Day 9: Antecedent, Behavior, Consequence

My activities today are:

• OT Individual
• PT individual
• Conditioning
• Pool
• Psychology group
• PT group
• Relaxation Group

Nociception (also called nocioception or nociperception) is defined as “the neural processes of encoding and processing noxious stimuli.” It is the afferent activity produced in the peripheral and central nervous systems by stimuli that have the potential to damage tissue. This activity is initiated by nociceptors (also called pain receptors), that can detect mechanical, thermal or chemical changes stimuli approaching or exceeding harmful intensity. Once stimulated, a nociceptor transmits a signal along the spinal cord to the brain. Nociception triggers a variety of autonomic responses and may also result in a subjective experience of pain in sentient beings. Nociceptive neurons generate trains of action potentials in response to painful stimuli, and the frequency of firing signals the intensity of the pain.

Nociceptive pain may be classified according to the mode of noxious stimulation; the most common categories being “thermal” (heat or cold), “mechanical” (crushing, tearing, etc.) and “chemical” (iodine in a cut, chili powder in the eyes).

Nociceptive pain may also be divided into “visceral”, “deep somatic” and “superficial somatic” pain. Visceral structures are highly sensitive to stretch, ischemia and inflammation, but relatively insensitive to other stimuli that normally evoke pain in other structures, such as burning and cutting. Visceral pain is diffuse, difficult to locate and often referred to a distant, usually superficial, structure. It may be accompanied by nausea and vomiting and may be described as sickening, deep, squeezing, and dull. Deep somatic pain is initiated by stimulation of nociceptors in ligaments, tendons, bones, blood vessels, fasciae and muscles; it is dull, aching, poorly localized pain. Examples include sprains and broken bones. Superficial pain is initiated by activation of nociceptors in the skin or other superficial tissue, and is sharp, well-defined and clearly located. Examples of injuries that produce superficial somatic pain include minor wounds and minor (first degree) burns.

Pain: Pain is an unpleasant feeling often caused by intense or damaging stimuli, such as stubbing a toe, burning a finger, putting alcohol on a cut, and bumping the “funny bone”. The International Association for the Study of Pain’s widely used definition states, “Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.”

Pain motivates the individual to withdraw from damaging situations, to protect a damaged body part while it heals, and to avoid similar experiences in the future. Most pain resolves promptly once the painful stimulus is removed and the body has healed, but sometimes pain persists despite removal of the stimulus and apparent healing of the body; and sometimes pain arises in the absence of any detectable stimulus, damage or disease.

Pain is the most common reason for physician consultation in the United States. It is a major symptom in many medical conditions, and can significantly interfere with a person’s quality of life and general functioning. Psychological factors such as social support, hypnotic suggestion, excitement, or distraction can significantly modulate pain’s intensity or unpleasantness.

In 1968, Ronald Melzack and Kenneth Casey described pain in terms of its three dimensions: “sensory-discriminative” (sense of the intensity, location, quality and duration of the pain), “affective-motivational” (unpleasantness and urge to escape the unpleasantness), and “cognitive-evaluative” (cognitions such as appraisal, cultural values, distraction and hypnotic suggestion). They theorized that pain intensity (the sensory discriminative dimension) and unpleasantness (the affective-motivational dimension) are not simply determined by the magnitude of the painful stimulus, but that “higher” cognitive activities can influence perceived intensity and unpleasantness. Cognitive activities “may affect both sensory and affective experience or they may modify primarily the affective-motivational dimension. Thus, excitement in games or war appears to block both dimensions of pain, while suggestion and placebos may modulate the affective-motivational dimension and leave the sensory-discriminative dimension relatively undisturbed.” (p. 432) The paper ends with a call to action: “Pain can be treated not only by trying to cut down the sensory input by anesthetic block, surgical intervention and the like, but also by influencing the motivational-affective and cognitive factors as well.” (p. 435)

Suffering, or pain in a broad sense, is an experience of unpleasantness and aversion associated with the perception of harm or threat of harm in an individual. Suffering is the basic element that makes up the negative valence of affective phenomena.

Suffering may be qualified as physical or mental. It may come in all degrees of intensity, from mild to intolerable. Factors of duration and frequency of occurrence usually compound that of intensity. Attitudes toward suffering may vary widely, in the sufferer or other people, according to how much it is regarded as avoidable or unavoidable, useful or useless, deserved or undeserved.

Suffering occurs in the lives of sentient beings in numerous manners, and often dramatically. As a result, many fields of human activity are concerned, from their own points of view, with some aspects of suffering. These aspects may include the nature of suffering, its processes, its origin and causes, its meaning and significance, its related personal, social, and cultural behaviors, its remedies, management, and uses.
The word suffering is sometimes used in the narrow sense of physical pain, but more often it refers to mental or emotional pain, or more often yet to pain in the broad sense, i.e. to any unpleasant feeling, emotion or sensation. The word “pain” usually refers to physical pain, but it is also a common synonym of suffering. The words “pain” and “suffering” are often used both together in different ways. For instance, they may be used as interchangeable synonyms. Or they may be used in ‘contradistinction’ to one another, as in “pain is physical, suffering is mental”, or “pain is inevitable, suffering is optional”. Or they may be used to define each other, as in “pain is physical suffering”, or “suffering is severe physical or mental pain”.

Qualifiers, such as mental, emotional, psychological, and spiritual, are often used for referring to certain types of pain or suffering. In particular, mental pain (or suffering) may be used in relationship with physical pain (or suffering) for distinguishing between two wide categories of pain or suffering. A first caveat concerning such a distinction is that it uses physical pain in a sense that normally includes not only the ‘typical sensory experience of physical pain’ but also other unpleasant bodily experiences such as itching or nausea. A second caveat is that the terms “physical” or “mental” should not be taken too literally: physical pain or suffering, as a matter of fact, happens through conscious minds and involves emotional aspects, while mental pain or suffering happens through physical brains and, being an emotion, involves important physiological aspects.

Unpleasantness, another synonym of suffering or pain in the broad sense, is used in physical pain science to refer to the basic affective dimension of pain (its suffering aspect), usually in contrast with the sensory dimension, as for instance in this sentence from Professor Donald Price: “Pain—unpleasantness—is often, though not always, closely linked to both the intensity and unique qualities of the painful sensation.” Words that are roughly synonymous with suffering, in addition to pain and unpleasantness, include distress, sorrow, unhappiness, misery, affliction, woe, ill, discomfort, displeasure, disagreeableness, and chagrin.

