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Unraveling chronic pain

Reading time: 13 minutes

According to renowned spine surgeon David Hanscom, most spine operations are unnecessary and too often make things worse.  After quitting his surgical practice, Hanscom developed a revolutionary approach to treating chronic pain that has helped hundreds of patients live pain-free. At its core is understanding the nature of chronic pain and your own capacity to heal.

There has been a lot of controversy around the treatment of chronic pain, and patients and physicians alike are frustrated by the inability to solve it. Chronic pain is a complicated phenomenon shaped by many influences, and modern medicine’s approach is to offer simplistic, random solutions while ignoring current neuroscience that points the way to a new paradigm. The current definition of chronic pain is “. . . an embedded memory that becomes associated with more and more life experiences, and the memory cannot be erased.”1 Understanding how this process evolves and the neurochemical nature of chronic pain is the first step to resolving it.

The evolution of chronic pain 

The brain is a dynamic structure, changing every millisecond. New nerve cells are formed, additional connections through small tentacles called dendrites are created, myelin (the insulation around the nerves) thickens and thins, and glial cells (supporting structural cells) undergo ongoing revision. The constantly changing nature of the brain, called neuroplasticity, allows us to learn and adapt quickly. 

To understand how you came to develop chronic pain, we need to consider these ongoing changes within the nervous system. Three significant factors contribute to the development of chronic pain: 1) Sensitization, 2) Memorization and 3) the “Modifiers”— anxiety, anger and sleep. By addressing all aspects of it, chronic pain is a solvable problem. 

Sensitization 

I have encountered scores of patients who strongly believed that, if their chronic pain got worse, some anatomical problem was progressing—even in the absence of further injury. In most cases the pain worsens simply because of the way the brain processes repetitive stimuli. 

When your brain is constantly bombarded with pain impulses, it will eventually take less of an impulse to elicit the same response (pain) in the brain. In addition, that same impulse can cause more neurons in the brain to fire, resulting in patients complaining that their pain is getting worse although there is no additional trauma. They have become sensitized to their pain. 

This phenomenon was clearly documented in a clinical study performed in 2004.2 As pain-free volunteers had light pressure applied to one of their fingers, the researchers measured the response in their brains with a functional magnetic resonance imaging (fMRI) machine, which tracks metabolic activity. 

Researchers consistently identified only one small area of the brain that responded to the pressure. They then applied the same pressure stimulus to patients who were experiencing chronic pain. There were two chronic pain groups: one consisted of people with chronic low back pain lasting more than three months; the other consisted of people who suffered from fibromyalgia (chronically widespread musculoskeletal pain). 

In both groups, five areas of the brain lit up. Although the fibromyalgia group experienced more diffuse body pain, anxiety and depression than the low back pain group, the fMRI scan data were almost identical. 

Memorization 

Another consequence of repetition of pain impulses is memorization. When pain impulses are repeated for any length of time, the brain “learns” them. However, while it might take years to become an expert baseball player or pianist, pain can be memorized within a matter of months. Once learned, the memory is permanent—just like riding a bicycle. 

A prime example of memorization is the “phantom limb” phenomenon, which occurs in patients who have had a limb amputated after experiencing great pain from disease or trauma. After the limb is removed, up to 60 percent of patients still feel pain, as though the limb were still there. Almost 40 percent of sufferers characterize the pain as anywhere from distressing to even more severe than before.3 The neurological connections associated with pain continue to function, even when the offending stimulus is removed. 

Memorized thoughts

“The curse of consciousness” may be the biggest culprit in creating chronic pain. As your brain memorizes unpleasant thoughts, they can develop into uncontrollable, obsessive loops. Hard as you try to make them go away, repressing them gives negative thoughts more neurological attention. “The surgeon screwed up my back.” “I can’t get out of bed.” “The pain is ruining my life.” If left unchecked, recurring thoughts can become stubborn obstacles to recovery. 

Strangely, the more legitimate your complaints, the more havoc they create. Maybe you are right. Maybe the surgeon did screw up your back. Maybe you really can’t get out of bed without help. And that makes it more difficult to let those thoughts go. 

And what about the physical manifestations brought on by your repetitive, unsettling thoughts and the feelings they generate? Your bodily reactions, including your chronic pain, are manifestations of the body’s stress hormones and intimately tied to your thought-generated negative stimuli. 

One landmark study compared fMRIs of volunteers suffering from acute low back pain (less than two months) to those with chronic low back pain (over 10 years), and recorded the areas of the brain that “lit up” during pain sensations. 

