STOMP - CO Pain Guide – Central Oregon Pain Guide · • The Pain Survival Guide: How to Reclaim...

STOMPStructuring Your Own Management of Pain

Setting goals that help you and your doctor alleviate your pain and improve your quality of life.

www.swedish.org/STOMP

STOMPStructuring Your Own Management of Pain

ContentsIntroduction ...................................................................... 3

Chapter 1 – Learn about Pain .......................................... 5• IntroductiontoMindBodyMedicine• Neuroplasticity• Resources oDeterminingtheValidityofOnlineResources oBooksandOnlineResources

Chapter 2 – Sleep .......................................................... 13

Chapter 3 – Calming the Nervous System..................... 19• AMindBodyApproach oMindfulness oRelaxation oClinicalHypnosis oWriting/Journaling oMusicTherapy oAnxietyandDepression oTrauma oThoughts oJoy,Pleasure,andSpirituality

Chapter 4 – Outside the “Box” ...................................... 41• Relationships• Hobbies

Chapter 5 – Caring for Your Body .................................. 45• NutritionandWeightManagement• Smoking• PhysicalActivity• HeadacheManagement

Chapter 6 – Complementary Therapies for Pain ........... 57

Chapter 7 – Medications ................................................ 61• PainMedications• ProtectingYourMedications• SubstanceUse

Chapter 8 – Role of Procedures ..................................... 67• SpinalInjections• ImplantablePainDevices

Chapter 9 – Role of Spine Surgery ................................ 71• SurgicalDecisionMaking

IntroductionWorkingwithpatientswhosufferchronicpain,nomatterwhatthecause,canbedistressingforbothhealthcareprovidersandpatients.Often,primarycarepractitionersdonothavethetimeorresourcestotrynewapproachesforchronicpainmanagement.Theywriteprescriptionsformedicinesortreatmentsthatmaynotwork,havetroublesomesideeffects,orareonlypartlyeffective.Thismayleadtomultiplereferralsandprocedures,often,unfortunately,withnoimprovementinlong-termpainorqualityoflife.

Thisbookletisintendedtobearesourceforthoseofyoufacingthelimitationsofthemedicalsystemindealingwithyourcomplexneeds.Thechoiceisclear.Youhavetolearntotakechargeofyourowncare.

Eachchapterinthebookletaddressesatopicthataffectstheperceptionofpain.Therearerecommendedreadingsandlinkstoseveralhelpfulwebsites(notsponsoredbydrugcompanies).Forthosewhowishtoexplorethesubjectinmoredepth,visittheSwedishSTOMP(StructureYourOwnManagementofPain)website:www.swedish.org/STOMP.

Thisbookletpresentsalotofinformationandmanydifferentareastofocusonandtoolstochoosefrom.Ifsuggestionsinthisbookandthehyperlinkstootherinformationsitesarefollowed,thereadercanexpectpositivelifestylechanges,improvedfunctionanddecreasedpain.However,thewaytousethisbookistochooseonesmallareatoworkon,apaththatsuitsyou,seemsdoableandfeelslikeagoodfit.Itisveryimportantnottofeeloverwhelmed;nooneisexpectedtofollowallofthesesuggestions.Althoughtacklingmorethanoneoftheseareaseventuallyisimportantindecreasingyourpainandimprovingyourqualityoflife,workinanyoneoftheseareaswillbringimprovement.Lastingchangeisgradualandtakestime.Discusswithyourhealthcareproviderand,ifappropriate,yoursignificantothertochooseanareatostartwithandsetafewsimplemeasurablerealisticgoals.

Ifyouarereadytocontrolyourcare,stimulatechangesinyourbrain(neuroplasticity)anddecreaseyourpain,usetheSTOMPinformationtodevelopyourgoalsandanactionplan.

TheSTOMPmedicalteamdevelopedthisprogramspecificallywithyouinmind.

Wewishyougoodluckonyourvoyagetorecovery.

Editors and ContributorsGordonIrving,M.D.DavidA.Hanscom,M.D.

ContributorsLouiseBerkowicz,M.D.AllenHume,Ph.D.HubertA.Leonard,M.D.,Ph.D.CarolynMcManus,PT,MS,MAMaureenC.Pierce,Ph.D.HowardSchubiner,M.D.

Chapter One:

LearnAboutPainIntroduction to Mind Body MedicineHoward Schubiner, M.D.

Theroleofthemindhasbeenlargelyoverlookedinchronicpaintreatment.However,thereisstrongevidencethatthemindcanchangethepainexperiencetoalargedegree.Infact,theconsciousexperienceofpainisonlypossiblebecausethehumanbraincaninterpretsignalsfromourbodiestocreatethesensationofpain.Fromthispointofview,thesaying“Allpainisinthebrain”isanactualfact.Ourbrainshavespecializedareasthatcanbothincreaseordecreasethefeelingofpain.Howweperceivepainisaffectedbymanyfactors.Forexample,astudybyHenryKnowlesBeecherfoundthatonly32percentofrecentlywoundedsoldiersinWWIIreportedexperiencingpain.Andthinkoftheboywhodoesn’tcryafterskinninghiskneeuntilheseeshismotherrunningtowardhim.

Chronicpainismuchmorecomplexthanacutepainandthemindplaysalargeroleinhowthispainisexperienced.However,mostcurrenttreatmentmethodsstillrelyonbiotechnologicaltreatmentssuchasmedications,injections,ablationsandsurgery.Unfortunately,researchhasshownthatthesemethodsarenotparticularlyusefulinreducingchronicpain.Mostprovidersassumethatchronicpainissimplycausedbytissuedamageinthebody.Withoutaddressingtheroleofthebrain,attemptstofullyresolvethepainareusuallynotsuccessful.Thisstandardapproachleavesmostpatientswithlittlehopeofbecomingpain-free.

Recently,researchershaveshownthatpaincanbecausedby“nervepathways”evenwhenthereisnosignoftissuedamage.Anervepathwayisacollectionofnervecellsinthebrainthattriggersacertainactionorresponseinthebody.Anervepathwayiscreatedwhenagroupofnervecellsareusedoverandoveruntileventuallytheylearntofireautomaticallycreatingpain.Paincausedbynervepathwaysiseverybitasrealandsevereaspaincausedbyactualtissuedamage.Thediscoverythatourbraincanlearntocausepainhasledtothedevelopmentofnewbrain-basedtherapies.

Recentresearchhasshownthatpeoplewithmigraineandtensionheadaches,neckandbackpain,fibromyalgia,abdominalandpelvicpainsyndromesandmanyotherdisorderscan“unlearn”pain.It’spossibletodramaticallyreduceorcompletelygetridofsymptomsinarelativelyshorttimeperiod.

Therefore,itisimportantforpeoplewithchronicpaintobeevaluatedcarefully.Providerswhoarenotfamiliarwiththeconceptofpaincausedbynervepathwaysarelikelytoassumethatsmallchangesonapatient’sX-raysorMRIexamsmustpointtothereasonforthepain.Thismaynotonlybewrong,butmaypreventpatientsandtheirprovidersfromfindingmoreeffectivetreatment.Onceitbecomesclearifanindividualhasnervepathwaypain,tissuedamagepain,oracombination,amoreeffectivetreatmentplancanbedeveloped.

NeuroplasticityDavid A. Hanscom, M.D.

Scientistshadlongthoughtthatapersonwasbornwithacertainnumberofneurons(nervecells)andwouldslowlylosethemoveralifetimethatthecellswouldnotchangeorgrow.Althoughthebrainismoreactiveduringthefirstfewyearsoflife,ithasbeenclearlyshownthatthebraincanchangeatanyage—forbetterorworse.

Theword“neuroplasticity”describestheabilityofthebraintoadaptandchange.Dependingonthestimulation,thechangescanbeeitherhelpfulorharmful.

Thebraincanchangeinanumberofways:

• Growthofnewneurons

• Shrinkingofunusedneurons

• Increasingordecreasingthenumberofconnectionsperneuron

• Buildinguporlosinglayersoftheinsulationaroundnerves(myelin).Thislayerimprovesthespeedofnerveconduction.

• Ahealthyareaofthebraincantakeoversomeoftheworkofaninjuredpartofthebrainanddevelopnewcapacities.

Thebottomlineisthatyourbrainisconstantlychangingdependingonhowmuchitisstimulated—ornotstimulated.

• Thereisgreatimprovementpotentialbecausethenervoussystemisabletocontinuetochangeinahelpfulway,butitmustbekeptactive.

• Ontheotherhandifyourbrainchangesnegatively,cellsshrinkorwither,itishardertoundo.Itisstillasolvableproblembutyouneedhelpandtools.

Withmodernbrainscansthatcanactuallymeasurebrainsizeandactivityweareabletoseethesechanges.Somechangescanhappenquickly.Arecentstudyshowedthatcertainpartsofmedicalstudents’brainsenlargedwithinafewmonthsafterstartingschool.(1)

Ithasalsobeenshownthatthebrainsofpatientsinchronicpainshrink,however,thebrainalsore-expandswithsuccessfulresolutionofpain.

Whywouldyourbrainshrinkinthepresenceofchronicpain?Onewayofthinkingaboutitistoviewthepainnervoussystemasanenergydrainthatstealsenergyawayfromhealthycreativepartsofyourbrain.Thebrainareasthatallowustoenjoyfriends,entertainment,community,creativityetc.,graduallyshrink.Thereisahugeamountofneuronactivitygeneratedbytheseregularenjoyablepastimesthatdoesnotoccurinthepresenceofunrelentingpain.

Onceapainpathwayiscreatedinyourbrainitisessentiallypermanent.Itmaybecomelessactivebutitisnotgoingtodisappear.Sowhatistheanswer?ThereisonlyoneandthatiswhattheSwedishSTOMPprojectisallabout.Youmustbuildnewpathwaysordetoursaroundtheproblempathways.Onceyoulearnthetoolsandchoosetheonesthatarethebestfitforyou,itisremarkablehowconsistentlythepainwilllessenorevendisappear.

Welcometoabigadventureandthestartofyournewbrain.Itwillnotbeeasybutitisalsonotdifficult.Youwilldothebrainbuilding.UsetheSTOMPbookletasyourresource.Choosejustthetoolsthatseemagoodfitforyouandmakeitanenjoyableexperience.TheaimoftheSTOMPteamistoassistyouinregainingarichandfulllife.

References1. Dragananski,etal.Temporalandspatialdynamicsofbrainstructure

changesduringextensivelearning.The Journal of Neuroscience 2006;26:6314-6317.

2. ApkarianAV,SosaY,SontyS.ChronicBackPainisassociatedwithdecreasedprefrontalandthalamicgraymatterdensity.Journal of Neuroscience 2004;24:10410-10415.

ResourcesGordon Irving, M.D.

Determining the Validity of Online Resources

Therearehundredsofwebsitesanditmaybehardtoknowwhichonesofferusefulinformationandwhichprobablydonot,oraretryingtosellyousomething.Youshouldasksomesimplequestionsbeforeusingawebsiteforthefirsttimesoyouknowifyoucantrustit.

• Whorunsandpaysforthesite?

• Doesitlistanycredentials?

• Doesitrepresentanorganizationthatiswell-knownandrespected?

• Whatisthepurposeofthesiteandwhoisitfor?

• Isthesitesellingorpromotingsomething?

• Wheredoestheinformationcomefrom?

• Istheinformationbasedonfactsoronlyonsomeone’s“testimonial”andfeelings?

• Howcurrentistheinformation?

• Doesthesiteshowwhenitwaslastupdated?

• Howarelinksyoucanfollowfromthesitechosenorformorehelpfultipsviewthefactsheet“EvaluatingOnlineSourcesofHealthInformation”whichcanbefoundatthewebsite:www.cancer.gov(searchfor“internet”).

Belowaresomerecommendedresources.Resourcesforadditionaltopicscanbefoundattheendofeachsectionthroughoutthebook.

Books and Websites

General Pain Information

• Pain TamersbyHelenM.Dearman

• The Pain Survival Guide: How to Reclaim Your LifebyDennisC.Turk

• Cognitive Therapy for Chronic Pain: A Step-by-Step GuidebyBeverlyE.Thorn,Ph.D.

• Managing Chronic Pain: A Cognitive-Behavioral Therapy ApproachbyJohnD.Otis,Ph.D.

• Back in ControlbyDavidHanscom,M.D.

• The Feeling Good HandbookbyDavidD.Burns,M.D.

• Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain and IllnessbyJonKabat-Zinn

• Managing Pain Before It Manages YoubyMargaretACaudill,M.D.,Ph.D.,MPH

• Mind Over Mood: Change How You Feel by Changing the Way You ThinkbyDennisGreenbergerandChristinePadesky

• Unlearn Your PainbyHowardSchubiner,M.D.withMichaelBetzold

• The War on PainbyScottFishman&LisaBerger

• Heal Your Headache: The 1-2-3 Program for Taking Charge of Your PainbyDavidBuchholz

• The Chronic Pain Solution: Your Personal Path to Pain ReliefbyJamesN.DillardandLeighAnnHirschman

• The Trigger Point Therapy WorkbookbyClairDavies,AmberDaviesandDavidG.Simons

• PainConnection,www.painconnection.com

• AmericanChronicPainAssociation,www.theacpa.org

• TheMaydayPainProject,www.painandhealth.org

• painACTION,www.painaction.com

• U.S.PainFoundation,www.ctpainfoundation.org

• CreakyJoints,www.creakyjoints.org

• TheAmericanAcademyofPainMedicine,www.painmed.org/patient/facts.html

• P.U.R.E.H.O.P.E.,www.pure-hope.org

• AmericanHeadacheSocietyCommitteeforHeadacheEducation,www.achenet.org

• CancerCare,www.cancercare.org

• NationalCouncilonAging,www.ncoa.org

• NationalCouncilonAgingCenterforHealthyAging,www.healthyagingprograms.org

Back Pain

• Treat Your Own Neck and Treat Your Own BackbyRobinMcKenzie

• BackCare,www.backcare.org.uk

• NationalBackExchange,www.nationalbackexchange.org

Care Givers

• Chicken Soup for the Volunteer’s SoulbyJackCanfield,MarkVictorHansen,ArlineOberst,JohnBoal,TomLaganaandLauraLagana

• Staying Sane: When You Care for Someone with a Chronic IllnessbyMelvinPohlandJ.KayDeniston

Fibromyalgia Resources

• The Fibromyalgia Relief HandbookbyChetCunningham

• Fibromyalgia and Chronic Myofascial Pain: A Survival ManualbyDevinJ.StarlynandMaryEllenCopeland

• FibromyalgiaInformationFoundation,www.myalgia.com

• FibroCenter,www.fibrocenter.com

• FibromyalgiaNetwork,www.fmnetnews.com

• NationalFibromyalgiaAssociation,www.fmaware.org

Meditation

• Living With it Daily: Meditations for People with Chronic PainbyPatriciaD.Nielsen

• MindfulnesswithJonKabat-Zinn,http://goo.gl/4aAd

• CognitiveNeuroscienceofMindfulnessMeditation,http://goo.gl/Idnw

• IAMheart,www.applied-meditation.org

• Wildmind,www.wildmind.org

• MeditationCDs,www.carolynmcmanus.com/

Medication Information

• AmericanSocietyofHealth-SystemPharmacists,www.safemedication.com

• ThePartnershipforaDrugFreeAmerica,www.drugfree.org

Nutrition

• Prescription for Dietary Wellness: Using foods to healbyPhyllisA.Balch

• Turn Off the Fat Genes: The Revolutionary Guide to Losing WeightbyNealBarnard

• USDACenterforNutritionPolicyandPromotion,www.cnpp.usda.gov

Prescription Assistance

• RxAssist,www.rxassist.org

• PrescriptionAssistanceProgram,www.pparx.org

Suicide Prevention

• AmericanFoundationforSuicidePrevention,www.afsp.org

Temporomandibular Joint Problems

• TheTMJAssociation,Ltd.,www.tmj.org

Chapter Two:

SleepSleep and PainGordon Irving, M.D.

