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Oleg I. Reznik, M.D. Board Certified Family Physician |
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Assistant Professor at OHSU Department of Family Medicine |
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Chronic Pain Syndromes |
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The usual medical treatments for chronic pain syndromes only lock the sufferer into a never ending cycle of pain medication use, treatments, and surgery that usually provide only a temporary and partial relief. These medications (opiates), treatments (such as epidural steroid injections), and surgery (decompression or fusion for back and neck pain, arthroscopy for chronic joint pain), only create a false impression that these measures, if taken far enough, will provide a perfect solution—an idea that is far from the truth. Unfortunately the usual approach fosters dependency while providing only a short lasting improvement. Even conventional medical thinking is coming to an understanding that interventional approaches, such as back surgery for chronic back pain and degenerative disc disease for example, is usually unjustified. It was found that an intensive rehabilitation program incorporating stretching, strengthening, cardiovascular conditioning, and cognitive-behavioral therapy provides as much benefit for chronic back pain as does fusion surgery5. The meaning of pain in the Eastern spiritual tradition is—purification. In the West it means—punishment. Turning the pain of distress into the pain of learning is the first step toward |
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Fear-Avoidance Beliefs Questionnaire4 Here are some of the things other patients have told us about their pain. For each statement, please circle the number from 0 to 6 to indicate how much physical activities such as bending, lifting, walking, or driving affect or would affect your back pain. (In the actual questionnaire there are numbers 0 to 6 following each statement. The participant is asked to circle zero or 1 if he completely disagrees, 2-4 if he is unsure, 5-6 if he completely agrees). 1. My pain was caused by physical activity. 2. Physical activity makes my pain worse. 3. Physical activity might harm my back. 4. I should not do physical activities which (might) make my pain worse. 5. I cannot do physical activities which (might) make my pain worse.
The following statements are about how your normal work affects or would affect your back pain.
6. My pain was caused by my work or by an accident at work. 7. My work aggravated my pain. 8. I have a claim for compensation for my pain. 9. My work is too heavy for me. 10. My work makes or would make my pain worse. 11. My work might harm by back. 12. I should not do my regular work with my present pain. 13. I cannot do my normal work with my present pain. 14. I cannot do my normal work until my pain is treated. 15. I do not think that I will be back to my normal work within 3 months. 16. I do not think that I will ever be able to go back to that work.
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the possibility of being pain-free. From the perspective of Mind-Body medicine: one cannot disown what one does not own. Pain is always a signal that tells us that something is wrong, even when no physical cause for it was discovered. By accepting the possibility that we may be contributing or possibly creating our own pain we open ourselves up to the possibility of correcting its source. The usual measure—pill taking, is an attempt at escaping, isolating, or otherwise resisting the pain or other unpleasant feelings or sensations. It doesn’t provide a lasting or effective solution. One of the axioms of mind-body medicine: what we resist—persists, may offer a new perspective on dealing with suffering. The techniques of mental imagery, dreamwork, and directed will can help to discover and correct the underlying issues. They permit one to change the deeply held false beliefs that determine out painful experience in the world. Everyone who has a chronic pain condition discovers sooner or later that running away from it does not work. Taking pain medications is one form of running, but one soon finds out that there is no medication that keeps one pain free, and there is no amount of medication that is enough. Instead, one becomes locked into a vicious circle that keeps one imprisoned, for ever running toward but never reaching the goal of being pain free. Mind-body medicine follows a principle: as above—so below, as outside—so inside. Thus physical pain is seen as a reflection of pain that is experienced or denied at other levels of our existence (mental, emotional, social, moral, spiritual). While each case is unique, some examples can be given for illustrative purposes. A person with chronic neck pain is invited to explore what has been “a pain in the neck” in his or her mental or emotional life. One with low back pain may explore what heavy burden one is carrying. For irritable bowel syndrome we may ask what has been irritating you, or has been ‘hard to swallow, stomach, or digest’ mentally. A person with migraines may have something that’s been “a headache” in her life. Migraines also may have to do with rage, anger, worry. Pelvic pain may involve guilt, anger, or resentment about sexual issues. Fibromyalgia often reflects deeply seated guilt feelings or difficulty with a transition in life. Chronic fatigue syndrome indicates a general rundown state, where fatigue is reflective of an overextension of one’s vital resources in an attempt to gain something in the personal, social, profession or other arenas. It may also be body’s way of expressing being tired of something, as in the expression “I’m tired of this.” Mind-body work is not a form of psychotherapy. Rather, it is a phenomenological work which uses the universal language of the mind—image. The issues involved and means of correcting them are discovered in the moment and without analysis or interpretation of person’s thought, emotions or behavior. The effect of person’s beliefs on chronic back pain, for example, has been well documented even by the conventional scientific methods1,2,3. A high score (more than 18 points) on the Fear-Avoidance Beliefs Questionnaire presented below is associated with poor response to physical therapy and chiropractic manipulation, in patients with chronic low back pain1. Note that these are beliefs, not physical findings. People with these beliefs are less likely to improve. Take a moment to look them over and see how many of them you share, and how strongly you feel about them. |
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Most of our usual education teaches us that our experience creates our beliefs. That leads many of us to be trapped by our past experiences. We say “ I tried to go back to work fifteen times, but every time I went to work I could not work because of the pain, therefore it is impossible to me to return to work.” I invite you to experiment with changing of the habitual beliefs to see whether the reverse of our usual thinking is true, namely that it is beliefs that create our experience. Try changing your most strongly held limiting belief about your back pain. Take, for instance My pain was caused by my work or by an accident at work. Explore the possibility that your work was a coinciding factor, or a mechanism, but not the cause. Other people who have done what you do did not have the same consequence as you. Consider that there is a meaning, though this meaning is obscure for the moment. You may consider any number of possibilities. Perhaps there is something you can learn from what happened. Consider changing this strongly held belief into its opposite. In this example, that the pain was not caused by the outside agent (your work) but by the inside agent (yourself, or came from yourself to help you understand something). Try to see it as your own creation. You may experience surprising changes within several months of doing this work. Certain physical exercises can be very helpful. In chronic back pain, neck pain, and fibromyalgia, a set of five simple exercises from Tibetan Yoga can be of great help if done regularly. You can purchase a video and learn how to do them on your own (The Fountain of Youth: Five Tibetan Exercises for Rejuvenation (1992).
References: 1. Childs, J.D. et al. A Clinical Prediction Rule To Identify Patients with Low Back Pain Most Likely To Benefit from Spinal Manipulation: A Validation Study. Annals of Internal Medicine. 21 December 2004, Volume 141, Issue 12, Pages 920-928. Abstracted in The Family Practice Newsletter Vol. 21 No. 3 Feb. 1, 2005. http://www.primarycarepress.com/ 2. Fritz, F.T. et al. A clinical prediction rule for classifying patients with low back pain who demonstrate short-term improvement with spinal manipulation. Spine. 2002; 27: 2835-43. 3. Waddel, G. et al. A fear-avoidance belief questionnaire (FABQ) and the role of fear-avoidance beliefs in chronic back pain and disability. Pain. 1993; 52: 157-68. 4. A full Fear-Avoidance Beliefs Questionnaire can be found on the web-site of ‘Back Care Boot Camp’ at http://www.sechrest.com/bcbc/providers_questionarres.html. 5. Fairbank F et al. Randomized controlled trial to compare surgical stabilisation of the lumbar spine with an intensive rehabilitation programme for patients with chronic low back pain: the MRC stabilisation trial, BMJ, May 23, 2005 |