• When your nervous system is inflamed and hyper-reactive, lesser levels of stress cause your body to go into flight or fight.
• In contrast, you are able to more easily deal with challenges if you feel safe and calm.
• Four categories of factors influence your baseline physiological state of safety versus threat: 1) sleep 2) diet 3) exercise/activity level 4) childhood programming/ patterns.
• All of these factors are addressed throughout the course, but the initial focus is on getting adequate sleep.

Your nervous system gathers about 20-40 million bits of information per second, and interprets the sum total as safe or threatening. Signals are continuously sent out to adjust the body’s physiology (output) and actions to optimize your function. The reactivity of your nervous system ranges from calm to hypervigilant. These four categories of factors influence the sensitivity of the nervous system.

• Consistently restful sleep is necessary for your brain to refuel and empty waste products.
• Lack of exercise affects your physiology and also your capacity to cope with both mental and physical stress.
• A poor diet is inflammatory.
• Your baseline physiology is also affected by your past. Survival depends on learning what is dangerous and then avoiding it in the future. If you were raised in a chaotic abusive environment, many situations were dangerous or perceived as such. That doesn’t change as you age even when you intellectually know you are safe. So, more scenarios in the present seem threatening with less stress than you might expect.

Although all these variables affecting your nervous system are presented throughout the course, successfully addressing sleep is a high priority. The DOC Journey approaches will be marginally effective if you aren’t getting 7 or 8 hours of restful sleep. Not sleeping is NOT an option. No major decisions regarding your medical care should be made until you feel rested during the day. This is particularly true regarding surgical procedures.

Systematic Approach to Sleep

Insomnia is consistently solvable with a stepwise approach regardless of the level of your pain. The key is focus and persistence. It is a myth that you need less sleep as an adult and at least seven hours of sleep is desirable. Few patients suffering from chronic pain are getting adequate sleep.

Incorporating sleep into the treatment was my first step in conceiving the DOC protocol. I had a new resource that was effective and measurable. My patients’ sense of well-being improved and often other symptoms diminished.

Sleep and pain

I originally thought that people suffering from chronic pain couldn’t sleep because of their pain. But a large study out of Israel demonstrated that lack of sleep induces chronic low back pain, and that the reverse was not true – that pain caused insomnia.¹

Another study documented that consistently poor sleep was a greater predictor of disability than the severity of back pain. Even more interesting was that this was also true for leg pain (sciatica), which surgeons generally feel is an incredibly disabling symptom.²

I treated one businessman who had experienced chronic neck pain for almost two years. There was no specific injury. He continued working as an owner of a small accounting firm, but he was miserable. He had been through multiple courses of physical therapy. I started him on a strong sleep medication, which immediately allowed him to experience restful sleep. I saw him back at two weeks and noted the medication was working well. I was planning on starting aggressive physical therapy on the next visit. When he returned six weeks later, I was surprised that he was pain-free without any other interventions.

Start sleeping – NOW

Most people find a way to sleep using a combination of the suggestions listed below. If you are still struggling after a few weeks, Discuss sleep with your primary care physician. The details of each of these suggestions are outlined in chapter 14 of my book, Back in Control. Please use this as a resource.

Approaches to Insomnia

Self-directed

1. Sleep hygiene – well-known set of principles to optimize sleep.
2. Stress management at bedtime – i.e., don’t read business emails for at least an hour before going to bed.
3. Exercise – Physical conditioning improves sleep, but don’t exercise late in the evening.
4. Expressive writing –  shortens the time it takes to fall asleep.
5. CBT-I –  Cognitive Behavioral Therapy Insomnia is documented to improve sleep. Online resources are readily available.
6. Over-the-counter sleep aids – I do not have specific recommendations. They may be helpful, but should not be used long-term. Alert your physicians if you are using them.

