STOMP

Structuring Your Own Management of Pain

Setting goals that help you and your doctor alleviate your
pain and improve your quality of life.

[Link]/STOMP
STOMP
Structuring Your Own Management of Pain
Contents
Introduction....................................................................... 3
Chapter 1 – Learn about Pain........................................... 5
• Introduction to Mind Body Medicine
• Neuroplasticity
• Resources
o Determining the Validity of Online Resources
o Books and Online Resources

Chapter 2 – Sleep........................................................... 13
Chapter 3 – Calming the Nervous System..................... 19
• A Mind Body Approach
o Mindfulness
o Relaxation
o Clinical Hypnosis
o Writing/Journaling
o Music Therapy
o Anxiety and Depression
o Trauma
o Thoughts
o Joy, Pleasure, and Spirituality

Chapter 4 – Outside the “Box”....................................... 41

• Relationships
• Hobbies

Chapter 5 – Caring for Your Body................................... 45

• Nutrition and Weight Management
• Smoking
• Physical Activity
• Headache Management

Chapter 6 – Complementary Therapies for Pain............ 57

Chapter 7 – Medications................................................. 61
• Pain Medications
• Protecting Your Medications
• Substance Use

Chapter 8 – Role of Procedures...................................... 67

• Spinal Injections
• Implantable Pain Devices

Chapter 9 – Role of Spine Surgery................................. 71

• Surgical Decision Making

1
2
Introduction
Working with patients who suffer chronic pain, no matter what
the cause, can be distressing for both health care providers and
patients. Often, primary care practitioners do not have the time or
resources to try new approaches for chronic pain management.
They write prescriptions for medicines or treatments that may not
work, have troublesome side effects, or are only partly effective. This
may lead to multiple referrals and procedures, often, unfortunately,
with no improvement in long-term pain or quality of life.

This booklet is intended to be a resource for those of you facing

the limitations of the medical system in dealing with your complex
needs. The choice is clear. You have to learn to take charge of your
own care.

Each chapter in the booklet addresses a topic that affects the

perception of pain. There are recommended readings and links
to several helpful web sites (not sponsored by drug companies).
For those who wish to explore the subject in more depth, visit
the Swedish STOMP (Structure Your Own Management of Pain)
website: [Link]/STOMP.

This booklet presents a lot of information and many different areas to

focus on and tools to choose from. If suggestions in this book and
the hyperlinks to other information sites are followed, the reader can
expect positive lifestyle changes, improved function and decreased
pain. However, the way to use this book is to choose one small
area to work on, a path that suits you, seems doable and feels like
a good fit. It is very important not to feel overwhelmed; no one is
expected to follow all of these suggestions. Although tackling more
than one of these areas eventually is important in decreasing your
pain and improving your quality of life, work in any one of these
areas will bring improvement. Lasting change is gradual and takes
time. Discuss with your healthcare provider and, if appropriate, your
significant other to choose an area to start with and set a few simple
measurable realistic goals.

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 If you are ready to control your care, stimulate changes in your brain
(neuroplasticity) and decrease your pain, use the STOMP information
to develop your goals and an action plan.

The STOMP medical team developed this program specifically with

you in mind.

We wish you good luck on your voyage to recovery.

Editors and Contributors

Gordon Irving, M.D.
David A. Hanscom, M.D.

Contributors
Louise Berkowicz, M.D.
Allen Hume, Ph.D.
Hubert A. Leonard, M.D., Ph.D.
Carolyn McManus, PT, MS, MA
Maureen C. Pierce, Ph.D.
Howard Schubiner, M.D.

4
Chapter One:

Learn About Pain

Introduction to Mind Body Medicine
Howard Schubiner, M.D.

The role of the mind has been largely overlooked in chronic pain
treatment. However, there is strong evidence that the mind can
change the pain experience to a large degree. In fact, the conscious
experience of pain is only possible because the human brain can
interpret signals from our bodies to create the sensation of pain.
From this point of view, the saying “All pain is in the brain” is an
actual fact. Our brains have specialized areas that can both increase
or decrease the feeling of pain. How we perceive pain is affected
by many factors. For example, a study by Henry Knowles Beecher
found that only 32 percent of recently wounded soldiers in WWII
reported experiencing pain. And think of the boy who doesn’t cry
after skinning his knee until he sees his mother running toward him.

Chronic pain is much more complex than acute pain and the mind
plays a large role in how this pain is experienced. However, most
current treatment methods still rely on biotechnological treatments
such as medications, injections, ablations and surgery. Unfortunately,
research has shown that these methods are not particularly useful
in reducing chronic pain. Most providers assume that chronic pain
is simply caused by tissue damage in the body. Without addressing
the role of the brain, attempts to fully resolve the pain are usually not
successful. This standard approach leaves most patients with little
hope of becoming pain-free.

Recently, researchers have shown that pain can be caused by

“nerve pathways” even when there is no sign of tissue damage. A
nerve pathway is a collection of nerve cells in the brain that triggers
a certain action or response in the body. A nerve pathway is created
when a group of nerve cells are used over and over until eventually
they learn to fire automatically creating pain. Pain caused by nerve
pathways is every bit as real and severe as pain caused by actual
tissue damage. The discovery that our brain can learn to cause
pain has led to the development of new brain-based therapies.
5
 Recent research has shown that people with migraine and tension
headaches, neck and back pain, fibromyalgia, abdominal and pelvic
pain syndromes and many other disorders can “unlearn” pain. It’s
possible to dramatically reduce or completely get rid of symptoms in
a relatively short time period.

Therefore, it is important for people with chronic pain to be evaluated

carefully. Providers who are not familiar with the concept of pain
caused by nerve pathways are likely to assume that small changes
on a patient’s X-rays or MRI exams must point to the reason for the
pain. This may not only be wrong, but may prevent patients and their
providers from finding more effective treatment. Once it becomes
clear if an individual has nerve pathway pain, tissue damage pain, or
a combination, a more effective treatment plan can be developed.

Neuroplasticity
David A. Hanscom, M.D.

Scientists had long thought that a person was born with a certain
number of neurons (nerve cells) and would slowly lose them over a
lifetime that the cells would not change or grow. Although the brain
is more active during the first few years of life, it has been clearly
shown that the brain can change at any age—for better or worse.

The word “neuroplasticity” describes the ability of the brain to adapt

and change. Depending on the stimulation, the changes can be
either helpful or harmful.

The brain can change in a number of ways:

• Growth of new neurons
• Shrinking of unused neurons
• Increasing or decreasing the number of connections per neuron
• Building up or losing layers of the insulation around nerves (myelin).
This layer improves the speed of nerve conduction.
• A healthy area of the brain can take over some of the work of an
injured part of the brain and develop new capacities.

6
The bottom line is that your brain is constantly changing depending
on how much it is stimulated—or not stimulated.
• There is great improvement potential because the nervous system
is able to continue to change in a helpful way, but it must be kept
active.
• On the other hand if your brain changes negatively, cells shrink or
wither, it is harder to undo. It is still a solvable problem but you need
help and tools.

With modern brain scans that can actually measure brain size and
activity we are able to see these changes. Some changes can
happen quickly. A recent study showed that certain parts of medical
students’ brains enlarged within a few months after starting school.(1)

It has also been shown that the brains of patients in chronic pain
shrink, however, the brain also re-expands with successful resolution
of pain.

Why would your brain shrink in the presence of chronic pain?

One way of thinking about it is to view the pain nervous system
as an energy drain that steals energy away from healthy creative
parts of your brain. The brain areas that allow us to enjoy friends,
entertainment, community, creativity etc., gradually shrink. There is a
huge amount of neuron activity generated by these regular enjoyable
pastimes that does not occur in the presence of unrelenting pain.

Once a pain pathway is created in your brain it is essentially

permanent. It may become less active but it is not going to
disappear. So what is the answer? There is only one and that is
what the Swedish STOMP project is all about. You must build new
pathways or detours around the problem pathways. Once you
learn the tools and choose the ones that are the best fit for you, it is
remarkable how consistently the pain will lessen or even disappear.

Welcome to a big adventure and the start of your new brain. It will not
be easy but it is also not difficult. You will do the brain building. Use
the STOMP booklet as your resource. Choose just the tools that seem
a good fit for you and make it an enjoyable experience. The aim of the
STOMP team is to assist you in regaining a rich and full life.

7
 References
1. Dragananski, et al. Temporal and spatial dynamics of brain structure
changes during extensive learning. The Journal of Neuroscience
2006; 26: 6314-6317.
2. Apkarian AV, Sosa Y, Sonty S. Chronic Back Pain is associated with
decreased prefrontal and thalamic gray matter density. Journal of
Neuroscience 2004; 24: 10410 -10415.

Resources
Gordon Irving, M.D.

Determining the Validity of Online Resources

There are hundreds of websites and it may be hard to know which
ones offer useful information and which probably do not, or are trying
to sell you something. You should ask some simple questions before
using a website for the first time so you know if you can trust it.
• Who runs and pays for the site?
• Does it list any credentials?
• Does it represent an organization that is well-known and respected?
• What is the purpose of the site and who is it for?
• Is the site selling or promoting something?
• Where does the information come from?
• Is the information based on facts or only on someone’s “testimonial”
and feelings?
• How current is the information?
• Does the site show when it was last updated?
• How are links you can follow from the site chosen or for more
helpful tips view the fact sheet “Evaluating Online Sources of Health
Information” which can be found at the website: [Link]
(search for “internet”).

Below are some recommended resources. Resources for additional

topics can be found at the end of each section throughout the book.

8
Books and Websites
General Pain Information
• Pain Tamers by Helen M. Dearman
• The Pain Survival Guide: How to Reclaim Your Life by Dennis C. Turk
• Cognitive Therapy for Chronic Pain: A Step-by-Step Guide by
Beverly E. Thorn, Ph.D.
• Managing Chronic Pain: A Cognitive-Behavioral Therapy Approach
by John D. Otis, Ph.D.
• Back in Control by David Hanscom, M.D.
• The Feeling Good Handbook by David D. Burns, M.D.
• Full Catastrophe Living: Using the Wisdom of Your Body and Mind
to Face Stress, Pain and Illness by Jon Kabat-Zinn
• Managing Pain Before It Manages You by Margaret A Caudill, M.D.,
Ph.D., MPH
• Mind Over Mood: Change How You Feel by Changing the Way You
Think by Dennis Greenberger and Christine Padesky
• Unlearn Your Pain by Howard Schubiner, M.D. with Michael Betzold
• The War on Pain by Scott Fishman & Lisa Berger
• Heal Your Headache: The 1-2-3 Program for Taking Charge of Your
Pain by David Buchholz
• The Chronic Pain Solution: Your Personal Path to Pain Relief by
James N. Dillard and Leigh Ann Hirschman
• The Trigger Point Therapy Workbook by Clair Davies, Amber Davies
and David G. Simons
• Pain Connection, [Link]
• American Chronic Pain Association, [Link]
• The Mayday Pain Project, [Link]
• painACTION, [Link]
• U.S. Pain Foundation, [Link]
• CreakyJoints, [Link]
• The American Academy of Pain Medicine,
[Link]/patient/[Link]
• P.U.R.E. H.O.P.E., [Link]

9
 • American Headache Society Committee for Headache Education,
[Link]
• CancerCare, [Link]
• National Council on Aging, [Link]
• National Council on Aging Center for Healthy Aging,
[Link]

Back Pain
• Treat Your Own Neck and Treat Your Own Back by Robin McKenzie
• Back Care, [Link]
• National Back Exchange, [Link]

Care Givers
• Chicken Soup for the Volunteer’s Soul by Jack Canfield, Mark Victor
Hansen, Arline Oberst, John Boal, Tom Lagana and Laura Lagana
• Staying Sane: When You Care for Someone with a Chronic Illness by
Melvin Pohl and J. Kay Deniston

Fibromyalgia Resources
• The Fibromyalgia Relief Handbook by Chet Cunningham
• Fibromyalgia and Chronic Myofascial Pain: A Survival Manual by
Devin J. Starlyn and Mary Ellen Copeland
• Fibromyalgia Information Foundation, [Link]
• FibroCenter, [Link]
• Fibromyalgia Network, [Link]
• National Fibromyalgia Association, [Link]

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Meditation
• Living With it Daily: Meditations for People with Chronic Pain by
Patricia D. Nielsen
• Mindfulness with Jon Kabat-Zinn, [Link]
• Cognitive Neuroscience of Mindfulness Meditation,
[Link]
• I AM heart, [Link]
• Wildmind, [Link]
• Meditation CDs, [Link]/

Medication Information
• American Society of Health-System Pharmacists,
[Link]
• The Partnership for a Drug Free America, [Link]

Nutrition
• Prescription for Dietary Wellness: Using foods to heal by Phyllis A. Balch
• Turn Off the Fat Genes: The Revolutionary Guide to Losing Weight
by Neal Barnard
• USDA Center for Nutrition Policy and Promotion, [Link]

Prescription Assistance
• RxAssist, [Link]
• Prescription Assistance Program, [Link]

Suicide Prevention
• American Foundation for Suicide Prevention, [Link]

Temporomandibular Joint Problems

• The TMJ Association, Ltd., [Link]

11
12
Chapter Two:

Sleep
Sleep and Pain
Gordon Irving, M.D.