At Two Dreams, we work with the concept of the cycle of thoughts → feelings → behavior—that a thought may evoke a feeling, a feeling may stimulate a behavior (reaction), a behavior may create a thought, or any other combination of pairs may occur. We teach that an individual should insert a [PAUSE] after a feeling before acting—that thoughtless actions following a feeling can be dangerous. We teach that an individual should insert a pause after a thought before acting on it—the pause again can avoid reactive, non-deliberative knee jerks that may cause damage to oneself or others. Likewise, a thought that is examined may be then linked to true and current interpretations and feelings—rather than “old tapes” created in the past. We have learned that individuals who suffer from the disease of chemical dependency are often at great risk of the rash actions associated with a fleeting thought or an urge to medicate a feeling.

Today this concept is reviewed for me in my psychology group. The antecedent, noiciceptive reception, leads to the perception of PAIN, my feeling. This triggers SUFFERING, which is pain and what I think of it, my thoughts. This results in a variety of behaviors.

CONSEQUENCES of PAIN

Physiological:

• increased tension
• Increased inflammation
• Increased cortisol
• Decreased sleep
• Increased sympathetic nervous system activity

These behavioral/physiological consequences of noicieception/pain lead to the following heightened emotional states:

Emotional/feelings:

• Fear of loss of function, income, autonomy, etc. (future loss)
• Anxiety
• Sadness over the situation (current loss)
• Anger

These emotions lead to these thoughts:

Cognitions/thoughts:

• My pain will go on.
• My pain will get worse.
• I’d rather be dead than go through this anymore.
• This is not fair.
• Am I being punished?
• Why am I being punished?
• Why is this happening to me?

The consequence of this pain → feeling → thought cycle is more pain.

So, to avoid the cycle that heightens pain, I am taught to relax, use my PT and OT tools, use thermal or chemical strategies, and diet.

If you learn about yourself, you can help yourself. These are the questions I am asked to answer:

Are you guarding? What part of your body is tense?

Are you deconditioned? Which activities have you decreased or stopped doing?

Is your sleep disrupted? Do you wake up feeling tired?

Are you under stress? What stressors besides the pain?

Are your moods affected by the pain? How?

Are you taking narcotic analgesics or muscle relaxants every day? Which ones?

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Day 8: Tight Muscles, Weak Muscles, Sick Muscles, Stress

Pain is an antecedent and a consequence of tight muscles, weak muscles, sick muscles, and stress.

Guarding against the pain leads to tight muscles, due to tension, like the ones in my neck. All day long I try to remember to drop my shoulders to stretch the muscles that have shortened over time. Tight.

I hurt and do not move, I become weak and it is harder to move, to be motivated. My muscles become weak and fragile. I become weak. I decondition. I obsess on the pain or ignore it and become disconnected from my body—more prone to injure or overdo.

Sick muscles, due to lack of Stage 4 sleep, hurt, they contain toxins, metabolic waste. They leech material into the bloodstream. There is inflammation and poor circulation.

Stress makes it all worse. Tight muscles, weak muscles, sick muscles, and stress.

May you be safe.
May you be peaceful.
May you be healthy.
May you live with ease.

Day 7: Parts of the Program

My schedule today:

• Feldenkrais
• Nutritional Support Group
• Relaxation Group
• Physical Therapy, Individual
• Outing Planning Group
• Mindfulness Group
• Conditioning

Today I want to talk about what some of the groups that are part of the program consist of.

The Feldenkrais Method® is a an approach to human movement, learning and change originally developed by physicist Moshe Feldenkrais. It is based on principles of physics, neurology and physiology. Feldenkrais seeks to improve posture, flexibility, coordination, athletic and artistic ability and to help those with restricted movement, chronic pain and tension (including back pain and other common ailments), as well as neurological, developmental and psychological problems. Feldenkrais therapy allows for for new patterns of thinking, moving and feeling to emerge by ferreting out outmoded and dysfunctional patters of physical and psychological behavior and helping to eliminate them.
(Adapted from the The Feldenkrais Institute of NY.)

Feldenkrais. Years ago a therapist recommended that I attend Feldenkrais and I felt overwhelmed by what was on my plate at the time so I resisted going. I was dealing with the early stages of chronic pain including physical and occupational therapy as a young mother, a working woman and a wife—what an order, and not necessarily in that order. Things rise to the surface to be handled when there is too much to get done in any one day, even for the most organized of people. So, every week when I would sit down on his couch for our session, which included hypnotherapy, looking for peace and serenity, he would ruin it with yet another recommendation that I attend Feldenkrais! I was juggling all that I could without drowning I would remind him, so I did not think I could go. I finally had to stop seeing him so that I could stop the pressure. While he was well-meaning, he was not a very good therapist who could never hear me. (Years later I ran into him on the street and he was just as clueless!)

But, I digress. This time when I saw Feldenkrais in the schedule, I was interested, not at all resistant, and curious. What could this process do for me? I was just as baffled after the first session—these series of moves in a prescribed sequence developed by a physicist to retrain the body after injury. The Feldenkrais instructor asked how I liked it and I had no real answer, so I told him, “I’ll let you know after the third session—it takes that long to tell, you know, like eating Sushi.”

So, today was my third trial of Feldenkrais and I got a pelvic release. It was amazing. I was in the middle of the session, scanning my body after a move to see what points were resting on the floor and there it was—no tension in my back, a nice lumbar lordosis supported by points around it and a neutral pelvis. I curled it front and back (like a scorpion—the old Jane Fonda term) and it moved effortlessly. So, what do I think of Feldenkrais? I love it but not enough to make a part of my routines, at least for now.

Foods that fight inflammation:

• Blueberries
• Cayenne Pepper
• Celery
• Celery Seeds
• Cherries
• Dark Green Veggies
• Fish
• Flax seeds and Flax Oil
• Ginger
• Raspberries
• Blackberries
• Strawberries
• Turmeric
• Walnuts

(List adapted from here.)

Nutritional Support Group. Nutritional Support Group is a session led by a therapist (the lawyer in the group queried, “Why isn’t it a nutritionist?” which is a good point but I think they only take it so seriously and she takes it seriously so it’s probably easier than hiring the professional in the field). It is part lecture, discussion, and handouts. The support, which often comes with group therapy in the form of peer- and professional-support, is sharing ideas and reactions to the topics. How does one incorporate a certain spice in one’s cooking at home? Although, based on how this group works I think the “support” modifies “nutritional” and not “group.” The subject today was foods that fight inflammation.