Under the guidance of a physician

1. Prescription Medications – Many stronger medications are effective for treating insomnia. I have observed that if you are suffering from chronic mental and/or physcial pain that you often need a kick-start with strong sleep meds. Once your nervous system quiets down you can and should come from them relatively soon. Using narcotics for sleep is not recommended and creates many additional problems.
2. Diagnosing a sleep disorder – there are over 100 sleep disorders with the most common one being sleep apnea. Sleep apnea is caused from your airway intermittently becoming partially occluded. Oxygen levels drop as you gasp for air. Sleep quality is poor, and daytime sleepness is one of the hallmarks of this disorder. More importantly, your heart is stressed and its function is progressively compromised. It is important to diagnose and treat it if there is any suspicion. Restless Leg Syndrome is another common sleep disorder that is treatable with the correct medications.

Recap

The other factors affect the reactivity of your nervous system, buy a consistently restful night’s sleep is necessary for healing. It must be not only be addressed, but at least partially solved as an early step. Most people improve their sleep with simple self-directed interventions, but you should not hesitate to seek help from your physician.

Questions and considerations

1. Assess your sleep.
   1. How many hours do you sleep per night?
   2. How often do you wake up?
   3. How long does it take for you to fall asleep?
   4. Do you feel rested in the morning?
   5. Do you fall asleep easily during waking hours?
2. Do you notice a difference in your physical and mental symptoms after several nights of restful sleep? What symptoms are worse with poor sleep?
3. From a practical perspective, how can you really enjoy your life if you are tired? Why pursue so many other treatments without covering this base?
4. Temporarily push away the other aspects of your situation and focus on sleep. It is a clear and measurable variable.
5. “I can’t sleep because of my pain.” You have to flip that idea around. Remember, it is lack of sleep that is causing so many problems.

References

1. Agmon M and Galit Armon. “Increased insomnia symptoms predict the onset of back pain among employed adults.” PLOS One (2014); 9: 1-7.
2. Zarrabian MM, et al. “Relationship between sleep, pain, and disability in patients with spinal pathology.” Archives of Physical Medicine and Rehabilitation (2014); 95:1504-1509.

The post Calming and Stabilizing Your Nervous System first appeared on Back in Control.

The post Calming and Stabilizing Your Nervous System appeared first on Back in Control.

His letter

I met Dr. Hanscom under the most stressful circumstances imaginable.

When I moved back to the Northwest a little over a year ago, I experienced crippling anxiety, panic and agoraphobia – combined with excruciating lower cervical and upper thoracic pain radiating down not one, but both arms. I was in and out of the ER four times in one month, and over a period of several months, with new and emerging physical symptoms, I had seen over sixteen doctors of different specialties and had nearly every study and workup imaginable, running up some fifty-thousand dollars in medical expenses in the process. I simply did not know what was wrong with me and was completely frustrated with the medical care system to a great degree.

When my back pain became the focus, I came to the local spine center and presented to Dr. Hanscom my symptoms. After filling out an extensive questionnaire, which covered not just physical lifestyle, but emotional and behavioral issues as well, I sat in the exam room waiting. He came into the room after having viewed my MRI and offered not surgery, but something different, as an option. He told me to read a book Feeling Good, use the tools in it and begin to look at how my lifestyle and the way I was thinking were affecting my physical symptoms. In fact, he said, if I quote correctly, “I believe that when you do the exercises in this book and get a handle on your anxiety and depression, these symptoms will clear up.” He also stressed the importance of good quality, full stage sleep, which I was also being deprived of, as a crucial aid to the healing process.

After this experience, while driving home I remember telling a friend down in LA on the phone, “Gee I went to see a doctor and I ended up finding a healer.” In light of everything, it just made sense. In short, I was ready to move on to the advanced user features of my own software and hardware for that matter. I purchased the book, read it and did the exercises, used the tools contained therein, followed up with Dr. Hanscom and after a few months, I began to notice a difference.

Then on a recent trip to Los Angeles for work this year, I noticed I had no back pain at all. Diligence is key and maintenance is the watchword, but I remain asymptomatic to this moment and when I do feel the twinges, the spaciness, or any other telltale symptoms, my first impulse now is to confront the thought behind the physical and emotional feeling. And more often than not, I return to a normal, happy and focused state of mind – only this time with a much easier disposition.

