Dr. Hanscom's Blog “The Doctor is Missing Something”

Neurological Pathways
The Mind Body Syndrome (MBS) is about brain pathways. There are many symptoms that disappear with the successful treatment of MBS. Most of them are physical. The most difficult concept for many patients to grasp is that since the symptoms are physical 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.
YOUR BRAIN IS CONNECTED TO EVERY CELL IN YOUR BODY either chemically or by nerves. The only place that physical symptoms, pleasant or unpleasant, can be felt is in your head.
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 head? How can it not be in your head? The fact that just a simple push can elicit pain just means that the threshold for stimulating those pain fibers has been lowered – dramatically. Your pain switch is either on or off.
Water Torture versus a Rock
Do you think that the pain felt during water torture is imaginary? It is just a simple, painless drop of water. There is no reason it should 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. Why is so hard for my patients to understand that repetition of any activity lays down pathways that are repeatable and efficient. It is true for musicians, artists, and athletes. It is 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 pathways that will not shut down. Logic alone will not break them up. I honestly do not know what will break them up. The reason why it is such an unfortunate situation is that is also blocks treatment. The one variable that predicts success or failure in treating MBS is willingness to engage in the tools. I also know that these circuits elicit a lot of anger. Mind Body Syndrome – “Short Circuits”
My Weekly Battle
I was reminded of the problem again several times this week. This occurs every week. I had a middle-aged woman who had not really engaged in the DOCC project. She had experienced anxiety (another MBS 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 pain pathways it was a very 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 pain pathways are addressed at the same time. For me 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 very direct conversations before and after the surgery I could not convince her that her LBP was coming from the soft tissues around her spine and that spine surgery never 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 missing something 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 just 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 at an effective level. She is doomed to a lifetime of chronic back pain and anxiety. 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%. When the surgery has failed then the surgeon “has done their part” and sends them on their way – to where??
I will never perform surgery unless I can see the exact source of the pain. Even then, I will 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 very 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 discomfort. I am just sad and frustrated that only a fraction of the benefit will be realized.
Not only is the suffering of these 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. Medicine is more than happy to oblige as the endless testing and treatment is a tremendous revenue stream. Treating MBS costs essentially nothing. Most of it is self-directed.
MBS both causes pain and blocks effective treatment. I do not have an answer.

 

I am glad you do not perform surgery unless direct pain paths are found.

Here is a concern that I have, part of the missing link once someone understands or thinks that pain is psychogenic. This does not apply to all of course; maybe not even the majority, but for those who "can reach around" and feel the contracted muscles but not understand the anatomy of the situation (what sensations those muscles can cause and where) it can lead to rejection of the entire MB process, especially when the resumption of activity leads to pain seemingly unrelated to the contracted muscle. Many MB patients are where they are because they are exacting, demanding and needing to know and have control -- all leading to anger and anxiety. Knowledge is the cure, but for some of us with only a semester of anatomy, we don't automatically understand body functioning. When you in a panic words are not processed correctly. When I went to the head of the neurology department of a major medical center here in Chicago, and showed him my MRI and he read the transcript, he came back with a totally honest answer -- that surgery may not relieve the pain. I had a herniated thoracic disc, and my uneducated reading, and the horrific responses I got from most doctors sent me over the edge. My symptoms only got worse. However, had I had the presence of mind, which I didn't, to ask the neurology head "why", he might have just replied as you did.

My first encounter, in fact, was with my PCP at the time, and he took note of my complaints, did a quick pat over, and sent me off for a boat load of tests, including one for MS. I had just awakened one morning with stiffness on my side. Had he told me that my muscles in my back were tight, which he admitted later that they were, and that they can cause X effect for some people, my fear right then and there may have been eliminated. As it was, I was convinced by fear and the internet that I had a back problem, and got an MRI and found the disc herniation, which, by the way, was just sitting there and not "restricting" any nerves with a good "signal", blah, blah, blah.... My PCP was a DO, and he did not even have the idea to explain the concept of what tight muscles can do to a person, especially after I told him I was a health anxiety sufferer (no doubt due to my life long list of strange anxiety caused maladies), so I applaud you for your approach, but when people are in a state of panic, such as the woman you mentioned, all the exhortations of psychogenic cause will not go far if she (maybe not others) doses not understand basic anatomy.

I know it is a little picture idea, but a mosaic is built tile by tile.

I'm not even sure if it will make sense to most, but I had to give myself a lesson in anatomy of the muscular-skeletal system and talked to knowledgeable medical massage therapists before my TMS/MB personality could accept the process and lead to my "cure".

Anxiety and the MB process should be required in health courses in high school, because, often or shortly thereafter, is when the first physical manifestations of anxiety occur. Knowing the basic symptoms early on could save some a lifetime of suffering.

 

amen. what they don't teach in high school could fill a life.

 

I am so glad your'e on this forum and I appreciate your posts and videos so much !

 

You don't know how happy that comment makes me...I am holding on to those words ... Thank You so much !

 

I can relate to this. For the longest time, I was very much like the patient that Dr. Hanscom described, in that doctors would tell me I may have a psychogenic problem but I just couldn’t accept that. Now, they never mentioned TMS and explained it in a way that was more along the lines of I was wasting their time so i shouldn't come see them again. My anger towards these doctors was probably rooted in my desire to feel connected and heard.

My personality has always been that exacting, demanding and needing to know and have control. I now know that it is the TMS personality, but at the time you don’t recognize it as that. One of the more difficult challenges is understanding that our need to know exactly what is going one is in fact the driving force of our symptoms. It took me awhile to understand this.

 

I would like to think I would have so appreciated a Doctor like you who would have suggested I take a look at understanding the pain pathways. I have had numerous physical problems over the years with not one Doctor suggesting the mind body connection. They want to cut off your head, put it on a shelf then just look at the body. Or shrinks want to cut off the body looking at only the head not considering the minds impact on the physical body.

I know it is very frustrating but those on this site have great appreciation for your efforts. Sandy