David Hanscom, M.D. is an orthopedic spine surgeon and author of “Back in Control: A Spine Surgeon’s Roadmap out of Chronic Pain.” He currently practices at the Swedish Medical Center in Seattle, WA. A large part of his practice is focused on salvaging situations in which patients have undergone multiple failed attempts at surgery. Salonpas sat down with Dr. Hanscom to learn why understanding pain allows one to gain control of their care and about his action plan which guides the pain sufferer along a transformative path from suffering to empowerment and vitality:
What led you from being a spine surgeon to being known as a “recovering spine surgeon” or “orthopedic psychiatrist”?
I began to experience burnout in 1990 and by 1995, I was in a full-blown major depression. A significant aspect of the ordeal was experiencing many of the physical symptoms of the Mind Body Syndrome. Chronic pain is one of the core symptoms. At one point I had 16 of the over 30 possible symptoms. My symptoms included back pain, migraine headaches, severe anxiety, burning in my feet, tinnitus, etc. I was fortunate to pull out of it in 2003, which is a long time to be suffering at that level. I rarely experience any of these symptoms today. I began to share my insights with my patients and have witnessed hundreds of patients become pain free, as well as my of their other symptoms disappear. I am still a very busy complex spine surgeon but have been able to help many patients completely avoid surgery that I would have operated on in the past.
Why did you stop doing fusions for low back pain?
I was trained as a complex spinal deformity surgeon and held the view for many years that spinal surgery was usually the definitive answer when all other treatments had failed. Many of my patients did not do well in the face of technically, well-done surgeries. In 1993, an article was published that showed that only 15% of injured workers returned to work after a spine fusion for lower back pain at one-year follow up after surgery. At that point I quit doing spine fusions for back pain.
Since 1993, there still has yet to be a paper published that demonstrates that a spine fusion for lower back pain is effective. Another paper came out in 2006 that showed the success rate was only about 27% for very carefully selected patients who were not under a lot of stress. We also know that any surgery can induce chronic pain from 10-40% of the time with a significant number progressing to significant term pain. This operation does not work yet there are an increasing number of them being performed every year.
What understanding can a reader gain by reading your book, “Back in Control: A Spine Surgeon’s Roadmap out of Chronic Pain”?
It is important to first understand that chronic pain is completely different than acute pain. As pain impulses keep being rapidly fired at the brain, they quickly become permanently etched in; similar to an athlete or musician learning a skill. Like riding a bicycle, you cannot unlearn these pathways. Additionally, the location of chronic pain has been shown by functional brain MRI scans that the pain is sensed only in the emotional centers and not the pain centers. This shift has been documented to occur within 12 months. The book will teach you about the evolutions of chronic pain and that is always associated with anxiety and anger. These emotions are also a pathways issue, not a psychological problem. You will learn how to separate these out from the pain pathways and eventually shift your brain over to areas not involved with pain. The outcome for most people is a relatively pain-free state. The key is full engagement with the principles. The book is just a framework. In and of itself, it will not solve your chronic pain.
What is the DOCC project and why is it important for people who’ve had multiple failed surgeries on their backs?
There are three layers to successfully solving chronic pain:
- The first step is to learn about chronic pain and your specific situation with regards to the symptoms.
- There is never a single solution for chronic pain. You must treat all the variables relevant to you AT THE SAME TIME.
- Finally, every successful patient has taken control of his or her own care. Once you have a clear understanding of the problem, it is not difficult to solve it.
DOCC stands for “Defined Organized Comprehensive Care.” In addition to the central nervous system there are other factors to consider. The book and DOCC protocol provide a framework to organize your thinking around your pain. The areas considered are education, sleep, stress, medications, physical conditioning and life outlook/goal setting.
I was in chronic pain for over 15 years with the last seven being extreme. I was fortunate to inadvertently solve my own problem but it took far too long. It took a while to figure out what contributed to my success and then the correct sequence. People can improve within days and weeks and sometimes it has taken several years. I have not been able to figure out why there is such a wide variation. Most of us that use these principles in our practices feel that we see 90 – 95% of patients become successful with full engagement. Without full engagement, the prognosis is very poor. Chronic pain usually worsens with time.
By saying the pain is all in a patient’s head, are you blaming the patient for their pain?
Pain is only perceived in the nervous system. There is somewhat of a tendency to conceptualize fixing pain in a similar manner to taking your car to the shop. Usually the car comes out almost as good as new. Machines do not have pain fibers and there is not even a close equivalent example. The pain impulses are programmed into the nervous system in the unconscious brain and a given person has absolutely no control over this process. However, once you understand chronic pain, it is a matter of using strategies in a repetitive manner to re-program around and shift off of the pain pathways. BTW, the unconscious brain is one million times stronger than the rational brain. It is a gross mismatch if you attempt to do battle with these circuits using rational means.
How effective are prescription pain medications for most patients?
Medication management is critical in solving chronic pain. It is important to experience some symptomatic relief in order to be able to engage with the tools that allow you to heal. I discuss the following categories of medications:
- Sleep – it is the first step. It is difficult to sleep without medications in the presence of pain.
- Pain meds – will eventually be easily weaned as the pain abates. Initially they can be very helpful.
- Anti-anxiety meds – the anxiety associated with chronic pain is often extreme and meds can be helpful on a short-term basis.
- Anti-seizure drugs – to stabilize the firing of the nerves
Do your patients benefit from OTC topical analgesic products like from Salonpas?
As I mentioned above, there is never a single answer for chronic pain. For example, sleep could help 20%, decreasing stress 30%, massage – 15%, etc. In the context of a self-directed structured approach OTC analgesics can definitely add a certain percent of improvement. With the overall correct combination pain free is probable.
Can you detail some examples of patients (anonymity is fine) who went from being in severe pain to being pain free who did not have to resort to surgery?
George was about 55 years old when he fell from a horse while riding in the mountains. He was at a high elevation that was well below freezing at night. He was by himself and had fractured his collarbone, spine, and eight ribs. He almost died of hypothermia and shock. He was able to radio for help, which arrived the next morning. After extensive surgery on his spine he was fully functional but developed crippling back pain throughout his whole upper and lower back. He finally gave up and after eight years of considerable suffering he visited two different spine surgeons who both recommended about 12 to 15 hours of surgery to fuse his spine from his neck to his pelvis. He decided to visit me for a third opinion and had already signed up for the surgery.
I felt his spine looked pretty good to me and did not think further surgery would be helpful. I gave him a copy of my book and asked him to look at my website, www.back-in-control.com.
The first exercise is always one that came out of extensive research in the 1980’s and that was to simply write down his negative thoughts and instantly destroy them. With much skepticism, he began to write that night and by the third day, he was about 80% free of pain for the first time in eight years. We were both surprised how quickly he experienced improvement.
He attended a five-day workshop led by Dr. Fred Luskin, author of “Forgive for Good” from Stanford, Babs Yohai who is a professional tap dancer and me. The workshop was titled, “Rewire Your Brain to Alleviate Pain.” By the end of the week he was pain-free along with most of the other participants. He is now back riding horses and fully functional without pain. Although his turnaround was quicker than most the overall sequence is what I observe on a regular basis.