A few years ago, I saw four surgical patients within two weeks who caused a profound change in my thinking about patients’ perception of pain. Historically, I would focus on pain patterns and correlate them with imaging studies. If the symptoms seemed to be caused by the anatomical abnormality, I would consider surgery. If there was not a match, surgery wasn’t an option. I have long considered anxiety as a factor that affected the level of pain, but not as a primary complaint. I have since learned that anxiety is what signals “danger” and is the pain.
The conversation with these four men was around the decision to undergo spine surgery. All were successful professionals between the ages of 45 and 65. They had leg pain originating from an identifiable problem in their spine, and it was severe enough that each wanted to have surgery. I noticed on the intake questionnaire that they were all at least an 8 out of 10 on the anxiety scale and weren’t sleeping well. Their stresses included seriously ill children, loss of jobs, marital problems, other medical problems, and none of them were coping that well.
Each of them was familiar with the self-directed care program for solving chronic pain, Direct your Own Care (DOC). The principles and tools are presented on the website www.backincontrol.com. They were skeptical and had not engaged with the concepts at a meaningful level and were coming back for their second and third visits.
Finally, I asked each of them the same question: “What would it be like if I could surgically solve the pain in your leg, but the anxiety you are experiencing would continue to progress?” Their eyes widened with a panicked look and they replied, “That would not be OK. I couldn’t live like this.” Each of them also grabbed his leg and asked, “Won’t getting rid of this pain alleviate my anxiety?” My answer was “no.”
Anxiety is a reaction to any threat. Although surgically removing the spur and decreasing the pain would relieve some anxiety, it wouldn’t come close to solving it. Your brain will land on something else to worry about. Solving anxiety is a different problem requiring a specific skill set.
I told them that although I would love to get rid of their leg pain with surgery, my bigger concern was their severe anxiety and possibly chronic pain. I recalled my 15-year battle with pain and anxiety. I was on an endless quest to find the one answer that would give me relief; especially for the anxiety. I also remembered the intensity of that need. At that moment I realized that each of these patients felt that by getting rid of the pain they could lessen or solve their anxiety.
It is actually the opposite scenario. As your anxiety resolves, it is common for pain to abate. As stress chemicals decrease, nerve conduction slows and there is less pain.1 The techniques for addressing anxiety don’t include surgery. Also, after a failed surgery, another level of hope has been taken away.
CAN YOU LIVE WITH YOUR LEG PAIN?
Then I asked each of them, if I could help them resolve their anxiety but they would have to live with their leg pain, what would that be like? Although not completely happy about the scenario, they thought they could deal with it. It was more palatable than experiencing no improvement in their fear.
“NO” TO SURGERY
These patients didn’t want to jump to surgery, and they wanted to give the DOC program a try. Within six to twelve weeks, as they calmed their nervous system, their pain disappeared or subsided to the level where they weren’t even considering surgery. Although I know pain and anxiety are linked circuits, I had never realized that for many patients the pain relief they were asking for was really peace of mind.
Conversely, I’ve had many patients over the years undergo a successful surgery for a severe structural problem with no improvement or worsening of their pain. Now I understand. “Neurons that fire together wire together.” Pain, anxiety and anger are tightly intertwined. As long as the anxiety/anger pathways are fired up, they will keep the pain circuits firing.
DECIDING ON SURGERY
My surgical decision-making dramatically changed over the last five years of my practice. In spite of watching so many successes of people healing from chronic pain without surgery, I still had a surgical mindset and was always looking for a surgical lesion that I could “fix.”
In the first edition of my book, Back in Control: A Surgeon’s Roadmap Out of Chronic Pain,2 my advice was that if you had a surgical problem, get the surgery done first and engage in the rehab process later. But I wasn’t aware of the research that shows there is a 40% chance of inducing chronic pain as a complication of any surgery if you operate in the presence of untreated chronic pain in any part of the body. It can become a permanent problem 5-10% of the time.3
Chronic pain as a complication of surgery is not a well-known concept. If I had a neurological complication rate of 5%, I would not have remained in practice for long. This occurs even if the procedure goes well.
ANXIETY IS AN INFLAMMATORY PROCESS
The most important point of this article is to understand that anxiety is not primarily a psychological issue. It is your whole body’s response to a threat. Part of this reaction is mediated through the immune system and cytokines.
Cytokines are small proteins that serve as messengers, transmitting higher-level signals and coordinating activities at the cellular level. They are central to modulating the immune system and inflammatory response. There are two kinds of cytokines: pro-inflammatory (Pro-I) and anti-inflammatory (Anti-I). While Pro-I cytokines protect us by warding off acute perils, Anti-I cytokines keep us safe by allowing us to regenerate, thrive and prepare us for battle with environmental enemies.
