There is a recent blog article from NPR about the importance of keeping moving and actually using your body. What they miss is the fundamental mind-body nature of the pain, but it is at least good that they are encouraging people to get out there and live their lives. The feeling of their treatment is a lot like TMS, even if their model is all wrong. One phrase I really liked from the article was "Worship at the volcano god of pain." Rainville explains: "In primitive cultures, if you lived near a volcano and the volcano started smoking and looking like something was going to happen, well, it was obvious[ly] because gods were mad at you. And you'd start doing silly things — sacrificing chickens or goats or whatever, thinking that that would appease the gods." In a strange way, Rainville says, people with chronic back pain do something very similar. They sacrifice parts of their life — playing golf or softball, running, picking up bags of groceries or grandchildren. Patients get so afraid of pain, they do anything to avoid it. That makes so much sense to me. I remember that when my pain was running my life, I studied it obsessively, trying to figure out what was causing it. Now I know that I was like one of those members of a primitive culture, trying to understand a volcano without knowing about the underground pressures that lead to the eruption and thinking that maybe a chicken sacrifice is what did it. Now I know I've got my own "underground pressures," and that I need to let off some steam of my own once in a while. Anyway, after reading the article, I knew that I had seen those names before, so I did a bit of Googling. It turns out that Groopman, one of the people quoted in the article had written a New Yorker article about the craziness of back surgery back in 2002, entitled "A Knife in the Back: Is surgery the best approach to chronic back pain?" (With a title like that, you can guess what conclusion he came to.) .... And Groopman also told the same story in his mind-body book, The Anatomy of Hope. I'd say that the story is best in his book. The NPR article is probably the weakest of the three, being the most physical. The 2014 NPR article: http://www.npr.org/blogs/health/201...ck-exercise-may-help-you-learn-not-to-feel-it The 2002 New Yorker article: http://www.newyorker.com/archive/2002/04/08/020408fa_FACT Here is the section from Anatomy of Hope where he tells his story. He doesn't get the mind-body basis of TMS, but he does at least understand how important hope is and how important it can be to resume physical activity, even when it hurts. He also explains the "volcano-god of pain" metaphor better, and there is a lot of wisdom in there. Plus, he is just a good writer. Exiting a Labyrinth of Pain In the autumn of 1979, while training for the Boston Marathon, I ruptured a lumbar disc. When the pain did not immediately subside, I underwent a discectomy, a limited operation that removed the edge of the bulging disc. The surgery did not fully return me to my prior state. When I tried to run, a dull ache grew in my back and hip. Six months after the surgery, I moved from Boston to Los Angeles. One Sunday morning after breakfast, I stood up from a chair and collapsed. My lower back felt as if it were being twisted in a vise, and electric shocks sped down my buttocks into my legs. X rays showed no clear cause for the pain. There were no ruptured discs. I saw many consultants: rheumatologists, neurosurgeons, doctors of sports medicine. Each told me that the lumbar spine is a “black box” and often a mystery in terms of persistent pain. I kept seeking clinical opinions. Finally, an orthopedist in Beverly Hills told me what I wanted to hear: “Your spine is unstable,” he said. “I can fix it with a fusion. You’ll be running in a few weeks.” A fusion, done by harvesting bone from my pelvis and inserting it like a bridge along the sides of my lower vertebrae, would create an internal brace and remedy my lumbar instability. The heady promise of running again erased any other consideration. I awoke from the operation in the intensive-care unit, red blood cells being infused into my arms. As the anesthesia lightened, I was hit with excruciating pain throughout my lower body like none I had ever experienced. Even more terrifying, I could not move my legs. They seemed to be frozen. No one was sure why. The orthopedist postulated that the blood spilled during surgery had inflamed my nerve roots, causing the severe pain and preventing my legs from functioning normally. I was taken home in a body brace, a large metal cagelike structure that fit tightly around my lower torso. It prevented me from moving too far in any direction and stressing the bone grafts. But it was hardly necessary to artificially