Relaxation Group. In this session we go as a group to a large room, settle ourselves on thick, luxurious, comfortable mats (if we are unable to get on the ground we sit in chairs with our rolled towels for back support, foot rests so that our knees are at 90 degree angles, etc.) and do what we can of the exercise. The instructor talks us through the relaxation exercise; I put emphasis on the word “exercise” because relaxation is an active process. We are not on the mats to sleep, though from time to time we snore, whimper, and breathe adorably through slightly parted lips as we drift in and out of consciousness. When we drift off, the instructor or a neighbor, gently touches us and we resume our practice.

Some instructors take us on a trip or journey, others coax us to scan and relax body parts. Either way, our pain scores go down and our satisfaction is always up afterwards.
Physical Therapy Individual. During an individual session—we have at least one daily—we meet with the representative of the discipline assigned to us. So for PT, I run downstairs to the PT space to meet with my girl “A”. Most of the PTs in this program are young women with perfect posture. But they all have a story and understand our issues, having had to correct a posture problem or rehabilitate an injury in their own lives. “A” is a runner, and has had her share of injury so she “gets me.” Not that the others don’t; I actually have worked individually with two different therapists because I wanted a consultation with one that specializes in mechanical processes. (A benefit of this program is the collaborative nature of the work with all disciplines weighing in and contributing to the solution.) “A” and I also met in the elevator on my first day and she was friendly and engaging and has brought that ever since. I tease her that the other PTs are jealous because she has in me the best patient ever. I am serious about that: we attack our work with vigor and I am getting better. In an individual session, I warm up on a treadmill or bike for 6-10 minutes, stretch, do nerve glides, and get put through my exercises. If I need to be advanced I get new exercises that are drawn out with specifications to how many and how often. If I am having a bad day, “A” slows it down, steps down my exercises so they are not as difficult or address the new problem, and sometimes just lets me breathe. I entered the program with high expectations about Physical Therapy as I have had a lot of care over the years. My expectations had to be reset as this program will not do anything for you that you cannot do for yourself at home. So, no massage, fascia release, ultrasound, etc. Just plain old work with bands, assists, and core balls!

Outing Planning Group. This is a group managed by the Occupational Therapists. They offer a variety of services from individual sessions, assessments, computer mechanics, grooming (shampoo my hair standing against the wall of the shower for support and keep my elbows straight out in front of me hinging there to get from the top of my head to the nape of my neck, keeping my scapulae from winging out which puts stress on my rhomboids), and other functional applications of mechanics to support my core and not re-injure. PACING is a big deal to OTs. Today, we are meeting as a group today to discuss where we want to go on an outing that occurs in the last week of the program. We all have goals that relate to being functional and self-sufficient so the outing is a way to put us through the paces of the anatomy of an outing, planning for success, and execution of a plan. We have tons of interesting things to do in location of the program so we first decide how much money we are willing to spend then decide on a site to visit. There is a large mall nearby and a tourist overlook so we decide to go there, check out the sights, then do some shopping. It will involve walking to the site (walking outside on concrete is different from the treadmill), pacing, standing, and shopping. We are given worksheets to assess what problems we might encounter and plan how we will approach the trip from our own set of abilities. Every member of the group has a different source of pain and tolerance level so we set to work on our own solutions. We’re all excited.

Mindfulness Group. Mindfulness Group is run by the psychologist who provides me with individual sessions. I am always excited to see her on the schedule. When I see her individually I call her “Master” or “Buddha” because she is well practiced in the art and science of mindfulness. We do the group in the conference room with our binders, notes, and sit-assists (cushions, rolls, foot stools, etc.). From time-to-time someone has to stand to relieve a pain, shift a pressure point, or as a matter of pacing. We are used to it as we all have different tolerance levels for sitting and standing. Today’s lecture is about how the brain is trained or prone to a negativity bias—it is out looking for problems. It is a survival skill. We do a small exercise where we asked to attend to the clock. The clock got louder as we paid more attention to it. Zen master says, “Be careful what you attend to.” She also advises us to allow, step back, and watch. “Don’t be a slave to automatic thoughts.”

Conditioning. We finish the day in the gym, conditioning. I spend at least 20 minutes on the treadmill at 60% my target heart rate. It’s easier every day. I do some stretches and rest on the Styrofoam roll- stretching out my chest to undo the tightness I developed sitting at the table for mindfulness and in the outing planning group.

Day 6: Mindfulness: What you Resist Persists

My schedule today consists of 2 hours of tolerance group, weekend review, psychology group, PT individual, OT individual, and psychology individual.  Only 4 hours of physical conditioning today but the theme is on being, not doing.

Mindfulness is intentionally paying attention, being present in the moment with compassion (understanding, kindness, empathy), with acceptance (not denial—see previous post), and without judgment.

Many of us live life not paying attention but we cannot be fully successful in that because our attention is drawn to things—unfortunately if we do not train ourselves to pay attention we will have really good, complete experiences of the really bad times.

Our brains are good at being on auto-pilot, thinking of the past or the future. For example, as soon as an exercise is assigned my brain goes to the past and memories emerge.  I think about when I have done it in the past and what happened as a result—pain—and I don’t want that to happen again.  I resist doing the exercise; the brain living in the past keeps me safe.  If you think about it, the brain evolved for survival, not happiness.  The person who survived to procreate was the one who had memories of bad things warn off repeating them, not the happy-go-lucky person hanging out under the tree.  But the person living in the past is different from the person living in the present.

If I am not drawn to the past, I am projecting the future.  Take that exercise again: as soon as it is assigned my mind runs off and thinks, “Hmmm, I’m not sure if I should do that exercise. What if I flare?”  I start to worry about what will happen and anticipate a bad outcome.  I am paralyzed from my fear and find it hard to engage in the good stuff for my recovery.

I can live in the past problems or future fears but the only thing that is truly certain is RIGHT NOW.  The past is gone; the future uncertain; so the only thing that I realy have is being squarely focused on paying attention to the current moment.  What a luxury.  So, mindfulness is a practice to engage in for mind-body health, a way of life.

The brain also evolved to be JUDGMENTAL.  We are constantly making judgments, often without much thought and certainly without conscious awareness.  Danger, flee.  Threatened, fight!  Not safe, stay back, keep your distance.  Yummy, lean in.

Mindfulness enlarges the mind and moves us beyond tunnel vision.  Stress and pain give us tunnel vision.  What we focus on continues to grow.  When we feel pain, we want to fight it.  But, with pain, ground zero is in my body and if I fight it, I lose.  If I fight my own mind, I lose.  Both of these increase the stress response.  Stress increases my pain and starts the vicious cycle all over again.