Sleep affects pain. You may have noticed that when you sleep
poorly and are tired your pain tends to be worse. Research shows
that one of the most important predictors for pain intensity is the
number of hours slept the night before. Bottom line: if you sleep
poorly, your pain will be worse the next day.

Medication management should include sleep as well as pain.

As sleep improves, the need for pain medications will decrease.
Eventually the need for sleep meds will also decrease.

Sleep Hygiene
How Much Sleep Do We Need?

The amount of sleep each person needs depends on many factors,

including age. For most adults, seven to eight hours a night appears
to be the best amount of sleep, although some people may need as
few as five hours or as many as 10 hours of sleep each day.

If you feel drowsy during the day, especially during stimulating

activities, you haven’t had enough sleep. If you routinely fall asleep
within five minutes of lying down, you probably have severe sleep
deprivation, possibly even a sleep disorder. Micro-sleeps, or very
brief episodes of sleep in an otherwise awake person, are another
mark of sleep deprivation. In many cases, people are not aware
that they are experiencing micro-sleeps. This may be a cause of
accidents both on the road and at work. It will certainly reduce your
ability to perform at your full potential.

Unfortunately many medications including those that are given

for pain can interfere with normal sleep patterns. These include
antidepressants, opioids and anti-anxiety medications, even those
given as sleeping aids.

13
 Obesity worsens sleep and increases the risk of snoring and sleep
apnea (pauses in breathing while you sleep). Chronic lack of sleep
also increases the risk of obesity by changing the level of certain
hormones. In a study of American adults who slept fewer than six
hours, 33 percent were obese compared to only 22 percent of those
who had six-nine hours of sleep.

Reaching a Pre-sleep Brain State

(Techniques to get asleep and stay asleep)

The brain state associated with meditation or self-hypnosis is

much like the pre-sleep brain state. A pre-sleep brain state can be
brought on by mental activities that involve experiencing absorbing
sensations and images instead of planning or worrying.

Reaching a pre-sleep brain state will increase the chance that you
will fall asleep.

You can use these methods when you first go to bed at night, or if
you wake up in the middle of the night.

The 3-2-1 technique:

• Get into a comfortable position, mentally checking your body to
make sure that every body part is as comfortable as possible.
• Listen for and note three sounds, any three sounds.
• Note three neutral or comfortable body sensations, any three
sensations.
• Allow three images to appear in your mind’s eye, and note them.
• Note two sounds, two sensations, and two images.
• Note one sound, one sensation, and one image.
• Note three sounds, three sensations, and three images.
• Note two sounds, sensations, and images.
• Note one sound, sensation, and image.
• Keep repeating until you drift off to sleep.

14
Relaxation by mental scanning:
• Get into a comfortable position, mentally scanning your body to
make sure that every body part is as comfortable as possible.
• Starting with one foot, note relaxing feelings and sensations in the
foot, and allow those sensations and feelings to grow and spread.
• Systematically allow those feelings to move into each area of
your body (one foot, lower leg, upper leg, other foot, other lower
leg, other upper leg, one hand, that arm, other hand, other arm,
shoulders, etc.)
• Pay close attention to feelings of relaxation and “letting go”.
• Enjoy and become absorbed by those feelings and sensations until
you drift off to sleep.

Using imagery (your imagination) to go to a relaxing and

absorbing place in your mind:
• Get into a comfortable position, mentally scanning your body to
make sure that every body part is as comfortable as possible.
• Select a place that you would like to go to in your mind’s eye. A
place where you can feel safe, very relaxed and comfortable.
• Imagine being in that place and just notice what is around you and
how relaxed you feel. Notice the colors, the smells, the comfortable
breeze.
• Keep imaging the details of this place (and your own comfort) until
you drift off to sleep.

Sleep Restriction therapy

• Use a sleep diary to keep track of your total hours of sleep at night.
• Get up at your usual time but go to bed later so you are only in bed
for as long as you are currently sleeping. For example if you find that
you are only sleeping about four hours a night and you normally get
up at 7 a.m., go to bed at 3 a.m.
• Do not lie in your bed or sleep during the day.
• Gradually increase length of time in bed by 30 minutes until you are
getting a full night’s sleep.

15
 Specific Sleep Issues
Some specific sleep problems may need specific treatments
• Sleep apnea: Observers say you snore loudly and often hold your
breath while sleeping. It may make you grumpy, impatient, irritable,
forgetful, or fall asleep while being active. You may experience hard-
to-treat headaches. It tends to make obesity, depression and leg
swelling worse.
• Restless leg syndrome: You feel a creeping, crawling, aching, or
tingling sensation in your lower legs worse at night-time. It may last
for one hour or longer. Sometimes it also occurs in the upper leg,
feet, or arms. You feel an irresistible urge to walk or move your legs,
which almost always relieves the discomfort.
• Periodic leg movement: This is a repetitive cramping or jerking of the
legs during sleep.
• Depression and anxiety: These are also associated with poor
sleep. These can be helped by non-medication methods as well as
medications.

A restful night’s sleep is one of the top priorities in solving your

chronic pain. The effectiveness of your other treatments is limited
until you are regularly experiencing a full night’s sleep for at least
six weeks. Usually medications are required for a while in the
presence of pain. As your pain diminishes so will your need for sleep
medicines.

No major additional treatment decisions should be made until this

goal is accomplished.

Steps to Get There

Keep a regular sleep routine
• Go to bed at the same time, each night. Wake up at the same time.
Ideally, your schedule should remain the same (+/- 20 minutes)
every night of the week.

16
Avoid naps if possible
• Each of us needs a certain amount of sleep per 24-hour period. We
need that amount, and we don’t need more than that.
• When we take naps, it decreases the amount of sleep that we
need the next night – which may cause broken sleep and lead to
insomnia.

Don’t stay in bed awake for more than 5-10 minutes

• If you find your mind racing, or worrying about not being able to
sleep during the middle of the night, get out of bed and sit in a chair
in the dark. Let your mind race while you are in the chair until you
are sleepy, and then return to bed. No TV or internet during these
periods! They will just stimulate you more.
• If this happens several times during the night, that is OK. Just
maintain your regular wake time, and try to avoid naps.

Don’t watch TV or read in bed

• When you watch TV or read in bed, your brain associates the bed
with being awake.
• The bed is saved for two things – sleep and sex.

Do not drink caffeine after 12 noon

• The effects of caffeine may last for several hours after you drink it. It
can break up sleep as well as make it harder to get to sleep. If you
use caffeine, only drink it before noon.
• Remember that many sodas and teas contain caffeine as well.

Avoid substances that may interfere with sleep

• Cigarettes, alcohol, beta-blockers (medications given for blood
pressure), antidepressants taken in the evening and many over-the-
counter medications may cause poor sleep.

Exercise regularly
• Exercise before 2 p.m. every day. Exercise helps continuous sleep.
• Avoid heavy exercise before bedtime. It may increase hormones,
which may disrupt sleep.

17
 Have a quiet, comfortable bedroom
• Set your bedroom thermostat at a comfortable temperature.
Generally, a little cooler is better than a little warmer.
• Turn off the TV and other noise that may disrupt sleep. Background
‘white noise’ like a fan is okay.
• If your pets wake you, keep them outside the bedroom.
• Your bedroom should be dark. Turn off bright lights.

Clock watching
• If you are a “clock watcher” at night, hide the clock.

Have a comfortable pre-bedtime routine

• A warm bath or shower.
• A warm milk drink without caffeine.
• Meditation, or quiet time.

Resources
• World Sleep Foundation, [Link]
• Exercises to treat sleep apnea, [Link] (Download the
free attached online video supplement)

18
Chapter Three:

Calming the Nervous

System
A Mind Body Approach to Healing
Chronic Pain that is Non-Structural
Howard Schubiner, M.D.

For many people with chronic pain, the cause is a nerve pathway
problem rather than tissue damage. The treatment for a tissue
damage problem is different than for a nerve pathway problem. This
section deals only with nerve pathway problems. These include
fibromyalgia; neck and back pain without a significant structural
problem; migraine and tension headaches; and most chronic
abdominal and pelvic pain syndromes like irritable bowel syndrome
and interstitial cystitis.

There are four parts of treatment for a nerve pathway problem:

1. Education
It is difficult to overcome a nerve pathway problem unless you
understand it fully. Educate yourself about nerve pathways (see the
reading list below). It is critical for your healing to understand that a
structural physical disease is not the main reason for your pain and
that you can get better! If you believe that, then you are on the road
to recovery.
2. Behavioral interventions
Meditation can help soothe the mind and calm fears. Since these
nerve pathways start in the brain, it is also possible to relieve pain
by reprogramming the brain. This can be done by talking to the pain
and telling it to stop! If you are forceful and firm, you can retrain the
nerve pathways. Since nerve pathways are learned, they can be
“unlearned” by repeatedly challenging the symptoms and taking
control over them. It is a “mind over brain” technique and is very
effective.
In addition, if the pain has “triggers,” such as movements, activities,
foods, or weather changes, challenge those triggers to unlearn
them. Decide that the triggers will not control you anymore and
create powerful affirmations (positive messages) to overcome them.
19
 Each day when you have pain or when you face pain triggers, tell
yourself “I am healthy and strong. There is nothing seriously wrong
with me. I can be pain free and I will not let this stop me. Pain, go
away. I don’t need you and I don’t want you.” The more forceful
words you use, the better. Then continue with your activities.
3. Emotional interventions
Emotions are often the key to unlocking chronic pain. Most people
with chronic pain have deep emotions that have been held in, such
as anger, guilt, fear, or sadness and loss. Recognize these emotions
and deal with them. Therapeutic writing is often good method for
resolving feelings. An emotion-based psychotherapy known as
Intensive Short-Term Dynamic Psychotherapy (ISTDP) is also a very
effective process created by Dr. Habib Davanloo that is now being
taught and practiced around the world. More information on this
technique can be found in Unlearn Your Pain (see below).
4. Life changes
Many people need to make changes in their lives. If you are trapped
in a relationship that is hurtful or destructive, something needs to be
done to ease or resolve the situation. If you are on bad terms with
people you love, this situation may need to be changed. If you are
stuck in a work situation that is overwhelming or overly stressful,
that may need to be changed. Take a close look at your life and see
if there are some issues that should be addressed and seek help to
find solutions for them. These issues are often key towards solving a
chronic pain problem caused by learned nerve pathways.

Resources
• Back in Control by David Hanscom, M.D.
• Unlearn Your Pain by Howard Schubiner, M.D.
• They Can’t Find Anything Wrong! by David D. Clarke
• Healing Back Pain, The Mindbody Prescription, and The Divided
Mind by John E. Sarno, M.D.

20
Mindfulness
Carolyn McManus, PT, MS, MA

Chronic pain means you are likely to have more stress than people
who don’t have pain. You have probably noticed that when your
pain is worse, you feel more stressed. It’s true: pain is stressful! Also,
having pain means you may be able to do less in your life and this
can create stress. Stress is associated with tighter muscles, poorer
sleep, anxiety, shallow breathing patterns, depressed mood — and
all of these lead to worse pain! Without even knowing it, you may be
medicating pain flares that are fueled by stress. 
Instead of focusing
on medication, you can learn how to reduce the stress and will find
you need less medication.


Mindfulness Stress Reduction

Why should I use the Mindfulness Technique?

How you choose to respond to the physical sensation of pain has

a major impact on how your nervous system creates pain and on
the quality of your life. Your automatic reactions to pain often amplify
the pain generating activity of your nervous system and cause an
increase in your pain and distress.

Mindfulness techniques are evidence-based practices (research has

been done and published in the medical literature) that help change
the nervous system back towards a normal non-pain state.