Charlies-story-pain-free-after-17-different-doctors

My Perspective

I met Charley in 2006. I had just re-commited to the DOC project. I realized that my patients either with or without surgery were not doing nearly as well as I had experienced in Sun Valley where the project was born. He was experiencing a lot of neck pain, but was also not sleeping. It was also clear that he was quite anxious and becoming increasinly discouraged by not finding a way out of the Abyss. He clearly was motivated to get better, as he had seen 16 physicians within an 18-month span.

At that time I did not have much clarity about the links between anxiety, anger, and pain. I happened to have a slow clinic day and was able to talk to him for a while. We hit it off and had a great conversation. We began by working on his sleep and I shared the book, Feeling Good with him. I asked him to begin the writing that David Burns, the author, had suggested.

The first six months were not that easy for him and we had frequent phone calls. He all of a sudden, “woke up” and went after everything with a vengeance. There was no book or website at the time presenting the Back in Control concepts. What he taught me was there is no magic formula to any of this. It is a matter of re-connecting with the best part of yourself. Then there is no stopping you.

Charley moved back to Southern California were he is re-engaging in a busy, rich, full life and career. He has been pain free for over 10 years. We recently shot a short video to encapsulate his story and discuss his last ten years. He has not only remained active but has launched in a massive startup company. He will be the first to tell you, as will I, that this is not a straight-line journey but overall incredibly rewarding and you will connect with your capacity to create whatever life you wish.

We have become good friends and regularly stay in touch. I appreciate his willingness to share his journey with you.

The post Charley’s Story: Pain Free After 17 Doctors first appeared on Back in Control.

The post Charley’s Story: Pain Free After 17 Doctors appeared first on Back in Control.

• Adequate sleep is a necessary requirement for healing.
• Insomnia is a cause of chronic pain, and it is not the other way around.
• It is almost always possible to experience a consistently good night’s sleep using a combination of approaches.
• Do not undergo any major invasive interventions until you have solved this issue.

Insufficient sleep is a major factor that compromises one’s coping capacity and increases pain. It is consistently solvable with a stepwise approach regardless of the level of your pain. The outcomes of the various treatments are easily assessed. The key is focus and persistence. It is a myth that you need less sleep as an adult and at least seven hours of sleep is the desired amount. Few patients suffering from chronic pain are getting adequate sleep.

Incorporating sleep into the 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 was always some improvement in their sense of well-being if not also their pain.

 Sleep and pain

I had originally thought that people in chronic pain could not sleep because of their pain. But a large study out of Israel showed that it is lack of sleep that induces chronic low back pain. It also demonstrated that the reverse was not true – that pain caused insomnia.¹

Another study documented that lack of sleep was a bigger predictor of becoming disabled than the severity of back pain. Even more interesting to me was that this was also true for leg pain (sciatica), which surgeons generally feel is the most disabling problem.²

Successfully addressing insomnia is the highest priority. The DOC Journey will be marginally effective if you aren’t getting 7 or 8 hours of restful sleep. Not sleeping is NOT an option. No major decisions regarding your spine care should be made until you feel rested during the day. This is particularly true regarding spine surgery.

I had one businessman that had experienced chronic neck pain for almost two years. There was no specific injury. He continued to 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.

Start sleeping – NOW

There are many ways to get a good night’s sleep. Most people can figure out a solution using a combination of the self-directed suggestions below. If you are still struggling after a few weeks, you should discuss it with your primary care physician. The details of each of these suggestions are outlined in the next lesson, which is the sleep chapter of my book, Back in Control. Please use this a reference to devise your own approach.

Approaches to Insomnia – self-directed

1. Sleep hygiene – well-known set of principles to optimize sleep.
2. Stress management at bedtime – i.e., don’t read business emails while you are trying to fall asleep.
3. Exercise – It is not helpful to exercise late in the evening, but overall physical conditioning improves sleep.
4. Expressive writing – has been shown to help decrease the time it takes to fall asleep.
5. CBT-I – stands for Cognitive Behavioral Therapy Insomnia. There are online resources that may be helpful in addressing some of the anxiety around trying to get a good night’s sleep.
6. Over the counter sleep aids – I do not have specific recommendations and they should not be used long-term. You also should make your physicians aware that you are using them.