Sleepaffectspain.Youmayhavenoticedthatwhenyousleeppoorlyandaretiredyourpaintendstobeworse.Researchshowsthatoneofthemostimportantpredictorsforpainintensityisthenumberofhourssleptthenightbefore.Bottomline:ifyousleeppoorly,yourpainwillbeworsethenextday.

Medicationmanagementshouldincludesleepaswellaspain.Assleepimproves,theneedforpainmedicationswilldecrease.Eventuallytheneedforsleepmedswillalsodecrease.

Sleep Hygiene

How Much Sleep Do We Need?

Theamountofsleepeachpersonneedsdependsonmanyfactors,includingage.Formostadults,seventoeighthoursanightappearstobethebestamountofsleep,althoughsomepeoplemayneedasfewasfivehoursorasmanyas10hoursofsleepeachday.

Ifyoufeeldrowsyduringtheday,especiallyduringstimulatingactivities,youhaven’thadenoughsleep.Ifyouroutinelyfallasleepwithinfiveminutesoflyingdown,youprobablyhaveseveresleepdeprivation,possiblyevenasleepdisorder.Micro-sleeps,orverybriefepisodesofsleepinanotherwiseawakeperson,areanothermarkofsleepdeprivation.Inmanycases,peoplearenotawarethattheyareexperiencingmicro-sleeps.Thismaybeacauseofaccidentsbothontheroadandatwork.Itwillcertainlyreduceyourabilitytoperformatyourfullpotential.

Unfortunatelymanymedicationsincludingthosethataregivenforpaincaninterferewithnormalsleeppatterns.Theseincludeantidepressants,opioidsandanti-anxietymedications,eventhosegivenassleepingaids.

Obesityworsenssleepandincreasestheriskofsnoringandsleepapnea(pausesinbreathingwhileyousleep).Chroniclackofsleepalsoincreasestheriskofobesitybychangingthelevelofcertainhormones.InastudyofAmericanadultswhosleptfewerthansixhours,33percentwereobesecomparedtoonly22percentofthosewhohadsix-ninehoursofsleep.

Reaching a Pre-sleep Brain State (Techniques to get asleep and stay asleep)

Thebrainstateassociatedwithmeditationorself-hypnosisismuchlikethepre-sleepbrainstate.Apre-sleepbrainstatecanbebroughtonbymentalactivitiesthatinvolveexperiencingabsorbingsensationsandimagesinsteadofplanningorworrying.

Reachingapre-sleepbrainstatewillincreasethechancethatyouwillfallasleep.

Youcanusethesemethodswhenyoufirstgotobedatnight,orifyouwakeupinthemiddleofthenight.

The 3-2-1 technique:

• Getintoacomfortableposition,mentallycheckingyourbodytomakesurethateverybodypartisascomfortableaspossible.

• Listenforandnotethreesounds,anythreesounds.

• Notethreeneutralorcomfortablebodysensations,anythreesensations.

• Allowthreeimagestoappearinyourmind’seye,andnotethem.

• Notetwosounds,twosensations,andtwoimages.

• Noteonesound,onesensation,andoneimage.

• Notethreesounds,threesensations,andthreeimages.

• Notetwosounds,sensations,andimages.

• Noteonesound,sensation,andimage.

• Keeprepeatinguntilyoudriftofftosleep.

Relaxation by mental scanning:

• Getintoacomfortableposition,mentallyscanningyourbodytomakesurethateverybodypartisascomfortableaspossible.

• Startingwithonefoot,noterelaxingfeelingsandsensationsinthefoot,andallowthosesensationsandfeelingstogrowandspread.

• Systematicallyallowthosefeelingstomoveintoeachareaofyourbody(onefoot,lowerleg,upperleg,otherfoot,otherlowerleg,otherupperleg,onehand,thatarm,otherhand,otherarm,shoulders,etc.)

• Paycloseattentiontofeelingsofrelaxationand“lettinggo”.

• Enjoyandbecomeabsorbedbythosefeelingsandsensationsuntilyoudriftofftosleep.

Using imagery (your imagination) to go to a relaxing and absorbing place in your mind:

• Getintoacomfortableposition,mentallyscanningyourbodytomakesurethateverybodypartisascomfortableaspossible.

• Selectaplacethatyouwouldliketogotoinyourmind’seye.Aplacewhereyoucanfeelsafe,veryrelaxedandcomfortable.

• Imaginebeinginthatplaceandjustnoticewhatisaroundyouandhowrelaxedyoufeel.Noticethecolors,thesmells,thecomfortablebreeze.

• Keepimagingthedetailsofthisplace(andyourowncomfort)untilyoudriftofftosleep.

Sleep Restriction therapy

• Useasleepdiarytokeeptrackofyourtotalhoursofsleepatnight.

• Getupatyourusualtimebutgotobedlatersoyouareonlyinbedforaslongasyouarecurrentlysleeping.Forexampleifyoufindthatyouareonlysleepingaboutfourhoursanightandyounormallygetupat7a.m.,gotobedat3a.m.

• Donotlieinyourbedorsleepduringtheday.

• Graduallyincreaselengthoftimeinbedby30minutesuntilyouaregettingafullnight’ssleep.

Specific Sleep Issues

Somespecificsleepproblemsmayneedspecifictreatments

• Sleepapnea:Observerssayyousnoreloudlyandoftenholdyourbreathwhilesleeping.Itmaymakeyougrumpy,impatient,irritable,forgetful,orfallasleepwhilebeingactive.Youmayexperiencehard-to-treatheadaches.Ittendstomakeobesity,depressionandlegswellingworse.

• Restlesslegsyndrome:Youfeelacreeping,crawling,aching,ortinglingsensationinyourlowerlegsworseatnight-time.Itmaylastforonehourorlonger.Sometimesitalsooccursintheupperleg,feet,orarms.Youfeelanirresistibleurgetowalkormoveyourlegs,whichalmostalwaysrelievesthediscomfort.

• Periodiclegmovement:Thisisarepetitivecrampingorjerkingofthelegsduringsleep.

• Depressionandanxiety:Thesearealsoassociatedwithpoorsleep.Thesecanbehelpedbynon-medicationmethodsaswellasmedications.

Arestfulnight’ssleepisoneofthetopprioritiesinsolvingyourchronicpain.Theeffectivenessofyourothertreatmentsislimiteduntilyouareregularlyexperiencingafullnight’ssleepforatleastsixweeks.Usuallymedicationsarerequiredforawhileinthepresenceofpain.Asyourpaindiminishessowillyourneedforsleepmedicines.

Nomajoradditionaltreatmentdecisionsshouldbemadeuntilthisgoalisaccomplished.

Steps to Get There

Keep a regular sleep routine

• Gotobedatthesametime,eachnight.Wakeupatthesametime.Ideally,yourscheduleshouldremainthesame(+/-20minutes)everynightoftheweek.

Avoid naps if possible

• Eachofusneedsacertainamountofsleepper24-hourperiod.Weneedthatamount,andwedon’tneedmorethanthat.

• Whenwetakenaps,itdecreasestheamountofsleepthatweneedthenextnight–whichmaycausebrokensleepandleadtoinsomnia.

Don’t stay in bed awake for more than 5-10 minutes

• Ifyoufindyourmindracing,orworryingaboutnotbeingabletosleepduringthemiddleofthenight,getoutofbedandsitinachairinthedark.Letyourmindracewhileyouareinthechairuntilyouaresleepy,andthenreturntobed.NoTVorinternetduringtheseperiods!Theywilljuststimulateyoumore.

• Ifthishappensseveraltimesduringthenight,thatisOK.Justmaintainyourregularwaketime,andtrytoavoidnaps.

Don’t watch TV or read in bed

• WhenyouwatchTVorreadinbed,yourbrainassociatesthebedwithbeingawake.

• Thebedissavedfortwothings–sleepandsex.

Do not drink caffeine after 12 noon

• Theeffectsofcaffeinemaylastforseveralhoursafteryoudrinkit.Itcanbreakupsleepaswellasmakeithardertogettosleep.Ifyouusecaffeine,onlydrinkitbeforenoon.

• Rememberthatmanysodasandteascontaincaffeineaswell.

Avoid substances that may interfere with sleep

• Cigarettes,alcohol,beta-blockers(medicationsgivenforbloodpressure),antidepressantstakenintheeveningandmanyover-the-countermedicationsmaycausepoorsleep.

Exercise regularly

• Exercisebefore2p.m.everyday.Exercisehelpscontinuoussleep.

• Avoidheavyexercisebeforebedtime.Itmayincreasehormones,whichmaydisruptsleep.

Have a quiet, comfortable bedroom

• Setyourbedroomthermostatatacomfortabletemperature.Generally,alittlecoolerisbetterthanalittlewarmer.

• TurnofftheTVandothernoisethatmaydisruptsleep.Background‘whitenoise’likeafanisokay.

• Ifyourpetswakeyou,keepthemoutsidethebedroom.

• Yourbedroomshouldbedark.Turnoffbrightlights.

Clock watching

• Ifyouarea“clockwatcher”atnight,hidetheclock.

Have a comfortable pre-bedtime routine

• Awarmbathorshower.

• Awarmmilkdrinkwithoutcaffeine.

• Meditation,orquiettime.

Resources• WorldSleepFoundation,www.worldsleepfoundation.com

• Exercisestotreatsleepapnea,http://goo.gl/iDMul(Downloadthefreeattachedonlinevideosupplement)

Chapter Three:

CalmingtheNervousSystemA Mind Body Approach to Healing Chronic Pain that is Non-StructuralHoward Schubiner, M.D.

Formanypeoplewithchronicpain,thecauseisanervepathwayproblemratherthantissuedamage.Thetreatmentforatissuedamageproblemisdifferentthanforanervepathwayproblem.Thissectiondealsonlywithnervepathwayproblems.Theseincludefibromyalgia;neckandbackpainwithoutasignificantstructuralproblem;migraineandtensionheadaches;andmostchronicabdominalandpelvicpainsyndromeslikeirritablebowelsyndromeandinterstitialcystitis.

Therearefourpartsoftreatmentforanervepathwayproblem:

1. Education Itisdifficulttoovercomeanervepathwayproblemunlessyou

understanditfully.Educateyourselfaboutnervepathways(seethereadinglistbelow).Itiscriticalforyourhealingtounderstandthatastructuralphysicaldiseaseisnotthemainreasonforyourpainandthatyoucangetbetter!Ifyoubelievethat,thenyouareontheroadtorecovery.

2. Behavioral interventions Meditationcanhelpsoothethemindandcalmfears.Sincethese

nervepathwaysstartinthebrain,itisalsopossibletorelievepainbyreprogrammingthebrain.Thiscanbedonebytalkingtothepainandtellingittostop!Ifyouareforcefulandfirm,youcanretrainthenervepathways.Sincenervepathwaysarelearned,theycanbe“unlearned”byrepeatedlychallengingthesymptomsandtakingcontroloverthem.Itisa“mindoverbrain”techniqueandisveryeffective.

Inaddition,ifthepainhas“triggers,”suchasmovements,activities,foods,orweatherchanges,challengethosetriggerstounlearnthem.Decidethatthetriggerswillnotcontrolyouanymoreandcreatepowerfulaffirmations(positivemessages)toovercomethem.

Eachdaywhenyouhavepainorwhenyoufacepaintriggers,tellyourself“Iamhealthyandstrong.Thereisnothingseriouslywrongwithme.IcanbepainfreeandIwillnotletthisstopme.Pain,goaway.Idon’tneedyouandIdon’twantyou.”Themoreforcefulwordsyouuse,thebetter.Thencontinuewithyouractivities.

3. Emotional interventions Emotionsareoftenthekeytounlockingchronicpain.Mostpeople

withchronicpainhavedeepemotionsthathavebeenheldin,suchasanger,guilt,fear,orsadnessandloss.Recognizetheseemotionsanddealwiththem.Therapeuticwritingisoftengoodmethodforresolvingfeelings.Anemotion-basedpsychotherapyknownasIntensiveShort-TermDynamicPsychotherapy(ISTDP)isalsoaveryeffectiveprocesscreatedbyDr.HabibDavanloothatisnowbeingtaughtandpracticedaroundtheworld.MoreinformationonthistechniquecanbefoundinUnlearn Your Pain(seebelow).

4. Life changes Manypeopleneedtomakechangesintheirlives.Ifyouaretrapped

inarelationshipthatishurtfulordestructive,somethingneedstobedonetoeaseorresolvethesituation.Ifyouareonbadtermswithpeopleyoulove,thissituationmayneedtobechanged.Ifyouarestuckinaworksituationthatisoverwhelmingoroverlystressful,thatmayneedtobechanged.Takeacloselookatyourlifeandseeiftherearesomeissuesthatshouldbeaddressedandseekhelptofindsolutionsforthem.Theseissuesareoftenkeytowardssolvingachronicpainproblemcausedbylearnednervepathways.

Resources• Back in ControlbyDavidHanscom,M.D.• Unlearn Your PainbyHowardSchubiner,M.D.• They Can’t Find Anything Wrong!byDavidD.Clarke

• Healing Back Pain, The Mindbody Prescription, and The Divided MindbyJohnE.Sarno,M.D.

MindfulnessCarolyn McManus, PT, MS, MA

Chronicpainmeansyouarelikelytohavemorestressthanpeoplewhodon’thavepain.Youhaveprobablynoticedthatwhenyourpainisworse,youfeelmorestressed.It’strue:painisstressful!Also,havingpainmeansyoumaybeabletodolessinyourlifeandthiscancreatestress.Stressisassociatedwithtightermuscles,poorersleep,anxiety,shallowbreathingpatterns,depressedmood—andalloftheseleadtoworsepain!Withoutevenknowingit,youmaybemedicatingpainflaresthatarefueledbystress.Insteadoffocusingonmedication,youcanlearnhowtoreducethestressandwillfindyouneedlessmedication.

Mindfulness Stress Reduction

Why should I use the Mindfulness Technique?

Howyouchoosetorespondtothephysicalsensationofpainhasamajorimpactonhowyournervoussystemcreatespainandonthequalityofyourlife.Yourautomaticreactionstopainoftenamplifythepaingeneratingactivityofyournervoussystemandcauseanincreaseinyourpainanddistress.

Mindfulnesstechniquesareevidence-basedpractices(researchhasbeendoneandpublishedinthemedicalliterature)thathelpchangethenervoussystembacktowardsanormalnon-painstate.

ThroughtheMindfulnessTechnique:

• Youcanlearnskillfulresponsestopainthatreducepainanddistress.

• Youcanidentifyandchooseskillfulresponsestomoreeffectivelymanagepain.

• Considerthefollowingequation.Doyourelatetoit?

ª Pain=unpleasantphysicalsensation+yourphysical,cognitive(thinking,understanding)andemotionalreactionstothesensation

Mindfulnessmeanspresent-momentawarenessandoffersyouaconstructive,practicalandeffectivewaytoobserveyourphysical,cognitiveandemotionalreactionsandmakeskillfulchoicesthatcandecreaseyourpainanddistress.