MINDFULNESS EXPLAINED:  This mindfulness process is a four-piece process: 1. Concentration; 2. open monitoring/mindfulness; 3. Compassion; and 4. equanimity.  Concentration is a skill by which I gain a piece of peace of mind.  It is the foundation for the house.  Mindfulness is the wall or scaffolding.  Compassion is the fireplace or heating system of the house; it adds cozy warmth to the house.  Equanimity is the capacity for a person to not be flat in terms of responding to life, but also not reactive.  It keeps us on an even keel.

This is what I have learned.  The first insult is the pain. I have no control over it.  God, grant me the serenity to accept the pain (the thing I cannot change).  The second insult is my toxic reaction to the pain and I re-injure.  This is one that I have control over.   God, grant me the courage to change my reaction to the pain and what I can do to reduce it (the thing I can change), and the wisdom to know the difference between the two.

If I develop a formal practice for a set amount of time a couple times a day I can develop my concentration and mindfulness.  I can also practice informally by paying attention to what I am doing and using my senses at the same time.  For example, I can wash my dishes mindfully and pay attention to the smell of the soap, the feel of the dried debris on the plate, the odor of the stale food, the warmth of the water, the clinking sounds of the plates being piled in the drying rack, etc.

We practice an exercise in the group.  We are asked to be mindful of sound.  The clock, which I have never noticed before is banging out each second!  Murmurs of office conversation in the next room increase in volume.  My mind focuses on the sound and the volume of the pain decreases  for a moment, for as long as I am engaged in mindfulness.  I am aware that I need to be mindful of what I am attending to (read—do not pay attention to the pain).  Certainly I learned last week that the pain is not supposed to warn off activity.

I get in a terrible spin in my head.  My confidence is not increasing and I start beating myself up.  In addition to judgmentalism, the brain is also trained to a negativity bias. It looks for problems and sets us about trying to fix things.  When I should be celebrating that the exercise has enlarged the container so that I am less aware of the pain—not denying it but less aware—I am beating myself up about wasting my life by being limited by the pain.  It’s so unfair to judge myself harshly; I was doing what I thought was right to defend against hurting myself.  I let others take care of things that I could do had I known that lifting a clothes basket would not send me back to the hospital.  Of course, without good posture it might have.  I start to feel a bit of compassion.  I am not denying the pain but mindfulness has enlarged the container.  I have experienced putting pain on the back burner.  Can I hope to put life on the other burners?   Do I dare hope to develop this skill so that I can approach my pain with compassion for me, rather than shame, disappointment in myself, and fear of rejection?  I guess I will have to wait to find out.  And, practice.

Many people have long recognized the need to be present.  Which is your favorite quote?

Yesterday is history.  Tomorrow is a mystery.  And today?  Today is a gift.  That’s why we call it the present.  —Babatunde Olatunji, a similar version is also attributed to Alice Morse Earle

    The secret of health for both mind and body is not to mourn for the past, not to worry about the future, or not to anticipate troubles, but to live in the present moment wisely and earnestly.  —Buddha

Waste not fresh tears over old griefs.  —Euripides, Alexander

We crucify ourselves between two thieves:  regret for yesterday and fear of tomorrow.  —Fulton Oursler

Having spent the better part of my life trying either to relive the past or experience the future before it arrives, I have come to believe that in between these two extremes is peace.  —Author Unknown

Be here now. Be someplace else later. Is that so complicated?   —David Bader

If you wait for tomorrow, tomorrow comes.  If you don’t wait for tomorrow, tomorrow comes.    —Senegalese Proverb

The best thing about the future is that it comes only one day at a time.  —Abraham Lincoln

The future is an opaque mirror.  Anyone who tries to look into it sees nothing but the dim outlines of an old and worried face.  —Jim Bishop

The ability to be in the present moment is a major component of mental wellness. —Abraham Maslow

When I am anxious it is because I am living in the future. When I am depressed it is because I am living in the past.  —Author Unknown

Day 5: A Pain Free Day

My schedule today consists of relaxation group, music group, conditioning, pool (aerobics), PT group, individual relaxation, and Preview group (A dream is not a plan).  These sessions are all 55 minutes in length.

I woke up today pain free!

My usual routine is to open my eyes and “scan” my body for pain and tension.  I then initiate a routine of stretches in bed to warm the muscles, wake them up gently to reduce risk of injury and put most of my joints through range of motion movements to lubricate the joints—preparing them to move without injury.  Every day for the last 21 years, I have recognized pain in bed, sometimes only after I move.  Sometimes the pain wakes me up, but I have been fortunate because I generally do not have pain at rest.  The problem with that has been that I can’t run my life from bed at rest!  The upside is that at my worst I can feel better if I take the weight of my head off my spine and get still.  (There are downsides to stillness and limiting my range of motion as I am discovering.)

Today, I move through my exercises and I am still pain free!  I get out of bed and move to my sun room where I do my sun salute to wake the brain.  I am still pain free!  I drink my morning 4 ounce smoothie getting in my carbs to break my fast; I am still pain free!   I groom; I am still pain free!  I enjoy my breakfast of a high fiber cereal that will contribute to my sense of satiety mid-afternoon; I am still pain free!  (Two Dreams clients will recognize the morning ritual that assists in the transition from the sleep to the awake state!)  I pack my lunch, drive to rehab, and I am still pain free!  Only after conditioning does my pain rear its ugly head but it is a low 3 with a tension of 2.  I address the tension in individual relaxation where I reduce the perception of tension in my upper back even though the surface EMG remains virtually unchanged (6.1 baseline to 6.3 at the end of the session).  Still, the joy of a pain free day just 5 days into the program gives me hope.

I am so happy but full of fear.  It is hard to unlearn fear of re-injury or flare.  Intellectually I get it—I have a lot of control over what happens this weekend.  But, I have had flare ups that I could not attribute to anything.  I am learning that without the proper body mechanics what looks like the insult to my body is just what I label as the insult.  The flare is really due to hundreds of little insults over time leading up to the flare.  And, the flare really did have a herald sign as my pain and tension increased without my notice.  I vow to be more self-aware.  What an order!  I have lived with this condition 21 years by compartmentalizing and denying the pain conscious awareness.  I am sometimes aware that it is happening but often I am looking at it from afar, not seeing it as happening to me.

We get instruction on management over the weekend in our Preview Group.  I am prescribed a home exercise program which includes aerobic conditioning, strengthening, and stretching which I am to do once per day.  I am to practice relaxation for 10 minutes twice per day.  I am going to focus on deep breathing this weekend, the only technique I have been trained in.  I have reading in my text book, continuous posture practice, body mechanics, and a plan for the use of distraction if my pain increases.  To give me the best chance of making it through the weekend without having a flare I am to  breathe, use thermal techniques such as heat or ice on the affected muscle group, pace myself (I need to pace the homework!) and use medications.  I want to make it through the weekend without a flare but A DREAM IS NOT A PLAN.  So, I plan and I hope.