immobilize me. The pain was so severe that I could not stand or sit. I was in bed all day and all night, sleeping a few scant hours only with large doses of painkillers. Yet even narcotics could not stop the relentless pain in my back, buttocks, and legs. For months I lay on ice packs, the numbing cold affording a few moments of relief. When I returned to see the orthopedic surgeon, I asked why I wasn’t getting better. His words wove a tight narrative of what I could look forward to: “You must have developed scars around the nerves from all the inflammation. With the nerves tethered, every time you move quickly, or twist or turn, they get tugged, setting off the pain.” My throat closing, I asked what could be done. “I can operate again and try to cut away some of the scar.” Wouldn’t that cause further inflammation and new scars? Probably yes. I returned home feeling as if I had entered a maze with no exit in which I would wander from one point of pain to the next. I began physical therapy at a local facility. Most of the people in the treatment area were elderly, with severely arthritic hips and knees that had been replaced. The staff was compassionate and encouraging, but the therapy was largely passive. I would lie on my back, and the therapists would slowly move my legs up and down. Then they put me in a warm pool with submerged parallel bars. I took step after faltering step, learning to walk again. A stretcher was moved into my laboratory, and I spent most of the day flat, reading scientific articles and planning experiments with my technicians. I learned how to do basic things in ways that didn’t set off pain—how to get up from a chair, turn my torso, reach down to pick up something from the floor. After nearly two years, I could swim four or five laps and sit on a stationary bicycle to pedal some minutes. In the quiet of the day, the orthopedic surgeon’s words echoed in my mind, that the scar would encase my nerves for life. Disgusted with myself for undergoing the fusion surgery, I decided to stay away from doctors. One had badly hurt me, and none could help me. I would have to live within narrow limits. And so, for nineteen years, I did. The boundary on my life was like an electrified fence at the perimeter of a prison: If I ventured too far and tested it, I was thrown back from the shock of its force into my confinement. If I stayed inside the fence, I was somewhat safe. So, I assessed each movement and task of the waking day for its distance from that perilous perimeter. When I awoke in the morning, I would shift my legs over the side of the bed and cautiously lift my trunk, using the force of my forearms to avoid a pull on my back. In my laboratory, I would lean at a minimal angle to peer into the ocular of a microscope, or to inspect cells in a petri dish, because quick flexion was risky. On ward rounds, I would sit down every ten minutes or so to rest my back. When my sons were in grade school, I wanted to teach them to play baseball, but swinging a bat triggered sharp pains in my back, and I retreated to the sidelines. When my four-year-old daughter climbed monkey bars and jungle gyms, I worried that I lacked the resilience to catch her if she fell. I had been an avid walker, strolling the neighborhood in the evenings for an hour or more with Pam, but now, after I walked four or five blocks, my hips and back would cramp, forcing me to abandon the excursion. There were periods of respite, months of relative comfort, but then an apparently innocuous movement would cause my lumbar area to explode in spasm. I never knew when or where it might happen. Along with unpredictable pain came its companion, a sense of prevailing fear. In the summer of 1999, such an unpredictable event occurred. A close friend, aghast at my restricted mobility, had encouraged me to try back massage. I was leery of allowing anyone to touch my spine, and my concern was borne out. Despite the licensed massage therapist’s good intentions, he was too aggressive in his work. I left the session with a growing ache, and by the end of the day I was gripped by vicious pain from the base of my neck to the bottom of my coccyx. Days passed, and the muscle spasm did not relent. Frustrated, in deepening pain, I sought advice from a rheumatologist, an expert in bone and joint disease, at the Beth Israel Deaconess Medical Center where I work. He examined me and said that the muscles in my back had been traumatized by the massage; with rest, anti-inflammatory medication, and tincture of time, the acute pain should quiet down, and I would return to my previous level of functioning. But he made me promise that when this flare-up abated, I would see a physician at the New England Baptist Hospital who specialized