Under the guidance of a physician

1. Prescription Medications – There are many medications that are effective in dealing with insomnia. I have observed that if you are suffering from chronic pain that you often need a kick-start with strong sleep meds. Once your nervous system quiets down you can and should come from them relatively soon. Using narcotics for sleep is not recommended and creates many additional problems.
2. Diagnosing a sleep disorder – there are over 100 sleep disorders with the most common one being sleep apnea. In sleep apnea your airway intermittently becomes occluded while sleeping and you are gasping for air. Sleep quality is poor, and you are tired the next day. More importantly it has an adverse effect on your heart. If simple measures are not working, it is important to diagnose and treat this. Restless Leg Syndrome is another common sleep disorder that is treatable with the correct medications.

Recap

A consistently restful night’s sleep is necessary for healing from chronic mental or physical pain. Insomnia causes chronic LBP and must be addressed as the first step of healing. It is generally solvable regardless of the level of your pain. Most people can improve their sleep with simple self-directed interventions, but you should not hesitate to seek help from your physician.

Use the sleep chapter from my book, Back in Control, as a reference. Read it carefully and implement the steps that are doable for you. As you layer on additional strategies, you will find a way to sleep.

References

1. Agmon M and Galit Armon. “Increased insomnia symptoms predict the onset of back pain among employed adults.” PLOS One (2014); 9: 1-7.
2. Zarrabian MM, et al. “Relationship between sleep, pain, and disability in patients with spinal pathology.” Archives of Physical Medicine and Rehabilitation (2014); 95:1504-1509.

The post Systematic Approach to Sleep first appeared on Back in Control.

The post Systematic Approach to Sleep appeared first on Back in Control.

Sleep apnea 

With sleep apnea your upper airway becomes intermittently obstructed by the tissues at the back of your mouth called the soft palate. It is a little unclear why and who comes down with the diagnosis. Symptoms include heavy snoring, frequent episodes of not breathing for a short period followed by a gasp for air, not feeling rested during the day, and falling asleep in the afternoon. It is an important diagnosis to make in that left untreated it adversely affects your heart. Certain sleep medications, such as Ambien, should not be used if you have sleep apnea.

The disorder is made in a sleep lab where your breathing is observed and monitored. There are also home monitoring devices that can help with diagnosis. Treatment involves around mechanically keeping the airway open through maintaining a positive airway pressure. The name of the device is a CPAP (continuous positive airway pressure) machine. A tightly fitting face mask keeps the airways open with air pressure and is the standard treatment for sleep apnea. Patients usually feel more rested during the day and have more energy. Other treatments include oral appliances and surgical alteration of the back of your mouth. The choices are outlined by the sleep center.

Restless leg syndrome

Patients with restless leg syndrome experience multiple strong movements of their legs at night that will awake them. Often the patient’s partner is the one who is the most frustrated, as the kicking will also keep them awake. Medications that are used in the treatment of Parkinson’s disease can be helpful in reducing the intensity of the movements.

If sleep medications, pain medications, exercise and stress management do not help your sleep over a reasonable period of time, then you should get further testing by a sleep specialist to establish a firm diagnosis.

1. Dement, William C, and Christopher Vaughan. The Prom­ise of Sleep. Dell Publishing, 2000.

.

BF

The post Sleep Disorders first appeared on Back in Control.

The post Sleep Disorders appeared first on Back in Control.

As you more effectively process stress, your sleep will improve. As a lack of sleep is itself is a major stress, getting the ball rolling is a little tricky. Getting to sleep with meds may be the starting point. A simpler step would be to do the expressive writing exercises outlined throughout this website at bedtime. Many sleep specialists are encouraging these types of cognitive behavioral exercises at bedtime as a sleep strategy. It’s remarkable how quickly writing can slow down these whirlpools of obsessive racing thoughts. The writing has been shown to decrease the time it takes to fall asleep. (1) Personally, expressive writing is the only tool I find effective for getting back to sleep if I am experiencing a particularly stressful week.

Additionally, it is very helpful to keep a notepad by the side of your bed.  When you wake up at night, it is often effective to engage in the writing exercises at that time.  You may initially be doing this three or four times per night.  The alternative of just laying there and hoping you will fall back asleep seldom works. I received an email from a patient who discovered that using one finger to “write” on her other hand had the same benefits as writing on paper and she would fall back asleep quickly.