Day 4: Acceptance is Not Concession, Acceptance is REALITY

My schedule today consists  of PT individual, OT lecture, Conditioning, OT individual, Psychology group, PT group, and Relaxation group.

ac·cep·tance (k-sptns)
n.

1. The act or process of accepting.

2. The state of being accepted or acceptable.

3. Favorable reception; approval.

4. Belief in something; agreement.

5. Abbr. acpt.

a. A formal indication by a debtor of willingness to pay a time draft or bill of exchange.

b. A written instrument so accepted.

6. Law Compliance by one party with the terms and conditions of another’s offer so that a contract becomes legally binding between them.

Acceptance in human psychology is a person’s assent to the reality of a situation, recognizing a process or condition (often a negative or uncomfortable situation) without attempting to change it, protest, or exit. The concept is close in meaning to ‘acquiescence’, derived from the Latin ‘acquiēscere’ (to find rest in).
Religions and psychological treatments often suggest the path of acceptance when a situation is both disliked and unchangeable, or when change may be possible only at great cost or risk. Acceptance may imply only a lack of outward, behavioral attempts at possible change, but the word is also used more specifically for a felt or hypothesized cognitive or emotional state.

We start the day in psychology group exploring the notion of acceptance.  Acceptance, according to our psychologist, is not concession, which implies the end of hope. Rather, it is reality (defined as the way it is NOW—No Other Way) which offers a ray of hope.  With acceptance, I can make the best of what I have now and I can hold onto hope for the future.

Acceptance is the key to serenity and that key unlocks the door to happiness. Acceptance does not mean we have to like, condone, or ignore our circumstance or situation.  It does mean one is powerless over the circumstance or situation.  If you don’t get that you are powerless, you may spend a lot of much needed energy trying to change a situation that cannot be changed.  Think about the energy that goes into scolding, manipulating, pleading, begging, crying, pouting, bribing, cajoling, imploring, humoring, screaming at, accusing, and shaming the world’s worst bureaucrat at the DMV when you show up without the proper ID for your license renewal.  At the end of the day, you WILL go home to get the right piece of identification before you get a license.  You may not get it until the person behind the counter looks right through you and says, “Next!” but you will, eventually.  Imagine how much sooner you could be on your way back home if you would merely accept your REALITY, turn around, and come back with the right paperwork.  Imagine the wasted energy trying to turn the situation around to your liking, the raised blood pressure, the tension in your muscles, the knot in your stomach.  Contrast that with the calm associated with turning around with purpose and coming back another day prepared to go at it again, this time with the right paperwork.

Dr. Barbara L. Fredrickson, Principal Investigator of the Positive Emotions and Psychophysiology Lab and Professor at the University of North Carolina, Chapel Hill, argues that hope “…comes into play when our circumstances are dire,” when “things are not going well or at least there’s considerable uncertainty about how things will turn out.” She states that “[h]ope literally opens us up…[and] removes the blinders of fear and despair and allows us to see the big picture [thus allowing us to] become creative” and have “[b]elief in [a] better future”.

“Psychologist, C.R. Snyder and his colleagues say that hope is cultivated when we have a goal in mind, determination that a goal can be reached, and a plan on how to reach those goals”. Hopeful people are “like the little engine that could, [because] they keep telling themselves, “I think I can, I think I can.”  My rehab program is cultivating that HOPE.

One of the most famous passages from the Big Book of Alcoholics Anonymous is from page 449 and reads, “Acceptance is the answer to all my problems today. When I am disturbed, it is because I find some person, place, thing, or situation—some fact of my life—unacceptable to me, and I can find no serenity until I accept that person, place, thing, or situation as being exactly the way it is supposed to be at this moment. Nothing, absolutely nothing happens in God’s world by mistake. Until I could accept my alcoholism, I could not stay sober; unless I accept life completely on life’s terms, I cannot be happy. I need to concentrate not so much on what needs to be changed in the world as on what needs to be changed in me and my attitudes.”

I use the Serentiy prayer to remind me of that REALITY:  God, grant me the serenity to accept the things I cannot change, the courage to change the things I can, and the wisdom to know the difference

WE can expand the focus of the blessing with this modification: God, grant us the serenity to accept the things we cannot change, the courage to change the things we can, and the wisdom to know the difference.  This expansion is very much in keeping with the program of Alcoholics Anonymous where the focus is on the power of the group and mutual help.

The prayer can also be modified to acknowledge the source of that serenity, courage and wisdom in this way:   God grants us the serenity to accept the things we cannot change, the courage to change the things we can, and the wisdom to know the difference.  (Thanks to Garrett O’Conner, MD of the Betty Ford Center for making me aware of this nuanced version.)

No matter the version, the point is that with acceptance comes serenity; with serenity comes health, happiness, and hope.  WE also talk about starting the journey from where we are to know that we must accept ourselves, our disease.  If I do not understand my chronic pain condition, I will not understand what I can and must do to manage it.

I realize today that this program is not so much about what caused my pain in the first place, or even what causes my flare ups.  It is about the chronic pain.  This is why the group that has been assembled can travel this path together no matter the source of our pain.  We are extremely varied in cause and effect, but what we do have in common is Chronic Pain, a condition for which treatment advances have been accumulating over the last decade.  Today we explored the Gate Control Theory of Pain.

The Gate Control Theory suggests there are five (5) Gates between the source of pain and the perception of pain; at each gate there are strategies to apply which help us manage our pain and the conscious perception of it.

• Gate #1:  Muscle tension; inflammation.  The role of the local source of pain can be managed with one of two strategies: 1 anti-prostaglandin medications (NSAIDs) and analgesics (aspirin, aceptmenophin); and 2. muscle strategies such as biofeedback, heat, cold, and massage.

Anticonvulsants: Pregabalin (Lyrica) and gabapentin (Neurontin) work by blocking specific calcium channels on neurons and are preferred first-line medications for diabetic neuropathy. The anticonvulsants carbamazepine (Tegretol) and oxcarbazepine (Trileptal) are especially effective in trigeminal neuralgia. The actions of these two drugs are medicated principally through sodium channels.
Lamotrigine may have a special role in treating two conditions for which there are few alternatives, namely post stroke pain and HIV/AIDS-related neuropathy in patients already receiving antiretroviral therapy.