Rememberyoumaynothavecontroloverthesensationofpain,butyoudohavecontroloveryourreactionstothesensationofpain.Yourchoicesdirectlyimpactyournervoussystemactivity.

Steps to Get There

Formal Mindful Awareness Exercise

1. Pausenowanddirectyourawarenesstoyourbodyandbreathing.Listentoyourpresent-momentexperiencewithastable,steadymind.Somesensationsmaybepleasant;others,suchaspain,maybeunpleasant;andstillothersneutral.

2. Imagineyourmindislikethesky,andthepainislikeacloudinthesky.

3. Listenwithcompassion.Bekindtoyourself.Listenwiththesamefriendlinessyouwouldofferalovedoneifheorshewereinyoursituation.

4. Avoidanytendencytojudgeorcriticizeyourself.Payattentiontoyourbodyasifyouweredoingsoforthefirsttime.Acceptyourexperiencejustasitiswithoutneedingtochangeorimproveanything.

5. Deliberatelyscanyourbody.Observeyourfeet,legs,torso,hands,arms,shoulders,neck,faceandhead.

6. Whenyouhavecompletedscanningyourbody,letyourattentionrestwiththerhythmofyourbreath.Breathedeeply.

7. Observeyourabdomenandribcagemovewithyourinbreathandoutbreath,hereandnow.Breatheintoyourwaistband.

8. Counteachexhalation.Onthefirstoutbreath,saytoyourself“one,”onthesecondoutbreath,saytoyourself“two,”andsoonuptothetenthexhalation.Whenyoureachthetenthoutbreath,returnto“one”andbeginagain.Whenyourmindwanders,labelit“thinking”andreturnyourattentiontoyourbreathandthecountingpractice.Beginagainwith“one.”Continueforfiveminutes.

Awanderingmindisthemostcommonconcernpeoplehavewhenbeginningtomeditate.

Thisisnormalandnotasignthatyouaredoingsomethingwrong.Whenyoubecomedistractedfromthepresentmoment,noticethatyourmindhaswanderedlikeaclouddriftingbyinthesky.Avoidjudgingyourexperienceasrightorwrong.Note“thinking”andreturnyourattentiontothepresentmomentandyourbreathing.

Althoughtheseinstructionsmaysoundsimple,themindquicklywandersoffandbecomeslostinthought.Painisalsodistracting.Justasthebodycanbetrainedtoperformwithgreaterstrengthandendurancethroughregularexercise,themindcanbetrainedtofunctionwithgreaterstabilityandclaritythroughthismindfulnesspractice.Beginpracticingthisformalmindfulnessexerciseforfive-to-10minuteseachday.

Informal Mindful Awareness Exercise

Aninformalpracticeinvolvesbringingpresent-momentawarenessintodailyactivities.Forexample,whenwalking,noticeyourpresent-momentexperience.Noticeyourbreath,thesensationsofyourfeetwhentheytouchthegroundandthefeelingofyourlegsmovingthroughspace.Or,whenyouwashyourhands,again,noticeyourbreath,thewarmwateronyourfingersandpalms,andthesensationsinyourshoulders.Anydailyactivitycanbecomeaninformalmeditationpractice.

Mindfulness and Pain Management• Youarenotyourpain.

• Painisaphysicalsensation,notyouridentity.

• Youareawholehumanbeingwhoisdealingwithamedicalcondition.

• Bylearningtobemindful,youcanobservepainwithastable,compassionateandcuriousmind.Youcanidentifypainsensationsandyourphysical,mentalandemotionalreactionstopainsensations.Thisaloneishelpful.

• Youcanexperimentwithnewresponsesthatreduceyourdistressandoftendecreaseyourpainintensity.

• Bytrainingyourmindtobeinthepresentmoment,youalsoworrylessaboutthefutureandputyourenergyintoskillfulchoicesandlivingwelltoday.

Resources• The Mindfulness Solution to Pain: Step-by-Step Techniques for

Chronic Pain ManagementbyJackieGardner-Nix

• Full-Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain and IllnessbyJonKabat-Zinn

• WhatMeditationReallyIswithJonKabat-Zinn,http://goo.gl/dXjpK

• GuidedMindfulnesspracticeswithJonKabat-Zinn,http://goo.gl/6aQPV

• CognitiveNeuroscienceofMindfulnessMeditationwithPhilippeGoldin,Ph.D.,http://goo.gl/Idnw

• GuidedMindfulnessMeditationBodyScan,http://goo.gl/rpk9R

• UniversityofWisconsin,DepartmentofFamilyMedicine:GuidedMeditationInstructionbymultipleteachers.www.fammed.wisc.edu/mindfulness

• MindfulnessmeditationCDscanbefoundatwww.carolynmcmanus.com.

RelaxationCarolyn McManus, PT, MS, MA

Mostpeoplewithchronicpainnoticethattheycarryalotoftensionintheirbody.Forexample,nomatterwhereyourpainislocated,youmaynoticethatyourneckorshouldersfeeltight.Paincreatesoverallbodytensionbecauseourmusclestightenaswe‘brace’againstpain.Tightmusclesmakepainworse.How?

1) Tightmuscles“pull”onthebody.Forinstance,tightshoulderscanpullontheneck,irritatingjointsandnervestothescalp.Thiscancreatetensionheadaches.Tightbackmusclescanworsenbackpainbypullingonthespineandconnectingtissues.

2) Tightmusclesgeneratechemicalsthatactivatepain-relatednerves,makingpainevenworse.Musclerelaxants,orpainmedicinetoeasemuscletension,areoftennoteffectivewhenusedforalongtime.Theymayhaveunwantedside-effectsandcauseotherproblems.Therearebetterwaystomanageyourpain.Youcanlearnexercisestoreducemuscletensionandrelax.Researchshowstheseexercisescanhelpyoufeelbetterandreducepain.

Relaxation Techniques

Belowisalistofsuggestionstohelpyoulearnhowtorelax.

Deep Breathing: Whenyouareunderstressorinpain,yourbreathingpatterncanbecomemoreshallowandfaster.Manypeopleholdtheirbreath.Thispatternofshallowbreathingreinforcesthebody’sstressreaction.Incontrast,diaphragmaticorbellybreathingdecreasesthebody’sstressreactionandpromotesacalmingofyourmindandbody.Theinstructiontoobserveyourbreathingandtakeadeepbreathsoundssimple;butitisnotalwayseasytodowhenstressandpainlevelsarehigh.Itdoesgeteasierwithpractice.Developthehabitofobservingyourbreathandbreathingdeeplyduringtimesofstress.Deepbreathingisaprovenwaytoreduceyourstressreaction.Belowaresomestepsyoucantaketopracticedeepbreathing.

1. Formalbreathingpractice

a. Sitcomfortablywithagoodposture.Placeyourhandonyourbelly,justbelowyournavel.Asyoubreathein,trytobreatheintoyourhand.Allowyourbreathtomovedeepintoyourlungsandyourstomachtogentlymoveoutwardandyourlowerribstomoveouttothesideslightly.Itmayfeellikeyouarebreathingintoyourwaistband.

b. Asyoubreatheout,allowyourstomachtogentlyfall.

c. Youdonothavetotakeanextra-largebreath.Yourbreathcanbeanormalsize.

d. Thekeyistoallowyourbreathtofillthebottomofyourlungs.Youknowthisishappeningwhenyourstomachslightlyrisesontheinbreathandfallsontheoutbreath.

e. Nowrepeatawordorphrasetoyourselfthathelpsyourelaxinconcertwithyourbreath.Thesimplestoftheseis“in”ontheinbreathand“out”ontheoutbreath.Youcanuseanywordorphrasethathasmeaningforyou.Forexample:i. Yourownnameontheinbreathfollowedbythewords“let

go”ontheoutbreath.ii. “MayI”ontheinbreath,“bepeaceful”ontheoutbreath.iii. “Presentmoment”ontheinbreath,“onlymoment”onthe

outbreath.

iv. Ifyoupracticewithinareligioustradition,youcanuseawordorphrasefromspiritualwritingsorthephrases“letgo”ontheinbreath,“letGod”ontheoutbreath,or“intheKingdomofGod...Idwell.”

f. Practicefortwominutesatleastonceaday.

2. Informaldeepbreathing

a. Usedeepbreathingwhenyouhavepain,duringdailyactivitiesandwhengoingtobed.

b. Whereveryoufindyourself,whateverthetimeofday,takeamomenttobringyourattentiontoyourbreathandtakeadeepbreath.

c. Observeyourbreathduringroutinedailyactivities,suchassittingataredlightintraffic,standinginlineatthegrocerystoreorwaitinginadoctor’soffice.

d. Ifyourpainincreases,noticeyourbreathandbreathedeeply.

e. Whenyouaregoingtosleep,noticeyourbreath,breathedeeplyandrepeatthewordorphrasethathelpstocalmyourmindandbody.

Progressive RelaxationThisexerciseinvolvesgentlytensingthenrelaxingthemajormusclegroupsthroughoutyourbody.Itpromotesthebodyawarenessyouneedtocontrolyourstressandtensionandwillhelpyourelax.

Autogenic TrainingAutogenictrainingpromotesstatesofdeeprelaxationbyinvitingyoutorepeatkeyphrasestoyourself.“Myrightarmfeelsheavyandwarm”isanexampleofanautogenicphrase.Youguideyourawarenesstodifferentbodyareas,repeatingthesecalmingphrases.

Body-Scan RelaxationBodyscanrelaxationinvolvesguidingyourawarenessthroughyourbodyinanorderlyway,relaxingeachbodyarea.Itisasimpleandcommonlyusedrelaxationtechnique.

Guided ImageryGuidedimageryexercisescanbetaughttopromoterelaxationandengagethemind-bodyrelationshipinahealingprocess.Imagescanbegeneral,forexample:“Imagineyourselfinacalmandpeacefulplace.”Ortheycanbespecific,forexample:“Imaginelotsofoxygenbathinganareaofpain.”

Movement MeditationsMovementmeditationssuchasgentleyoga,walkingmeditationandTaiChi,involvemovinginaslow,controlledmannerwithawarenesswhilealsobreathingcalmlyandpeacefully.

Hypnotic TechniquesTobringonastateofspecificfocusedattentionusingimagery.

BiofeedbackProvidesapersonwithinformationaboutthebody,suchasmuscletensionlevels,thatcanbechanged.Theinformationmaynotusuallybeundervoluntarycontrolorisnormallyundercontrolbutregulationhasbrokendown

Varioustypesofbiofeedbackincludemuscleelectromyography(EMG),temperature,breathingandheartratevariability.

Resources• The Relaxation & Stress Reduction WorkbookbyMarthaDavis,

MatthewMcKayandElizabethRobbinsEshelman

• MayoClinic-StressManagementAssessment,http://goo.gl/eDMro

• UniversityofMaryland:StressRelaxationTechniques,www.umm.edu/sleep/relax_tech.htm

• HobartandWilliamSmithColleges:RelaxationTechniques,www.hws.edu/studentlife/counseling_relax.aspx

• CDrecordingsofrelaxationexercises,www.carolynmcmanus.com

Clinical HypnosisMaureen C. Pierce, Ph.D.

What is Hypnosis?

Hypnosisisastateoffocusedattention.Itusestheimaginationtoincreaseyourresponsivenesstosuggestions.Hypnosiscanhelpchangethoughts,feelings,behavior,andphysicalstate.Whenyoufocusyourmind,youareabletouseittoyourbenefit.Hypnosiscantreatmanypsychologicalandmedicalproblems,notablypainmanagement.Hypnosiscanhelpyousleepbetter,stopsmoking,manageyourweight,prepareforsurgery,andmanageanxiety.

WhataretheBenefitsofUsingHypnosisfortheManagementofPain?

• Affectsareasofthebrainassociatedwithpain

• Lowerspainsensation

• Lessensintensityofpain

• Youcanexperiencecomfortandsafetywithinyourbody

• Itincreasesasenseofcontrol

• Therearefew,ifany,sideeffects

Common Myths Regarding the Use of Hypnosis• MYTH:Thepractitionerhascontroloverthepatient. TRUTH:Whenyouareinastateofrelaxedandfocusedawareness,

youarealwaysincontrolandareawareofthiscontrol.

• MYTH:Hypnosisdoesnotworkwhenphysicalsymptomsare“real.” TRUTH: Regardlessofthecause,allsymptomsarereal.Hypnosis

helpstreatmanypsychologicalandmedicalconditions.

• MYTH:Hypnosisisthesameassleep. TRUTH:Hypnosisisnotthesameassleep.Infact,thebrainactivity

seenduringhypnosisislikethebrainactivityseenwhenpeopleareawake.

• MYTH:Onlyweak-mindedpeoplecanbehypnotized. TRUTH: Somepeoplerespondbettertohypnoticsuggestionsthan

others.Respondingtohypnosisisnotdependentonpersonality.afewpeoplearelessabletorespondtohypnosis,butthemajorityrespondreadily.

• MYTH:Apersonwillnotbeawakeandwillnotrememberanything. TRUTH:Hypnosisisverymuchlikewhathappenswhenyouare

absorbedinahobbyorotherinterestingactivity.

• MYTH:Stagehypnosisisthesameasclinicalhypnosis. TRUTH:Stagehypnosisisforentertainment;Clinicalormedical

hypnosisisusedtohelppeople.

Resources• AmericanSocietyofClinicalHypnosis,www.asch.net/

• AmericanPsychologicalAssociation,http://goo.gl/buW15

Writing/JournalingDavid A. Hanscom, M.D.

Anxietyisauniversalandnecessarypartofthehumanexperience.Itisaprotectivemechanism.Whenyoufeelthreatenedorcannotmeetabasicneed,suchasair,foodorwater,youwilltakeactiontosolvethesituationanddecreaseyouranxiety.Notbeinginpainisabasichumanneed.Yourfirstreactiontopainisanxietyandifyoucannotrelieveyourpainthenextresponsewillbeanger.Whenyouareexperiencingchronicpainyouaretrulytrappedandyourfrustrationlevelswillrisetointenselevels.ThetermIuseis“TheAbyss,”whichisanxietyxangerxtime.

Itisimportanttounderstandthelinkbetweenanxietyandanger.Anxietycausestheneedforcontrol.Angerresultsfromlossofcontrol.Thereforeangerisreally“highanxiety.”

UsingtheMindBodyconceptwelookatpain,anxiety,andangerintermsofneurologicalpathways.Justlikeanathlete,artistormusicianlaysdownroutinepathwayswithrepetitionandpractice,yourbrainlaysdownpathwaysorcircuitsinresponsetorepeatedpain,anxiety,andfrustration.Onceyouhaveapathwayofanykindinyournervoussystemitispermanentandcanalwaysbetriggered.Sowhatcanyoudo?

Theanswerissimpleandeffective.Youcreate“detours”aroundthepathways.TherearemanywaysofdoingthisbutIhavefoundonefoundationalsteptobecritical.Thatisthetaskofwritingdownyournegativethoughtsandimmediatelythrowingthemaway.

Thissoundstooeasy.Whywouldyoudothis?