in rehabilitation medicine, Dr. James Rainville. “He may be able to help you in a more fundamental way,” the rheumatologist said. “The Baptist was where Larry Bird was put on his feet after his back problem.” I nodded politely but did not believe that anything substantial could be done. Like all Celtics fans, I had closely followed Bird’s condition, especially given my years of debility. He had undergone spine surgery and returned from rehabilitation still a star. And basketball was an unforgiving sport: The impact, as you fought for rebounds under the the boards, took jump shots from the three-point line, and made fast breaks, would tax even a normal spine. Bird seemed more than able to keep up. Contrary to the rheumatologist’s prognosis, my back spasms did not fully subside. In fact, I had episodic pains not only in my lower back but between my shoulders and in my neck. I moved through the day with even more tension and worry than before, and I shied away from any activity that might exacerbate the muscle spasms. I went for an MRI scan of my spine, but it did not reveal a cause for the muscle spasm that gripped me from my neck to my hips. Weeks passed, and my despair deepened. I came home from work exhausted by the pain. For almost two decades, I had tried to achieve an uneasy truce with my condition. Now it seemed as if I had violated the terms of the treaty, disregarding the limits that were set for me. Because it didn’t make sense that the pain would be lasting for weeks, it became even more frightening. Pain can be a volatile and fickle force and, when provoked, might unleash a torrent that overwhelms the initial provocation. I knew of cases in which people suffered with no obvious explanation. All of my former strategies and remedies, resting in bed on ice packs, taking Valium for muscle spasms, gently stretching my legs and torso, were to no avail. With the sense that I had nothing to lose but also that my plight would only be confirmed, I visited Dr. James Rainville at the Spine Center of the New England Baptist Hospital. The New England Baptist Hospital is a stately old brick building at the crest of Boston’s Mission Hill. Its large lobby is appointed much like a traditional Yankee living room, with muted carpeting, upholstered wing chairs, and an antique grandfather clock. A long, narrow corridor leads from the lobby to the clinics and operating rooms. Along this passageway, the history and achievements of the hospital are presented in a series of enlarged photographs arranged chronologically and annotated like a display at a museum. As I walked down the corridor, my eyes stopped at a picture of a young Senator Edward Kennedy. He was lying in bed, his head propped up, offering a warm smile of relief. The text adjoining the picture explained that, as a young man, Kennedy had been in a plane crash and had fractured his spine. He had come to the Baptist Hospital for rehabilitation. I tried to recall recent images of the senator that might indicate continued debility. But newspaper pictures and TV footage showed Kennedy standing tall in Congress, deftly navigating his boat off Hyannis, and walking briskly on the campaign trail. There was no hint that he was once bedridden with a fractured spine. A few short steps down the corridor was a photographic tableau of Larry Bird. In the first photo, he was seated next to a smiling doctor in surgical garb. An adjoining picture showed Bird in the midst of physical therapy. The text explained that the celebrated Celtic had been successfully restored to the parquet of the Boston Garden. I lingered, studying Bird, his physician, and his physical therapist, then proceeded to the Spine Center on the fifth floor. As I changed into a hospital gown, I cursed myself once again for my stupidity in letting anyone touch my fragile back. My thoughts were broken as Dr. Rainville strode into the examining room. He was a tall, athletic man with thick, graying eyebrows and the rugged good looks of a Hollywood gunslinger. He greeted me with a firm handshake. “Tell me the story from the beginning,” he said. I recounted the past nineteen years—the running injury, the fusion surgery, the many precautions of my days, ending with the massage and the unrelenting spasms. Dr. Rainville listened intently, his face registering no reaction. He began a detailed physical examination, testing each muscle and joint individually for strength by pressing with his palm. Then he applied a calibrated instrument that resembled a protractor, and took exact measurements of the range of rotation of my hips, spine, and neck as I moved forward, bent backward, and turned to each side. My muscles tensed as I performed each of these maneuvers, and my jaw tightened in fear that the