The acute group’s brain activity was confined to the area known for low back pain, while the chronic group’s activity was located in the emotional centers of the brain.4 

The experimenters then followed a subset of acute patients for a year. In the subjects whose pain became chronic, the brain activity shifted from the areas associated with acute back pain to the emotional centers. In the group whose symptoms resolved, both areas quieted down. 

Neurons that fire together wire together. When pain sensations are located in the emotional area of your brain, they can be triggered by unpleasant thoughts. We each have some version of a negative thought loop. “I’m not good enough.” “What will people think?” “How am I going to pay my bills?” “What’s wrong with me?” Obsessive thought loops are so common that we think of them as normal. Like phantom limb pain, they haunt us because they have become neurologically embedded. I call them “phantom brain pain.” 

Regardless of the origins of your chronic pain, repetitive pain signals bombard your brain and form lasting memories. Knowing this, it is imperative that you visualize your pain as a network of well-established, programmed circuits. You can never remove or “fix” these neural connections by surgery, but by using reprogramming tools, you can create pain-free “detours” around old pain circuits. 

Treating pain holistically

I have developed a systematic, self-directed process to solving chronic pain called Direct your Own Care (DOC), consisting of tools to calm and reprogram your nervous system. These include:

Somatic work: connecting thoughts with physical sensations (expressive writing) 

Relaxation tools: active meditation, mindfulness meditation, visualization 

Forgiveness: you can’t simultaneously move forward and hang on to the past 

Refraining from discussing your pain or medical care with anyone but your health care providers—redirect your attention away from the pain 

Identifying triggers that affect symptoms—and dealing with them 

Returning to familiar, fun activities such as art, hobbies, music, dance, sports, etc. 

Re-learning how to play—the antithesis of anger 

Giving back: a reward in itself

Reconnecting with playfulness is particularly powerful.

 Results are swift, and repetition can strengthen pleasurable circuits until they become habitual. When this happens, your body experiences a profound shift from stress chemicals to relaxation hormones. As your organs luxuriate in this rejuvenating chemical bath, your physical symptoms, including your pain, resolve. Since emotional pain and physical pain are processed in similar areas of the brain, people who are socially isolated often develop chronic pain. An essential component of the DOC project is meaningful human connection. People naturally heal each other. Reconnecting with friends and family has been a powerful force in moving away from pain. As you broaden your perspective on life, you will regain the best part of you, and then, the sky will be the limit. 

For more information on my DOC strategies, see my book – Back in Control: A Surgeon’s Roadmap Out of Chronic Pain (Vertus Press, 2016).

The modifiers

As memorized pain circuits and negative thought loops sensitize your nervous system, both physical and emotional pain intensifies. Your body, ever vigilant to protect you, responds with more stress chemicals, inviting anxiety, anger and sleeplessness to the party. 

Other physical symptoms can appear during hyper-alert states as well. The combination of sleep deprivation, chronic anxiety and anxiety-fueled anger can become intolerable—for both you and those close to you. 

Anxiety 

Anxiety is that deeply unpleasant sensation that signals the presence of elevated levels of stress hormones, which are generated in response to a threat. Whether the threat is a physical reality or a negative thought, the body’s response is the same. The unpleasant sensation is there to compel you to resolve the problem, to survive. 

What if the threat is habitual self-doubt, recurring thoughts such as “I’m not good enough” or “I’m not attractive”? Since such sources of anxiety are not readily solvable, you suffer sustained levels of stress hormones that wreak havoc on your body. 

Your efforts to ignore these thoughts, suppress them or distract yourself are not only futile, but actually increase the levels of these chemicals. The long-term consequence of chronic stress is a life expectancy of seven years less than the average population.5 Other punishing effects on your body include: 

  • Increased blood supply to your muscles and skin, causing tension and perspiration 
  • Decreased blood flow to your intestines and bladder, causing irritable bowel syndrome and spastic bladder 
  • Accelerated nerve conduction, resulting in heightened pain sensitivity.

For most people, unrelenting anxiety is the worst part of chronic pain. 

Anger 

As far as your nervous system is concerned, anxiety and anger are one and the same. Like anxiety, anger is generated by high levels of stress chemicals. 

