Jean was a middle-aged business owner who had come to me for a second opinion.  I had her fill out an extensive spine pain questionnaire, which includes many psychosocial questions in addition to a history and diagram of the pain.

Jean was very healthy and normally extremely physically active. Her low back pain started in the summer of 2005 after a lifting injury. The pain was fairly constant and was located throughout most of her back. She was still functioning at a fairly high level in spite of the pain.

Jean’s care so far had consisted of six visits to physical therapy and two sets of cortisone injections in her back, none of which had been helpful. She had not been prescribed any specific treatment plan or self-directed exercise program. On her second visit to a spine surgeon, it was recommended that she undergo a six-level fusion of her lower back.

Jean’s x-rays showed that she had a mild curvature of her lower back.  Other tests did not reveal any identifiable structural source of pain. From my perspective as a scoliosis surgeon, I felt her spine was essentially normal for her age. Instead, I felt that her pain was probably from the muscles and ligaments around the spine. The medical term that we use is myofascial. When an operation geared towards the bones, such a fusion, is done in the presence of mostly soft tissue pain, it rarely works. There is also significant surgical risk associated with a six-level fusion.  Also, with your entire lower back now turned into a solid piece of bone, you are just not the same person. There are long-term lifestyle limitations. At this point I was perplexed as to why surgery had been recommended when she’d undergone such little rehab. I also didn’t understand why she was continuing to experience such severe ongoing back pain without an obvious cause.

At this point, I knew to consult Jean’s intake spine questionnaire to look for clues. The questionnaire revealed that she’d had some marital difficulties and had just reconciled with her husband six months earlier. That immediately caught my attention because marital troubles indicate significant stress.  She then said her job had become much more stressful. Although she worked for the same employer, they had forced her to switch duties without adequate training. She was anxious about not only her performance, but also her ability to keep her job. This was another major stress.

I turned the page.  A month before her pain began, her twenty-six-year old son had drowned.

Up until that point, I knew that outside stressors played a role in chronic pain, but this factor had never been so powerfully demonstrated. Her case really brought home for me how crucial it was to take a full view of the patient’s life and circumstances instead of just looking at surgical solutions.  As I sat there stunned, I realized that I needed to do something different. Structured rehab started to become the main focus of my practice.

I have not taken my eyes off of that vision since that day.

NH, BF

Marsha was a 36 year-old businesswoman with two young children. She was referred to me by another patient and came to see me from the east coast. She had the spontaneous onset of back pain about eight years ago. Everything possible had been tried, but she continued to spiral downward with increasing pain.

In 2005, she had an MRI scan done that showed some mild degeneration of the discs in her lower back. These were normal for her age. A surgeon recommended she undergo two artificial discs at L3-4 and L4-5. They did not help her pain, and in fact, she got worse. The discs buckled, and a year later, they were removed at another hospital on the west coast. During this operation, they went back in through her abdomen to remove these artificial discs. In this situation, the major blood vessels are scarred down and attached to the discs. It is a very difficult procedure, and during the operation, her major vein, the vena cava, was torn. Her ureter (tube from the kidneys to the bladder) was also torn. Both were repaired, but she was left with residual swelling of her feet due to the partial disruption of the vena cava. A year later she had L5-S1 fused for ongoing low back pain.

When she saw me, she still had ongoing low back pain, thoracic pain, and neck pain. Two other spine surgeons had recommended to her that she should undergo a two-level fusion in her neck. Her MRI of her neck was normal for her age showing just some mild degeneration.

She desperately wanted to go back to work. Her husband was threatening to leave her. She was on drugs to wean her off narcotics but was having a difficult time. She was extremely motivated to get better but completely trapped by her pain and lack of a plan to solve her pain problem.

None of her surgeries were helpful or necessary. Yet the spine world was offering her only more surgery. I do not know the end of this story. I spent a couple of extra hours with her explaining the DOCC protocol to her in detail. She is fully engaged and I do think over 12-24 months she can become pain-free and functional. It is upsetting to me that she does have the three-level fusion in her lower back and residual swelling in her feet. If she had been able to engage in the structured rehab before any surgery, she might have completely come back to normal. Now she will have some permanent structural limitations.

BF

This story about how anger can affect the perception of pain involves one of my patients who had a complication from a revision spine fusion. Mike was a 52 year-old respiratory therapist who was very active–the man ran marathons. Years after an initial spine fusion at L5-S1 at age 30, his spine broke down above the level of the prior fusion and became very unstable. He waited almost five years before talking to a surgeon.

I performed surgery through his abdomen to place a hollow cage filled with bone graft at L4-5, the level just above his prior fusion. The purpose of the cage was to both stabilize the spine as well as to improve the chances of a successful fusion. Still, under anesthesia, he was turned over and had screws placed into the vertebrae to further increase the chances of a good outcome.

The surgery went very well, and he felt much better for a few weeks. He felt good enough that he increased his activity too quickly, which placed too much stress on the screws. For reasons that were unclear, he also had very soft bone. The screws broke out of the bone and irritated the fifth nerve root that travels down the side of the leg. His sciatic pain was unbearable.