Through the Mindfulness Technique:

• You can learn skillful responses to pain that reduce pain and
distress.
• You can identify and choose skillful responses to more effectively
manage pain.
• Consider the following equation. Do you relate to it?
ª Pain = unpleasant physical sensation + your physical, cognitive
(thinking, understanding) and emotional reactions to the sensation

21
 Mindfulness means present-moment awareness and offers you a
constructive, practical and effective way to observe your physical,
cognitive and emotional reactions and make skillful choices that can
decrease your pain and distress.

Remember you may not have control over the sensation of pain, but
you do have control over your reactions to the sensation of pain.
Your choices directly impact your nervous system activity.

Steps to Get There

Formal Mindful Awareness Exercise
1. Pause now and direct your awareness to your body and breathing.
Listen to your present-moment experience with a stable, steady
mind. Some sensations may be pleasant; others, such as pain, may
be unpleasant; and still others neutral.
2. Imagine your mind is like the sky, and the pain is like a cloud in the sky.
3. Listen with compassion. Be kind to yourself. Listen with the same
friendliness you would offer a loved one if he or she were in your
situation.
4. Avoid any tendency to judge or criticize yourself. Pay attention to
your body as if you were doing so for the first time. Accept your
experience just as it is without needing to change or improve
anything.
5. Deliberately scan your body. Observe your feet, legs, torso, hands,
arms, shoulders, neck, face and head.
6. When you have completed scanning your body, let your attention
rest with the rhythm of your breath. Breathe deeply.
7. Observe your abdomen and rib cage move with your in breath and
out breath, here and now. Breathe into your waistband.
8. Count each exhalation. On the first out breath, say to yourself “one,”
on the second out breath, say to yourself “two,” and so on up to
the tenth exhalation. When you reach the tenth out breath, return to
“one” and begin again. When your mind wanders, label it “thinking”
and return your attention to your breath and the counting practice.
Begin again with “one.” Continue for five minutes.

A wandering mind is the most common concern people have when

beginning to meditate.

22
This is normal and not a sign that you are doing something wrong.
When you become distracted from the present moment, notice that
your mind has wandered like a cloud drifting by in the sky. Avoid
judging your experience as right or wrong. Note “thinking” and return
your attention to the present moment and your breathing.

Although these instructions may sound simple, the mind quickly

wanders off and becomes lost in thought. Pain is also distracting.
Just as the body can be trained to perform with greater strength
and endurance through regular exercise, the mind can be trained
to function with greater stability and clarity through this mindfulness
practice. Begin practicing this formal mindfulness exercise for five-
to-10 minutes each day.

Informal Mindful Awareness Exercise

An informal practice involves bringing present-moment awareness

into daily activities. For example, when walking, notice your present-
moment experience. Notice your breath, the sensations of your feet
when they touch the ground and the feeling of your legs moving
through space. Or, when you wash your hands, again, notice
your breath, the warm water on your fingers and palms, and the
sensations in your shoulders. Any daily activity can become an
informal meditation practice.

Mindfulness and Pain Management

• You are not your pain.
• Pain is a physical sensation, not your identity.
• You are a whole human being who is dealing with a medical
condition.
• By learning to be mindful, you can observe pain with a stable,
compassionate and curious mind. You can identify pain sensations
and your physical, mental and emotional reactions to pain
sensations. This alone is helpful.
• You can experiment with new responses that reduce your distress
and often decrease your pain intensity.
• By training your mind to be in the present moment, you also worry
less about the future and put your energy into skillful choices and
living well today.

23
 Resources
• The Mindfulness Solution to Pain: Step-by-Step Techniques for
Chronic Pain Management by Jackie Gardner-Nix
• Full-Catastrophe Living: Using the Wisdom of Your Body and Mind
to Face Stress, Pain and Illness by Jon Kabat-Zinn
• What Meditation Really Is with Jon Kabat-Zinn, [Link]
• Guided Mindfulness practices with Jon Kabat-Zinn,
[Link]
• Cognitive Neuroscience of Mindfulness Meditation with Philippe
Goldin, Ph.D., [Link]
• Guided Mindfulness Meditation Body Scan, [Link]
• University of Wisconsin, Department of Family Medicine: Guided
Meditation Instruction by multiple teachers.
[Link]/mindfulness
• Mindfulness meditation CDs can be found at [Link].

Relaxation
Carolyn McManus, PT, MS, MA

Most people with chronic pain notice that they carry a lot of tension
in their body. For example, no matter where your pain is located,
you may notice that your neck or shoulders feel tight. Pain creates
overall body tension because our muscles tighten as we ‘brace’
against pain. Tight muscles make pain worse. How?
1) Tight muscles “pull” on the body. For instance, tight shoulders can
pull on the neck, irritating joints and nerves to the scalp. This can
create tension headaches. Tight back muscles can worsen back
pain by pulling on the spine and connecting tissues.
2) Tight muscles generate chemicals that activate pain-related nerves,
making pain even worse. Muscle relaxants, or pain medicine to ease
muscle tension, are often not effective when used for a long time. They
may have unwanted side-effects and cause other problems. There are
better ways to manage your pain. You can learn exercises to reduce
muscle tension and relax. Research shows these exercises can help
you feel better and reduce pain.

24
Relaxation Techniques
Below is a list of suggestions to help you learn how to relax.

Deep Breathing: When you are under stress or in pain, your

breathing pattern can become more shallow and faster. Many
people hold their breath. This pattern of shallow breathing reinforces
the body’s stress reaction. In contrast, diaphragmatic or belly
breathing decreases the body’s stress reaction and promotes a
calming of your mind and body. The instruction to observe your
breathing and take a deep breath sounds simple; but it is not
always easy to do when stress and pain levels are high. It does get
easier with practice. Develop the habit of observing your breath and
breathing deeply during times of stress. Deep breathing is a proven
way to reduce your stress reaction. Below are some steps you can
take to practice deep breathing.
1. Formal breathing practice
a. Sit comfortably with a good posture. Place your hand on your
belly, just below your navel. As you breathe in, try to breathe
into your hand. Allow your breath to move deep into your lungs
and your stomach to gently move outward and your lower
ribs to move out to the side slightly. It may feel like you are
breathing into your waistband.
b. As you breathe out, allow your stomach to gently fall.
c. You do not have to take an extra-large breath. Your breath can
be a normal size.
d. The key is to allow your breath to fill the bottom of your lungs.
You know this is happening when your stomach slightly rises on
the in breath and falls on the out breath.
e. Now repeat a word or phrase to yourself that helps you relax in
concert with your breath. The simplest of these is “in” on the in
breath and “out” on the out breath. You can use any word or
phrase that has meaning for you. For example:
i. Your own name on the in breath followed by the words “let
go” on the out breath.
ii. “May I” on the in breath, “be peaceful” on the out breath.
iii. “Present moment” on the in breath, “only moment” on the
out breath.

25
 iv. If you practice within a religious tradition, you can use a
word or phrase from spiritual writings or the phrases “let
go” on the in breath, “let God” on the out breath, or “in the
Kingdom of God...I dwell.”
f. Practice for two minutes at least once a day.
2. Informal deep breathing
a. Use deep breathing when you have pain, during daily activities
and when going to bed.
b. Wherever you find yourself, whatever the time of day, take a
moment to bring your attention to your breath and take a deep
breath.
c. Observe your breath during routine daily activities, such as
sitting at a red light in traffic, standing in line at the grocery
store or waiting in a doctor’s office.
d. If your pain increases, notice your breath and breathe deeply.
e. When you are going to sleep, notice your breath, breathe
deeply and repeat the word or phrase that helps to calm your
mind and body.

Progressive Relaxation
This exercise involves gently tensing then relaxing the major muscle
groups throughout your body. It promotes the body awareness you
need to control your stress and tension and will help you relax.

Autogenic Training
Autogenic training promotes states of deep relaxation by inviting
you to repeat key phrases to yourself. “My right arm feels heavy
and warm” is an example of an autogenic phrase. You guide your
awareness to different body areas, repeating these calming phrases.

Body-Scan Relaxation
Body scan relaxation involves guiding your awareness through your
body in an orderly way, relaxing each body area. It is a simple and
commonly used relaxation technique.

Guided Imagery
Guided imagery exercises can be taught to promote relaxation and
engage the mind-body relationship in a healing process. Images can
be general, for example: “Imagine yourself in a calm and peaceful
place.” Or they can be specific, for example: “Imagine lots of oxygen
bathing an area of pain.”

26
Movement Meditations
Movement meditations such as gentle yoga, walking meditation and
Tai Chi, involve moving in a slow, controlled manner with awareness
while also breathing calmly and peacefully.

Hypnotic Techniques
To bring on a state of specific focused attention using imagery.

Biofeedback
Provides a person with information about the body, such as muscle
tension levels, that can be changed. The information may not usually
be under voluntary control or is normally under control but regulation
has broken down

Various types of biofeedback include muscle electromyography

(EMG), temperature, breathing and heart rate variability.

Resources
• The Relaxation & Stress Reduction Workbook by Martha Davis,
Matthew McKay and Elizabeth Robbins Eshelman
• Mayo Clinic - Stress Management Assessment, [Link]
• University of Maryland: Stress Relaxation Techniques,
[Link]/sleep/relax_tech.htm
• Hobart and William Smith Colleges: Relaxation Techniques,
[Link]/studentlife/counseling_relax.aspx
• CD recordings of relaxation exercises, [Link]

27
 Clinical Hypnosis
Maureen C. Pierce, Ph.D.

What is Hypnosis?
Hypnosis is a state of focused attention. It uses the imagination to
increase your responsiveness to suggestions. Hypnosis can help
change thoughts, feelings, behavior, and physical state. When you
focus your mind, you are able to use it to your benefit. Hypnosis
can treat many psychological and medical problems, notably pain
management. Hypnosis can help you sleep better, stop smoking,
manage your weight, prepare for surgery, and manage anxiety.

What are the Benefits of Using Hypnosis for the Management of

Pain?
• Affects areas of the brain associated with pain
• Lowers pain sensation
• Lessens intensity of pain
• You can experience comfort and safety within your body
• It increases a sense of control
• There are few, if any, side effects

Common Myths Regarding the Use of Hypnosis

• MYTH: The practitioner has control over the patient.
TRUTH: When you are in a state of relaxed and focused awareness,
you are always in control and are aware of this control.
• MYTH: Hypnosis does not work when physical symptoms are “real.”
TRUTH: Regardless of the cause, all symptoms are real. Hypnosis
helps treat many psychological and medical conditions.
• MYTH: Hypnosis is the same as sleep.
TRUTH: Hypnosis is not the same as sleep. In fact, the brain activity
seen during hypnosis is like the brain activity seen when people are
awake.
• MYTH: Only weak-minded people can be hypnotized.
TRUTH: Some people respond better to hypnotic suggestions than
others. Responding to hypnosis is not dependent on personality. a few
people are less able to respond to hypnosis, but the majority respond
readily.
28
• MYTH: A person will not be awake and will not remember anything.
TRUTH: Hypnosis is very much like what happens when you are
absorbed in a hobby or other interesting activity.
• MYTH: Stage hypnosis is the same as clinical hypnosis.
TRUTH: Stage hypnosis is for entertainment; Clinical or medical
hypnosis is used to help people.

Resources
• American Society of Clinical Hypnosis, [Link]/
• American Psychological Association, [Link]

Writing/Journaling
David A. Hanscom, M.D.

Anxiety is a universal and necessary part of the human experience.

It is a protective mechanism. When you feel threatened or cannot
meet a basic need, such as air, food or water, you will take action
to solve the situation and decrease your anxiety. Not being in pain
is a basic human need. Your first reaction to pain is anxiety and if
you cannot relieve your pain the next response will be anger. When
you are experiencing chronic pain you are truly trapped and your
frustration levels will rise to intense levels. The term I use is “The
Abyss,” which is anxiety x anger x time.

It is important to understand the link between anxiety and anger.

Anxiety causes the need for control. Anger results from loss of
control. Therefore anger is really “high anxiety.”

Using the Mind Body concept we look at pain, anxiety, and anger
in terms of neurological pathways. Just like an athlete, artist or
musician lays down routine pathways with repetition and practice,
your brain lays down pathways or circuits in response to repeated
pain, anxiety, and frustration. Once you have a pathway of any kind
in your nervous system it is permanent and can always be triggered.
So what can you do?