As one of your body’s responses to regain control, it is ironic that anger often puts you even more out of control. There is a “genealogy” of anger: 

  1. Anger-provoking situation (real or imagined) 
  2. Blame
  3. Victim role 
  4. Anger

If the extra chemical kick provided by your anger allows you to solve the problem, your anger will abate. If not, the levels of stress hormones go even higher, causing more intense and frequent physical reactions. 

Anger is destructive because it is focused only on your survival. Relationships are particularly affected. The more intimate the relationship, the worse the damage. Instead of cultivating much-needed family support, the angry chronic pain patient often targets his or her family with verbal, emotional or physical abuse. 

Destructive tendencies also turn inward. One manifestation is complete disregard for one’s health. Another that many patients fall into is deep depression and hopelessness. All these symptoms abate when you can let go of your anger. It is a learned skill. 

Sleep 

Addressing sleep disorders is a vital step toward the resolution of chronic pain. Loss of even one night’s rest impairs judgment, learning and response times. But sleep deprivation also profoundly affects chronic pain. 

Insomnia seems to be associated with a higher intensity of pain.6 Sleep deprivation for just one night lowers the pain threshold.7 One study, which followed more than 2,000 patients for almost four years, found that people with insomnia have nearly a 40 percent higher chance of suffering from chronic back pain.8 While this study did not find evidence of the reverse relationship (i.e., pain suffering did not lead to poor sleep), other studies have. 

A large survey in Turkey found that patients in chronic pain had almost double the rates of insomnia compared to those without pain. Another study, which surveyed around 19,000 individuals from five European countries, showed that people with chronically painful conditions (e.g., limb or joint pain, backache, gastrointestinal pain, headache) experienced significantly more insomnia than those without pain. 

Compared to individuals without chronic pain conditions, those with pain were three times more likely to report difficulties with initiating sleep, maintaining sleep, early morning awakenings and non-restorative sleep.9 

In addition to aggravating your pain and compromising your capacity to cope, sleep deprivation interferes with thinking clearly, which may affect your ability to make sound decisions about your care. Prior to considering surgery, you should be sleeping at least six cumulative (but not necessarily consecutive) hours during a 24-hour period for a minimum of six weeks. Insomnia is treatable with minimal risks. 

Sleeping off the pain

A study that followed over 2,000 people for four years found insomnia was linked to a 40 percent increase in the risk of chronic back pain. Other studies have shown the reverse relationship, i.e., suffering from chronic pain can also increase the risk of insomnia

Resolving chronic pain 

The essence of resolving chronic pain is connecting to your own healing power through your ability to regulate your body’s chemistry. Here are some tools that are crucial to your healing, whether or not surgery is part of your solution. 

Direct approach: relaxation techniques

Anxiety is the substance of chronic pain. Since anxiety is a symptom of elevated stress chemicals, once we learn how to control the levels of these chemicals, we will have control over our anxiety, rather than it controlling us. 

By understanding that anxiety is only feedback about the state of your body, you can detach from it rather than identify with it. Compare it to the engine’s temperature gauge in your car: the more you feel threatened, whether the threat is real or imagined, the higher the reading on your anxiety gauge. 

But, as the temperature gauge in your car does not represent your whole car or even your whole engine (only its temperature), your anxiety does not define you or your life—it’s only a measure of your stress-hormone level. You can read it objectively and take appropriate action when it rises to uncomfortable levels. 

These actions consist of techniques to lower your stress chemicals—both directly, by employing relaxation techniques, and indirectly, by reducing your brain’s reactivity. 

Relaxation techniques reduce the stress response and strengthen the relaxation response, resulting in a body chemistry that is less sensitive to pain and more conducive to better treatment outcomes. Such practices as taking long, deep breaths, meditating, doing yoga or tai chi, walking in nature, guided imagery and body scan (progressive muscle relaxation) are a few popular methods. 

Direct approaches are ideal for addressing day-to-day, minute-to-minute reactions to stress. A favorite of mine is active meditation. When you feel anxious or upset, simply focus on a physical sensation such as touch, sight, sound, etc. for five to 10 seconds. You can do this as many times a day as needed. Over time, it becomes fairly automatic. 

Another direct strategy is reminding yourself that any time you are anxious or upset, you have been triggered. In other words, a current situation has reminded you of an unpleasant experience from the past, and your brain says, “Danger!” 

When you are triggered, your unconscious brain takes over your rational thinking, and you may behave badly or make poor decisions. In these situations, it is wise to withdraw from the triggering incident until the energy spike has abated. A mantra I have found helpful is, “No action in reaction.” Use whatever method you find most effective. 