Newneurologicalpathwaysarecreatedbyconnectingthoughtswith:

• Thoughts• Emotions• Experiences• Physicalsensations

Whenyouhavewrittendownthesenegative/disruptivethoughtsyoumakea“space”foryourselfoutsideofthethoughts.Thereasontothrowthemawayquicklyisnottogetridofthembuttohelpyoutowritemorefreely.Donottakethesethoughtspersonallyorseriously.Theyarejustchronicemotionalcircuitstiedinwithyourpain.Theyhavenothingtodowithwhoyoureallyare.Writingdownthesethoughtscreatesanawarenessofthesourceofyouranxietyandfrustration.Younowhaveachancetochooseadifferentresponsetoagivenstressor.Asyoucontinuetomakemorethoughtful,skillfulchoices,yourbrainwillgrownewneuronsandformmorefunctionalconnections.

Therearethreepartstore-programmingyournervoussystem:

1. Awareness–becomeawareofyourrepeatingnervepathways/circuits.

2. Detachment–takeastepbacktoseewhatisreallygoingon.

3. Layingdownnewcircuits/pathways–newpathwayscanbypasstroublesomeolderonesandquietthemdown.

Thekeytoincreasingyourchancestoresolveyourchronicpainisyourabilityandwillingnesstoletgooftheangerandanxietyassociatedwithit.Theemotionandpainpathwaysaresocloselylinkedthatitisonlypossibletoexperiencemeaningfulpainreliefwhenyoubreakthisconnection.Separatingyouremotionsfromyourpainpathwayisalearnedskillandwritingisanessentialtool.

Writingdownnegativethoughtsisaprocessyoumayneedtodofortherestofyourlife.Thispracticeisnotaphilosophybutapracticaltooltoreprogramthenervoussystem.Consideritaself-careactionsimilartobrushingyourteeth.

Steps to Get There• Learnabouthowthebrainlaysdownpathwaysbyreading,The

Talent CodebyDanCoyle.

• Afteryouhavebecomecomfortablewithfreewriting,readFeeling GoodbyDavidBurns,M.D.Dr.Burnshasdevelopedstructuredformatsthatareveryeffective.Learntowriteinthe“three-columntechnique.”

• Onceyouhavemadeprogresswithyouranxiety,engageinthetoolssuggestedbyFredLuskin,Ph.D.,inForgive for Good.HediscusseshisfourresearchprojectsoutofStanfordonforgivenessandprovidesstrategiesthatwillenableyoutoexperiencethementalandphysicalbenefitsofforgiveness.

• Unlearn Your PainbyHowardSchubiner,M.D.,clearlyexplainstheMind-BodySyndrome.Itincludesmanysuggestionsforhowtocreatemorefunctionalpainfreecircuitsinyourbrain.

• TheHoffmanInstitutewebsiteprovidesaframeworkforexaminingyourlifeintermsofpatternsandMind-BodyConcepts.Itisaneffectiveeight-day,in-house,reprogrammingprocessthatcanbeconsideredlaterinyourhealing.

• BackinControl:ASpineSurgeon’sRoadmapOutofChronicPain(www.back-in-control.com)Thisresourceprovidesamethodtocreateanactionplanbasedontheprinciplesdelineatedinthebookofthesamename.

Resources• The Talent CodebyDanielCoyle

• Feeling GoodbyDavidD.Burns,M.D.

• Forgive for GoodbyFredLuskin,Ph.D.

• Unlearn Your PainbyHowardSchubiner,M.D.

• TheHoffmanInstitute,www.hoffmaninstitute.org/

• Back in Control: A Spine Surgeon’s Roadmap Out of Chronic PainbyDavidHanscom,M.D.,www.back-in-control.com

Music TherapyGordon Irving, M.D.

Why do music therapy?

Musichasbeenassociatedwithhealingthebodyandmindforcenturies.Researchhasshownthatlisteningtolivemusicresultsinamuchgreatereffectonphysicalandpsychologicalstatesthandoesrecordedmusic.Howeverthegreatestpositivemedicaleffectsarewithpatient-preferredmusic.Listeningto,orbetteryetengaginginfocusedmusicalactivityiseffectiveinchangingthemood,creatingrelaxation,andcanassistindecreasingyourpain.

Steps to Get There• Choosethemusicthatsuitsyou,yourmoodandyouractivity.

• Doyourexerciseprogramwhilelisteningtoyourfavoritemusic.Thiswillcreateaquickandpleasantpassageoftime.

• Ifyoucanplayaninstrumentyoumayhavetomodifyyourtechniqueorevengetaninstrumentlikeanelectronickeyboardthatdoesnotrequireasmuchwristandfingermovementandpressureasapianotoplay.

• Evenifyoudonotownorcannotplayamusicalinstrument,tappingoutrhythms,xylophones,handchimes,rainsticksandotherpercussioninstrumentscanbeusedtoreducepainandpromotepleasureandrelaxation.

• Dodeeprelaxedbreathingtotherhythmofthemusic.Thisencouragesregularbreathingandrelaxation.

• Closeyoureyeswhilelisteningtomusicandimagineyourselfinaplaceyouwouldliketogo.

o Visualizationisapowerfulreprogrammingtool

• Composingsongsabouttheexperienceofpainandcopingwithitcanbefreeing

o Aspointedoutinthewritingsectionthemoreaccuratelyyoucanconveyyourfrustrationsaroundpainthemoreeffectivetheexercise.

Helpful Hints • Choosemusicthatyoulikeandthatisappropriatetoyouractivities.

• Makethewholeexperienceasenjoyableaspossible.

o IffinancesareaproblemgoingtoathriftstoremayallowyoutobuyanMP3playertodownloadmusicyoulikeorbuyamusicalinstrumentthatyouwanttoplay.

Resources• AmericanMusicTherapyAssociation,www.musictherapy.org

• EffectofMusicTherapyAmongHospitalizedPatientswithChronicLowBackPain:AControlled,RandomizedTrial.NationalCenterforBiotechnologyInformation,www.ncbi.nlm.nih.gov/pubmed/15914256

• Music Therapy for PainbyDr.ScottStoney(Part1),http://goo.gl/GXclW

• Music Therapy for PainbyDr.ScottStoney(Part2),http://goo.gl/GXclW

• Music Therapy for PainbyDr.ScottStoney(Part3),http://goo.gl/AEgcp

Anxiety and DepressionAllen Hume, Ph.D. and Maureen C. Pierce, Ph.D.

Chronicpainandotherhealthcareissuesmayresultinnegativeemotionalstates,includinganxietyanddepression.Whenweexperiencepain,ourbrain“soundsthealarm”bysendingmessagestoreleaseneurotransmitters,hormonesandotherchemicalstoprotectus.Oncethethreatisdiminished,ourbodyandbraingoesbacktoastateofbalance,orhomeostasis.Whenthepaindoesnotstop,however,ourbodycontinuestosendoutmessagestoprotectus,whichovertimedrainsus,bothphysicallyandemotionally.Wearethenatgreaterriskofdevelopinganxietyanddepressivesymptoms,thatwhenleftunaddressedcanbecometheirownproblem.Forexample,manyfolksinpainmayexperiencegreaterworry,lesscontrolovertheseworriedthoughts,increasedrestlessnessandtension,andgreaterirritabilityduetothepainresponse.Ortheremaybegreatersadness,lossofinterestinpreviouslyenjoyedactivities,feelingguiltyorworthlessfornogood

reason,orperhapsevenhopelessaboutthesituation.Theseresponsesareunderstandableandoccurinmanywithchronicpainandotherhealthcareissues.

Addressingthesefeelingsisapriorityandcanbedoneinmanyways,acknowledgingthefeelingsandthoughts,seekingcounseling,discussingwithyourmedicalprovider,and/ortakingamedicationthatistargetedtothesymptomsyouexperience.Interestingly,thereisevidencethatthepartofthebrainwherephysicalpainisexperiencedisalsothepartofthebrainwherenegativeemotionalstatesareexperienced.Soinasense,ourpainresponseisbothphysicalandemotionalatthesametime.Takealookatthewebsiteslistedin“resources,”consideraccessingyourfamilyandsocialsupportsystem,andtalkwithyourhealthcareproviderifyouareexperiencingthesefeelings.

Steps to Get There1. Takepartagaininactivitiesyouusedtoenjoyasmuchasyoucan

—youmayhavetomakealistofactivitiesandselecttheonesyoucanstilldoinspiteofpain.

2. Learnsomenewstressmanagementskills,includingrelaxation,deepbreathing,guidedimagery,andmeditation,allofwhichhavebeenshowntohelpdepression,anxiety,andpain.

3. Useyoursocialsupportnetwork.Withchronicpain,youmayhavetomakenewcontactswithothers,eitherindividuallyorinagroupsetting.Therearemanyresourcesavailableinyourcommunity,online,andprofessionally.

4. Learnhowtousecognitivebehavioraltherapy(CBT)toaddressyournegativethoughts,whichwillhelpyoufeelbetter.

5. Listentoyourfavoritemusic,watchamovieyouparticularlyenjoyorreadagoodbook.

6. Stayfocusedonbeingasactiveaspossible—whenwearepassiveinourapproachtolifewearemorelikelytodwellonnegativefeelings,experiences,andpain.

7. Discussyourfeelingswithatrustedmedicalprovider.Followallrecommendations,bothforpainandemotionalsymptoms.Painandstressinteract;therefore,wemustaddressbothatthesametime.

8. Youmaywanttoenterindividualcounselingwithsomeonewhounderstandschronicpain.Grouptherapycanalsobeveryhelpful.

Resources

Anxiety

• AmericanPsychologicalAssociation,www.apa.org/helpcenter/stress.aspx

• AnxietyDisordersAssociationofAmerica,www.adaa.org

• NationalInstituteofMentalHealth,www.nimh.nih.gov

• MentalHealthAmerica,www.mentalhealthamerica.net

Depression

• DepressionScreening,www.depressionscreening.org

• NationalAllianceonMentalIllness,www.nami.org

• AmericanPsychologicalAssociation,www.apa.org

Trauma Allen Hume, Ph.D. and Maureen C. Pierce, Ph.D.

Traumaispresentinapproximately40percentormoreofindividualswhosufferfromchronicpain,whetherithappenedbeforetheonsetofpain(i.e.childhoodabuse),orwasthecauseofthepain(seriousmotorvehicleaccident).Thepainweexperiencemaybeaffectedbyourprevioustraumahistory.Wemayspendalotoftimethinkingaboutpainfulemotionalevents,wemaybeunabletoworkor“physically”manageourtraumaticmemoriesanylongerduetopain,orthepainmayserveasatriggerforpastnegativeemotionalexperiences.

Inordertoeffectivelymanagethepainandtrauma,bothissueswillrequireyourattention,alongwithyourhealthcareprovider.Manytimes,wedon’twanttodiscloseinformationaboutpasttrauma.Wemaynotfeelreadytotrusttheproviderwiththatinformation.Wemightthinkthatourpainwon’tbetakenseriously.Seekingcarefromapsychologistorothermentalhealthproviderwhohasexperiencewithbothpainandtraumaismostlikelytobehelpful.Thisprovider

canhelpyouunravelthecomplexinteractionbetweenpainandtraumaanddevelopeffectivecopingskills.Inaddition,ifandwhenitisappropriate,therearetherapiestoreprocesstheexperiencethathelpsresolvetheemotionalpain,whichinturnmayalsohelpthephysicalpain.

Steps to Get There1. LearnmoreaboutPTSD(post-traumaticstressdisorder),trauma

andhowitinteractswithpain.Therearemanygoodresourceslistedbelowthatyoucanuse.

2. Learnwaystoreduceyourstressandtoleratedistress,includingbreathingexercises,guidedimagery,relaxationskillsandmeditation.Themoreyoucanself-soothe,thebetteryouwillbeabletomanagetraumaticstress.

3. Listentoyourfavoritemusic,readagoodbookorwatchamovieyouenjoy.

4. IfyouhavePTSD,professionalinterventionismosthelpful.Talktoyourhealthcareproviderforareferraltoamentalhealthproviderwhoworkswithbothpainandtrauma.

5. Likeotherformsofanxiety,individualswithtraumaticstressbenefitfromgoodsocialandfamilysupport.Besuretoseekoutothersforemotionalsupport,leisureactivitiesandskillsdevelopment.

6. Considerjoiningatherapygroupforindividualswhohaveexperiencedtraumaandpain.Themoreresourcesyouhavethebetter.

Resources• EMDRNetwork,www.emdrnetwork.org

• U.S.DepartmentofVeteranAffairs,www.ptsd.va.gov

• AmericanPsychologicalAssociation,http://goo.gl/KAPSK

Thoughts Allen Hume, Ph.D. and Maureen C. Pierce, Ph.D.

Chronicpainhasaprofoundimpactonourthoughtsandbeliefs,andmoreimportantlyonourselves.Folksinpainoftentalkabouttheirexperiencesin“absolutes,”usingwordssuchasalways,never,shouldandmustwhenfacingdifficulties.Wearealsoinclinedtounrealistic,distortedinourthinking,particularlywhenwedon’tfeelgoodphysicallyoremotionally.

Forexample,wemay“catastrophize,”whichmeansassumetheworstwithoutgoodreason.Forexample,thebackmayhurtabitandweassumethatwewillwindupbackinsurgery,wheninfactthesensationmaybetemporary.Whileitiscommontothinkthiswayattimes,itisn’tahelpfulwaytothinkaboutourproblems.Individualswithchronicpainmayfeelverybadwhentheyfirstgetupinthemorningduetoarestlessnightofsleep.Thepersonmaybetired,stiff,andfrustrated.Astheythinkabouthowtheyfeeltheynoticethoughtssuchas“Ishouldn’tfeelthisway”or“I’llnevergetanybetter.”Thesethoughtsinturnaffectemotions,increasingfeelingsofworry,depressionandhopelessness.

Acommonemotionaloutcomeisbelievingthatotherswillthinkbadlyofthepersoninpainbecausethepersoninpainfeelsbad.Therearemanywaystoaddressthistypeofthinkingandbeliefs,butthebestmaybecognitivebehavioraltherapyorCBT.ThebasicideaofCBTisthatonecanchangehowtheyfeelbyrecognizingandchangingtheirdistortedthoughts.Keepinmindthateveryone,andwemeaneveryone,hasdistortionsinthinkingattimes.Themostcommontendtobeblackandwhitethinking,jumpingtoconclusions,minimizingsuccess,focusingonthenegative,andcatastrophizing.

Thegoodnewsisthatbyfirmlychallengingourthoughts,wecanchangehowwefeel,bothemotionallyandphysically.Takealookattheresourcesprovidedanddiscusswithyourhealthcareprovider.

Youmaywanttofindapsychologist,eitherindividuallyorinagroupsettingtoworkwithyourthoughts–justbecareful–makingthesechangesmightimproveyouroutlookandhowyoufeel!

Steps to Get There1. Learntorecognizeyourthoughtdistortionssothatyoucanbeginto

challengeandchangethem.Therearemanywebsitesandbooksthatcanhelp.

2. Seeksupportandfeedbackfromothersyoutrust,includingfamily,friends,andproviders.

3. Noticewhenyouusewordslikeshould,ought,must,neverandalways,eitherinyourheadoroutloud.Thesewordsareoftensignsofthoughtdistortionsandcanbeasignaltoexamineandconfrontyourthoughts.

4. Considerseeingatherapistwhousescognitivebehavioraltherapy(CBT).Thisisapractical,generallyshorttermtherapyfocusedonteachingyouhowtochangeyourownthoughtsandfeelings.

Resources• FeelingGoodbyDavidBurns

• NationalAssociationofCognitiveBehavioralTherapists,www.nacbt.org

• RationalEmotiveBehaviorTherapy,www.rebtnetwork.org/whatis.html

Joy, Pleasure and Spirituality Louise Berkowicz, M.D.

