Back In Control Blog
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Neurological Pathways
The Mind Body Syndrome (MBS) is about brain pathways. There are many symptoms that disappear with the successful treatment of MBS. Most of them are physical. The most difficult concept for many patients to grasp is that since the symptoms are physical then there must be some structural source. It does not matter how many different ways I explain it or how many negative tests that have been done. They just will not believe that physical symptoms can be generated from the brain.
YOUR BRAIN IS CONNECTED TO EVERY CELL IN YOUR BODY either chemically or by nerves. The only place that physical symptoms, pleasant or unpleasant, can be felt is in your head.
The “Pain Switch”
Then he or she proceeds to explain to me in detail that since they can push on a certain spot and feel the pain then how can it be in their head? How can it not be in your head? The fact that just a simple push can elicit pain just means that the threshold for stimulating those pain fibers has been lowered – dramatically. Your pain switch is either on or off.
Water Torture versus a Rock
Do you think that the pain felt during water torture is imaginary? It is just a simple, painless drop of water. There is no reason it should cause pain. If water constantly drips on a rock does that cause pain? In fact over years, decades, or centuries the rock will be eroded by the simple repetition of dripping. Why is there not pain in that scenario? Obviously a rock has no nervous system. Why is so hard for my patients to understand that repetition of any activity lays down pathways that are repeatable and efficient. It is true for musicians, artists, and athletes. It is also true for the perception of pain.
Obsessive Thought Patterns
Unfortunately it is also true for the thought, “My doctor is missing something because I am in pain.” I am repeatedly told that I just don’t understand how they feel. That set of thoughts becomes it’s own set of repeatable pathways that will not shut down. Logic alone will not break them up. I honestly do not know what will break them up. The reason why it is such an unfortunate situation is that is also blocks treatment. The one variable that predicts success or failure in treating MBS is willingness to engage in the tools. I also know that these circuits elicit a lot of anger. Mind Body Syndrome – “Short Circuits”
My Weekly Battle
I was reminded of the problem again several times this week. This occurs every week. I had a middle-aged woman who had not really engaged in the DOCC project. She had experienced anxiety (another MBS symptom) since she was a teen along with chronic LBP. She had ruptured a disc in her back six months earlier and was experiencing screaming leg pain. She did have a large ruptured disc. When I explained the pain pathways it was a very ugly conversation. I asked her to come back when she calmed down. I was surprised that she returned the next week. On the second visit I told her that I seldom operate anymore unless pain pathways are addressed at the same time. For me that means that the patient is actively reading, writing, learning, and generally taking full responsibility for their care. However this disc was so large that I felt that I had to take it out first. She swore that she would engage.
Guess what? The simple disc excision that took away all of her leg pain, as expected, did not relieve any of her LBP. In spite of at least 10 very direct conversations before and after the surgery I could not convince her that her LBP was coming from the soft tissues around her spine and that spine surgery never helps LBP. It is a rehab issue. She was convinced that there was something causing her pain that I was missing.
Doctors do not like to miss anything. We are extremely aware, even paranoid, of missing something that can and should be fixed. It is one of the reasons why health care costs are so high. We will often order testing when we know that the chance of it being positive is less than one in a thousand.
Another Failure
I did not get through. She just thought if we could “fix it” her pain would disappear and her anxiety around it would diminish. I don’t think she will ever engage in any structured rehab program at an effective level. She is doomed to a lifetime of chronic back pain and anxiety. The tragedy is that both are easily treatable with usual outcome to be pain free with minimal anxiety.
The general wisdom in surgery is that if a patient has had the surgical risks explained to them then they must be in enough pain to undergo the operation. What the surgeons don’t understand (historically including me) is that the decision-making has become irrational.
The success of a spine fusion for LBP is less than 30%. When the surgery has failed then the surgeon “has done their part” and sends them on their way – to where??
I will never perform surgery unless I can see the exact source of the pain. Even then, I will rarely perform it in the face of chronic pain unless the patient is experiencing a full nights sleep for at least six weeks and actively engaging in the tools that allow the nervous system to remodel. I feel in very case that surgery is only about a third of the solution. Physical conditioning and healing the nervous system are the other two thirds of the picture.
Personal and Societal Costs
I don’t regret performing her surgery, as it was necessary from a perspective of the need to relieve her severe discomfort. I am just sad and frustrated that only a fraction of the benefit will be realized.
Not only is the suffering of these trapped patients not solved they are also costing the rest of society untold billions dollars with the relentless pursuit of an answer that does not exist. Medicine is more than happy to oblige as the endless testing and treatment is a tremendous revenue stream. Treating MBS costs essentially nothing. Most of it is self-directed.
MBS both causes pain and blocks effective treatment. I do not have an answer.
