate their own way through the morass.

I am suggesting the following regarding the role of the claims examiners:

• Respect the injured worker and treat them accordingly.
  • It should be a major part of their orientation and ongoing in-service training.
• They should not be involved in medical decision making.
  • They should be able to approve reasonable care quickly and then ask for RN or physician input if they have questions.
  • This process should be expedited as quickly as possible.
  • How does delaying the ordering of tests save any money?  It would be different if there were no time loss.  The delay costs much more than the test.
• Their main role should be to make sure that the claim is run as seamlessly as possible.  Improving communication between all parties should be emphasized.
• They need to understand how trapped their claimants feel and not react when the worker is upset.  What would they do in a similar circumstance?  I don’t think any of us on the roundtable would react much differently.

There are many physicians who will not see worker’s comp patients due to the hassle factor.  Often, if a surgeon deals with worker’s comp, it is just to do a consultation and perform surgery.  By isolating out the worker’s comp variables, the decision making process regarding major surgery can become flawed.

I spend most of my time talking patients out of any type of spine surgery.  I specifically work just on discrete structural problems with matching clinical symptoms. I am diligent in trying to deal with all of the variables affecting the outcome of surgery, especially with a worker’s comp situation.  I will meet with nurse case managers as well as talk and meet with vocational counselors.  I will not close a claim until all parties have a plan in place.  I have one patient who had eight people involved in getting him back to work.  It took me ten months and at least five hours of phone calls and meetings.  After four years of chronic pain and disability, he is now working full time again.

I am one of the most interactive surgeons I know in getting a claim resolved.  I have learned how broken this system is.  I am not blaming the claims examiners.  It is a system that sets them up to fail.  Although I think the ultimate answer is to give the patients the tools to navigate their own way back to full health, there are many system changes that must be made.

I realize that there are several claims examiners on the roundtable.  I will be looking for their input with interest.  Right now, life in the trenches with my injured workers is intolerable.

BF

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BF

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