Ourthoughtsandemotionsaffecthowourbodiesworkandfeel.Forgettingto“smelltheroses”iscommonwhenapersonhaschronicpain.Findingjoy,pleasureandconnectiontolifehelpsusfocusonthepositiveaspectsofliving.

Asyouworktobuildandkeepasenseofwellbeingandconnectedness,lessenergyandattentionwillbepaidtoyourpainpathwaysandpainwilloftendecreasenotably.Certainpracticesandexerciseshelptoincreaseawarenessofthemind/body/spiritconnection.Dotheseexercisesoftentohelpyoutrainyourbrain.

Steps to Get There1. Deep Breathing:Breathinslowlycountingtofiveandfillyour

lungssothatyourstomachexpandsbutyourshouldersdonotlift.Expandingyourlungsfullycantriggerarelaxationresponse.Repeatbybreathingoutforacountoffiveandthenbreathingintofive.Repeatuptotentimes

2. Meditate:Meditationcanmeanmanydifferentthings.Somepeopleuseitasatimetothink.Othersmeditatewhilewalkingorrunning.Findtechniquesthatyouenjoy.Meditatetwiceaday

3. Eat Mindfully:Occasionallyeatinsilence,cheweachbite20timesandenjoythetaste.Thisenhancesappreciationoffood.

4. Laugh Often:Laughinghasmanygreathealtheffects.Itboostsyourbody’sabilitytofightgerms,increasesenergyrelievesachesandpains,lowersbloodpressure,andimprovesmood.

5. Be Gentle and Kind to Yourself:Saypositivewordstoyourselfsuchas“Iamwonderful,Ihonorandrespectmyself,Ilovemyself.”Dothisdaily.

6. Express Yourself:Speakfromanopenheartandbetruetoyourselfandothers.

7. Exercise:Chooseanexerciseyouenjoyanddoitdaily.

8. Learn:Lookatthelessonsyouarelearning,especiallyintimesofdifficultyandchallenge.

9. Be Mindful:Taketimetobeawareofthebeautyaroundyou,fromnaturetothehumantouch.

10.Be Grateful:Whenyouwakeup,thinkofonethingforwhichyouaregrateful.

11.Notice Stress:Becomeawareofhowyourbodyreactstostress.Relax(see#1,#2and#4)tohelpdealwiththestress.

Resources• The Wise HeartbyJackKornfield,Ph.D.

• The Four Agreements: A Practical Guide to Personal FreedombyDonMiguelRuiz

• Anatomy of the SpiritbyCarolynMyss,Ph.D.

• A New EarthbyEckhartTolle

• Vibrational MedicinebyRichardGerber,M.D.

• LaughterYogaInternational,www.laughteryoga.org

• HelpGuide,www.helpguide.org/life/humor_laughter_health.htm

• UniversityofMarylandMedicalCenter:Laughteristhe“BestMedicine”forYourHeart,www.umm.edu/features/laughter.htm

• ISSEEM(InternationalSocietyfortheStudyofSubtleEnergiesandEnergyMedicine),www.issseem.org

• IONS(InstituteofNoeticSciences),www.noetic.org

• WilliamA.TillerFoundation,www.tiller.org

• MindBodyMedicineCenter,www.cmbm.org

• WisdomatWork:JoelandMichelleLevey,www.wisdomatwork.com

Chapter Four:

Outsidethe“Box”Relationships Allen Hume, Ph.D. and Maureen C. Pierce, Ph.D.

Painoftenaffectsourrelationshipswithothers,includingfamily,friends,employersandphysicians.Oftenthepersoninpaindoesn’twanttofeellikeaburdentoothers;othertimestheyseemtowanttohavesomeoneelsetakecareofeverythingforthem.Thefamilymemberorfriendmayfeelhelplessandunsurehowtohelp—infacttheymaynotunderstandhowthepersoninpainisfeeling.Sowhatdoyoudo?

Youmightbesurprisedathowsimilaryourfeelingsandthoughtsarewiththosearoundyou.Manytimespeoplefeelpowerless,outofcontrol,angry,andfrustratedbutweoftenfeelbetteroncewehavetalkedtoourfriends,family,andothers.

Steps to Get There1. Askforwhatyouneedfromothers–don’tassumethattheyknow.

2. Talkaboutyourconcerns.

3. Balanceyourneedswiththeotherperson’sneedsaswell.

4. Pointoutcommongoalsandtryworkingthroughyourdifferencescalmlywithoutraisingyourvoice.Trynottobedefensive.

5. Rememberthattheotherpersonmaynotknowhowyoufeel—useclearlanguageandcheckintoseeiftheyunderstood.

6. Rememberthatpainisonlyonepartofyourlife.It’sokaytoletothersknowthatyouwanttotalkabout“normal”things.

7. Dowhatyoucantoenjoytimewithfriendsandfamily.Remembertotakeiteasy,becompassionate,theymaynotthinkaboutthingsthewayyouhavecometounderstandthem

8. Trynewactivitiesandinvolveothers.

9. Rememberthatfamilyandfriendswanttobesupportiveandunderstanding,evenifyoufeelliketheydon’t.Letthemknowitisokaytonotknowwhattodoorsay.Familyand/orcouplestherapymaybehelpfulaswell.

Resources• AmericanPsychologicalAssociation,

www.apa.org/monitor/jan06/chronic.aspx

• RelationshipsandPain,www.goalistics.com/tag/relationships-and-pain/

• HealthTalkOnline(UnitedKingdom),www.healthtalkonline.org/chronichealthissues/Chronic_Pain

Hobbies Gordon Irving, M.D.

Manypeopleinpainfeeltheycan’tdoorenjoyanything..Isthisyou?Haveyouhadtostopdoingsomethingyoulovebecauseyoufeltyoucouldnolongerdoit?

Thegoodnewsisthatyoucanoftenfindawaytodoitbutatalowerintensity.Tryanewhobbyoroneyouhadbeforeyouexperiencedchronicpain.

Youcanuseanyhobbythatyouhaveenjoyedinthepastorwanttodonow.Sometimesjustwritingdownthestepsyouneedtogetthereisimportantinmotivatingyoutodoit.Onepossibilityislearningmagic.

MagicAlan Kazam

Ifyouenjoyedentertainingpeoplewithmagictrickswhenyouwereyoungerwhynottryitagain?Evenifyoudon’thaveexperience,whynottrysomethingnew?

Becoming a magician

Learningsomesimplemagictrickswillworkyourbrainandyourbody,plusitwillgiveyouanewskillwhichyoucanusetoentertainfamilyandfriends.Evenpeoplewithdisabilitiescandomagic:famousArgentineanmagician,RenéLavand,performedgreatsleightofhandeventhoughheonlyhadonehand!

BeforewebegintherearethreerulesthatyouMUSTconsenttocalled“themagician’scode.”Therulesare:

1. Practice,practice,andpracticetricksbeforeyoushowthemtoanyone.

2. Neverrepeatthesametrickforthesamepeople.

3. Nevertellhowyoudoyourtricks.

Magicisbasedonsimpleprinciplesandifyouraudiencefindsouthowitisdone,themagicdisappears

Steps to Get There

VisitamagicshopandaskthemtohelpyoufindbooksorDVDstostudy(seeresources.)Getadvicefromothermagiciansatclubs,magicshops,orontheInternet(seeResources.)

Magiccanhelpwithmanycommonsocialandworksituations.Toperformmagicmeanslearningtobeconfidentinpublicandunderstandinghowtocontrolaudiences.

Resources• Mark Wilson’s Complete Course inMagicbyMarkAnthonyWilson.

Thisisremarkablyinexpensiveforwhatitcontainsandmanymagicianswouldrecommenditasafirstbook.

• JaySankey’sAmazing Magic and Mentalism that Anyone Can Do—Volumes1and2DVDs.TheseDVDscanalsobeorderedfromhiswebsite,www.sankeymagic.com

• LearnMagic,www.magic.about.com/od/beginningmagic/u/learnmagic.htmThishaslotsoffreetrickswithexplanatorypictures,greattipsforbeginnersandplentyoflinkstoothersiteswhereyoucangetevenmorefreetricks.

Chapter Five:

CaringforYourBodyNutrition and Weight ManagementGordon Irving, M.D.

Goodnutritionimprovessleep,energylevels,mentalfocusandemotionalhealth.Ourfoodchoiceshelpfightgerms,soifwearen’teatingwellwearemorelikelytobecomesickorfeelpoorly.

Poornutritionand/oreatingcalories,particularlyderivedfromprocessedfoodsandsugarmaycauseweightgainandobesity.Abodymassindex(BMI,whichisyourweightinpoundsdividedbyyourheightininches)of30ormoreindicatesobesity.ABMIofmorethan40iscalledmorbidobesityandcarriessignificantriskofshorteningyourlife.Obesitymakespainworseandincreasesstressonyourknees,hips,andotherjoints.Itisimportanttoloseweightforyourhealthandtocontrolpain.

How does nutrition help pain?1. Manypainsufferershavefoodsensitivitiesthattheymayormaynot

knowabout(seetheeliminationdietlistedbelow).

2. Somefoodscauseinflammationinthebodywhichcanmakepainworse.Youmayhelpyourpainbyeatingfoodsthatdecreaseinflammation.Searchtheinternetfor“anti-inflammatoryfoods”formoreinformation.

3. Beingoverweightcancausepainalloverthebodypainaswellasintheknees,hips,orback.Losing10-15poundsinweightcandecreaseyourpainsignificantly.

Changinghowyoueat,drink,andexercisecanbehard,buttheresultsarerewardingineverypartofyourlife.Itcanhelpyouthinkclearly,improvememory,andbetteryourmoods.Eatinghealthilycanalsohelpyoudecreaseyourriskofheartdisease,diabetes,andcancer.

Ifyouareoverweight:

1. Checkyourweightatleastonceaweek.

2. Focusonlosingonetotwopoundseveryweek.Cutoutsodasandfriedfoodasafirststep.

3. Usemeasurementtools(cups,spoons,andfoodscales)andreadnutritionlabels.Patientswhoneedtoloseweight,especiallythosehavingtrouble,maynotrealizehowmanycaloriestheyeat.Thesetoolscanhelp.

4. Loweryourbodymassindex(BMI)(weightinpoundsdividedbyheightininches)tolessthan30.Weightlosslastslongerforpeoplewhoarehappywiththeirresultssoaimforrealisticgoals.Thiswillhelpbuildyourconfidencesoyoumaynotneedprofessionalhelp.

Steps to Get There

Belowisalistoftipstoimproveyournutrition.

• Choose a diet that follows basic rules. Thereisnosingledietthatwillworkwellforeveryonewhoneedstoloseweight.Thebasicruleofanyhealthydietistolimitfoodsthatarehighinunhealthyfat,getplentyofhealthyproteinsuchasskinlesschicken,non-fattymeatportions,orfish,eatmorevegetables(exceptpotatoeswhicharehighincarbohydrates)andfreshfruit(exceptbananaswhicharehighinstarch)anddrinkplentyofwater.Avoidsodas,evendietsodas.

• Eat only at meal times.

• Choose foods that you enjoy. Findinghealthyfoodsyoulovetoeathelps!

• Remove triggers for overeating:o Gotothegrocerystoreafteramealtopreventimpulsebuys.o Keepunhealthyfoodoutofsight.o Avoidbuyingunhealthyfood.

• Shopping:Whenyoushop,usecashinsteadofyourcreditcard;thismayhelpyoufrombuying“comfortfood”.

• Have a reward system:Setweeklygoalsandrewardyourselfwhenyoureachthem,butnotthroughfood.Tellyourself“I’vebeenOK,”“I’mdoinggreat,”and“Ihavetheabilitytoloseweightandtohaveanactivelifestyle.”

• Figure out your emotional eating cues and replace them with other behaviors.Choosebehaviorsthataredifficulttodowheneating(e.g.,writing,knitting,housekeeping,exercising,andtakingabath).

• Vitamin supplements: Somevitaminsupplementsmayhelp.VitaminDmayhelpwithmusclepain.HowmuchvitaminDyouneeddependsonmanyfactorslikesunexposure;skincolor;foodchoicesanddigestivehealth.IftakingamultivitaminsupplementmosthaveonlyrelativelysmallamountsofvitaminD.YoumayhavetotakeasinglevitaminDsupplementtogettothe2,000to4,000IU(internationalunits)perdaythatisfrequentlyrecommended.

• Nutritionists and Naturopathic doctors (NDs):Registereddietitiansandnaturopathicdoctorsaregreatnutritioncounselors.Seeanutritionistornaturopathtogethelpwithnewhealthyhabits.

• Elimination diets: Ifyouthinkyoumayhavefoodintolerances,tryingan“eliminationdiet”mayhelpyoufindoutwhichfoodsyouaresensitiveto.First,stopeatingallfoodsyoumaybesensitiveto.Thenreintroducethemonefoodatatime.Meetingwithadietitianornaturopathicdoctorduringaneliminationdietmayhelp.

o Keepafooddiaryandwritedownwhatandhowmuchyouateandanysymptomsyounotice.Thiscanhelpyouidentifyfoodallergiesorintolerances.

o Stopeatingthesefoodsfortwoweeks.Ifyoucannotdothisallatonetime,chooseafewandthentrynoteatingtheothersduringasecondtwo-weektrial.(Onlydotwotrials.)1. Dairyproducts,includingcheese.Instead,usesoymilk

andsoycheese,orricemilk,andrice-basedicecream.2. Eggandfoodswithegg.3. Foodswithgluten,suchaswheatandwheat-based

products(pasta/noodles,barley,oats,orryegrains.)Instead,youcaneatbrownrice,nuts,buckwheat,spelt,millet,potatoes,orsweetpotatoes.

4. Citrusfruits.5. Cornandfoodswithcorn.6. Plantsfromthenightshadefamily(tomatoes,potatoes,

eggplant,peppers,andtobacco.)7. Allprocessedfoods,includingcaffeine.Suddenlystopping

somefoods(suchasdrinkswithcaffeine)maycausewithdrawalsymptoms(suchasheadaches)butthisshouldonlylastafewdays.

o Aftertwoweeks,addbackonefoodgrouptoyourdieteverythree-fivedays.Writingdownwhatyouareeatingandhowyouarefeelingduringthistimecanhelpyoutonoticehowafoodmaybeaffectingyourmood,energy,andpain(usingnumberstorankhowyouarefeelingmaybehelpful).

o Yourpainmayflare-uporyoumayfeelmoretiredwhenyoueatsomethingthatyouaresensitiveto.Ifyounoticethis,youmaywanttostopeatingthatfood.

Resources• Good Calories, Bad Calories and Why We Get Fat: And What to Do

About ItbyGaryTaubes

• The Primal BlueprintbyMarkSission

• New Atkins for a New YoubyDrs.EricC.Westman;StephenD.PhinneyandJeffS.Volek

• The Dukan DietbyDr.PierreDukan

• The Paleo DietbyLorenCordain,Ph.D.

• USDACenterforNutritionPolicyandPromotion,www.cnpp.usda.gov

• AcademyofNutritionandDietetics,www.eatright.org

• CDCHealthyWeight:BMICalculator,www.cdc.gov/healthyweight/assessing/bmi/

• HarvardSchoolofPublicHealth,TheNutritionSource,www.hsph.harvard.edu/nutritionsource

• TheVegetarianResourceGroup,www.vrg.org

• PhysiciansCommitteeforResponsibleMedicine,www.pcrm.org

• MemorialSloan-KletteringCancerCenter:Herbaltherapieswww.mskcc.org(searchfor“herbs”)

Smoking Gordon Irving, M.D.