Sleep is a critical anchor point of successfully solving your pain. Using this simple risk-free strategy might be of great benefit.

1. Baikie K WK. Emotional and physical health benefits of expressive writing. Advances in Psychiatric Treatment. 2005;11:338-346.

BF

The post Writing at Bedtime first appeared on Back in Control.

The post Writing at Bedtime appeared first on Back in Control.

If you are having sleeping problems, work carefully with your doctor to figure out which sleep medication is the best for you. Once you’ve started taking it, check with him or her every five to seven days—either at follow-up appointments or via phone–to report back on how things are going. If the first treatment plan isn’t working, adjustments should be made promptly so that you’re sleeping well within three to four weeks. This is the kind of aggressive, solution-oriented approach that I’ve found is most effective.

Insist on getting adequate sleep

If your doctor resists this kind of follow up, do not back down.  Calmly explain that getting sleep is a central part of your recovery program, one that you are taking seriously. Of course, if he/she still resists, don’t be afraid to find another physician.

Note: in dealing with sleep problems, some physicians opt for treating your depression, which does improve sleep. However, it takes far too long.

Categories of sleep medications

There are several categories of sleep medications and two basic strategies in terms of how they work. I am including them here to give you an idea of the wealth of options available. One group has a direct effect–they will simply induce sleep. The other group includes medications that are intended for other problems but have drowsiness as a side effect.  Sleep can be obtained by taking advantage of this side effect.

In addition to sleep medication, it can be helpful to take a slow-release narcotic, which will last for eight to twelve hours, to help with pain. I don’t like narcotics solely as a means to get a patient to sleep, but they lessen the pain enough to allow the sleep medications to work. Narcotics are covered later in this chapter.

Here are the different types of sleep medications:

• Sedative-hypnotics
  • With anti-anxiety properties: Valium, Klonopin, Xanax, Halcion, Ativan, etc.
  • Without anti-anxiety properties: Ambien, Lunesta, Sonata

• Antidepressants with drowsiness as a side effect
  • Non-SSRI: Remeron, Trazodone

• • Tricyclics: Amitryptiline (Elavil), Nortriptyline (Pamelor)

• Anti-psychotics with drowsiness as a side effect

• • Seroquel, Risperdol
• Melatonin agonists
  • Melatonin, Rozeram

• Antihistamines
  • Benadryl
  • Over the counter sleep aids

I won’t go into the pros and cons of each medication–that is something to discuss with your doctor. But know that one of the above will work for you if used correctly. Pain is not a reason to lose a night’s sleep.

BF

The post Sleep Meds first appeared on Back in Control.

The post Sleep Meds appeared first on Back in Control.

It’s your first priority

First of all, you must be pro-active in getting a full night’s sleep, which is seven to eight hours. The percent of adults who do not get a consistent full night’s sleep is around 35-40%.  Some type of sleep disturbance is an issue with over 60 million Americans. Allowing yourself to just lie in your bed not sleeping night after night is unacceptable. You may not see any results initially, but your persistence will be rewarded.

In the surgical world, it is somewhat of a perverse badge of honor to see how hard you can work with just sleeping five to six hours a night. It can and does become a way of life. However, at that point, you no longer know what it is like to function regularly on a full night’s sleep. Your quality of life is compromised, and you are unaware of the extent.

Sleep Hygiene

Some sleep hygiene concepts are:

• Don’t get into bed until you are ready to fall asleep. Watch TV, read, etc. in another room.
• Do not drink any caffeine after noon.
• Minimize alcohol intake in the evening—you will fall asleep but not stay asleep
• No heavy exercise in the evenings.
• Remove any clocks from the room.
• Do something relaxing just before going to bed.
• If you are hungry have a light snack.
• Concentrate on relaxing each muscle group in your body from head to toe.

The older you are, the more important it may become to practice good sleep hygiene. The ability to get a good night’s sleep takes a definite downturn around age 25 and another one at age 45.

BF

The post Sleep Hygiene first appeared on Back in Control.

The post Sleep Hygiene 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.