Phantom Brain Pain – “The Doctor is Missing Something”

Any skill in life, mental or physical is first learned and them embedded in our brains with repetition. This is true for physical sensory input as well as mental. In both chronic mental and physical pain, the impulse are memorized in about 6-12 months and then it does not matter what is done surgically. The circuits are embedded and permanent. The more you fight them, the more attention you are paying to them, and where your brain will evolve.

The same process occurs with thought patterns, which are also embedded and permanent. It is how we navigate life. You don’t have to learn to touch a hot stove every time you pass it or purposely put yourself in an emotionally abusive situation.

Your body’s response to sustained stress is the root cause of chronic mental and physical diseases. Your body is flooded with inflammatory molecules called cytokines and your stress hormones including adrenaline, cortisol, and histamines keep your body on high alert. This “threat physiology” translates into multiple physical and mental symptoms.They resolve as you learn to regulate your own body’s chemistry. Many of them are physical. The most difficult concept for many patients to grasp is that since the symptoms are physically experienced then there must be some structural source. It does not matter how many different ways I explain it or how many negative tests that have been done. They just will not believe that physical symptoms can be generated from the brain and body’s stress chemistry. YOUR BRAIN IS CONNECTED TO EVERY ONE OF THE 30 TRILLION CELLS IN YOUR BODY either chemically or by nerves. The only way that physical sensations can be experienced is by being processed and interpreted in your brain. BTW, there is something terribly wrong. Your body’s physiology is way out of balance.

The “Pain Switch”

Then he or she proceeds to explain to me in detail that since they can push on a certain spot and feel the pain, then how can it be in their brain? How can it not be there? The fact that a simple push can elicit pain means that the threshold for stimulating those pain fibers has been lowered –  often dramatically. Your pain switch is either on or off. The only place these switches exist is in the brain.

Water Torture versus a Rock

Do you think that the pain felt during water torture is imaginary? It is a simple, painless drop of water. There is no reason it should ever cause pain. If water constantly drips on a rock does that cause pain? In fact over years, decades, or centuries the rock will be eroded by the simple repetition of dripping. Why is there not pain in that scenario? Obviously a rock has no nervous system. Repetition of any activity lays down circuits that are repeatable and become increasingly efficient? It is true for musicians, artists, and athletes, and also true for the perception of pain.

 

 

Obsessive Thought Patterns

Unfortunately, it is also true for the thought, “My doctor is missing something because I am in pain.” I am repeatedly told that I just don’t understand how they feel. That set of thoughts becomes it’s own set of repeatable circuits that will not shut down. Logic alone will not break them up. The reason why it is such an unfortunate situation is that it also limits treatment. The one variable that predicts success or failure in treating chronic diseases is your willingness to engage in the tools. The problem is that these endlessly repeating circuits also block opens to learning. It is the reason why that The DOC Journey app and course emphasise expressive writing so early in that is the one necessary exercise that begins to break up these endlessly repeating circuits.

 

My Weekly Battle

I was reminded of the problem several times every week. I had a middle-aged woman who had not really engaged in the DOC project. She had experienced anxiety (another stress symptom) since she was a teen along with chronic LBP. She had ruptured a disc in her back six months earlier and was experiencing screaming leg pain. She did have a large ruptured disc. When I explained the neurological nature of chronic pain, it was an ugly conversation. I asked her to come back when she calmed down. I was surprised that she returned the next week. On the second visit I told her that I seldom operate anymore unless the chronic pain is being actively addressed. That means that the patient is actively reading, writing, learning, and generally taking full responsibility for their care. However this disc was so large that I felt that I had to take it out first. She swore that she would engage.

Guess what? The simple disc excision that took away all of her leg pain, as expected, did not relieve any of her LBP. In spite of at least 10  direct conversations that the operation was only effective in relieving leg pain. I could not convince her that her LBP was coming from the soft tissues around her spine and that spine surgery rarely helps LBP. It is a rehab issue. She was convinced that there was something causing her pain that I was missing.

Doctors do not like to miss anything. We are extremely aware, even paranoid, of overlooking a problem that can and should be fixed. It is one of the reasons why health care costs are so high. We will often order testing when we know that the chance of it being positive is less than one in a thousand.

 

 

Another Failure

I did not get through. She thought if we could “fix it” her pain would disappear and her anxiety around it would diminish. I don’t think she will ever engage in any structured rehab program. The tragedy is that both are easily treatable with usual outcome to be pain free with minimal anxiety. The general wisdom in surgery is that if a patient has had the surgical risks explained to them then they must be in enough pain to undergo the operation. What the surgeons don’t understand (historically including me) is that the decision-making has become irrational.

The success of a spine fusion for LBP is less than 30%. (1,2) When the surgery has failed then the surgeon “has done their part” and sends them on their way – to where??

I never again performed elective surgery unless the patient would engage in his or her own care. Even then, I would rarely perform it in the face of chronic pain unless the patient is experiencing a full nights sleep for at least six weeks and actively engaging in the tools that allow the nervous system to remodel. I feel in every case that surgery is only about a third of the solution. Physical conditioning and healing the nervous system are the other two thirds of the picture.

Personal and Societal Costs

I don’t regret performing her surgery, as it was necessary from a perspective of the need to relieve her severe leg discomfort. I am sad and frustrated that only a fraction of the benefit will be realized. Not only is the suffering of truly trapped patients not solved, they are also costing the rest of society untold billions dollars with the relentless pursuit of an answer that does not exist. Obsessive thought patterns, which is one of the symptoms created by stress physiology, both exacerbates pain and blocks effective treatment. It is truly phantom brain pain.

Are You Kidding Me?

  1. Franklin, GM et al. “Outcome of lumbar fusion in Washington State Workers’ Compensation.” Spine(1994); 19: 1897 – 1903.
  2. Nguyen, TH et al. “Long-term outcomes of lumbar fusion among worker’s compensation subjects.” Spine (2010); 20: 1– 11.