Mostpeoplearesurprisedtolearnthatsmokingmakespainworse.Oneofthebestthingsyoucandotohelpyourpainistoquitsmoking.Smokingchangeshowyourbrainandbodyfeelpain.Mostpeoplethinkthatsmokinghelpswithstress.Infact,smokingcausesstressonthebody,anditislinkedtomoreanxiety.Cigarettesmokekeepsoxygenfromgoingtoyourdiscsandthetightmusclesaffectedbypain.Byquittingsmokingyouwillsavemoney,improveyourphysicalandemotionalhealthANDyouwillimproveyourpain!

Why should I stop smoking?1. Overtimesmokingmakesyourbrainmoreanxious,stressed,and

tensed.Likeanyhighlyaddictivedrugyouthenhavetotakeanothercigarettetoavoidwithdrawaland“feelbetter”.

2. Foranhouraftersmoking,oxygencannotgettoareasofyourbody,suchasthediscsofthespineortightmuscles.Smokerstendtohavemorebackandmusclepain.

3. Smokingmaymakesomepainmedicationsnotworkaswell.

4. Inastudy,peoplewhohadlungcancerandcontinuedtosmokehadmorepainthanthosewhostopped.

Steps to Get There

Belowisalistoftipstohelpyoustopsmoking.

1. Keep telling yourself your reasons for quittingandimagineyourselfasyou’dliketofeel,enjoyingyourfavoriteactivitieswithoutsmoking.

2. Promise yourself something you enjoy,suchasamovieordinneroutasareward,forgettingthroughthefirstweek.

3. Get involved in activitiesthatdon’tgowithsmoking,suchasmeditationorexercise.

4. For two days before you quit, every time you smoke, write down the feelings you had before smoking each cigarette:

• Wereyoutired?Bored?Hungry?Restless?

• Writedownthepositivefeelingthatcamefromsmokingeachcigarette.Didithelpyourelax?Didyoufeellessbored?Didithelpyouwakeup?Didithelpyougotoasleep?

• Studyyourlist.You’llprobablynoticeapattern.Considerhowyoucouldsubstituteamorepositivelifestyletogetthatsamefeelingsuchasanactivitylikeabriskwalk.

5. Make specific plans ahead of time for dealing with temptations.Findtwoorthreecopingstrategiesthatworkforyou,suchastakingawalkorcallingafriend.

6. Set a quit date.Ifyousmokemostlyatwork,tryquittingonaweekend.Ifyousmokemostlywhenrelaxingorwithfriends,quitonaweekday.

7. Find things to distract you when you start feeling like smoking.Ifyousmoketorelax,figureouthowtorelaxwithoutacigarette.Ifyousmoketoclearyourmind,figureouthowtodothatwithoutacigarette.

8. Get help from family and friends.Theycan’tquitforyou,buttheycanhelpbynotsmokingaroundyou,listeningtoyourstrugglesandencouragingyou,andleavingyoualonewhenyouneedsomespace.

9. Make it clear to your smoking friends that you don’t want them to give you a cigarette.Whenpeoplerelapseandsmoke,theyusuallygettheircigarettesfromfriends.

Helpful Hints• Theaveragepersonquitsuptoninetimesbeforetheyareableto

staysmoke-free.Ifyoureturntosmoking,itdoesn’tmeanyoucan’tquit.Itjustmeansyouneedtotryagain.Findoutwhatcausedyoutoslipupandchangeyourplanfornexttime.

• Askyourdoctoraboutotheroptionstohelpyouquit.Tryasupportgroup,anindividualcounselororothersourceofhelpifyouhavenotbeenabletoquitonyourown.

• Youdonotreduceyourhealthrisksbysmokinglowtar/nicotine.Smokelesstobacco,pipesandcigarsarejustasharmful.

• Ascientifictrialofcytosine,soldoverthecounterasTabex,showedsimilarresultstonicotinereplacementtherapywithnoserioussideeffectsreported.

Resources• SmokingCessation,www.smoking-cessation.org

• NationalInstitutesofHealth:MedlinePlus,www.nlm.nih.gov/medlineplus/quittingsmoking.html

Physical Activity Gordon Irving, M.D.

Painmaygetworsewhenyoudotoomuchortoolittleactivity.Ifwearenotactiveenough,ourbodiesagemorequicklyandourmusclesgetweak.Researchshowsthatcontrolledexercisecanhelpchronicpainbetterthananyothertreatment,includingmedication!

Exerciseisalsooneofthebesttreatmentsforanxiety,stress,anddepression.Butifpeoplewithchronicpaintrytodotoomuch,theirpaingetsworseanditmaytakedaystofeelbetter.

Beginningagentleexerciseprogramisoneofthebestthingsyoucandotohelpyourbodyandyourpain,butgoslowly.Youcanreducethepressureonyourselfbysettinggoalsyoucanmeet.Havingpainmeansyoucan’tdoallthingsyouusedtodo.Pushingyourselftodomorethanyouareablemayleadtomorepain,bothphysicalandemotional.

Steps to Get There1. Pacingmeansstartingslowandfiguringouthowmuchyoucando

withoutcausingyourpaintoflareup.Startbywalkingtothemailboxtwotothreetimesaday.

2. Frequency:Doinganactivitymoreoftenduringthedaymayallowthebodytorecoverandstrengthen.

3. Onceyouhavedoneanactivitythreetimes,tryincreasingthedistanceortime.Beforelong,youwillbedoingmoreactivityonaregularbasisthanyouhavedoneforalongtime,andfeelingthementalandphysicalbenefits.

4. Exercisingdailycanhelpyoumovemoreeasilyandwithlesspaininaslittleasthreeweeks.

5. Rememberevenifyoustartslowly,pacingandconsistencyarethekeys.

6. Exerciseisnotaboutovernightsuccess,butifyouareconsistentandpatient,youwilllikelymeetyourgoal.

7. Workuptoexercisingforatleasttwoandahalfhoursaweek.

8. Recordhowmuchyouexercisecurrently.Checkhowmuchyouwalkeverydaybyusingapedometer.Workupto10,000stepseveryday.

9. Bothaerobicexercise(likewalkingorrunning)andstrengthtraining(liftingweights)areimportant.Startoffusingsmallerweightsandhigherrepetitions(numberoftimesyoulifttheweights).

10. YoumaywanttotryTaiChi,whichresearchhasshowncanhelppainsufferers.

Helpful hints1. Doexercisesyouenjoy.Walkingisoftentheeasiestbecauseallyou

needisyourlegs.Swimming,biking,TaiChi,yogaanddancinghelpchronicpain,too.Trydifferentactivitiesondifferentdaystokeepfromgettingbored.

2. Trytoexercisewithapartnerorpet.Takingadogforawalkisgoodforbothofyou.

3. Getapedometer.Setweeklygoalsthatinvolveincreasingnumberofstepsorlengthoftime(e.g.,walk500morestepseveryweek)

4. Makeexerciseapriority.Setascheduleandsticktoit.

5. Listentoyourbody.Setgoalsthatworkforyou:Nogoalistoosmall.

Resources• 23 and ½ Hours: What is the Single Best Thing We Can Do For Our

Health?ByMikeEvans,M.D.,http://goo.gl/zVZPM

• TheChronicPainHaven,www.chronic-pain-haven.com/exercise.html

Headache ManagementHubert A. Leonard, M.D., Ph.D.

Types of Headaches• Tension headachesarethemostcommontypeofheadache.

Asmanyas90percentofadultshavehadorwillhavetensionheadaches.Theyaremorecommoninwomenthanmenandarenotasbadasmigraines.

• Migraine headachesarethesecondmostcommontypeofheadachebutthemostcommonheadachecausingdistressanddisability.Anestimated30millionpeopleintheUnitedStates,about12percentofthepopulation,willexperiencemigraineheadaches.Anestimatedsixpercentofmenand18percentofwomenwillexperiencemigraineheadaches.Chronicmigraine(morethan15daysofheadacheeachmonthwithatleasteightdaysofmigraine)affectsone-and-a-halftotwo-and-a-halfpercentofAmericansandcausesdisability.Migraineismorethanjustheadache;itinvolvesnauseaand/orvomitingorsensitivitytolightandsound.

Stages of Migraine

Identifying Your Level of Disability

Migrainedisabilityisdifferentforeveryone.Treatmentdependsonthelevel/stageofdisability.InManagingMigraine(seeResourcesList),theauthorstalkaboutfourstagesofdisability:

• Stage 1: Migrainesonlyhappenonceinawhile.Betweenmigraines,peoplefeelnormalanddonotfearanotherone.Strongmedicationsworkwell.Migraineisshort-livedandnotadisease.

• Stage 2:Migraineshappenmanytimeseverymonthandgetinthewayofdailylife.Peoplehavethreetoeightheadachedaysamonthwithsomedisability.Medicationmaynotalwayswork.Migrainemaygetinthewayofsleepandaffectmood.Eatingwell,exercise,anddailymedicationmayhelp.

• Stage 3:Peoplehave10to14headachedaysamonthforatleastthreemonths.Medicationsmayhelpbutpainmaycomeback.Theymayhaveanxiety,badmoods,andtroublesleeping.Theymaymisswork,school,orfamilyevents.Theymayoverusemedications.Eatinghealthy,excising,andtakingdailymedicationisneeded.Oftenthereareothermedicalorpsychiatricissuesthatmustbeidentifiedandtreated.

• Stage 4:Headacheshappenon15ormoredaysamonth.Overuseofmedicationoftenbecomespartoftheproblem.Mostpeoplehavetroublesleeping,depressionandotherproblemswiththeirhealth.Thesepeoplehavechronicpainthatcanonlybetreatedwithbiglifestylechanges,dailymedication,andhelpfromapainpsychologistandothers.

Steps to Get There

Know Your Triggers

• Some foodsmaycausemigraineheadachesbutthisisdifferentforeverybody.Also,thesefoodswillnotalwaysbringonamigraineheadache.Somecommontriggersincludealcohol,monosodiumglutamate(MSG),citrusfruit(lemons,lime,orangesorgrapefruits),aspartame(onekindofartificialsweetener),caffeineandagedcheeses.

• Caffeine–foundinsodas,coffee,tea,chocolate,caffeinepills,somemedicines,andpainkillerslikeAnacin,Empirin,MidolandExcedrin–isamajorcauseofheadaches.Theheadachepainkillerscancausea“rebound”effect:Youtakeittogetridoftheheadache,whichgoesaway,butthencomesbackworsethanever.Trytoremoveallcaffeinefromyourdiet.Althoughyoumayhavewithdrawalsymptomsforafewdays,includingheadaches,itwillbeworthit.

• Medical issuescancauseheadachesandmigraines,includingmentalstress,drugsofalltypes,thyroidproblems,diabetes,chronicpain,lowmagnesium,andbraindiseases.

• Alcoholcancauseheadachesormigrainesbyitselforbycausingdehydration.Toavoiddehydration,drinkwaterwhileyouaredrinkingalcoholandbeforebedtime.

• Smokingcancauseheadachesbecausethenicotineandcarbonmonoxideincigarettesmokeaffectthebloodvessels.Secondhandsmokecausesheadachesinsomepeople.

• Stressisthemostcommoncauseofheadaches.Knowthecommonsourcesofstressathomeandatwork.Ifitisdifficulttogetridofthestresses,gethelpfromotherfamilymembersorthroughapsychologistorcounselor.

Treat the Symptoms without Medication

• Rest in a cool, dark, and quiet place.Usecoldcompresses,anicepack,orabagoffrozenvegetables.Somepeoplefindheathelps.

• Changing behavior helpscontrolheadaches.Eatahealthydiet,getenoughsleep,drinkatleastaliterofwateraday,andfindwaystomanagestressfulrelationshipsandresponsibilities.Learnhowtosay“No.”

• Havesomeonemassageyourneckandlowerback.Tryahotshower.

• Acupressureisgoodforpainrelief.Placeonefingerbetweenyoureyebrowsandanotherfingeronthetopofyourhead.Pushgentlyandholdfortwominutes.Anotherpressurepointisbetweenyourthumbandindexfinger.Pushtherefortwominutes.

• Relax!Tensionisamajorcauseofheadaches.Liedownwhereitisquietandbreatheinforeightseconds;breatheoutslowly.Dothismanytimesuntilyoufeelyourselfrelaxing.Breathedeepintoyourbelly.

Resources• Managing Migraine. A Patient’s Guide to Successful Migraine Care

byRogerCadyetal.

• Heal Your HeadachebyDavidBuchholz,M.D.

• NationalHeadacheFoundation,www.headaches.org

ClickonFAQ’s(frequentlyaskedquestions).Overtensubsectionscoveringdifferentheadachetopics.

• AmericanHeadacheSociety,www.achenet.org/resources/articles

• ManagingMigrane,www.managingmigraine.org

Chapter Six:

ComplementaryTherapiesforPainComplementary and Alternative Medicine (CAM)Gordon Irving, M.D.

Itisnormaltowanttotreatyourpaininanywaythatworksandisnotharmfultoyou.ManypeopleuseCAMtherapyandmostofthisbookletisaboutcomplementarytherapysuchasexercise,relaxation,andmeditation,whichcandecreasepainandimprovefunction.Manyherbals,vitamins,andnaturalproductshavenotbeenscientificallytestedforbenefit,sideeffectsorinteractionswithanymedicationsyoumaybetaking.Thereasonyougetinformationwithyourmedicineatthepharmacyisbecauseithasbeentestedandthesideeffectslisted.“Naturalproducts”arenotcontrolledbytheFoodandDrugAdministration(FDA)andtheirsideeffectshavenotbeenstudied.Usesiteslikewww.mskcc.org(searchfor“herbs”),www.naturaldatabase.com,orwww.sciencebasedmedicine.orgtolearnmoreaboutnaturalproducts.

Definitions

Complementary Medicine: Thisisusedwithstandardmedicaltreatment(e.g.acupuncturewithpainmedications)

Alternative Therapy:Thisisusedinsteadofstandardmedicaltreatment(e.g.aspecialdietforchronicstomachpain)

Integrative Medicine: Thistreatmentinvolvesthemind,body,andspirit.ItusesstandardmedicinewithCAMtreatments.ThatiswhatSwedishSTOMPhastriedtodo.

TherearefivemaintypesofCAM:

1. Mind-Body Medicines

• Meditation:Focusedbreathingandrepeatingwordsorphrasestoquietthemind.

• Biofeedback:Simplemachineshelpyoulearntochangemuscletensionandheartrate.

• Hypnosis:Relaxed,focusedattentiononafeelings,ideas,orsuggestionstoaidhealing.

• Yoga:Stretchesandposeswithattentiononbreathing.

• Creativeoutlets:Art,music,dance,etc.

2. Biologically based practices:Oftenfoundindietarysupplementsandherbalproducts:vitamins,herbs,foods,andspecialdiets.

3. Manipulative and body based practices

• Massage

• Chiropracticcare:Adjustingthejointsandspine.

• Reflexology:Pushingonpartsofthehandsandfeettoaffectotherpartsofthebody.

4. Energy medicines

• TaiChi:Slow,gentlemovementswithafocusonbreathandconcentration.

• Reiki:Balancingenergyeitherfromadistanceorplacinghandsonornearthepatient.

• Therapeutictouch:Movinghandsoverenergyfieldsofthebody.