29
 The answer is simple and effective. You create “detours” around the
pathways. There are many ways of doing this but I have found one
foundational step to be critical. That is the task of writing down your
negative thoughts and immediately throwing them away.

This sounds too easy. Why would you do this?

New neurological pathways are created by connecting thoughts with:

• Thoughts
• Emotions
• Experiences
• Physical sensations

When you have written down these negative/disruptive thoughts you

make a “space” for yourself outside of the thoughts. The reason to
throw them away quickly is not to get rid of them but to help you to
write more freely. Do not take these thoughts personally or seriously.
They are just chronic emotional circuits tied in with your pain. They
have nothing to do with who you really are. Writing down these
thoughts creates an awareness of the source of your anxiety and
frustration. You now have a chance to choose a different response
to a given stressor. As you continue to make more thoughtful, skillful
choices, your brain will grow new neurons and form more functional
connections.

There are three parts to re-programming your nervous system:

1. Awareness – become aware of your repeating nerve pathways/
circuits.
2. Detachment – take a step back to see what is really going on.
3. Laying down new circuits/pathways – new pathways can bypass
troublesome older ones and quiet them down.

The key to increasing your chances to resolve your chronic pain

is your ability and willingness to let go of the anger and anxiety
associated with it. The emotion and pain pathways are so closely
linked that it is only possible to experience meaningful pain relief
when you break this connection. Separating your emotions from
your pain pathway is a learned skill and writing is an essential tool.

30
Writing down negative thoughts is a process you may need to do for
the rest of your life. This practice is not a philosophy but a practical
tool to reprogram the nervous system. Consider it a self-care action
similar to brushing your teeth.

Steps to Get There

• Learn about how the brain lays down pathways by reading, The
Talent Code by Dan Coyle.
• After you have become comfortable with free writing, read Feeling
Good by David Burns, M.D. Dr. Burns has developed structured
formats that are very effective. Learn to write in the “three-column
technique.”
• Once you have made progress with your anxiety, engage in the tools
suggested by Fred Luskin, Ph.D., in Forgive for Good. He discusses
his four research projects out of Stanford on forgiveness and
provides strategies that will enable you to experience the mental
and physical benefits of forgiveness.
• Unlearn Your Pain by Howard Schubiner, M.D., clearly explains the
Mind-Body Syndrome. It includes many suggestions for how to
create more functional pain free circuits in your brain.
• The Hoffman Institute website provides a framework for examining
your life in terms of patterns and Mind-Body Concepts. It is an
effective eight-day, in-house, reprogramming process that can be
considered later in your healing.
• Back in Control: A Spine Surgeon’s Roadmap Out of Chronic Pain
([Link]) This resource provides a method to
create an action plan based on the principles delineated in the book
of the same name.

Resources
• The Talent Code by Daniel Coyle
• Feeling Good by David D. Burns, M.D.
• Forgive for Good by Fred Luskin, Ph.D.
• Unlearn Your Pain by Howard Schubiner, M.D.
• The Hoffman Institute, [Link]/
• Back in Control: A Spine Surgeon’s Roadmap Out of Chronic Pain
by David Hanscom, M.D., [Link]

31
 Music Therapy
Gordon Irving, M.D.

Why do music therapy?

Music has been associated with healing the body and mind for
centuries. Research has shown that listening to live music results
in a much greater effect on physical and psychological states than
does recorded music. However the greatest positive medical effects
are with patient-preferred music. Listening to, or better yet engaging
in focused musical activity is effective in changing the mood,
creating relaxation, and can assist in decreasing your pain.

Steps to Get There

• Choose the music that suits you, your mood and your activity.
• Do your exercise program while listening to your favorite music. This
will create a quick and pleasant passage of time.
• If you can play an instrument you may have to modify your
technique or even get an instrument like an electronic keyboard that
does not require as much wrist and finger movement and pressure
as a piano to play.
• Even if you do not own or cannot play a musical instrument, tapping
out rhythms, xylophones, hand chimes, rain sticks and other
percussion instruments can be used to reduce pain and promote
pleasure and relaxation.
• Do deep relaxed breathing to the rhythm of the music. This
encourages regular breathing and relaxation.
• Close your eyes while listening to music and imagine yourself in a
place you would like to go.
o Visualization is a powerful reprogramming tool
• Composing songs about the experience of pain and coping with it
can be freeing
o As pointed out in the writing section the more accurately you
can convey your frustrations around pain the more effective the
exercise.

32
Helpful Hints
• Choose music that you like and that is appropriate to your activities.
• Make the whole experience as enjoyable as possible.
o If finances are a problem going to a thrift store may allow you to
buy an MP3 player to download music you like or buy a musical
instrument that you want to play.

Resources
• American Music Therapy Association, [Link]
• Effect of Music Therapy Among Hospitalized Patients with Chronic
Low Back Pain: A Controlled, Randomized Trial. National Center for
Biotechnology Information, [Link]/pubmed/15914256
• Music Therapy for Pain by Dr. Scott Stoney (Part 1),
[Link]
• Music Therapy for Pain by Dr. Scott Stoney (Part 2),
[Link]
• Music Therapy for Pain by Dr. Scott Stoney (Part 3),
[Link]

Anxiety and Depression

Allen Hume, Ph.D. and Maureen C. Pierce, Ph.D.

Chronic pain and other health care issues may result in negative
emotional states, including anxiety and depression. When we
experience pain, our brain “sounds the alarm” by sending messages
to release neurotransmitters, hormones and other chemicals to
protect us. Once the threat is diminished, our body and brain goes
back to a state of balance, or homeostasis. When the pain does
not stop, however, our body continues to send out messages
to protect us, which over time drains us, both physically and
emotionally. We are then at greater risk of developing anxiety and
depressive symptoms, that when left unaddressed can become
their own problem. For example, many folks in pain may experience
greater worry, less control over these worried thoughts, increased
restlessness and tension, and greater irritability due to the pain
response. Or there may be greater sadness, loss of interest in
previously enjoyed activities, feeling guilty or worthless for no good

33
 reason, or perhaps even hopeless about the situation. These
responses are understandable and occur in many with chronic pain
and other health care issues.

Addressing these feelings is a priority and can be done in many

ways, acknowledging the feelings and thoughts, seeking counseling,
discussing with your medical provider, and/or taking a medication
that is targeted to the symptoms you experience. Interestingly,
there is evidence that the part of the brain where physical pain is
experienced is also the part of the brain where negative emotional
states are experienced. So in a sense, our pain response is both
physical and emotional at the same time. Take a look at the
websites listed in “resources,” consider accessing your family and
social support system, and talk with your health care provider if you
are experiencing these feelings.

Steps to Get There

1. Take part again in activities you used to enjoy as much as you can
— you may have to make a list of activities and select the ones you
can still do in spite of pain.
2. Learn some new stress management skills, including relaxation, deep
breathing, guided imagery, and meditation, all of which have been
shown to help depression, anxiety, and pain.
3. Use your social support network. With chronic pain, you may have
to make new contacts with others, either individually or in a group
setting. There are many resources available in your community,
online, and professionally.
4. Learn how to use cognitive behavioral therapy (CBT) to address your
negative thoughts, which will help you feel better.
5. Listen to your favorite music, watch a movie you particularly enjoy or
read a good book.
6. Stay focused on being as active as possible — when we are passive
in our approach to life we are more likely to dwell on negative
feelings, experiences, and pain.
7. Discuss your feelings with a trusted medical provider. Follow all
recommendations, both for pain and emotional symptoms. Pain and
stress interact; therefore, we must address both at the same time.
8. You may want to enter individual counseling with someone who
understands chronic pain. Group therapy can also be very helpful.

34
Resources
Anxiety
• American Psychological Association,
[Link]/helpcenter/[Link]
• Anxiety Disorders Association of America, [Link]
• National Institute of Mental Health, [Link]
• Mental Health America, [Link]

Depression
• Depression Screening, [Link]
• National Alliance on Mental Illness, [Link]
• National Institute of Mental Health, [Link]
• American Psychological Association, [Link]

Trauma
Allen Hume, Ph.D. and Maureen C. Pierce, Ph.D.

Trauma is present in approximately 40 percent or more of individuals

who suffer from chronic pain, whether it happened before the
onset of pain (i.e. childhood abuse), or was the cause of the pain
(serious motor vehicle accident). The pain we experience may be
affected by our previous trauma history. We may spend a lot of time
thinking about painful emotional events, we may be unable to work
or “physically” manage our traumatic memories any longer due to
pain, or the pain may serve as a trigger for past negative emotional
experiences.

In order to effectively manage the pain and trauma, both issues will
require your attention, along with your healthcare provider. Many
times, we don’t want to disclose information about past trauma. We
may not feel ready to trust the provider with that information. We
might think that our pain won’t be taken seriously. Seeking care from
a psychologist or other mental health provider who has experience
with both pain and trauma is most likely to be helpful. This provider

35
 can help you unravel the complex interaction between pain and
trauma and develop effective coping skills. In addition, if and when it
is appropriate, there are therapies to reprocess the experience that
helps resolve the emotional pain, which in turn may also help the
physical pain.

Steps to Get There

1. Learn more about PTSD (post-traumatic stress disorder), trauma
and how it interacts with pain. There are many good resources listed
below that you can use.
2. Learn ways to reduce your stress and tolerate distress, including
breathing exercises, guided imagery, relaxation skills and meditation.
The more you can self-soothe, the better you will be able to manage
traumatic stress.
3. Listen to your favorite music, read a good book or watch a movie
you enjoy.
4. If you have PTSD, professional intervention is most helpful. Talk to
your healthcare provider for a referral to a mental health provider
who works with both pain and trauma.
5. Like other forms of anxiety, individuals with traumatic stress benefit
from good social and family support. Be sure to seek out others for
emotional support, leisure activities and skills development.
6. Consider joining a therapy group for individuals who have
experienced trauma and pain. The more resources you have the
better.

Resources
• EMDR Network, [Link]
• U.S. Department of Veteran Affairs, [Link]
• National Institute of Mental Health, [Link]
• American Psychological Association, [Link]

36
Thoughts
Allen Hume, Ph.D. and Maureen C. Pierce, Ph.D.

Chronic pain has a profound impact on our thoughts and beliefs,

and more importantly on ourselves. Folks in pain often talk about
their experiences in “absolutes,” using words such as always, never,
should and must when facing difficulties. We are also inclined to
unrealistic, distorted in our thinking, particularly when we don’t feel
good physically or emotionally.

For example, we may “catastrophize,” which means assume the

worst without good reason. For example, the back may hurt a bit
and we assume that we will wind up back in surgery, when in fact
the sensation may be temporary. While it is common to think this
way at times, it isn’t a helpful way to think about our problems.
Individuals with chronic pain may feel very bad when they first get
up in the morning due to a restless night of sleep. The person may
be tired, stiff, and frustrated. As they think about how they feel
they notice thoughts such as “I shouldn’t feel this way” or “I’ll never
get any better.” These thoughts in turn affect emotions, increasing
feelings of worry, depression and hopelessness.

A common emotional outcome is believing that others will think

badly of the person in pain because the person in pain feels bad.
There are many ways to address this type of thinking and beliefs,
but the best may be cognitive behavioral therapy or CBT. The basic
idea of CBT is that one can change how they feel by recognizing
and changing their distorted thoughts. Keep in mind that everyone,
and we mean everyone, has distortions in thinking at times. The
most common tend to be black and white thinking, jumping to
conclusions, minimizing success, focusing on the negative, and
catastrophizing.

The good news is that by firmly challenging our thoughts, we can

change how we feel, both emotionally and physically. Take a look at
the resources provided and discuss with your healthcare provider.

37
 You may want to find a psychologist, either individually or in a group
setting to work with your thoughts – just be careful – making these
changes might improve your outlook and how you feel!

Steps to Get There

1. Learn to recognize your thought distortions so that you can begin to
challenge and change them. There are many websites and books
that can help.
2. Seek support and feedback from others you trust, including family,
friends, and providers.
3. Notice when you use words like should, ought, must, never and
always, either in your head or out loud. These words are often signs
of thought distortions and can be a signal to examine and confront
your thoughts.
4. Consider seeing a therapist who uses cognitive behavioral therapy
(CBT). This is a practical, generally short term therapy focused on
teaching you how to change your own thoughts and feelings.

Resources
• Feeling Good by David Burns
• National Association of Cognitive Behavioral Therapists, [Link]
• Rational Emotive Behavior Therapy, [Link]/[Link]
• American Psychological Association, [Link]

Joy, Pleasure and Spirituality

Louise Berkowicz, M.D.