• Gate #2:  Nerve Transmission.  The peripheral nerve’s contribution to transmission of pain can be 1. slowed with medications such as Neurontin, Lyrica, and Gabatril;  or 2. “scrambled” with behavioral interventions such as TENS units (MY FAVORITE), acupuncture, and distraction.Lamotrigine may have a special role in treating two conditions for which there are few alternatives, namely post stroke pain and HIV/AIDS-related neuropathy in patients already receiving antiretroviral therapy.

Serotonin–norepinephrine reuptake inhibitors (SNRIs) are a class of antidepressant drugs used in the treatment of major depression and other mood disorders. They are sometimes also used to treat anxiety disorders, obsessive-compulsive disorder (OCD), attention deficit hyperactivity disorder (ADHD), chronic neuropathic pain, fibromyalgia syndrome (FMS), and for the relief of menopausal symptoms.
SNRIs act upon, and increase, the levels of two neurotransmitters in the brain known to play an important part in mood: serotonin, and norepinephrine. These can be contrasted with the more widely-used selective serotonin reuptake inhibitors (SSRIs) which act upon serotonin alone.

• Gate #3:  Spinal Cord Level: endorphins or norepinephrine. There are two (2) strategies to block the transmission of the pain message up the spinal cord to the brain using 1. the endorphin system stimulation/support (aerobic exercise, joy and laughter, antidepressant medications);  or 2. norepinephrine (the flight or fight system in our body) tone adjustment using antidepressant medication of the serotonin-norepinephrine reuptake inhibitors (SNRIs).

• Gate #4:  Limbic area of the brain.  “The limbic system (or paleomammalian brain) is a complex set of brain structures that lies on both sides of the thalamus, right under the cerebrum. It is not a separate system, but a collection of structures from the cerebrum, diencephalon, and midbrain, including the hippocampus, amygdalae, anterior thalamic nuclei, septum, limbic cortex and fornix. It supports a variety of functions, including emotion, behavior, motivation, long-term memory, and olfaction. It appears to be primarily responsible for our emotional life, and has a great deal to do with the formation of memories.” The modulators for Gate #3 also work here.

• Gate #5: Cortex (consciousness and thinking).  Many of the medications you associate with pain management work here—narcotic analgesics (vicodin, coseine, etc.) and muscle relaxants (flexural, etc.).  Adequate control here helps to reduce catastrophizing and awfulizing, and increases coping.  Narcotic analgesics do not reduce pain at the source but change the perception of it.  Muscle relaxants can reduce spasm at the source but may quickly be a source of more pain as dependence on them develops as the muscle may go into spasm when the effect wears off, creating a vicious cycle of pain/spam and relaxation.

The take home message—as pain increases, each one of us is taught to calmly look for gates to close vs. opening them wider with catastrophizing and increased stress.  Increased stress may be a normal reaction to the sensation of pain. Since the brain lives in the past and future better than the present, as soon as pain appears it is easy to panic in response to its presence.  Of course, that makes it worse and we actually contribute to and succumb to its arrival.

	Physical Factors	Emotional Factors	Cognitive Factors
Things that open the gates	extent of physical damage;readiness of nervous system to send pain messages;activity level too high or too low.	Depression;anxiety and worry;tension and stress; anger and blame.	focus ON THE PAIN; boredom;dysfunctional attitudes;catastrophic thoughts.
Things that close the gates	Medication;stimulation to compete with pain messages (heat, cold, massage, TENS, acupuncture, etc.);pacing.	relaxation and calm;positive emotions (joy and laughter);positive support.	getting involved in life; distraction;adaptive attitudes; coping and problem solving.

I feel better equipped to handle my pain because I know more about it.  Today I commit to using more of the gates when pain shows up.  I have been relying on my TENS machine to control all of my pain at Gate #2.  I was on the verge of getting a spinal implant before starting this program but feel as if that might not be necessary now.

I feel hope.

Day 3: Too Much Movement

My schedule today consists  of Feldenkrais, Conditioning, PT stretching, Big Movement Group, Psychology Group, PT Group, and PT Individual.  That’s four movement groups in a row so by the time I get to PT Group I am exhausted.  I have to be excused to an exam room where I fall asleep for an hour.

Since the nap is too long (the ideal nap is 20 minutes), I am grumpy and brittle when I get to PT Individual and do not want to be cooperative.  I make a commitment to pace myself in the future (as soon as I learn what that is—sounds like I should not have let myself get burnt out) and ponder why my reaction is so intense to not having paced myself.  I don’t want to take responsibility for being worn out: if the program had not changed my schedule, I might have been able to plan better; if I had been given the lecture about pacing, I might have been able to pace better; if I had known that big movement was really, really big movements, using every muscle group over and over for an hour, I might have been more prepared for what was to follow, etc. etc. etc.  I sound like someone who has no insight and wants to take no responsibility for her own care!

I am so conflicted. Should I take responsibility for not being able to take advantage of everything today?  Do I look like someone not grateful for this opportunity?  Can’t I expect the program personnel to take responsibility for their part in this and anticipate that these problems come up in the first few days of treatment?  Why aren’t the staff doing as much as they can to keep me connected and avoid setting up a situation where I might leave from anger?

I am caught off guard by how charged up and angry I feel about being confronted about needing a nap.  So, I know it is not just that I just woke up—there is a bigger issue here that has been exposed.  My brain is on auto-pilot and this minor confrontation about my performance is being responded to from a brain thinking of the past, not a brain in the present, dealing with what is in front of it.  I am flooded with feelings of performance anxiety and fear of failure due to my frailty, anger about having to be here doing this and feeling that the staff member involved should KNOW this (so she has to be perfect too), and frustration that I don’t have what it takes to make it and it is just the third day!

I wish I could say that I took a deep breath, got squarely focused on paying attention to the current moment, and recovered my footing to get the most out of the hour.  I didn’t.  It would be much too easy to paint my performance as perfect but all I could do was make progress toward that goal and warm up for my next evaluation.  Besides, there is good material in that perfect moment which I will have lots of opportunity to explore before the month is over.  At least I was able to pull back and follow directions because my suffering is not an excuse to make others around me suffer.

Day 2: Guarding, Deconditioning, Sleeping, and Stress: Scheduling Matters

My schedule today consists of introduction to physical therapy (PT), introduction to occupational therapy (OT) and body mechanics, psychology group, relaxation group, Feldenkrais, introduction to conditioning, and conditioning at the local gym.