5. Whole Medicine Systems

Comesfrommanyareasandculturesoftheworld.

• Ayurvedicmedicine:FromIndia,balancesbody,mindandspirit.

• Chinesemedicine:Balancesthebody’stwoforces,yinandyang.

• Acupuncture:Thinneedlesstimulatepointsonthebodytoclear“blockages”andpromotehealth.

• Homeopathy:Verysmallamountsofsubstancesareusedtohelpthebodyheal.

• Naturopathicmedicine:Usesdifferentmethodstohelpthebodyheal.

How will you know which may work for your pain?

FindingaCAMpractitioner:

• Askyourdoctortosuggestsomeone.

• Askifyourhospitalkeepsalistofcentersorhasstaffthatcansuggestsomeone.

• ContactCAMprofessionalorganizationstogetnamesofpractitionerswhoarecertified.

• Askaboutthepractitioner’strainingandexperience.

• Callyourhealthcareplantoseeifitcoversthistherapy.

Things to Consider:

• Justbecauseaproductisnaturaldoesnotmeanitissafe.Someproductsmayinterferewithyourusualmedications.

• SupplementsdonothavetobeapprovedbytheFederalGovernmentandsomemaynotcontainwhattheysaydo.

• LookonthelabelforproductsproducedinGermany.Theyarequalitycontrolledbythegovernmentsodocontainthestatedamountofproduct.

• Dosomehomeworkbeforeyouspendyourmoneyonanherbalornaturalremedy.

Resources• NationalCenterforComplementaryandAlternativeMedicine,

www.nccam.nih.gov

• MedlinePlus,www.medlineplus.gov

• PubMed,www.ncbi.nlm.nih.gov/pubmed

• MemorialSloan-KetteringCancerCenter,www.mskcc.org(searchfor“aboutherbs”)

• NaturalMedicinesComprehensiveDatabase,www.naturaldatabase.com

• Science-BasedMedicine,www.sciencebasedmedicine.org

Chapter Seven:

MedicationsPain MedicationsGordon Irving, M.D.

Helpful hints1. Painmedicationswillnotblockallpain.Mostmedicationseven

whentheyworkwillonlylowerpainbyaboutathird.

2. Whenyouhaveapainflare-up,takingmoremedicationthanprescribedmaynothelpandyoumayrunoutofyourprescriptionearly.Ifyouusemorepillsoneday,uselessoverthenextfewdayssoyoudonotrunout.

3. Takeshort-actingpainkillersbeforeyoudosomethingyouknowwillbepainful—forexample,gardening.Thismaystopthepainfrombecomingintense.

4. Trytohaveafewpainpillsleftoverattheendofthemonthsoyoualwayshaveatleastathree-daysupply.Havinganextrasupplydecreasesyouranxietywhenyougetclosetoyourrefilldate.

5. Alwaysgetarefillbeforeyouneeditsoyouarenotwaitinguntilthelastminute.

6. Youaretheonlyonewhoreallyunderstandsyourpainproblemandyourneeds.Itisuptoyoutocreateapain-managementplanwithyourdoctor.Yourprovidermaynotalwaysunderstandyourpain,anditmaysometimesbehardtoreachthem.

7. Medicationsareonlypartofthesolutionandwillnotsolveallyourpain.

a. Usingyourotherpain-managementtipsarejustasimportant.

b. Learntopaceyourselfduringactivities.

c. Avoidtryingtogeteverythingdonewhenyouarefeelinggoodbecauseitmaymakeyoufeelbadlater.

8. Youcanhavealifeevenwithpain.Thosewithpainwhodothebestarethosethataccepttheirlimitationsbutlivelifefully.Understandyourfears.Ifthefearofmorepainkeepsyoufromdoinganything,itcanincreasedisability.Whenyouarelessactiveyouhavemoretimetodwellonyourpain.Youwillhaveevenmorelimitationsovertime.

10. Thecureisinsideyou.

• Payattentiontoyourbodyandfeelings.

• Becomeanactivepartofyourhealthcareteam.o TheSTOMPprojectwillgiveyouthetoolstoimproveyourlife.o Youaretheonlyonewhocanworkwithyourteam.

• Youhavethemosttogain.

11. Remembertokeepyourpainmedicationssafe!

Common Medication Concerns1. Long-termopioids,includinghydrocodone,oxycodone,

hydromorphone,fentanyl,morphine,methadone,oxymorphone,buprenorphineandtapentadol

• Highdosestakenforalongtimemaymakeyourbodymoresensitivetopain[opioid-inducedhyperalgesia].Theonlyfixistostoptakingthemedication.

• Thesedrugsmayaffecthowyourbodyfightsgermsandlowerhormonessuchastestosterone,estrogen,andcortisol.

• Highdosesmayincreasefalls.Iftestosteronehasalsobeensuppressed,brokenbonesaremorelikely.

• Theymayaffectsleep[centralsleepapnea].

• Theyshouldneverbetakenwithalcohol.

• Otherdrugsthataffectthebrainlikebenzodiazepines(valium,Ativan,Xanax)increasetheriskofoverdoseandseriouslyaffectyourabilitytodrivesafely.

2. Benzodiazepines:Valium,Ativan,Xanax,andtemazepam

• Chronicpainisusuallylinkedtoanxiety.However,long-termusesofbenzodiazepinesdoesnottreatchronicpainwell.

• Theymaypainworse.

• Theyarealsoveryaddictiveandaffectsleep.

• Ifshort-actingones(Xanax,Ativan)arestoppedsuddenly,seizuresmayoccur.

3. Musclerelaxants:Flexeril,Soma,Robaxin,Zanaflex,Skelaxin,andbaclofen

• Mostofthesedrugsareveryoldandhaveneverbeentestedtotreatpain.Theyeachaffectthebodyindifferentwaysandsomaisaddictive.

• Likemanymedicationsforchronicpain,thesedrugsshouldbeusedaslittleaspossible.

4. Acetaminophen(Tylenol)

• Donottakemorethanthreegramsperday(forexample,6extra-strengthTylenol).Takelessifyouhaveanyliverproblemsordrinkalotofalcohol.

• Thisdrugcancauseliverandkidneyfailurewhentakenforalongtime.

• Somemedications,suchasVicodinandPercocet,containacetaminophen.Thisshouldbeaddedinyourdailydose.

5. Anti-InflammatoriessuchasAdvil,Aleve,ibuprofen,andCelebrex

• Thesedrugsmaycausestomachandintestinalbleeding,kidneydamageandhighbloodpressure.

• Theyoftendonothelpchronicpainexceptwhenthereisaflare-upduetophysicalover-activity.

• Iftheyarenothelping,donottakethem.Theyaredangerous.Over14,000Americansdiefromanti-inflammatorydrugseveryyear.

Common Side Effects

Allmedicationshavesideeffects.Someareobvious,othersarenot.

• Constipation:Manypainmedications,especiallytheopioids,causetheguttoslowdownandabsorbmorewater.Treatmentsincludelaxatives,eatingfiber,drinkingmorewater,andtakingstool-softeningmedicine.Thestoolshouldbesoftandyoushouldnotfeelbloatedafter.Ifyoustillhaveproblems,talktoyourdoctor.

• Dry mouth:Manymedicationsmaysloworstopyoursaliva(spit).Lesssalivacancausestomachache,mouthburning,difficultytalking,andcavities.Ifyoufeelyourmouthisdrybecauseofyourmedications,gotoyourdentist,drinkmorewater,usefluorideandmouthwash,andtryothermedicationstoincreasesaliva.

• Drowsiness (feeling tired):Todecreasedrowsiness,takelessofthemedicationthatismakingyoutired.Askyourdoctorifyoucantakeitbeforebedorchangetoadifferentmedicationifthatdoesnothelp.

Resources• AmericanChronicPainAssociation,www.theacpa.org

• PainAction,www.painaction.com

Protecting Your MedicationsGordon Irving, M.D.

Why should I protect my medications?

Youareresponsibleforusingyourmedicationsafelyandkeepingitfrombeingabusedorstolen.Doctorswillrarelygiveyouextramedication.

Ifyougivesomeoneyouropioids,thiscouldbeacrimecalled“supplying.”

Steps to Get There• Donotshareyourmedicationswithanyone.

• Lockyourmedicationsinacabinetorsafeboxandhidethekey.Youcanbuytheseboxesfrommanystores.

• Donotuseabathroomcabinet.Theserarelylockandarethefirstplaceanystrangerorvisitorinyourhousewilllook.

• Makesureyourprescriptionhastherightnumberofpillsandcounthowmanyyouhavelefteveryday.Ifyouaremissingpills,askyourfamilyandanyoneelseinyourhomeaboutit.

• Ifyouaremissingpills,movethelockedcontainerandchangethelock.

• Remember,stealingnarcoticsacrimeanditistakingmedicationthatyouneedforyourpain.

• Ifyoudothinksomeonehasstolenyourmedicine,tellthepolice.Thiswillhelpyouandmayhelpthepersonwhostoleyourmedicine.

Resources• SafeMedication,www.safemedication.com/meds/medSafety.cfm

• SmartDisposal,www.smarxtdisposal.net/

• StopOverdose,www.stopoverdose.org/

Substance UseAllen Hume, Ph.D.

Alcoholanddrugusecanaffectpainmanagement.Followalldirectionswithmedicationssinceitcouldcauseproblemsifyoudonot.Whenusingmedications,besuretobehonestwithyourprovider,whowilllikelyhaveyousignacontractifyouareonopioid(i.e.narcoticpain)orbenzodiazepine(i.e.Valium,Xanax,etc.)medications.Thiscontractisforyoursafetyandshouldbefollowed.Usingotherdrugsand/oralcoholcanhaveveryseriousandevendeadlyeffectsifusedwithyourmedications.Whileitmayseemthatdrugsoralcoholhelpwithpain,anxiety,ordepression,donotusethemformanagingpain.Alcohol,prescribeddrugs,andotherdrugscanmakepainfeelworseandcanleadtoinjury.Overusecanturnintoaddiction.Ifyouhaveconcernsaboutaddiction(yoursorafamilymember’s)seethelinksbelow.Remember,makinghealthychoicesaboutyourusagewillmakepainmanagementmucheasierforyou.

Steps to Get There1. Behonestwithyourselfandyourprovideraboutyouralcoholand

druguse.Thisincludesprescriptions,over-the-counter,andillicitdrugs,allofwhichcanaffectyourtreatment.

2. KnowyourfamilyhistoryofdrugandalcoholuseAddictionoftenrunsinfamilies.

3. Goonlineandtakeatestonyourdrugandalcoholuse.Talktoyourdoctororotherproviderandseektreatmentifneeded.

4. Therearemanyself-helpgroups,includingAlcoholicsAnonymous,NA,andRationalRecovery.Haveothershelpyoufigureoutifyouhaveadrugoralcoholproblem.Ifso,theycanhelpyougetbetter.

5. Learnaboutdrugandalcoholuse,eitheronyourownorwithaprovider’shelp.

6. Therearemanyexcellentproviderswhocanhelpyouwithyouralcohol,drug,andchronicpainissues.

7. Seekindividualand/orgroupcounselingtoaddressyourusageandconcerns.

8. Stayhopefulandoptimisticthatyoucanchangeyourbehavior,recover,andimproveyourpaincondition.

Resources• AlcoholScreening,www.alcoholscreening.org

• NationalInstituteonAlcoholismandAlcoholAbuse,www.niaaa.nih.gov

• NationalInstituteonDrugAbuse,www.nida.nih.gov

• AlcoholicsAnonymous,www.aa.org

• NarcoticsAnonymous,www.na.org

Chapter Eight:

RoleofProceduresSpinal InjectionsGordon Irving, M.D.

Therearemanypartsofthebackandneckthatcancausepain.Theseincludeligaments,muscles,joints,nerves,bones,anddiscs.Mostbackpaincomesfrommorethanoneoftheseparts.

Abulgingdiscordiscdegeneration,wherethepadsbetweenthebonesinyourspineweardown,isnormalasyouageandusuallydoesnotcausepain.Paingoingdownthelegorarmdoesnotmeanthereisa“pinchednerve”either.Apinchedorinflamednervewillusuallycausesudden,short,shootingpainsinthehandorfoot.Themostcommoncauseofbackpainforpeople20-50yearsoldarethepadsbetweenyourspinalbones(theintervertebraldisc);after65,itisarthritisofthespinaljoints.Themajorityofbackpaindoesnotneedinjectionsandcertainlynotsurgery.

HavinganMRIorCTscanofthespinewillnotusuallyshowthecauseofthepainunlessthereisapinchednerve.EvenX-rayscannotshowwhatiscausingpainandtheyareusuallynotneeded.Spinalinjectionsmaybeusedfordiagnosisandsometimestreatment.

Types of Injection• Trigger-point injections:Injectionsintoatightbandinamuscle

withalocalanesthetic(numbingmedicine).Thetightbandcausesortriggersoffpaininanareaawayfromthemuscle,hencethetermtriggerpoint.Theseinjectionscandecreasepain,loosentightmusclesandallowyoutostretchandstopthetriggerpointreforming.Triggerpointsareoftenoveracupuncturepoints.

• Acupuncture:Thinacupunctureneedlescanbeusedinclassicacupuncturepoints,justunderthesurfaceoftheskin,forelectricalacupuncture,orfor“pecking”treatments.totreatatriggerpointorgenerallytotreatpainorheadaches

• Ligaments:Ifnumbinginjectionshelpdecreasepain,prolotherapyinjectionsmaybeused.Fortheseinjections,amixtureoflocalanestheticdextrose(sugar)andsometimesothersubstancesareinjectedtocausecollagen(scartissue)tostrengthentheligamentandkillsmallpainnerveendings.

• Spinal joint injections (facet joint injections):Thesejointshelpthespinebendfromthetailbonetotheskull.Likeanyjoint,theycanbesprainedorgetarthritis.TheinjectionsareusuallydonewithX-ray,butultrasoundcanbeused.Numbingmedicineandsteroidsareinjectedintothejoint,orontothenervesinthejoint.Iftwoinjectionsandphysicaltherapyorexercisedonothelp,aradiofrequencyneurotomyprocedure(RF)mayhelp(seebelow).

• Radiofrequency neurotomy procedure:Aspecialneedleisplacednearthenervesinthepainfuljoints.Amicrowavecurrentintheneedlekillsthesmallnerve,soyoucan’tfeelpain.Thesenervesregrow,andifthejointproblemdoesnotgoaway,theRFproceduremayhavetoberepeated.

• Epidural injections:Thespacearoundthenervesinthespineiscalledtheepiduralspace.Thenerveexitsoutofthespinalbonesviatunnelscalledforamen.Epiduralinjectionscanbedoneintothemiddleofthespace(interlaminar)orintothetunnelfromtheside(transforaminal).Thetransforaminalrouteisusedifthereisaherniateddischurtinganerveinthatarea.Epiduralsteroidsareinjectedtodecreaseinflammationintheepiduralspace,becauseofadischerniationornarrowing(spinalstenosis).

• Selective nerve blocks:Blockingnerveswithlocalanestheticwheretheycomeoutofthespinehelpsdoctorsfigureoutwhichnerveiscausingpain.