Our thoughts and emotions affect how our bodies work and feel.
Forgetting to “smell the roses” is common when a person has
chronic pain. Finding joy, pleasure and connection to life helps us
focus on the positive aspects of living.

38
As you work to build and keep a sense of wellbeing and
connectedness, less energy and attention will be paid to your pain
pathways and pain will often decrease notably. Certain practices
and exercises help to increase awareness of the mind/body/spirit
connection. Do these exercises often to help you train your brain.

Steps to Get There

1. Deep Breathing: Breath in slowly counting to five and fill your
lungs so that your stomach expands but your shoulders do not lift.
Expanding your lungs fully can trigger a relaxation response. Repeat
by breathing out for a count of five and then breathing in to five.
Repeat up to ten times
2. Meditate: Meditation can mean many different things. Some people
use it as a time to think. Others meditate while walking or running.
Find techniques that you enjoy. Meditate twice a day
3. Eat Mindfully: Occasionally eat in silence, chew each bite 20 times
and enjoy the taste. This enhances appreciation of food.
4. Laugh Often: Laughing has many great health effects. It boosts
your body’s ability to fight germs, increases energy relieves aches
and pains, lowers blood pressure, and improves mood.
5. Be Gentle and Kind to Yourself: Say positive words to yourself
such as “I am wonderful, I honor and respect myself, I love myself.”
Do this daily.
6. Express Yourself: Speak from an open heart and be true to
yourself and others.
7. Exercise: Choose an exercise you enjoy and do it daily.
8. Learn: Look at the lessons you are learning, especially in times of
difficulty and challenge.
9. Be Mindful: Take time to be aware of the beauty around you, from
nature to the human touch.
10. Be Grateful: When you wake up, think of one thing for which you
are grateful.
11. Notice Stress: Become aware of how your body reacts to stress.
Relax (see #1, #2 and #4) to help deal with the stress.

39
 Resources
• The Wise Heart by Jack Kornfield, Ph.D.
• The Four Agreements: A Practical Guide to Personal Freedom by
Don Miguel Ruiz
• Anatomy of the Spirit by Carolyn Myss, Ph.D.
• A New Earth by Eckhart Tolle
• Vibrational Medicine by Richard Gerber, M.D.
• Laughter Yoga International, [Link]
• Help Guide, [Link]/life/humor_laughter_health.htm
• University of Maryland Medical Center: Laughter is the “Best
Medicine” for Your Heart, [Link]/features/[Link]
• ISSEEM (International Society for the Study of Subtle Energies and
Energy Medicine), [Link]
• IONS (Institute of Noetic Sciences), [Link]
• William A. Tiller Foundation, [Link]
• Mind Body Medicine Center, [Link]
• Wisdom at Work: Joel and Michelle Levey, [Link]

40
Chapter Four:

Outside the “Box”

Relationships
Allen Hume, Ph.D. and Maureen C. Pierce, Ph.D.

Pain often affects our relationships with others, including family,

friends, employers and physicians. Often the person in pain doesn’t
want to feel like a burden to others; other times they seem to want
to have someone else take care of everything for them. The family
member or friend may feel helpless and unsure how to help — in
fact they may not understand how the person in pain is feeling. So
what do you do?

You might be surprised at how similar your feelings and thoughts

are with those around you. Many times people feel powerless, out of
control, angry, and frustrated but we often feel better once we have
talked to our friends, family, and others.

Steps to Get There

1. Ask for what you need from others – don’t assume that they know.
2. Talk about your concerns.
3. Balance your needs with the other person’s needs as well.
4. Point out common goals and try working through your differences
calmly without raising your voice. Try not to be defensive.
5. Remember that the other person may not know how you feel — use
clear language and check in to see if they understood.
6. Remember that pain is only one part of your life. It’s okay to let
others know that you want to talk about “normal” things.
7. Do what you can to enjoy time with friends and family. Remember to
take it easy, be compassionate, they may not think about things the
way you have come to understand them
8. Try new activities and involve others.
9. Remember that family and friends want to be supportive and
understanding, even if you feel like they don’t. Let them know it is
okay to not know what to do or say. Family and/or couples therapy
may be helpful as well.
41
 Resources
• American Psychological Association,
[Link]/monitor/jan06/[Link]
• Relationships and Pain,
[Link]/tag/relationships-and-pain/
• Health Talk Online (United Kingdom),
[Link]/chronichealthissues/Chronic_Pain

Hobbies
Gordon Irving, M.D.

Many people in pain feel they can’t do or enjoy anything.. Is this

you? Have you had to stop doing something you love because you
felt you could no longer do it?

The good news is that you can often find a way to do it but at
a lower intensity. Try a new hobby or one you had before you
experienced chronic pain.

You can use any hobby that you have enjoyed in the past or want
to do now. Sometimes just writing down the steps you need to
get there is important in motivating you to do it. One possibility is
learning magic.

Magic
Alan Kazam

If you enjoyed entertaining people with magic tricks when you were
younger why not try it again? Even if you don’t have experience, why
not try something new?

Becoming a magician

Learning some simple magic tricks will work your brain and your
body, plus it will give you a new skill which you can use to entertain
family and friends. Even people with disabilities can do magic:
famous Argentinean magician, René Lavand, performed great
sleight of hand even though he only had one hand!

42
Before we begin there are three rules that you MUST consent to
called “the magician’s code.” The rules are:
1. Practice, practice, and practice tricks before you show them to
anyone.
2. Never repeat the same trick for the same people.
3. Never tell how you do your tricks.

Magic is based on simple principles and if your audience finds out

how it is done, the magic disappears

Steps to Get There

Visit a magic shop and ask them to help you find books or DVDs
to study (see resources.) Get advice from other magicians at clubs,
magic shops, or on the Internet (see Resources.)

Magic can help with many common social and work situations.
To perform magic means learning to be confident in public and
understanding how to control audiences.

Resources
• Mark Wilson’s Complete Course in Magic by Mark Anthony Wilson.
This is remarkably inexpensive for what it contains and many
magicians would recommend it as a first book.
• Jay Sankey’s Amazing Magic and Mentalism that Anyone Can Do —
Volumes 1 and 2 DVDs. These DVDs can also be ordered from his
website, [Link]
• Learn Magic, [Link]/od/beginningmagic/u/
[Link] This has lots of free tricks with explanatory pictures,
great tips for beginners and plenty of links to other sites where you
can get even more free tricks.

43
44
Chapter Five:

Caring for Your Body

Nutrition and Weight Management
Gordon Irving, M.D.

Good nutrition improves sleep, energy levels, mental focus and

emotional health. Our food choices help fight germs, so if we aren’t
eating well we are more likely to become sick or feel poorly.

Poor nutrition and/or eating calories, particularly derived from

processed foods and sugar may cause weight gain and obesity.
A body mass index (BMI, which is your weight in pounds divided
by your height in inches) of 30 or more indicates obesity. A BMI of
more than 40 is called morbid obesity and carries significant risk of
shortening your life. Obesity makes pain worse and increases stress
on your knees, hips, and other joints. It is important to lose weight
for your health and to control pain.

How does nutrition help pain?

1. Many pain sufferers have food sensitivities that they may or may not
know about (see the elimination diet listed below).
2. Some foods cause inflammation in the body which can make pain
worse. You may help your pain by eating foods that decrease
inflammation. Search the internet for “anti-inflammatory foods” for
more information.
3. Being overweight can cause pain all over the body pain as well as
in the knees, hips, or back. Losing 10-15 pounds in weight can
decrease your pain significantly.

Changing how you eat, drink, and exercise can be hard, but the
results are rewarding in every part of your life. It can help you think
clearly, improve memory, and better your moods. Eating healthily
can also help you decrease your risk of heart disease, diabetes, and
cancer.

45
 If you are overweight:
1. Check your weight at least once a week.
2. Focus on losing one to two pounds every week. Cut out sodas and
fried food as a first step.
3. Use measurement tools (cups, spoons, and food scales) and read
nutrition labels. Patients who need to lose weight, especially those
having trouble, may not realize how many calories they eat. These
tools can help.
4. Lower your body mass index (BMI) (weight in pounds divided by
height in inches) to less than 30. Weight loss lasts longer for people
who are happy with their results so aim for realistic goals. This will
help build your confidence so you may not need professional help.

Steps to Get There

Below is a list of tips to improve your nutrition.
• Choose a diet that follows basic rules. There is no single diet
that will work well for everyone who needs to lose weight. The basic
rule of any healthy diet is to limit foods that are high in unhealthy
fat, get plenty of healthy protein such as skinless chicken, non-fatty
meat portions, or fish, eat more vegetables (except potatoes which
are high in carbohydrates) and fresh fruit (except bananas which
are high in starch) and drink plenty of water. Avoid sodas, even diet
sodas.
• Eat only at meal times.
• Choose foods that you enjoy. Finding healthy foods you love to
eat helps!
• Remove triggers for overeating:
o Go to the grocery store after a meal to prevent impulse buys.
o Keep unhealthy food out of sight.
o Avoid buying unhealthy food.
• Shopping: When you shop, use cash instead of your credit card;
this may help you from buying “comfort food”.
• Have a reward system: Set weekly goals and reward yourself
when you reach them, but not through food. Tell yourself “I’ve been
OK,” “I’m doing great,” and “I have the ability to lose weight and to
have an active lifestyle.”

46
• Figure out your emotional eating cues and replace them with
other behaviors. Choose behaviors that are difficult to do when
eating (e.g., writing, knitting, housekeeping, exercising, and taking a
bath).
• Vitamin supplements: Some vitamin supplements may help.
Vitamin D may help with muscle pain. How much vitamin D you
need depends on many factors like sun exposure; skin color; food
choices and digestive health. If taking a multivitamin supplement
most have only relatively small amounts of vitamin D. You may have
to take a single vitamin D supplement to get to the 2,000 to 4,000
IU (international units) per day that is frequently recommended.
• Nutritionists and Naturopathic doctors (NDs): Registered
dietitians and naturopathic doctors are great nutrition counselors.
See a nutritionist or naturopath to get help with new healthy habits.
• Elimination diets: If you think you may have food intolerances,
trying an “elimination diet” may help you find out which foods you
are sensitive to. First, stop eating all foods you may be sensitive to.
Then reintroduce them one food at a time. Meeting with a dietitian
or naturopathic doctor during an elimination diet may help.
o Keep a food diary and write down what and how much you ate
and any symptoms you notice. This can help you identify food
allergies or intolerances.
o Stop eating these foods for two weeks. If you cannot do this
all at one time, choose a few and then try not eating the others
during a second two-week trial. (Only do two trials.)
1. Dairy products, including cheese. Instead, use soy milk
and soy cheese, or rice milk, and rice-based ice cream.
2. Egg and foods with egg.
3. Foods with gluten, such as wheat and wheat-based
products (pasta/noodles, barley, oats, or rye grains.)
Instead, you can eat brown rice, nuts, buckwheat, spelt,
millet, potatoes, or sweet potatoes.
4. Citrus fruits.
5. Corn and foods with corn.
6. Plants from the nightshade family (tomatoes, potatoes,
eggplant, peppers, and tobacco.)
7. All processed foods, including caffeine. Suddenly stopping
some foods (such as drinks with caffeine) may cause
withdrawal symptoms (such as headaches) but this should
only last a few days.

47
 o After two weeks, add back one food group to your diet every
three-five days. Writing down what you are eating and how you
are feeling during this time can help you to notice how a food
may be affecting your mood, energy, and pain (using numbers
to rank how you are feeling may be helpful).
o Your pain may flare-up or you may feel more tired when you eat
something that you are sensitive to. If you notice this, you may
want to stop eating that food.

Resources
• Good Calories, Bad Calories and Why We Get Fat: And What to Do
About It by Gary Taubes
• The Primal Blueprint by Mark Sission
• New Atkins for a New You by Drs. Eric C. Westman; Stephen D.
Phinney and Jeff S. Volek
• The Dukan Diet by Dr. Pierre Dukan
• The Paleo Diet by Loren Cordain, Ph.D.
• USDA Center for Nutrition Policy and Promotion,
[Link]
• Academy of Nutrition and Dietetics, [Link]
• CDC Healthy Weight: BMI Calculator,
[Link]/healthyweight/assessing/bmi/
• Harvard School of Public Health, The Nutrition Source,
[Link]/nutritionsource
• The Vegetarian Resource Group, [Link]
• Physicians Committee for Responsible Medicine, [Link]
• Memorial Sloan-Klettering Cancer Center: Herbal therapies
[Link] (search for “ herbs”)

48
Smoking
Gordon Irving, M.D.

Most people are surprised to learn that smoking makes pain worse.
One of the best things you can do to help your pain is to quit
smoking. Smoking changes how your brain and body feel pain.
Most people think that smoking helps with stress. In fact, smoking
causes stress on the body, and it is linked to more anxiety. Cigarette
smoke keeps oxygen from going to your discs and the tight muscles
affected by pain. By quitting smoking you will save money, improve
your physical and emotional health AND you will improve your pain!