physical examination itself might release a shower of pain. Dr. Rainville planted the MRI scan of my spine on a lighted box on the wall and systematically inspected the film, vertebra by vertebra. Seemingly satisfied that he had reviewed all the relevant data, he turned and stood before me. “You are worshiping the volcano god of pain,” he declared. “The volcano god of pain is your master.” I had been warned that Rainville was a brash, in-your-face clinician who held contrarian views. But what on earth was he talking about? “What do I mean that you are worshiping the volcano god of pain?” he asked. “You interpret pain as a red flag, a warning that you are doing damage to your body. So you sacrifice things that you love, activities that give your life joy, to be kept free from pain. You say to the volcano god: ‘I will give up walking long distances if you keep me out of pain. I will give up lifting my children if you keep me out of pain. I will give up travel, because long trips stress my spine. Just keep me from pain.’ “But this god is never fully satisfied with any offering: It is appeased for only a short while. So the more you sacrifice, the more the god demands, until your life contracts, as it has, into a very, very narrow space. “I believe you can be freed from your pain. I believe you can rebuild yourself and do much, much more.” I studied James Rainville’s face. He had the burning eyes of a zealot, and he read my thoughts. “Bullshit talks, results walk,” he said. “You think what I am saying is complete bullshit. You’ve lived all these years without any real hope, and it’s hard to open that door and glimpse a different kind of life.” He paused and then spoke with gravity. “It’s your choice: to try or not to try. You can walk out of my office now and believe everything you’ve believed for the past nineteen years, and live the way you have. Or you can test me. And I’ll tell you now, I’m right.” I remained mute, unsure how to respond to this barrage. My thoughts raced: He doesn’t understand my condition, the immutable scars from the surgery. He is dangerous, threatening to upset even the little equilibrium I’ve established over the years. But then a strange, powerful thought welled up: Could he be right? “How can I test you?” I finally asked. “Ignore the pain,” Dr. Rainville shot back. “No more worshiping this god. No more sacrifices. Just disregard its demands. The pain doesn’t mean anything serious. As your mind reorients its beliefs, the pain will lessen. Once that happens, you will be able to rebuild your body. It won’t be easy or quick or without setbacks. The muscles in your low back are at thirty percent of their normal tone. Your ligaments and tendons are contracted from lack of use. They carry a memory of the trauma done to you, and they recall the pain at the slightest provocation. By using your spine, muscles, and ligaments, and strengthening them, you erase that memory. You can compensate for the damage that was done and live a normal life again.” Rainville explained the basics of the program he was prescribing. My muscles would be challenged steadily with increasing weights until they were “reeducated” to relinquish their memory of past pain. Despite what I would feel during this process—almost certainly an increase in the muscle spasm, and release of the familiar electric shocks over my buttocks and thighs—I was not at risk of being hurt. Everything that was being done to my body would serve to rewire my brain until strength and endurance were restored and the perception of pain erased. My heart was racing as I exited the hospital. It was strange: There was a perverse comfort in inertia. As a physician, I had learned the need for hope. Yet I had completely abandoned it. Despite education and knowledge and experience, when you are the patient—suffering, confused, and despairing—it is very, very hard to take matters into your own hands. I was not a George Griffin, able to stand alone and challenge the prevailing assumptions. I needed an external voice, strong and determined, to guide me. But what if Rainville was wrong? His arduous rehabilitation program might end for me with worse pain. A mere massage had triggered weeks and weeks of suffering. What would even greater stresses do? And what was he really saying, in cold biological terms, not flamboyant metaphors of volcano gods? That changing my beliefs could dampen flaming circuits of pain? Was I some mystic or yogi who could walk barefoot over hot coals or lie down on a bed of nails? As the days passed, I kept returning to Dr. Rainville’s words. I pictured resuming activities so long gone. I imagined myself stronger, able to walk comfortably, to lift, to travel, to play sports. The power of the possibility became too