Just a short aside about Feldenkrais:  Many, many years ago when my condition was new and only involved the cervical spine, a therapist I was seeing advised me to join a Feldenkrais group.  It was something he had just been introduced to and he was excited about the results that people were observing with the method. I was working full time, had a newborn baby, was going to PT, seeing a therapist (because you go to address a problem or to enhance your life!), and running two households.  Week after week, the therapist would ask if I had gone to Feldenkrais and week after week, I would tell him that I was doing as much as I could to keep a life-pain balance and just did not have the time for Feldenkrais.  After about four (4) weeks of this, I was so annoyed with him that I stopped going to see him, too.  I had tried to explain that his insistence despite my protestations reminded me of being forced to do things against my will and it did not feel good or right.  His failure to get it or hear me was what drove me away.  Who wants a therapist who is insensitive to one’s pleas?  In retrospect, we might have been able to work through it if he had addressed my feelings—but he kept holding his position.  Anyway, when I saw Feldenkrais on the schedule, I thought, “Finally, I get to try this to see if it can help me.”  After the first day all I can say is that I don’t get it, but I will reserve judgment until after the third session. It is as my son taught me with sushi: “Try it three times before you give up on it.”  As it turned out, the third time was the charm for sushi and I found myself craving it afterwards.

The big concept for the day was understanding the source of pain accelerants: guarding, deconditioning, sleep deprivation, and stress.

Guarding: (gärˑ·ding), n 1. phenomenon in which muscles react to an injury to a joint, bone or ligament by contracting in order to form a protective splint. 2. a sign detected during physical pain whereby the patient involuntarily contracts muscles second to pain 3.  a spasm of muscles that minimizes the motion or agitation of sites that are affected by injury or disease.

Simply put, the contraction of the muscles increases tension in the muscles and the tension causes pain.  I have a big mass of tension in my upper back and tend to keep my shoulders raised.  This creates upper back pain, spasm, and twisting around the cervical spine because there is more tension on the left than right.  I am working to keep my shoulders down and achieve alignment of my cervical spine through relaxation.  Often, this leads to headaches. I am fortunate in that I do not get headaches!

De-conditioning:  conditioning [kon-dish´un-ing] in physical medicine, improvement of physical health by a program of exercises; called also physical conditioning, so, de-conditioning is the loss of physical health due to lack of exercise.

Simply put, I have had pain when I stand more than 3-5 minutes, so I have found it hard to work out over the past year.  Perhaps I could have done chair aerobics or chair yoga but I have not felt motivated to move for fear of re-injury and having had pain as a deterrent to movement.  I have also been sad and unmotivated; every day it is a simple challenge to get out of bed, shower, and get dressed.  But, the cure for de-conditioning is conditioning.  When increasing the physical demands on my body, I am told, it is normal to feel these demands in the way of increased soreness.  I am encouraged to work through this discomfort to gain endurance, balance, strength, and overall functional ability.

Sleeping:  While sleep is a natural process, it is not always easy to get and takes work to get into a rhythm where we fall asleep easily, if awakened return to sleep readily, and wake up feeling rested.

Pain is a common cause of insomnia; sleep loss increases the experience of pain; and a lack of sleep leads to a deficiency of production of a hormone that helps with tissue repair (Somatamedin C).  I have found it hard to fall asleep most of my adult life so I already have a very involved sleep hygiene program that I use and employ at Two Dreams.   This has not been a major concern of mine unless my pain is soaring!

This is a short description of the Two Dreams Sleep Hygiene Program:

• Create a switch from sleep (GABA state) to the aware state (Glutmate receptors) by facing the sunrise for 30 minutes every morning.  Bathing the retina through the eyelids with sunlight causes the switch in our brains to flip and we have the energy to face the day.
• Taking a power nap before 4 pm, no more than 20 minutes of sleep that follows a shot of caffeine (which peaks by the time the nap is over, giving us the energy to face the rest of the day)
• No caffeine after 2 pm, if at all.  I tend to drink de-caffeinated beverages so that I can use caffeine for its stimulant effect when needed.
• No electronic devices after 8 pm.  No digital clock, electronic equipment or chargers, no TV, etc. in the bedroom.
• No meals after 8 pm, unless you suffer from hypoglycemia mid-night awakening—then only a small bite before bedtime.
• A hot shower, hot bath, or hot tub soak for 30 minutes right before bedtime.
• A cool room, light covers, and warm fluffy socks to keep the feet warm. (Cold feet are a major cause of mid-night awakening.)
• The program also allows for sleep deprivation in extreme cases.  Suffice it to say, if you only get a few hours of sleep a few nights in a row you will start to fall asleep as soon as your head hits the pillow.  If the program does not work, and other causes of insomnia and mid-night awakening have been ruled out (pain, depression, etc.), then sleep aids that promote stage 4 sleep can be added.  We avoid agents that produce dependence and disrupt sleep.

Stress:  Stress is defined as an organism’s total response to an environmental condition or stimulus, also known as a stressor. Stress typically describes a negative condition that can have an impact on an organism’s mental and physical well-being.

Pain alone becomes the stressor. The loss of function and participation in normal activities, the inability to predict when I can be relied upon and when I cannot—all increase my stress and lead to distress.  Until this program I thought I was managing my stress!

The intersection of pain, guarding, de-conditioning, sleep deprivation, and stress is more complicated to negotiate than Chicago’s  Six Corners intersection.

So what about scheduling? We had a last minute scheduling snafu that caused a big, big blow up in the cohort.  The take-home message to me is that, as a patient in the program, I have little control over anything so we focus on the smallest of things.  Note to Sid: keep the schedule as consistent as you can and everyone at Two Dreams will be happier.

Judy protects the decision to enter rehab and I feel free: from fear to freedom or freedom from fear

After waiting two weeks for a new cohort to begin, I joined 8 other brave souls entering the Pain Center Back Rehabilitation Program to start our journey of recovery.  We all have different problems and have had them for varying time, ranging from 6 months to 23 years!  The psychologist tells us that when the program was started the average number of years of suffering before admission was 15; today it is down to 3-5 years.  This is due to better recognition of the need for a comprehensive program while at the same time we have added pain as the fifth vital sign and have a medical necessity to identify and treat.  Of course, this has led to more prescriptions and more prescription drug abuse, but this is not the main problem in our cohort.  Most patients here view this as a last resort—I know that it is not nor can it ever be.  Pain management will be a life-long activity; the best is to hope that it is not a life-long struggle.  I remember five years into this journey driving down the road and turning en masse to look over my shoulder to change a lane, frozen by pain.  I remember thinking, “I want my life back.” For a moment I was flooded with the sadness of my losses. Then I realized, “This is my life.”  I was not any less sad, my losses were real, but I became more resigned to accept my reality and work from that acceptance.

Some of my co-travelers hope to avoid surgery as a result of the program; others, like me, are trying to manage complications of surgery.   Some have traveled long distances to participate; they live at a local hotel during the four weeks of the program.  A few get to go home on weekends.  I am a day patient.