Why should I stop smoking?

1. Over time smoking makes your brain more anxious, stressed, and
tensed. Like any highly addictive drug you then have to take another
cigarette to avoid withdrawal and “feel better”.
2. For an hour after smoking, oxygen cannot get to areas of your body,
such as the discs of the spine or tight muscles. Smokers tend to
have more back and muscle pain.
3. Smoking may make some pain medications not work as well.
4. In a study, people who had lung cancer and continued to smoke
had more pain than those who stopped.

Steps to Get There

Below is a list of tips to help you stop smoking.
1. Keep telling yourself your reasons for quitting and imagine
yourself as you’d like to feel, enjoying your favorite activities without
smoking.
2. Promise yourself something you enjoy, such as a movie or
dinner out as a reward, for getting through the first week.
3. Get involved in activities that don’t go with smoking, such as
meditation or exercise.

49
 4. For two days before you quit, every time you smoke, write
down the feelings you had before smoking each cigarette:
• Were you tired? Bored? Hungry? Restless?
• Write down the positive feeling that came from smoking each
cigarette. Did it help you relax? Did you feel less bored? Did it
help you wake up? Did it help you go to asleep?
• Study your list. You’ll probably notice a pattern. Consider how
you could substitute a more positive lifestyle to get that same
feeling such as an activity like a brisk walk.
5. Make specific plans ahead of time for dealing with
temptations. Find two or three coping strategies that work for you,
such as taking a walk or calling a friend.
6. Set a quit date. If you smoke mostly at work, try quitting on a
weekend. If you smoke mostly when relaxing or with friends, quit on
a weekday.
7. Find things to distract you when you start feeling like
smoking. If you smoke to relax, figure out how to relax without a
cigarette. If you smoke to clear your mind, figure out how to do that
without a cigarette.
8. Get help from family and friends. They can’t quit for you, but
they can help by not smoking around you, listening to your struggles
and encouraging you, and leaving you alone when you need some
space.
9. Make it clear to your smoking friends that you don’t want
them to give you a cigarette. When people relapse and smoke,
they usually get their cigarettes from friends.

Helpful Hints
• The average person quits up to nine times before they are able to
stay smoke-free. If you return to smoking, it doesn’t mean you can’t
quit. It just means you need to try again. Find out what caused you
to slip up and change your plan for next time.
• Ask your doctor about other options to help you quit. Try a support
group, an individual counselor or other source of help if you have
not been able to quit on your own.

50
• You do not reduce your health risks by smoking low tar/nicotine.
Smokeless tobacco, pipes and cigars are just as harmful.
• A scientific trial of cytosine, sold over the counter as Tabex, showed
similar results to nicotine replacement therapy with no serious side
effects reported.

Resources
• Smoking Cessation, [Link]
• National Institutes of Health: Medline Plus,
[Link]/medlineplus/[Link]

Physical Activity
Gordon Irving, M.D.

Pain may get worse when you do too much or too little activity. If we
are not active enough, our bodies age more quickly and our muscles
get weak. Research shows that controlled exercise can help chronic
pain better than any other treatment, including medication!

Exercise is also one of the best treatments for anxiety, stress, and
depression. But if people with chronic pain try to do too much, their
pain gets worse and it may take days to feel better.

Beginning a gentle exercise program is one of the best things you

can do to help your body and your pain, but go slowly. You can
reduce the pressure on yourself by setting goals you can meet.
Having pain means you can’t do all things you used to do. Pushing
yourself to do more than you are able may lead to more pain, both
physical and emotional.

Steps to Get There

1. Pacing means starting slow and figuring out how much you can do
without causing your pain to flare up. Start by walking to the mail
box two to three times a day.
2. Frequency: Doing an activity more often during the day may allow
the body to recover and strengthen.

51
 3. Once you have done an activity three times, try increasing the
distance or time. Before long, you will be doing more activity on a
regular basis than you have done for a long time, and feeling the
mental and physical benefits.
4. Exercising daily can help you move more easily and with less pain in
as little as three weeks.
5. Remember even if you start slowly, pacing and consistency are
the keys.
6. Exercise is not about overnight success, but if you are consistent
and patient, you will likely meet your goal.
7. Work up to exercising for at least two and a half hours a week.
8. Record how much you exercise currently. Check how much you
walk every day by using a pedometer. Work up to 10,000 steps
every day.
9. Both aerobic exercise (like walking or running) and strength training
(lifting weights) are important. Start off using smaller weights and
higher repetitions (number of times you lift the weights).
10. You may want to try Tai Chi, which research has shown can help
pain sufferers.

Helpful hints
1. Do exercises you enjoy. Walking is often the easiest because all you
need is your legs. Swimming, biking, Tai Chi, yoga and dancing help
chronic pain, too. Try different activities on different days to keep
from getting bored.
2. Try to exercise with a partner or pet. Taking a dog for a walk is good
for both of you.
3. Get a pedometer. Set weekly goals that involve increasing number of
steps or length of time (e.g., walk 500 more steps every week)
4. Make exercise a priority. Set a schedule and stick to it.
5. Listen to your body. Set goals that work for you: No goal is too
small.

52
Resources
• 23 and ½ Hours: What is the Single Best Thing We Can Do For Our
Health? By Mike Evans, M.D., [Link]
• The Chronic Pain Haven,
[Link]/[Link]

Headache Management
Hubert A. Leonard, M.D., Ph.D.

Types of Headaches
• Tension headaches are the most common type of headache.
As many as 90 percent of adults have had or will have tension
headaches. They are more common in women than men and are
not as bad as migraines.
• Migraine headaches are the second most common type of
headache but the most common headache causing distress and
disability. An estimated 30 million people in the United States, about
12 percent of the population, will experience migraine headaches.
An estimated six percent of men and 18 percent of women will
experience migraine headaches. Chronic migraine (more than 15
days of headache each month with at least eight days of migraine)
affects one-and-a-half to two-and-a-half percent of Americans and
causes disability. Migraine is more than just headache; it involves
nausea and/or vomiting or sensitivity to light and sound.

Stages of Migraine
Identifying Your Level of Disability

Migraine disability is different for everyone. Treatment depends on

the level/stage of disability. In Managing Migraine (see Resources
List), the authors talk about four stages of disability:
• Stage 1: Migraines only happen once in a while. Between
migraines, people feel normal and do not fear another one. Strong
medications work well. Migraine is short-lived and not a disease.

53
 • Stage 2: Migraines happen many times every month and get in the
way of daily life. People have three to eight headache days a month
with some disability. Medication may not always work. Migraine may
get in the way of sleep and affect mood. Eating well, exercise, and
daily medication may help.
• Stage 3: People have 10 to 14 headache days a month for at least
three months. Medications may help but pain may come back. They
may have anxiety, bad moods, and trouble sleeping. They may miss
work, school, or family events. They may overuse medications.
Eating healthy, excising, and taking daily medication is needed.
Often there are other medical or psychiatric issues that must be
identified and treated.
• Stage 4: Headaches happen on 15 or more days a month. Overuse
of medication often becomes part of the problem. Most people
have trouble sleeping, depression and other problems with their
health. These people have chronic pain that can only be treated
with big lifestyle changes, daily medication, and help from a pain
psychologist and others.

Steps to Get There

Know Your Triggers
• Some foods may cause migraine headaches but this is different
for everybody. Also, these foods will not always bring on a migraine
headache. Some common triggers include alcohol, monosodium
glutamate (MSG), citrus fruit (lemons, lime, oranges or grapefruits),
aspartame (one kind of artificial sweetener), caffeine and aged
cheeses.
• Caffeine – found in sodas, coffee, tea, chocolate, caffeine pills,
some medicines, and painkillers like Anacin, Empirin, Midol and
Excedrin – is a major cause of headaches. The headache pain
killers can cause a “rebound” effect: You take it to get rid of the
headache, which goes away, but then comes back worse than ever.
Try to remove all caffeine from your diet. Although you may have
withdrawal symptoms for a few days, including headaches, it will be
worth it.
• Medical issues can cause headaches and migraines, including
mental stress, drugs of all types, thyroid problems, diabetes, chronic
pain, low magnesium, and brain diseases.

54
• Alcohol can cause headaches or migraines by itself or by causing
dehydration. To avoid dehydration, drink water while you are
drinking alcohol and before bedtime.
• Smoking can cause headaches because the nicotine and carbon
monoxide in cigarette smoke affect the blood vessels. Secondhand
smoke causes headaches in some people.
• Stress is the most common cause of headaches. Know the
common sources of stress at home and at work. If it is difficult
to get rid of the stresses, get help from other family members or
through a psychologist or counselor.

Treat the Symptoms without Medication

• Rest in a cool, dark, and quiet place. Use cold compresses,
an ice pack, or a bag of frozen vegetables. Some people find heat
helps.
• Changing behavior helps control headaches. Eat a healthy diet,
get enough sleep, drink at least a liter of water a day, and find ways
to manage stressful relationships and responsibilities. Learn how to
say “No.”
• Have someone massage your neck and lower back. Try a hot
shower.
• Acupressure is good for pain relief. Place one finger between your
eyebrows and another finger on the top of your head. Push gently
and hold for two minutes. Another pressure point is between your
thumb and index finger. Push there for two minutes.
• Relax! Tension is a major cause of headaches. Lie down where it is
quiet and breathe in for eight seconds; breathe out slowly. Do this
many times until you feel yourself relaxing. Breathe deep into your belly.

Resources
• Managing Migraine. A Patient’s Guide to Successful Migraine Care
by Roger Cady et al.
• Heal Your Headache by David Buchholz, M.D.
• National Headache Foundation, [Link]
Click on FAQ’s(frequently asked questions). Over ten subsections
covering different headache topics.
• American Headache Society, [Link]/resources/articles
• Managing Migrane, [Link]

55
56
Chapter Six:

Complementary Therapies
for Pain
Complementary and Alternative
Medicine (CAM)
Gordon Irving, M.D.

It is normal to want to treat your pain in any way that works and
is not harmful to you. Many people use CAM therapy and most
of this booklet is about complementary therapy such as exercise,
relaxation, and meditation, which can decrease pain and improve
function. Many herbals, vitamins, and natural products have not
been scientifically tested for benefit, side effects or interactions with
any medications you may be taking. The reason you get information
with your medicine at the pharmacy is because it has been tested
and the side effects listed. “Natural products” are not controlled by
the Food and Drug Administration (FDA) and their side effects have
not been studied. Use sites like [Link] (search for “herbs”),
[Link], or [Link] to
learn more about natural products.

Definitions
Complementary Medicine: This is used with standard medical
treatment (e.g. acupuncture with pain medications)

Alternative Therapy: This is used instead of standard medical

treatment (e.g. a special diet for chronic stomach pain)

Integrative Medicine: This treatment involves the mind, body, and

spirit. It uses standard medicine with CAM treatments. That is what
Swedish STOMP has tried to do.

57
 There are five main types of CAM:
1. Mind-Body Medicines
• Meditation: Focused breathing and repeating words or phrases
to quiet the mind.
• Biofeedback: Simple machines help you learn to change
muscle tension and heart rate.
• Hypnosis: Relaxed, focused attention on a feelings, ideas, or
suggestions to aid healing.
• Yoga: Stretches and poses with attention on breathing.
• Creative outlets: Art, music, dance, etc.
2. Biologically based practices: Often found in dietary supplements
and herbal products: vitamins, herbs, foods, and special diets.
3. Manipulative and body based practices
• Massage
• Chiropractic care: Adjusting the joints and spine.
• Reflexology: Pushing on parts of the hands and feet to affect
other parts of the body.
4. Energy medicines
• Tai Chi: Slow, gentle movements with a focus on breath and
concentration.
• Reiki: Balancing energy either from a distance or placing hands
on or near the patient.
• Therapeutic touch: Moving hands over energy fields of the
body.
5. Whole Medicine Systems
Comes from many areas and cultures of the world.
• Ayurvedic medicine: From India, balances body, mind and spirit.
• Chinese medicine: Balances the body’s two forces, yin and
yang.
• Acupuncture: Thin needles stimulate points on the body to
clear “blockages” and promote health.
• Homeopathy: Very small amounts of substances are used to
help the body heal.
• Naturopathic medicine: Uses different methods to help the
body heal.