I took Mike back to surgery to re-do the placement of the screws. Post-surgery, his nerve, already irritated and painful, did not calm down, and he developed a continuous, severe, burning leg pain.

At his one-month check-up, Mike exploded at me. His hour-long rant was not rational. Nothing I could say calmed him down. Afterward, he apologized. He said he was angry at the situation, not at me.

I was not in a great state of mind after the verbal barrage, but I elected to hang in there with him and began to apply the DOCC principles. Mike’s pain improved with aggressive pain medications. We also aggressively addressed his long-term problem with sleep. After some initial resistance, he engaged in the exercises in the Feeling Good book and started to look at his pain from a stress management point of view. He started to consistently write down his disruptive thoughts and then write down more rational thoughts. This process will be discussed further in Chapter Four, Reprogramming Your Nervous System.

At about three months after the second operation, his nervous system had calmed down enough to do aggressive physical therapy. If you do physical therapy too early while the nervous system is still fired up, it just flares up the pain and backfires. About six months into the healing process, he was doing much better. He had calmed down, and so did his leg pain.

The rehabilitation was difficult. Mike would be doing extremely well with little or no pain and then suddenly have severe flare-ups. At first, it wasn’t clear what was causing this back-and-forth. Gradually, however, he began to see the link between his level of stress and pain.

About six months into his recovery Mike went back to his job in the financial world. In spite of the work he had already done, he was still asked by his employer to participate in a month long anger management class. It had a dramatic additional impact on his ability to process his anger.

One year after the surgeries, the program had worked—Mike’s chronic pain was gone. He sometimes had a slight sensation of pain, but only when he became frustrated; it was nothing like the severe pain he had felt before his surgeries. At his two-year follow-up, he was back to work full-time and had improved to the point where he was running marathons. In addition to solving his back problems, he was able to enjoy his relationships and life again. As painful as the experience was for my patient and me, his journey was a gift to both of us.

Dramatic Turnaround

Another patient stands out when I think of these kinds of turnarounds. This one was a middle-aged woman, who had injured her back lifting on the job about two years earlier. She had mostly low back pain and some pain in her right leg. I am always very careful not to miss a problem that might require surgery. I obtained an MRI scan and it showed a bone spur that might or might not have been causing her leg to be painful. However, as her low back pain was the worst pain, she did not want surgery. I worked very hard with her with the protocols of the DOCC Project. Every visit was negative. She was angry with everyone, especially me for not fixing her. I set my goals lower; I wanted to just keep her at a relatively comfortable level. I did not think I could improve her function. Every time I saw her name on the schedule, I would just mentally give up. I felt my lines were always the same lines.

One day about nine months later, she walked in smiling. She told me that she had found a job. She wanted to stop her narcotics. She had joined Weight-Watchers and Curves. She wanted to see me one more time and that was it. On her last visit, she was on a roll.

When I asked her what had happened, she said that she was tired of being angry and just made a choice to do something different. This encounter occurred well before I had any concept of the role of anger in magnifying the perception of chronic pain. My only concept at the time was that if I couldn’t help someone’s pain with surgery, I would at least offer some stress management skills to help cope with the stress of having chronic pain. I was very surprised, as the DOCC protocol evolved, that a patient’s perception of pain would consistently decrease as their anger and stress decreased.

BF

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 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, 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.

Scott was a 50 year-old architect who had been experiencing low back pain for about three years. It was not clear what had started it. The pain was difficult, but he remained very active, riding his bike on a daily basis and working out in the gym several times a week. He continued to work.

When he saw me, we discovered that he had no clearly identifiable structural problem. I discussed the DOCC program with him and explained to him that it was important for him to “calm down” his nervous system before the soft tissues could be effectively addressed. He agreed to give it a try.

We started off with some strategies to improve his sleep. When you’re in chronic pain, getting a good amount of sleep is vital: it increases coping skills and usually diminishes the perception of pain. I often treat patients with short-term sleep medication to get them on track initially. Scott required sleeping meds for about three months. His sense of well being improved, although in his case, the pain remained unchanged.

Next, we began to delve into some stress-related issues. He grudgingly began doing the writing exercises prescribed by the DOCC Project. He revealed that he had experienced significant anxiety most of his life and that, lately, it was spiraling out of control. His business was suffering; his marriage was in trouble; he was in conflict with his son over the son’s future. Much of his anxiety was created by his controlling tendencies. I had him re-engage with his psychiatrist for medications and also had him work with a pain psychologist.

