Pinpointing The Real Source Of Chronic Pain In Patients Who Are Not Getting Better

A few months back, I met this incredible lady who is a double PhD in neuroscience and she tells me that she also works with hypnosis and pain management. Now I am hooked, let me tell you. I figure if she cannot help my patients with hypnosis, she can at least hypnotize me so I am not so bothered that I cannot help some of these folks. After some discussion, we decide that to quiet the skeptic inside my cranial vault, I will line up some of my patients for her and I can observe what she does.

A couple of weeks go by and my list grows and grows. I did not realize how many folks we (I) cannot get better. Why is there this epidemic of chronic pain in the United States? A couple of days ago, I got to see her magic.

Let me tell you about Joe Bob, who still comes in with pain. He has had pain for nearly 10 years in his feet with no history of trauma. He has tried everything ranging from Chinese herbs and moxibustion to neurolysis. Literally, this poor soul has tried everything and to no avail. 

I performed the neurolysis and intraoperatively, there was such a significant nerve entrapment that I captured it with all the glory of my mini iPad. I can still remember the glee that I had in the post-anesthesia care unit when he was awake enough to look at my “trophy.” With a grin wider than the Rio Grande, I told him with ultimate confidence that “I got it!”

Guess what? I got it, alright. Essentially, I got a course of gourmet crow shoved down my gullet with full force when his pain was still there. How could this be? The nerve was demonstrably entrapped and documented on Mr. Jobs’ handy high-res device. It had an “hourglass” deformity, for nerve god’s sake, and it was right where he had complained of pain for years. It was the pain generator for sure.

But how could he still have pain? I decompressed the damn thing and there had not been enough time postoperatively for fibrosis to have re-entrapped the nerve. His pain simply never went away.

So the skeptic and I set up the “meeting” with the double PhD. We are going to get into Joe Bob’s reptilian brain and conjure up the recipe that will finally release him from the hell he has been imprisoned in for all these years. 

The double PhD quickly went about her business with Joe Bob and literally had him crying a river of tears in about 10 minutes. The whole session took about 50 minutes and that alone consumed a half box of tissues. It seems Joe Bob had some secondary gain from having pain. He explained to her after being placed into the “trance” that he had never failed in anything he had ever done. Now he had a failing marriage and was losing his business. Interestingly, both aspects of his life started to crumble about the same time his pain just developed. The double PhD hypnotized him slickly and quickly, stripping off those layers and layers of protection mechanisms he had encased himself in for such a long time. It was almost like cracking off a cocoon or something like that with a big hammer and chisel. 

After the session, we were back in the office where she was debriefing me and helping me digest that giant serving of crow, which Joe Bob had adroitly served me.

“See, it seams that his ‘pain’ is his protection mechanism. He is a guy who has never failed, and now that the two most important things in his life are disintegrating, he can blame the pain and not himself.” She positioned herself closer to me to ready me for her next comment. “Maybe had you healed him with your surgery, there could be unintended consequences.”

I nodded and became incredibly pensive. “What will you do now?” I asked.

“I will have another session, actually several, and see if I can replace that defense mechanism with rebuilding him with positive belief and a mental reorganization.” 

Seeing The Whole Patient

I learned much that day and what I learned was that we had to look at more than what we believed was the potential pain generator(s). We had to look into the noggins of these patients a little bit more.

See more than the lower extremity. Hear the tone in the voice. Watch closely how patients dress and act. What do their faces do when they tell you their story? Emotion is inextricably related to pain and many studies have proven this.1 Take some time and evaluate the “emotion” of the patient, especially in tough cases.

The following bullet points should raise a high degree of awareness in you when you start planning your treatment, especially when it includes some type of intervention.

1. If a patient has seen numerous other doctors for his or her current problem, take more time to interview the patient.
2. If the pain prevents patients from working and they are being somehow subsidized via insurance or government assistance, then your chance of them getting well is diminished.
3. If patients tell you their life is horrible and they catastrophize their pathology, then think about how quickly you can refer them out for mental health screenings.
4. Order screenings on these patients for depression, anxiety and sleep. Any of them or all together are a formidable barrier to successful treatment.
5. See if you can find out some backstory if things are not going well with treatments that should be working and do work in 99 percent of your patients. 
6. Try to get an idea of your patients’ financial status. Do they still owe you money after your surgery and could that pain they have actually be a way of getting out of paying you?

Remember, the International Association for the Study of Pain’s definition of pain is: “An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.”

Reference

1. Jensen MP, Ehde DM, Day MA. The behavior activation and inhibition systems: implications for understanding and treating chronic pain. J Pain. 2016; epub March 24.