My close, close friend Judy called and offered to help when she found out I was going to back rehab—not to be confused with back to rehab.  After some thought, she offered to drive me in the first day, knowing that during the first week things get worse before they get better.   How lovely, I thought, and how sweet of Judy to want to help me in that way.  I’m really moved by her concern, the show of love and friendship.  She arrives at my house at 7 am (having had to leave hers by 6!) with the “Judy limo,” including chilled bottled water for the drive, the seat is heated, and the car is warm.  Once at the program, we park, she sits with me into the first part of the admission interview, and as she is leaving agrees to text David, my husband, to let him know I am safely delivered to this life saving program.  Then, as she lets it slip that the reason she drove me was to make sure I enrolled in the program and didn’t back out!  WHAT!  I can’t believe that anyone would think someone going to rehab is not to be trusted to arrive! I’m shocked, but I understand. It is true that your loved ones recover 6 months after you do.  Judy is evidence of that, of the uncertainty that sets in about whether a loved one will give themselves the gift of recovery.

We are given a 3-ring binder with resources prepared by every speciality that will work with us.  We are also given a book and homework.  (The book is: Managing Pain Before it Manages You, Margaret A. Caudill, MD, PhD, MPH.  I also recommend the following two books: 1. Healing Back Pain, The Mind Body Connection, John E Sarno, MD and 2. A Day Without Pain, Mel Pohl MD.  Dr. Pohl is a colleague in ASAM and was inspired to write his book because of his journey of recovery from back pain. view his bio here)

We have a rigorous schedule of appointments hourly, starting at 8 am and ending at 4 pm.  We have an hour for lunch and are pulled out of the schedule to do one-on-one sessions with the professionals assigned to us.  During the first week many of the sessions are evaluations or introductions to the role of the activity in our recovery.

I meet my physical therapist who has me walk 6 minutes on the treadmill at a speed of my choosing.  I cannot believe this since I can only stand 3-5 minutes before I am doubled over in pain.  I’m introduced to the first and most significant concept of the activity pyramid.  We are given a “green light/tolerance for my condition” for activity were our pain spikes during it as long as the pain is not worse afterwards and there is no change in range of motion or strength afterwards. This is so freeing!  FEAR has caused me to avoid any activity that increases my pain and I have become immobilized, weak, and gained weight as a result.  But, it gets even better—we have a “yellow-red light/flare up inflammation” when pain spikes during the activity, pain persists after the activity, but there is NO change in range of motion or strength as a result.  This scope of activity is managed by a plan that includes rest, ice, and medication for 72 hours.  So, I have permission to flare and treat.  I can move again—can push it beyond small steps.  She does not give permission for “injury” causing activates that are associated with severe spike in pain that stops the activity, pain that persists for more  than 3 days afterwards, or CHANGE in range of motion or strength (ability).  There is little that falls into that category—I am in pain but not that fragile.  Learning this makes being in the program worthwhile. If I learn nothing else, I can move again.  I am happy, joyous, and free again.  And tired, too—I fall asleep during relaxation which is an activity (more on that later) where sleeping is not allowed since it requires an active engagement of the mind.

It has been a really good day that feels like a week.  At home I immediately fall asleep and sleep eleven hours—even on my best sleep hygiene days I don’t get sleep like that!  I wake up eager to learn, to live, and to recover.  And Judy meets me again, this time more confident in my desire to attend the program.

Welcome Letter

Today, I received the welcoming letter to the program.  The names, of course, have been changed to protect the identity of the program.

Here’s the letter and my notes in bold:  

Welcome to Dr. B’s Spinal Rehabilitation Program. You have been selected to begin the full-day program on Monday, February 11, 2013. Please arrive promptly at 8:00 a.m. to the Spinal Rehabilitation Program at undisclosed location. You will receive your weekly schedule and materials upon arrival. The program is scheduled Monday through Friday from 8:00a.m. to 4:30p.m. for four weeks, depending on your progress. (Of course as I read this I can imagine being extended either for exemplary progress or failure to progress—either way, anyone who has ever been treated by me would expect that I would be extended so that I can extend the “platform of recovery on which I stand.”)

As a pain management program, our goals are to help you improve your ability to function in daily life with better pain management, return to work and/or recreational activities, enhance self-management techniques, and achieve maximum medical improvement for your diagnosis. (Mental peace, physical well-being, and personal productivity!  Yeah, I can relate and I am really excited at this point.  I haven’t allowed myself to hope for a long time—the downside of that is devastating and I have preferred to maintain the status quo, but the status quo is not working for me anymore.  I have had pain every day but six for the last 21 years but, as my friend Mel Pohl, MD (Las Vegas Recovery) notes, I have gone from pain to suffering.  And for the last year, since December 6, 2011 following an extended car ride, I have been suffering.  I need to change that. Pain alone has not been enough to motivate me but suffering is taking its toll.)  Your program will include physical therapy, occupational therapy, therapeutic recreation, psychological services, nursing education, relaxation training, vocational rehabilitation and medical management (Clinically luxurious!).

During your participation in the program, your family/friends will have an opportunity to learn about your treatment program and help you continue your pain management strategies after discharge. Family/friends meetings are generally held on Wednesdays at 4:30pm during the second and third weeks of the program (Of course, not right away.  It will get worse before it gets better, I am told.  That is what I tell my patients with alcoholism and other chemical dependencies). We strongly encourage you and your family or a close friend to attend one of these sessions. If you have questions regarding the family/friends meeting, please speak with your Spinal Rehabilitation Program psychologist (Family and friends need their own program of recovery.  They may have lost hope, too.  They have had to manage their expectations.  What happens to them when I change?).

You will be physically active during your participation in the program. You will need to wear comfortable clothes and supportive shoes (i.e. sweats, shorts, T-shirts, gym shoes). In order to fully participate in Physical Therapy groups, you will have to independently walk one block to our fitness facility at another undisclosed location. You will also need a swimming suit, or other appropriate attire, and your own combination lock. You may have periods of free time during your participation in the program. These open periods are times to complete assigned reading, perform therapy exercise/gym programs and practice relaxation/biofeedback techniques (Sounds like I will have restricted access to my phone, at least for the first week.  I wonder what that will feel like?).

Sincerely,

Dr. B’s Spinal Rehabilitation Program

It is my hope that my writing about the experience will help others who might consider making such an investment in themselves but are paralyzed by fear; I sincerely hope that I will be able to overcome that fear and help others do so as well.  I also hope that I am helped—I want to hope again and just for today I will allow myself the luxury of that.