stomp - swedish medical center
TRANSCRIPT
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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
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STOMPStructuring Your Own Management of Pain
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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
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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.
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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.
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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.
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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.
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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.
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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.
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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
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• 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
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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
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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.
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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.
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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.
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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.
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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.
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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)
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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.
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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.
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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
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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.
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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.
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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.
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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.
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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.”
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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
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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.
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• 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?
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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.
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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
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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.
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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
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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.
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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
• NationalInstituteofMentalHealth,www.nimh.nih.gov
• 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
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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
• NationalInstituteofMentalHealth,www.nimh.nih.gov
• AmericanPsychologicalAssociation,http://goo.gl/KAPSK
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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.
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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
• AmericanPsychologicalAssociation,www.apa.org
Joy, Pleasure and Spirituality Louise Berkowicz, M.D.
Ourthoughtsandemotionsaffecthowourbodiesworkandfeel.Forgettingto“smelltheroses”iscommonwhenapersonhaschronicpain.Findingjoy,pleasureandconnectiontolifehelpsusfocusonthepositiveaspectsofliving.
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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.
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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
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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.
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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!
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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.
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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.
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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.”
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• 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.
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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”)
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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.
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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.
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• 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.
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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.
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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.
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• 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.
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• 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
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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.
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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.
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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
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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.
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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.
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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
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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/
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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.
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Resources• AlcoholScreening,www.alcoholscreening.org
• NationalInstituteonAlcoholismandAlcoholAbuse,www.niaaa.nih.gov
• NationalInstituteonDrugAbuse,www.nida.nih.gov
• AmericanPsychologicalAssociation,www.apa.org
• AlcoholicsAnonymous,www.aa.org
• NarcoticsAnonymous,www.na.org
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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
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• 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.
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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.
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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.
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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)
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• 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
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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.
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Surgery and Dentistry
Youcancomparespinesurgerywithdentistry.Adentistcanusuallyfindthestructuralprobleminyourtooththatiscausingyourpain.Itcanbeaninfectedrootormaybeacavitythathasgonedowntotheroot.Thechancesofadentalprocedureonthattoothrelievingyourpainisessentially100percent.Butifyourdentistcannotfindthesourceofyourpainandoperatesanyway,itisunlikelythatheorshewillsolveyourproblem.
Summary
Nomatterthepartofthespine,surgeryisonlyindicatedforaclearstructuralproblemwithmatchingsymptoms.Thediscomfortshouldbesevereenoughtowarranttheriskofsurgery.Asyoursurgeonisnotabletoexperienceyourpainonlyyoucanandshouldmakethefinaldecisiontoproceed.Beverycarefulwhenchoosingspinesurgery.Ifyoudonotfeelinvolvedinthedecision-making,thentalktoanotherdoctor.Getitrightthefirsttime.
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MeettheAuthors
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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.
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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.
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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.
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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.
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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
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© 2013 SWEDISH HEALTH SERVICES. ALL RIGHTS RESERVED. CME-09-08881 Rev. 1/13
SWEDISH PAIN CENTER1101 Madison, Suite 200Seattle, WA 98104T 206- 386-2013
www.swedish.org