58
How will you know which may work for your pain?
Finding a CAM practitioner:
• Ask your doctor to suggest someone.
• Ask if your hospital keeps a list of centers or has staff that can
suggest someone.
• Contact CAM professional organizations to get names of
practitioners who are certified.
• Ask about the practitioner’s training and experience.
• Call your health care plan to see if it covers this therapy.

Things to Consider:
• Just because a product is natural does not mean it is safe. Some
products may interfere with your usual medications.
• Supplements do not have to be approved by the Federal
Government and some may not contain what they say do.
• Look on the label for products produced in Germany. They are
quality controlled by the government so do contain the stated
amount of product.
• Do some homework before you spend your money on an herbal or
natural remedy.

Resources
• National Center for Complementary and Alternative Medicine,
[Link]
• MedlinePlus, [Link]
• PubMed, [Link]/pubmed
• Memorial Sloan-Kettering Cancer Center, [Link] (search
for “about herbs”)
• Natural Medicines Comprehensive Database,
[Link]
• Science-Based Medicine, [Link]

59
60
Chapter Seven:

Medications
Pain Medications
Gordon Irving, M.D.

Helpful hints
1. Pain medications will not block all pain. Most medications even
when they work will only lower pain by about a third.
2. When you have a pain flare-up, taking more medication than
prescribed may not help and you may run out of your prescription
early. If you use more pills one day, use less over the next few days
so you do not run out.
3. Take short-acting painkillers before you do something you know will
be painful — for example, gardening. This may stop the pain from
becoming intense.
4. Try to have a few pain pills left over at the end of the month so you
always have at least a three-day supply. Having an extra supply
decreases your anxiety when you get close to your refill date.
5. Always get a refill before you need it so you are not waiting until the
last minute.
6. You are the only one who really understands your pain problem and
your needs. It is up to you to create a pain-management plan with
your doctor. Your provider may not always understand your pain,
and it may sometimes be hard to reach them.
7. Medications are only part of the solution and will not solve all your
pain.
a. Using your other pain-management tips are just as important.
b. Learn to pace yourself during activities.
c. Avoid trying to get everything done when you are feeling good
because it may make you feel bad later.
8. You can have a life even with pain. Those with pain who do the best
are those that accept their limitations but live life fully. Understand
your fears. If the fear of more pain keeps you from doing anything, it
can increase disability. When you are less active you have more time
to dwell on your pain. You will have even more limitations over time.

61
 10. The cure is inside you.
• Pay attention to your body and feelings.
• Become an active part of your healthcare team.
o The STOMP project will give you the tools to improve your life.
o You are the only one who can work with your team.
• You have the most to gain.
11. Remember to keep your pain medications safe!

Common Medication Concerns

1. Long-term opioids, including hydrocodone, oxycodone,
hydromorphone, fentanyl, morphine, methadone, oxymorphone,
buprenorphine and tapentadol
• High doses taken for a long time may make your body more
sensitive to pain [opioid-induced hyperalgesia]. The only fix is to
stop taking the medication.
• These drugs may affect how your body fights germs and lower
hormones such as testosterone, estrogen, and cortisol.
• High doses may increase falls. If testosterone has also been
suppressed, broken bones are more likely.
• They may affect sleep [central sleep apnea].
• They should never be taken with alcohol.
• Other drugs that affect the brain like benzodiazepines (valium,
Ativan, Xanax) increase the risk of overdose and seriously affect
your ability to drive safely.
2. Benzodiazepines: Valium, Ativan, Xanax, and temazepam
• Chronic pain is usually linked to anxiety. However, long-term
uses of benzodiazepines does not treat chronic pain well.
• They may pain worse.
• They are also very addictive and affect sleep.
• If short-acting ones (Xanax, Ativan) are stopped suddenly,
seizures may occur.
3. Muscle relaxants: Flexeril, Soma, Robaxin, Zanaflex, Skelaxin, and
baclofen
• Most of these drugs are very old and have never been tested
to treat pain. They each affect the body in different ways and
soma is addictive.
• Like many medications for chronic pain, these drugs should be
used as little as possible.

62
4. Acetaminophen (Tylenol)
• Do not take more than three grams per day (for example, 6
extra-strength Tylenol). Take less if you have any liver problems
or drink a lot of alcohol.
• This drug can cause liver and kidney failure when taken for a
long time.
• Some medications, such as Vicodin and Percocet, contain
acetaminophen. This should be added in your daily dose.
5. Anti-Inflammatories such as Advil, Aleve, ibuprofen, and Celebrex
• These drugs may cause stomach and intestinal bleeding,
kidney damage and high blood pressure.
• They often do not help chronic pain except when there is a
flare-up due to physical over-activity.
• If they are not helping, do not take them. They are dangerous.
Over 14,000 Americans die from anti-inflammatory drugs every
year.

Common Side Effects

All medications have side effects. Some are obvious, others are not.
• Constipation: Many pain medications, especially the opioids,
cause the gut to slow down and absorb more water. Treatments
include laxatives, eating fiber, drinking more water, and taking stool-
softening medicine. The stool should be soft and you should not feel
bloated after. If you still have problems, talk to your doctor.
• Dry mouth: Many medications may slow or stop your saliva (spit).
Less saliva can cause stomachache, mouth burning, difficulty
talking, and cavities. If you feel your mouth is dry because of your
medications, go to your dentist, drink more water, use fluoride and
mouthwash, and try other medications to increase saliva.
• Drowsiness (feeling tired): To decrease drowsiness, take less of
the medication that is making you tired. Ask your doctor if you can
take it before bed or change to a different medication if that does
not help.

Resources
• American Chronic Pain Association, [Link]
• Pain Action, [Link]

63
 Protecting Your Medications
Gordon Irving, M.D.

Why should I protect my medications?

You are responsible for using your medication safely and keeping
it from being abused or stolen. Doctors will rarely give you extra
medication.

If you give someone your opioids, this could be a crime called

“supplying.”

Steps to Get There

• Do not share your medications with anyone.
• Lock your medications in a cabinet or safe box and hide the key.
You can buy these boxes from many stores.
• Do not use a bathroom cabinet. These rarely lock and are the first
place any stranger or visitor in your house will look.
• Make sure your prescription has the right number of pills and count
how many you have left every day. If you are missing pills, ask your
family and anyone else in your home about it.
• If you are missing pills, move the locked container and change the lock.
• Remember, stealing narcotics a crime and it is taking medication
that you need for your pain.
• If you do think someone has stolen your medicine, tell the police.
This will help you and may help the person who stole your medicine.

Resources
• Safe Medication, [Link]/meds/[Link]
• Smart Disposal, [Link]/
• Stop Overdose, [Link]/

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Substance Use
Allen Hume, Ph.D.

Alcohol and drug use can affect pain management. Follow all
directions with medications since it could cause problems if you
do not. When using medications, be sure to be honest with your
provider, who will likely have you sign a contract if you are on opioid
(i.e. narcotic pain) or benzodiazepine (i.e. Valium, Xanax, etc.)
medications. This contract is for your safety and should be followed.
Using other drugs and/or alcohol can have very serious and even
deadly effects if used with your medications. While it may seem
that drugs or alcohol help with pain, anxiety, or depression, do not
use them for managing pain. Alcohol, prescribed drugs, and other
drugs can make pain feel worse and can lead to injury. Overuse can
turn into addiction. If you have concerns about addiction (yours or
a family member’s) see the links below. Remember, making healthy
choices about your usage will make pain management much easier
for you.

Steps to Get There

1. Be honest with yourself and your provider about your alcohol and
drug use. This includes prescriptions, over-the-counter, and illicit
drugs, all of which can affect your treatment.
2. Know your family history of drug and alcohol use Addiction often
runs in families.
3. Go online and take a test on your drug and alcohol use. Talk to your
doctor or other provider and seek treatment if needed.
4. There are many self-help groups, including Alcoholics Anonymous,
NA, and Rational Recovery. Have others help you figure out if you
have a drug or alcohol problem. If so, they can help you get better.
5. Learn about drug and alcohol use, either on your own or with a
provider’s help.
6. There are many excellent providers who can help you with your
alcohol, drug, and chronic pain issues.
7. Seek individual and/or group counseling to address your usage and
concerns.
8. Stay hopeful and optimistic that you can change your behavior,
recover, and improve your pain condition.

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 Resources
• Alcohol Screening, [Link]
• National Institute on Alcoholism and Alcohol Abuse,
[Link]
• National Institute on Drug Abuse, [Link]
• American Psychological Association, [Link]
• Alcoholics Anonymous, [Link]
• Narcotics Anonymous, [Link]

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Chapter Eight:

Role of Procedures
Spinal Injections
Gordon Irving, M.D.

There are many parts of the back and neck that can cause pain.
These include ligaments, muscles, joints, nerves, bones, and discs.
Most back pain comes from more than one of these parts.

A bulging disc or disc degeneration, where the pads between the

bones in your spine wear down, is normal as you age and usually
does not cause pain. Pain going down the leg or arm does not
mean there is a “pinched nerve” either. A pinched or inflamed nerve
will usually cause sudden, short, shooting pains in the hand or foot.
The most common cause of back pain for people 20-50 years old
are the pads between your spinal bones (the intervertebral disc);
after 65, it is arthritis of the spinal joints. The majority of back pain
does not need injections and certainly not surgery.

Having an MRI or CT scan of the spine will not usually show the
cause of the pain unless there is a pinched nerve. Even X-rays
cannot show what is causing pain and they are usually not needed.
Spinal injections may be used for diagnosis and sometimes
treatment.

Types of Injection
• Trigger-point injections: Injections into a tight band in a muscle
with a local anesthetic (numbing medicine). The tight band causes
or triggers off pain in an area away from the muscle, hence the
term trigger point. These injections can decrease pain, loosen
tight muscles and allow you to stretch and stop the trigger point
reforming. Trigger points are often over acupuncture points.
• Acupuncture: Thin acupuncture needles can be used in classic
acupuncture points, just under the surface of the skin, for electrical
acupuncture, or for “pecking” treatments. to treat a trigger point or
generally to treat pain or headaches

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 • Ligaments: If numbing injections help decrease pain, prolotherapy
injections may be used. For these injections, a mixture of local
anesthetic dextrose (sugar) and sometimes other substances are
injected to cause collagen (scar tissue) to strengthen the ligament
and kill small pain nerve endings.
• Spinal joint injections (facet joint injections): These joints help
the spine bend from the tailbone to the skull. Like any joint, they
can be sprained or get arthritis. The injections are usually done
with X-ray, but ultrasound can be used. Numbing medicine and
steroids are injected into the joint, or onto the nerves in the joint.
If two injections and physical therapy or exercise do not help, a
radiofrequency neurotomy procedure (RF) may help (see below).
• Radiofrequency neurotomy procedure: A special needle is
placed near the nerves in the painful joints. A microwave current in
the needle kills the small nerve, so you can’t feel pain. These nerves
regrow, and if the joint problem does not go away, the RF procedure
may have to be repeated.
• Epidural injections: The space around the nerves in the spine is
called the epidural space. The nerve exits out of the spinal bones
via tunnels called foramen. Epidural injections can be done into
the middle of the space (interlaminar) or into the tunnel from the
side (transforaminal). The transforaminal route is used if there is a
herniated disc hurting a nerve in that area. Epidural steroids are
injected to decrease inflammation in the epidural space, because of
a disc herniation or narrowing (spinal stenosis).
• Selective nerve blocks: Blocking nerves with local anesthetic
where they come out of the spine helps doctors figure out which
nerve is causing pain.
• Disc injections (discogram): Although these injections are
sometimes used to diagnose if a disc (pad between the spinal
bones) is the cause of pain, it carries significant risk with often
not much long term benefit. Blood does not flow to the disc so
it can get infected after an injection into it. More than one disc is
usually injected, which can be extremely painful if they are a cause
of pain. Often more than one disc causes the pain, and there are
not good treatments for more than one painful disc. There may be
advertisements for “minimally invasive disc surgeries,” unfortunately
the majority carry significant risk and have not been shown in careful
clinical trials to help in the long term.