One trait in Scott’s favor was his strong determination to get better. He did not want to spend the rest of his life with this level of pain and suffering. His suffering became even more severe for the first three months with increased pain, anxiety, and depression. Although the writing exercises are simple, it is a difficult process. We all have ways of covering up our anxieties and frustrations. Seeing them on paper initially is disconcerting. He began to realize how much he dealt with his anxiety by controlling circumstances and people close to him. His nervous system became more “fired up,” which increased his perception of the pain. But after six months of full engagement in the DOCC program, Scott made it through. His anxiety and depression improved. He did not need much physical therapy as he was in such good shape. He acknowledged some deep anger problems that he had not seen and took full responsibility. He was finally pain free. The greatest benefit, though, was that with the stress management skills he’d acquired, he was able to experience the kind of rich and full life with his family that he’d never thought possible. With the “reprogramming” skills outlined later in this book you are able to experience anxiety and anger without having them run your life. He was able to relax enough to actually listen to his family and enjoy being around them. They were able to enjoy being around him. It has not been a straight line up, but he is well on his way to creating a new life for himself.

BF

I was treating Gordon, a 32 year old patient. He had been in constant low back pain for over four years after being rear-ended in a car accident. He had undergone two laminectomies before he saw me. Both were done between the 4th and 5th lumbar vertebrae. I was practicing in Sun Valley, Idaho and had a fairly good idea of the effect of stress and lack of sleep on pain. I did not understand any of the stress management tools I outline in the DOCC Project.

His complaint was just low back pain. He had only a degenerated disc with very little motion. There is little if any correlation between pain and disc degeneration. As there was not an identifiable structural source of the pain, I did not recommend any surgery.

I was determined to get him back on track. I saw him every one to two weeks for over eight months. He had some personal stresses and was very anxious. I tried everything I could to help his pain, but nothing seemed to work.

He finally fired me and saw a surgeon in a neighboring town.  That surgeon performed a fusion at L4-5, both from the front and back of his spine.  Gordon felt so great, he took out an ad in the local paper thanking the neighboring surgeon for doing such a great job.

I did not feel great about it. It is not as if a fusion never works. It just does not work often enough in a predictable manner to warrant it being done in someone so young. In five to ten years, there is the additional chance of the spine severely breaking down around the fusion. Having been so exposed to this scenario, I was not willing to move forward with surgery.

He then filed a malpractice lawsuit against me for not performing the surgery that would have helped him. I was quickly cleared, but I had to engage the services of an attorney and go before a panel of peers to deal with it. I still, in retrospect, would not have done anything differently. I just wish I knew then what I know now about the mental health aspect of chronic pain. I did not understand the sensitization process or how to calm down the nervous system.

The situation was also awkward because I would frequently run into him while doing business around town. About a year after his surgery, during one of our awkward run-ins, he looked me right in the eye and said, “You were right.” A year after his spine surgery, Gordon’s pain was the same as when he was under my care.

How attached are you to your victim role? How willing are you to look at how it might be running your life? How victimized do you feel in regards to your pain and the circumstances surrounding it? How angry are you that no is willing to listen, believe, or care about your pain? How frustrating is it to feel that you might have to live the rest of your life with this pain?

The victim role is universal. The willingness to take an honest look at it is not.

BF

Jean was a middle-aged business owner who had come to me for a second opinion. I had her fill out an extensive spine pain questionnaire, which includes many psychosocial questions in addition to a history and diagram of the pain.

Jean was very healthy and normally extremely physically active. Her low back pain started in the summer of 2005 after a lifting injury. The pain was fairly constant and was located throughout most of her back. She was still functioning at a fairly high level in spite of the pain.

Jean’s care so far had consisted of six visits to physical therapy and two sets of cortisone injections in her back, none of which had been helpful. She had not been prescribed any specific treatment plan or self-directed exercise program. On her second visit to a spine surgeon, it was recommended that she undergo a six-level fusion of her lower back.

Jean’s x-rays showed that she had a mild curvature of her lower back. Other tests did not reveal any identifiable structural source of pain. From my perspective as a scoliosis surgeon, I felt her spine was essentially normal for her age. Instead, I felt that her pain was probably from the muscles and ligaments around the spine. The medical term that we use is myofascial. When an operation geared towards the bones, such a fusion, is done in the presence of mostly soft tissue pain, it rarely works. There is also significant surgical risk associated with a six-level fusion. And finally, with your entire lower back now turned into a solid piece of bone, you are just not the same person. There are long-term lifestyle limitations. At this point, I was perplexed as to why surgery had been recommended when she’d undergone such little rehab. I also didn’t understand why she was continuing to experience such severe ongoing back pain without an obvious cause.

At this point, I knew to consult Jean’s intake spine questionnaire to look for clues. The questionnaire revealed that she’d had some marital difficulties and had just reconciled with her husband six months earlier. That immediately caught my attention, as that is a significant stress. She then said her job had become much more stressful because although she worked for the same employer, they had forced her to switch duties without adequate training. She was anxious about not only her performance, but also her ability to keep her job. This was another major stress.

A month before her pain began, her twenty-six year-old son had drowned.

Before Jean, I knew that outside stressors played a role in chronic pain, but I had never seen this factor be so powerfully demonstrated. Her case really brought home for me how crucial it was to take a full view of the patient’s life and circumstances instead of just reviewing his or her physical condition and running tests. As I sat there stunned, I realized that I needed to do something different. Structured rehab began to be the main focus of my practice.

I have not taken my eyes off of that vision.

BF