• Disc injections (discogram):Althoughtheseinjectionsaresometimesusedtodiagnoseifadisc(padbetweenthespinalbones)isthecauseofpain,itcarriessignificantriskwithoftennotmuchlongtermbenefit.Blooddoesnotflowtothediscsoitcangetinfectedafteraninjectionintoit.Morethanonediscisusuallyinjected,whichcanbeextremelypainfuliftheyareacauseofpain.Oftenmorethanonedisccausesthepain,andtherearenotgoodtreatmentsformorethanonepainfuldisc.Theremaybeadvertisementsfor“minimallyinvasivediscsurgeries,”unfortunatelythemajoritycarrysignificantriskandhavenotbeenshownincarefulclinicaltrialstohelpinthelongterm.

Injection Facts1. Ifthefirstinjectiondoesnothelp,moreinjectionsinthesameplace

willnothelp.

2. Apositiveresultindicatingthatanareaiscausingthepainiswhenalocalanestheticnumbsthepainfortwoormorehours.Unfortunatelyevenifoneinjectionhelped,asecondinjectionmaynotwork.

3. Epiduralinjectionswillnothelppaininthemiddleofthebackthathasbeenpresentformorethanayear,unlessitisduetospinalstenosis.

4. Injectionsonlyhelpafewpatients.Weightloss,stoppingsmokingandexercisehaveallbeenshowntodecreasepaininthelongtermmoresuccessfullythaninjections

Problems with Spinal Injections

Thereareriskswillallinjections,especiallywithdiscinjectionsandsomeneckinjections.Bruisinganddiscomfort,infection,andreactionstothemedicationsarepossible,butrare.Epiduralandtransforaminalinjectionsintotheneck,however,havemanymorerisksandhavecauseddeath,strokeandparalysis.

Implantable Pain DevicesGordon Irving, M.D.

Spinal Cord Stimulators (SCS)

Thesearewiresthatsendasmallcurrenttothespinethatchangesthepainsignalsgoingtothebrain.Theyareusuallyusedforpatientswhoseusualtherapyhasnotworked.

SCShavebeenusedformanypainfulnerveconditions,includingfailedbacksurgerysyndrome,severebackandlegpain,andcomplexregionalpainsyndrome(CRPS)typesIandII(RSDandcausalgia).TheyareusedinEuropeforproblemslikesevereangina(chestpainbecauseofpoorcirculationtotheheart)andlegpainfrompoorcirculation.

Beforeimplantation,thewiresareplacedinthebackandconnectedtoanexternalgeneratorthatthepatientcancarryaround.Thepatientgoeshomeandhasanormalroutineforthenextweektoseeifthishelpsthepain.ThisisinexpensiveandreversibleandshowsifSCSwillworkovertime.Thepermanentgeneratorsareplacedinthebodyandcanberechargedathome.Thepatienthasahand-helddevicetoincreaseordecreasethestimulation.

Intrathecal Pumps

Thesepumpsareimplantedundertheskinandholdliquidmedications.Theypumpthemedicationthroughatubetothefluidaroundthenervesintheback(cerebrospinalfluid).Thisfluidbathesthespinalcordandthebrain,soitgetsthedrugtowherepainisfeltmoredirectly.Beforethepumpisplaced,thereisusuallyathree-daytrialinthehospital.

Themedicationusedisusuallyanopioid(morphine,hydromorphoneorfentanyl),baclofenforspasticity,orziconotideforneuropathicpain.Thereareothermedicationsthatmaybeused,includingclonidineandbupivacaine.Severalothersarebeingtested.

Problems include:• Thepumpcouldstoporthetubecoulddislodge.

• Scartissuecouldformatthetipofthetube,whichcanpressonthespinalcordandcausesevereproblemsincludingparalysisifnotcaughtintime.

• Thepumphastoberefilledeverytwotothreemonths.

Chapter Nine:

RoleofSpineSurgerySurgical Decision MakingDavid A. Hanscom, M.D.

Spinesurgeryisoftenagoodsolutiontostructuralspineproblems.Itisaverypoorsolutionwhenthesourcesofthepainaremuscles,ligaments,ortendons,orwhenthepainiscausedbyMindBodySyndrome.

Foraproblemtobeconsideredstructuralitmustbe:

• ClearlyseenonadiagnostictestAND

• Theremustbeclearsymptoms

Ifeitheroftheseisnotpresent,thenthesymptomsarenotstructural.Manypatientshavestructuralproblemsbutnosymptomsorthepainisfeltinanotherplace.Othershaveseverepainbutnormaldiagnostictests.

Everysymptomcouldbestructuralornon-structural.Evenifthereisaseeminglyclearsourceforthepain,itdoesnotnecessarilymeanthatiswherethepainiscomingfrom.Nervesarewhatcausethebraintofeelpainandyoubraindoesnotcarewhyorwherethepainsignaliscomingfrom.Treatingthepainpathwaysisalwaysmandatory.Thisappliestoeverypartofthespinefromnecktohips.

Commonanatomic(structural)diagnosesthatyoumayhearare:

• Degenerativediscdisease

o Degenerated(lossofwaterfromthecenterofthedisc)

o Bulgingdiscs(theouterringhascollapsedalittle)

o Herniated/ruptureddiscs(themiddleofthedischasbrokenthroughtheouterring)

o Spinalstenosis(narrowingofthespinalcanal,pushingonnerves)

• Spondylolithesis(slippageofonevertebraeonanother)

o Isthmic(smallbonydefectinthebackofthespine)

o Degenerative(thefacetjointsinthebackofthespinehavebrokendownandletthebackbonesmovearound)

• Spinaldeformity

o Kyphosis(hunchback)

o Scoliosis(sidewaysspinecurves)

• Brokenbones

Tumor,infection,autoimmunedisorders,andseveretraumahaveclearandspecialtreatmentsthatthisbookwillnotcover.

Overview — What May or May Not Be Causing Your Pain

Evenifyouhavetheseproblemstheymaynotcauseyourpain.Thesefactorsmakethemmorelikelytobepainful:

• Abnormalortoomuchmovementbetweenvertebrae(spinebones)(morethanthreetofourmillimeters)

• Apinchednerve.

o Thepressurecanbefromabonespurorsofttissueinthespine

• Deformitythatis:

o Decompensated(yourupperbodyisnotcenteredoveryourfeet)Youcanbetilted:• Forward• Sideways• Both

o Ascoliosis(sidewaysspinecurve)thatisworsewhenyouarestanding

o Spinecurvingthatgetsworse

• Abonebreakthathasnothealed:

o Inbabiesunderfourmonthsold

• Medications—Prednisone,anti-inflammatories,etc.,slowhealing

• Smokingandobesityalsoaffecthealing

Thesefactorsmakespineproblemslesslikelytocausepain:

• Littleornomotionbetweenvertebrae

• Completelycollapseddiscspace

o Thevertebraehavegetstucktogether

• Adiscthatdoesnotmovewillnotbeasourceofpain.

• Narrowingaroundanervewithoutpain

• Deformitythatis:

o Balanced(yourheadiscenteredoveryourfeet)

o Thesamewhenlyingdownorstanding

o Unchangingformanyyears

• Aspinebreakthathashealed

Theseproblemscancausebackorlegpain.Iftheproblemisjustlowbackpain,thenitismoredifficulttofindaclearstructuralsource.Withlowback,neckorthoracic(mid-body)pain,muscles,ligaments,andtendons(softtissue)arealwaysinvolved.Withjustlowbackpainwithoutsciatica,softtissuerehabilitation(i.e.physicaltherapy)isthefirststepbeforesurgery.Manypeoplecanavoidsurgerywithrehabilitation.

Itismucheasiertofindthesourceoflegpain.TruesciaticacausespainEXACTLYalongthenerve.Thepainmaybefeltjustonsomeparts.Thepainisusuallysteadyandlastshoursatatime.Oftenaspecificactivitywillsetitoff.

Surgery is Not the Only Answer

Manypeoplefeelthatifallelsehasfailed,surgeryistheonlyanswer.Itisonlytheanswerforaclearstructuralproblemwithmatchingsymptoms.Ifyoucannotclearlyfindthesourceofthepainthenhowcanyoufixit?

Theotherproblemwithspinesurgeryisthatitcouldcausefutureproblems.Oftenthesecanbeworsethantheoriginalissue.

Surgeryforaspecificstructuralproblemusuallyworkswell.

Surgery and Dentistry

Youcancomparespinesurgerywithdentistry.Adentistcanusuallyfindthestructuralprobleminyourtooththatiscausingyourpain.Itcanbeaninfectedrootormaybeacavitythathasgonedowntotheroot.Thechancesofadentalprocedureonthattoothrelievingyourpainisessentially100percent.Butifyourdentistcannotfindthesourceofyourpainandoperatesanyway,itisunlikelythatheorshewillsolveyourproblem.

Summary

Nomatterthepartofthespine,surgeryisonlyindicatedforaclearstructuralproblemwithmatchingsymptoms.Thediscomfortshouldbesevereenoughtowarranttheriskofsurgery.Asyoursurgeonisnotabletoexperienceyourpainonlyyoucanandshouldmakethefinaldecisiontoproceed.Beverycarefulwhenchoosingspinesurgery.Ifyoudonotfeelinvolvedinthedecision-making,thentalktoanotherdoctor.Getitrightthefirsttime.

MeettheAuthors

Louise Berkowicz, MD

Education: Medicaldegree,UniversityofCapeTown,SouthAfrica.

Board Certified: FamilyPractice;HyperbaricMedicine;CertifiedWoundSpecialist

Special Interests:Dr.Berkowiczhasaspecialinterestandpracticeinenergymedicine.Thisuniquetherapyutilizesdifferentformsofenergytobringaboutbothindividualself-awarenessandhealing.Theresultischangesinthebody,mindandspiritofthepatient.Sheassiststhepatientindealingwitheverydayissuesoflife,painandsufferingtomovetowardlivinglivesfilledwithmorepleasure,joyandgoodhealth

David A. Hanscom, M.D.

Education:Medicaldegree,LomaLindaUniversity,OrthopedictraumafellowshipUCDavis,spinaldeformityfellowshipMinneapolis

Board Certification:OrthopedicSpineSurgery

Special interests:Complexspineproblemsinallareasofthespine.HeisthefounderofthePugetSoundSpineInterestgroup.HedevelopedtheDOCC(DefinedOrganizedComprehensiveCare)projecttooptimizespinecare.Hefeelsthatmanytimesfurthersurgerycanbeavoidedthroughastructuredrehabilitationprogram.Theprogramshouldinvolveimprovingsleep,managingstress,engaginginstrengthandenduranceconditioning,obtainingadequatepaincontrol,andeducatingthepatientsoastoregaincontroloftheirdecisionmaking.

Allen Hume, Ph.D.

Education:Dr.HumeisaWashingtonStatelicensedpsychologistwhoearnedhisdoctoraldegreefromIndianaStateUniversity.HecompletedhisinternshipattheSeattleVAMedicalCenter.

Special Interests:Dr.Humespecializesinbehavioralmedicine,chronicpainmanagement,co-occurringpsychiatricandsubstanceusedisorders,andassessment.Heprovidesconsultationandtrainingforphysicians,psychologists,alliedhealthprofessionalsandorganizationsrelatedtohisspecialties.

Gordon Irving, M.D.

Education:Medicaldegree,UniversityofNewcastleinEngland,MastersdegreeinSportsScienceandFellowshipandMastersdegreeinAnesthesia,SouthAfricaFormerly:MedicalDirectorandassociateprofessorattheUniversityofTexasPainCenter,Houston.Currently:MedicalDirectoroftheSwedishPainCenterandclinicalassociateprofessor,UniversityofWashingtonMedicalSchool.

Board Certification:AmericanBoardofAnesthesiologywithaddedcertificationinPainManagement,AmericanBoardofPainMedicine

Special Interests:Dr.Irvingspecializesinacuteandchronicpainmanagementwithpharmacological,non-pharmacologicalandinterventionaltechniques.Hisinterestsincludeneuropathic,spinalandcancerpain.Hepublishesandlectureslocally,nationallyandinternationallyonpainrelatedtopics.

Hubert A. Leonard, M.D., Ph.D.

Education:TheonlyphysicianinOregoncertifiedinHeadacheMedicinebytheUnitedCouncilofNeurologicSubspecialties.HereceivedhisM.D.andhisPh.D.inBiochemistryfromOregonHealth&SciencesUniversityandcompletedaresidencyininternalmedicineatUniversityofCaliforniaHospitalinLosAngeles.HecompletedhisresidencyinNeurologyatUniversityofOregonHealthSciencesUniversity,inPortland,andservedaschiefresident.

Board Certification:Neurology

Special Interests:Hehasbeenaneurologistandeducatorformorethan30yearsandspecializesinthediagnosisandtreatmentofheadaches.Hehasbeentheprincipalinvestigatorfordozensofclinicaltrials.Amongotherhonors,heislistedbyThe Best Doctors in America®,whichrepresentsthetopfivepercentofdoctorsintheU.S.

Carolyn McManus, PT, MS, MA

Education:MasterofScience,PhysicalTherapy,DukeUniversity.MasterofArts,Psychology,AntiochUniversity

Special Interests:Chronicpainandstressmanagement,relaxationtrainingandmindfulnessmeditation.ShedevelopedtheSwedishMindfulness-BasedStressReductionProgram.Sheisanauthor,nationalspeakerandleaderinmind-bodytreatmentstrategiesforpeoplewithchronicpainconditions.

Maureen C. Pierce, Ph.D.

Education: Dr.PierceisaWashingtonStatelicensedpsychologistwhoearnedherdoctoraldegreefromIndianaStateUniversity.ShecompletedherinternshipattheCentralArkansasVAHospital.

Special Interests:Dr.Piercespecializesintheemotionalandbehavioralaspectsofmanagingchronicpainrelatedtoavarietyconditions.Hergoalistoempowerpeoplewithpaintotakeamoreactiveroleintheirhealthcare.Sheutilizesanumberoftreatments,includingcognitivebehaviortherapy(CBT),clinicalhypnosis,mindfulnessmeditationskills,andgrouptherapy.Shealsoleadsaneight-weekclass,LivingWellwithPain:StrategiesforCoping,andamonthlysupportgroup.Formoreinformationpleasevisit:www.drmaureenpierce.com.

Howard Schubiner, M.D.

Education:MedicaldegreefromWayneStateUniversity,InternalMedicineresidencyatWayneStateUniversity,PediatricsresidencyatMichiganStateUniversity.ClinicalProfessoratWayneStateUniversity.

Board Certification:BoardcertifiedinInternalMedicineandPediatrics.

Special interests:FounderanddirectoroftheMindBodyMedicineprogramatProvidenceHospitalinSouthfield,Mich.Seniorteacherofmindfulnessmeditation.Conductsresearchinfibromyalgiaandotherchronicpainfulconditions.

Preparedby:Swedish Pain Center

Gordon Irving, M.D.Louise Berkowicz, M.D.

Allen Hume, Ph.D.Maureen C. Pierce, Ph.D.

Swedish Neuroscience InstituteDavid A. Hanscom, M.D.

Swedish Rehabilitation CenterCarolyn McManus, PT, MS, MA

Providence Brain and Spine InstituteHubert A. Leonard, M.D., Ph.D.

Mind-Body Medicine Center of ProvidenceHoward Schubiner, M.D.

Swedish Continuing Medical EducationDanielle Westley

Swedish Neuroscience Institute Spine ProgramAlexis Takasumi

Swedish Patient Education CommitteeJeanine Keefe, R.N., MSN, GCNS-BC

Kaetlin Miller, MPH, CHES

Art DesignCarole Miguel

SWEDISH PAIN CENTER1101 Madison, Suite 200Seattle, WA 98104T 206- 386-2013

www.swedish.org

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