much to resist. With trepidation, I enrolled in the Baptist’s rehabilitation program. I was alarmed when the physical therapists took me into the treatment room. It was a large, open space filled with what looked like instruments of torture. A group of patients was in the midst of therapy, doing things that seemed designed to cause, not erase, pain: picking up milk crates filled with lead bricks; brusquely rotating their torso while holding a heavy medicine ball; performing a back press against some hundred pounds. Was Rainville out of his mind? How I could ever risk such maneuvers? The thought of it terrified me. But deep down flickered the desire to fight. The therapist prescribed three weeks of daily stretching at home before I could take part in formal rehabilitation exercises. If I acted too quickly, my muscles would be overwhelmed, and I might abandon the attempt. He instructed me to begin slowly, to move bones and joints that had not been tasked for years. This in itself proved exhausting; my body was so feeble that even lifting my legs up against gravity broke a sweat. It was the beginning of the school year when I went back to the treatment room. Boston in early September pulses with the steady pace of young men and women returning to college, nervous anticipation on their faces. I told myself I was a new student, ready to reeducate my mind and body. But it didn’t prove so easy. Even the first lessons in Rainville’s classroom were daunting. Each exercise caused shooting pains in my back that ran down my buttocks, thighs, and feet. The therapists were unmoved by my pains, telling me firmly to keep challenging my body. I would leave the sessions depleted, needing to rest for hours, lying in bed on ice packs to numb the protesting nerves and muscles. When the pain and exhaustion from the maneuvers were at their worst, when doubt raised its strident voice and said Rainville’s talk was bullshit, I summoned a dreamy vision of the future: walking hand in hand with my daughter to a pond some two miles from our home to feed ducks and search for frogs; emerging from an airplane feeling strong and ready to explore a new city; dancing a traditional Eastern European circle dance at a family wedding. Each fantasy released a current of warm, soft energy that suffused my body. My exhausted muscles and taut ligaments seemed deeply nourished in its wake. My spine, in its cacophony of pain, became distinctly quieter. These physical perceptions made me feel foolish and perplexed but also curiously intrigued. Over three months or so, the constant pain became intermittent, then rare. “The body has a remarkable ability to heal,” the physical therapist had said to me at the start of one session. Those words conjured a very different picture of what existed in my body. Yes, as the orthopedist said, there had been inflammation and probably some scarring. But it was not irremediable. There were ways for the muscles, ligaments, and tendons to become stronger and more supple at the same time, to insulate the nerves from the strain of sharp movements. Even when the nerves spoke up, the messages they sent to the brain were modulated, their anger tempered, so that severe pain did not result. Over time these messages, once bellowing, could become a whisper, and then fall largely silent. I realized that the surgeon had said to me what I had so ineptly said at times in my career to others: that there was no hope. Medicine is too uncertain a science, biology too variable, to have that kind of hubris. I began to walk—five blocks, then ten, then fifteen, then a mile. I challenged myself to travel longer distances, to hike one or two steep hills. I felt more at ease with and more eager about my rehabilitation exercises. Advancing to each new level caused days of spasm and pain, but I tried to ignore it all, repeating Rainville’s mantra, that my body was relinquishing an old form of memory and acquiring a new narrative. I did discover that there were limits, that I was vulnerable to injury. I joined an aerobics class called “Funky Groove” that involved doing 250 jumping jacks while earsplitting techno music blared in the background. The pounding proved too much for my muscles and joints and caused persistent pain that did not resolve with the Rainville regimen. So I quit the class. I realized I was not twenty-seven years old anymore. But I also told myself that I could live happily within my new boundaries. I had gained, above all, the sense that I had some level of control over my choices. After a little over a year, the daily pains all but passed. I awoke in the morning unafraid, moved through the day comfortably, and fell asleep with a prayer of thanksgiving on my lips. I felt reborn. It seemed almost magical.