68
Injection Facts
1. If the first injection does not help, more injections in the same place
will not help.
2. A positive result indicating that an area is causing the pain is
when a local anesthetic numbs the pain for two or more hours.
Unfortunately even if one injection helped, a second injection may
not work.
3. Epidural injections will not help pain in the middle of the back that
has been present for more than a year, unless it is due to spinal
stenosis.
4. Injections only help a few patients. Weight loss, stopping smoking
and exercise have all been shown to decrease pain in the long term
more successfully than injections

Problems with Spinal Injections

There are risks will all injections, especially with disc injections
and some neck injections. Bruising and discomfort, infection, and
reactions to the medications are possible, but rare. Epidural and
transforaminal injections into the neck, however, have many more
risks and have caused death, stroke and paralysis.

Implantable Pain Devices

Gordon Irving, M.D.

Spinal Cord Stimulators (SCS)

These are wires that send a small current to the spine that changes
the pain signals going to the brain. They are usually used for patients
whose usual therapy has not worked.

SCS have been used for many painful nerve conditions, including
failed back surgery syndrome, severe back and leg pain, and
complex regional pain syndrome (CRPS) types I and II (RSD and
causalgia). They are used in Europe for problems like severe angina
(chest pain because of poor circulation to the heart) and leg pain
from poor circulation.

69
 Before implantation, the wires are placed in the back and connected
to an external generator that the patient can carry around. The
patient goes home and has a normal routine for the next week to
see if this helps the pain. This is inexpensive and reversible and
shows if SCS will work over time. The permanent generators are
placed in the body and can be recharged at home. The patient has
a hand-held device to increase or decrease the stimulation.

Intrathecal Pumps
These pumps are implanted under the skin and hold liquid
medications. They pump the medication through a tube to the fluid
around the nerves in the back (cerebrospinal fluid). This fluid bathes
the spinal cord and the brain, so it gets the drug to where pain is felt
more directly. Before the pump is placed, there is usually a three-day
trial in the hospital.

The medication used is usually an opioid (morphine, hydromorphone

or fentanyl), baclofen for spasticity, or ziconotide for neuropathic
pain. There are other medications that may be used, including
clonidine and bupivacaine. Several others are being tested.

Problems include:
• The pump could stop or the tube could dislodge.
• Scar tissue could form at the tip of the tube, which can press on
the spinal cord and cause severe problems including paralysis if not
caught in time.
• The pump has to be refilled every two to three months.

70
Chapter Nine:

Role of Spine Surgery

Surgical Decision Making
David A. Hanscom, M.D.

Spine surgery is often a good solution to structural spine problems.

It is a very poor solution when the sources of the pain are muscles,
ligaments, or tendons, or when the pain is caused by Mind Body
Syndrome.

For a problem to be considered structural it must be:

• Clearly seen on a diagnostic test AND
• There must be clear symptoms

If either of these is not present, then the symptoms are not

structural. Many patients have structural problems but no symptoms
or the pain is felt in another place. Others have severe pain but
normal diagnostic tests.

Every symptom could be structural or non-structural. Even if there is

a seemingly clear source for the pain, it does not necessarily mean
that is where the pain is coming from. Nerves are what cause the
brain to feel pain and you brain does not care why or where the
pain signal is coming from. Treating the pain pathways is always
mandatory. This applies to every part of the spine from neck to hips.

Common anatomic (structural) diagnoses that you may hear are:

• Degenerative disc disease
o Degenerated (loss of water from the center of the disc)
o Bulging discs (the outer ring has collapsed a little)
o Herniated/ruptured discs (the middle of the disc has broken
through the outer ring)
o Spinal stenosis (narrowing of the spinal canal, pushing on
nerves)

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 • Spondylolithesis (slippage of one vertebrae on another)
o Isthmic (small bony defect in the back of the spine)
o Degenerative (the facet joints in the back of the spine have
broken down and let the back bones move around)
• Spinal deformity
o Kyphosis (hunchback)
o Scoliosis (sideways spine curves)
• Broken bones

Tumor, infection, autoimmune disorders, and severe trauma have

clear and special treatments that this book will not cover.

Overview — What May or May Not Be

Causing Your Pain
Even if you have these problems they may not cause your pain.
These factors make them more likely to be painful:
• Abnormal or too much movement between vertebrae (spine bones)
(more than three to four millimeters)
• A pinched nerve.
o The pressure can be from a bone spur or soft tissue in the
spine
• Deformity that is:
o Decompensated (your upper body is not centered over your
feet) You can be tilted:
• Forward
• Sideways
• Both
o A scoliosis (sideways spine curve) that is worse when you are
standing
o Spine curving that gets worse
• A bone break that has not healed:
o In babies under four months old
• Medications—Prednisone, anti-inflammatories, etc., slow healing
• Smoking and obesity also affect healing

72
These factors make spine problems less likely to cause pain:
• Little or no motion between vertebrae
• Completely collapsed disc space
o The vertebrae have get stuck together
• A disc that does not move will not be a source of pain.
• Narrowing around a nerve without pain
• Deformity that is:
o Balanced (your head is centered over your feet)
o The same when lying down or standing
o Unchanging for many years
• A spine break that has healed

These problems can cause back or leg pain. If the problem is

just low back pain, then it is more difficult to find a clear structural
source. With low back, neck or thoracic (mid-body) pain, muscles,
ligaments, and tendons (soft tissue) are always involved. With just
low back pain without sciatica, soft tissue rehabilitation (i.e. physical
therapy) is the first step before surgery. Many people can avoid
surgery with rehabilitation.

It is much easier to find the source of leg pain. True sciatica causes
pain EXACTLY along the nerve. The pain may be felt just on some
parts. The pain is usually steady and lasts hours at a time. Often a
specific activity will set it off.

Surgery is Not the Only Answer

Many people feel that if all else has failed, surgery is the only answer.
It is only the answer for a clear structural problem with matching
symptoms. If you cannot clearly find the source of the pain then how
can you fix it?

The other problem with spine surgery is that it could cause future
problems. Often these can be worse than the original issue.

Surgery for a specific structural problem usually works well.

73
 Surgery and Dentistry
You can compare spine surgery with dentistry. A dentist can usually
find the structural problem in your tooth that is causing your pain. It
can be an infected root or maybe a cavity that has gone down to the
root. The chances of a dental procedure on that tooth relieving your
pain is essentially 100 percent. But if your dentist cannot find the
source of your pain and operates anyway, it is unlikely that he or she
will solve your problem.

Summary
No matter the part of the spine, surgery is only indicated for a clear
structural problem with matching symptoms. The discomfort should
be severe enough to warrant the risk of surgery. As your surgeon
is not able to experience your pain only you can and should make
the final decision to proceed. Be very careful when choosing spine
surgery. If you do not feel involved in the decision-making, then talk
to another doctor. Get it right the first time.

74
Meet the Authors
Louise Berkowicz, MD
Education: Medical degree, University of Cape
Town, South Africa.

Board Certified: Family Practice; Hyperbaric

Medicine; Certified Wound Specialist

Special Interests: Dr. Berkowicz has a special

interest and practice in energy medicine. This
unique therapy utilizes different forms of energy
to bring about both individual self-awareness and
healing. The result is changes in the body, mind
and spirit of the patient. She assists the patient
in dealing with everyday issues of life, pain and
suffering to move toward living lives filled with
more pleasure, joy and good health

David A. Hanscom, M.D.

Education: Medical degree, Loma Linda
University, Orthopedic trauma fellowship UC
Davis, spinal deformity fellowship Minneapolis

Board Certification: Orthopedic Spine Surgery

Special interests: Complex spine problems in

all areas of the spine. He is the founder of the
Puget Sound Spine Interest group. He developed
the DOCC (Defined Organized Comprehensive
Care) project to optimize spine care. He feels
that many times further surgery can be avoided
through a structured rehabilitation program.
The program should involve improving sleep,
managing stress, engaging in strength and
endurance conditioning, obtaining adequate pain
control, and educating the patient so as to regain
control of their decision making.

75
 Allen Hume, Ph.D.
Education: Dr. Hume is a Washington State
licensed psychologist who earned his doctoral
degree from Indiana State University. He
completed his internship at the Seattle VA
Medical Center.

Special Interests: Dr. Hume specializes in

behavioral medicine, chronic pain management,
co-occurring psychiatric and substance use
disorders, and assessment. He provides
consultation and training for physicians,
psychologists, allied health professionals and
organizations related to his specialties.

Gordon Irving, M.D.

Education: Medical degree, University of
Newcastle in England, Masters degree in Sports
Science and Fellowship and Masters degree in
Anesthesia, South Africa
Formerly: Medical Director and associate
professor at the University of Texas Pain Center,
Houston.
Currently: Medical Director of the Swedish Pain
Center and clinical associate professor, University
of Washington Medical School.

Board Certification: American Board of

Anesthesiology with added certification in Pain
Management, American Board of Pain Medicine

Special Interests: Dr. Irving specializes in

acute and chronic pain management with
pharmacological, non-pharmacological and
interventional techniques. His interests include
neuropathic, spinal and cancer pain. He
publishes and lectures locally, nationally and
internationally on pain related topics.

76
Hubert A. Leonard, M.D., Ph.D.
Education: The only physician in Oregon
certified in Headache Medicine by the United
Council of Neurologic Subspecialties. He
received his M.D. and his Ph.D. in Biochemistry
from Oregon Health & Sciences University and
completed a residency in internal medicine at
University of California Hospital in Los Angeles.
He completed his residency in Neurology at
University of Oregon Health Sciences University,
in Portland, and served as chief resident.

Board Certification: Neurology

Special Interests: He has been a neurologist

and educator for more than 30 years and
specializes in the diagnosis and treatment
of headaches. He has been the principal
investigator for dozens of clinical trials. Among
other honors, he is listed by The Best Doctors in
America®, which represents the top five percent
of doctors in the U.S.

Carolyn McManus, PT, MS, MA

Education: Master of Science, Physical Therapy,
Duke University. Master of Arts, Psychology,
Antioch University

Special Interests: Chronic pain and stress

management, relaxation training and mindfulness
meditation. She developed the Swedish
Mindfulness-Based Stress Reduction Program.
She is an author, national speaker and leader in
mind-body treatment strategies for people with
chronic pain conditions.

77
 Maureen C. Pierce, Ph.D.
Education: Dr. Pierce is a Washington State
licensed psychologist who earned her doctoral
degree from Indiana State University. She
completed her internship at the Central Arkansas
VA Hospital.

Special Interests: Dr. Pierce specializes in the

emotional and behavioral aspects of managing
chronic pain related to a variety conditions. Her
goal is to empower people with pain to take a
more active role in their health care. She utilizes
a number of treatments, including cognitive
behavior therapy (CBT), clinical hypnosis,
mindfulness meditation skills, and group therapy.
She also leads an eight-week class, Living Well
with Pain: Strategies for Coping, and a monthly
support group. For more information please visit:
[Link].

Howard Schubiner, M.D.

Education: Medical degree from Wayne State
University, Internal Medicine residency at Wayne
State University, Pediatrics residency at Michigan
State University. Clinical Professor at Wayne
State University.

Board Certification: Board certified in Internal

Medicine and Pediatrics.

Special interests: Founder and director of the

Mind Body Medicine program at Providence
Hospital in Southfield, Mich. Senior teacher of
mindfulness meditation. Conducts research in
fibromyalgia and other chronic painful conditions.

78
 Prepared by:
Swedish Pain Center
Gordon Irving, M.D.
Louise Berkowicz, M.D.
Allen Hume, Ph.D.
Maureen C. Pierce, Ph.D.

Swedish Neuroscience Institute

David A. Hanscom, M.D.

Swedish Rehabilitation Center

Carolyn McManus, PT, MS, MA

Providence Brain and Spine Institute

Hubert A. Leonard, M.D., Ph.D.

Mind-Body Medicine Center of Providence

Howard Schubiner, M.D.

Swedish Continuing Medical Education

Danielle Westley

Swedish Neuroscience Institute Spine Program

Alexis Takasumi

Swedish Patient Education Committee

Jeanine Keefe, R.N., MSN, GCNS-BC
Kaetlin Miller, MPH, CHES

Art Design
Carole Miguel
SWEDISH PAIN CENTER
1101 Madison, Suite 200
Seattle, WA 98104
T 206- 386-2013
[Link]

© 2013 SWEDISH HEALTH SERVICES. ALL RIGHTS RESERVED. CME-09-08881 Rev. 1/13