Both Pro-I and Anti-I cytokines are necessary for survival – one to defend against threat, the other for growth and regeneration. However, sustained elevations of Pro-I’s can destroy parts of the body and give rise to chronic mental and physical disease. They are elevated in almost every chronic disease state. One paper showed that some types of depression are inflammatory responses of the central nervous system.4
Any mental or physical threat, perceived or real, is going to be met with a defensive response from your body. Much of this is mediated through the vagus nerve, at the core of the autonomic nervous system. The response is the well-known flight, fight or freeze reaction.5 We are all familiar with the physical manifestations of increased heart rate, sweating, muscle tension, elevated blood pressure, etc. But what you may not know is that the immune system also gets fired up and mobilizes many types of cells that fend off predators such as bacteria, viruses and cancer cells. The result is inflammation where the “warrior cells” exit the blood stream through widened openings in the vessels to destroy the invaders (antigens). Cytokines are small proteins that are the “switches” that activate and deactivate this response.
Although threats come in many forms, they always activate pro-inflammatory (Pro-I) cytokines. Physical threats include allergens, parasites, bacteria, viruses, lions, tigers, bears and people we perceive as dangerous. Less obvious but even more inflammatory are mental threats, because we can’t physically escape them. They create a sustained inflammatory response that forms the basis for chronic mental and physical disease. Examples of mental threats are memories, negative thoughts, suppressions, repressions, insecurities (social, financial, health, etc.), cognitive distortions and loss of life perspective and purpose.
Discovery and acknowledgement of all our threats – whether real, imagined, anticipated, or repressed – is the first step toward addressing them. The second is choosing an adaptive rather than a maladaptive escape to safety, whether the threat be physical or spiritual. We are better at physical escapes to safety than we are at spiritual ones.6 If you don’t feel safe and peaceful, you are carrying elevated levels of cytokines.
There are several distinct ways to reduce your inflammatory cytokines. When suffering from chronic pain, this is more challenging. The pain is a threat, which increases inflammation, which increases the speed of nerve conduction, and increases the pain.1
LOWERING YOUR CYTOKINES (ANXIETY AND PAIN)
Below I have outlined some ways to reduce your inflammatory cytokines. This is just a small sampling of possibilities.
1. Understand and treat anxiety. Anxiety is simply your body signaling danger. It is the sensation generated by elevations of your stress hormones, activation of the sympathetic nervous system, elevated Pro-I’s and the inflammatory reaction. It is not a “psychological issue,” although mental threats are more likely to over-stimulate the nervous system than physical ones. The unconscious survival response is much more powerful than your conscious brain, and this is not a “mental health” diagnosis. The treatment is centered around calming down the nervous system. In workers’ comp situations, this translates into being as supportive as possible of the worker’s plight. The overall approach is presented on the website www.backincontrol.com.
2. Get adequate sleep. At least seven hours a night of restful sleep lowers your stress response and inflammation levels. Lack of sleep actually induces chronic low back pain.7
3. Employ expressive writing. You can’t control your thoughts and emotions, but writing them down and then tearing up and discarding the paper separates you from them. The practice has a remarkable impact on both mental and physical symptoms.8
4. Practice forgiveness. Anger creates a powerful neurochemical reaction with marked elevations of Pro-I’s and inflammation. Interestingly, anger experienced while feeling trapped is deadly; but if the anger results in gaining control and power, it raises Anti-I’s – the safe cytokines.9,10 There is no shortcut to overcoming anger, but it needs to be dealt with quickly. You also must address your deepest wounds. Do you want the person or situation you hate to be what ultimately kills you? Who would win? It has also been shown that most people in chronic pain remain angry at the person or employer who caused the injury.11
5. Follow an anti-inflammatory diet. This can make a big difference in lowering Pro-I cytokines.
6. Decrease stimulation of your nervous system.
a. Limit watching the news.
b. Avoid watching violent and over-stimulating shows, especially at night. Just witnessing violence will increase Pro-I’s.12
c. Stop negative talk, such as complaining, gossiping, discussing your medical problems or care, giving unasked-for advice and criticism.
7. Maintain an exercise regimen.
d. At least 30 minutes a day
e. Moderate and enjoyable
8. Directly address family issues. All families trigger each other, but there are many effective ways to create a structure that will minimize conflict.
f. Living in chaos is not only unpleasant; it also has a negative impact on your health.
g. Your family is usually the source of your biggest triggers.
h. Be nice! Any member of your family who feels trapped is at higher risk for an illness or chronic disease.
9. Play. Having fun is one of the most powerful ways to stimulate the production of Anti-I’s and relaxation hormones.
From the claim’s position, I would summarize the approach as “being nice” regardless of how difficult the client may be. They are suffering, trapped and angry. It has been documented that the impact of chronic pain on a person’s life is similar to that of having terminal cancer.13 Anger is not that rational. It is remarkable how quickly this change in perspective can create a shift in the whole situation for both the examiner and client. Remember the whole comp system was set up to help, not harass an injured worker. Firing up the nervous system is not helpful.
I can’t put into words the depth of the paradigm shift that occurred with these four patients. As much as I knew about anxiety, I did not remotely place pain complaints and anxiety in the same bucket. My surgical decision-making changed dramatically and we instituted a program of rehab before elective surgery in every patient for at least 8-12 weeks.
Many patients with surgical problems canceled surgery because the pain (anxiety) resolved, including these four men. Surgery may or may not help your arm or leg pain. It rarely solves neck or back pain. It really doesn’t work for anxiety. What relief are your clients asking for?