Case study: Taking charge

A couple of years ago, a friend asked me for an opinion about his back. He had pain and numbness down the side of his leg. His MRI scan revealed a bone spur between the fifth lumbar and first sacral vertebra as it exited his spine, surrounding his fifth lumbar nerve root. I felt surgery might help, but I also thought he might be able to avoid surgery with exercises that flexed his spine and relaxed him. I wasn’t convinced that his pain was severe enough to warrant the risks of surgery. 

He elected for surgery in Spain, his home country. It helped for a couple of months before the same pain returned. He underwent a second operation about six months later that worsened his pain. It was then that I looked at a new MRI scan and saw that the bone spur was still there. The surgeon had neglected to remove it—twice—because he had worked only in the center of the spine and not far enough to the side, in the foramen where the nerve in fact exited. 

After a year of dealing with all of this, my friend told me that he had finally had enough and “fired everyone.” No more doctors, medications or surgery, he said. He decided to take charge and move forward on his own terms. Within a week his pain disappeared; five years later he has no pain and is playing golf several times a week. 

Harness your brain’s neuroplasticity

Rewiring our brains by creating “detours” around pre-existing pain circuits is similar to an athlete or musician learning a skill with repetition: new circuits are created and strengthened. 

Consider learning a new language. To master a foreign language requires a focused commitment for a long period of time. Eventually, you will have developed a new part of your brain that enables you to speak the new language. You will have increased the number of neurons and connections between them, laid down new insulating material (myelin) and brought about changes in the supporting glial cells. This is the essence of neuroplasticity.10 

Your brain never stops adapting and reprogramming. Why not encourage neuroplastic changes to your benefit? For example, you can “rewire” your brain to be less reactive to triggers that spike your reactivity. 

Instead of the normal scenario, which usually goes: 

Threat = Automatic survival response 

You can change it to: 

Threat = Chosen response 

You first feel the emotion, create some “space” for an instant, and then substitute a more desirable response. You can create this space using such techniques as writing down your feelings, practicing awareness of your automatic reactions, taking a deep breath and so on. 

The key is to avoid immediately reacting to something that is upsetting or anxiety-producing. The sequence is awareness, detachment, reprogramming. It works. The result is less frequent reactivity, shorter chemical surges and lower anxiety. 

 The best course of action is to learn a “new language” called “an enjoyable life.” 

The first step in any new endeavor is to visualize your destination. What do you want your life to look like? What do you want to leave behind? When you pursue a desired goal, you expand your nervous system. As you learn the new language called “an enjoyable life” and pay less attention to old pain circuits, the neglected circuits will recede from disuse. 

At some point your pain and anxiety will diminish dramatically—but not by resisting it. The process is similar to redirecting a river to a new channel. It may be slow at first, but as the water is diverted, it will create the new passage. 

Taking charge of your own care

This is probably the single most effective way to feel better. When you take control of any situation, you decrease anxiety. Once you understand chronic pain, your diagnosis and the issues that affect your perception of pain, you will take charge and move forward. I have seen it happen consistently, and it is a lot better than being bounced around the medical system without clear answers. 

Currently, mainstream medicine approaches chronic pain as a condition to be managed or accommodated by “helping you live your best life, in spite of the pain.” With all the neuroscience research that has provided exciting, revelatory solutions for chronic pain, generalized medical care has neither acknowledged nor adopted these findings.11 Instead, spine surgery clinics continue to employ random, simplistic solutions to treat your complex problem. 

Consistent evidence shows that many of these treatments, especially surgery for low back pain, are ineffective.12 For those who are willing to step up, participate in their healing and take charge of their lives, the outcomes have been consistently positive and inspiring. 

Keep it moving 

Tight muscles and joint contractures are painful. As the injured area approaches full range of motion, your body warns you with pain signals. Becoming more protective of these tissues, your pain grows with less motion. As you decrease your level of activity, your weakened body finds it harder to support your spinal column. 

It is imperative to work toward full range of motion of all of your painful joints, as well as spending three to five hours a week doing active resistance exercises, such as weight training. Begin with light weights and many repetitions. Some people even find the repetitions a calming influence. 

Adapted from Do You Really Need Spine Surgery? by Dr David Hanscom (Vertus, 2019)

References
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Treating pain holistically

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Brown, S and Vaughan, C. Play: How it Shapes the Brain, Opens the Imagination, and Invigorates the Soul (Penguin, 2010)

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