Wednesday, April 27, 2011

Pain, part 1

I didn't set out to become an expert in pain, but that's pretty much the way my life has gone. I think this is a fairly common thread among American acupuncturists -- the first two people I knew who became acupuncturists did so after breaking their necks in car crashes -- acupuncture was the only thing that helped them with their pain, so they followed through by becoming acupuncturists.

I've had chronic knee pain from soccer injuries since I was 13 years old. That's 37 years of chronic pain, and I thought I understood it pretty well. My knee pain led me to exercise therapy based on breath work and then to acupuncture. However, I've been having new experiences in the last decade which have blown my old ideas of pain out of the water.

First was the tectonic heave into fatherhood, which brought the simultaneous establishment of a huge increase in expectations of my ability to provide long-term protection, financial support and emotional stability with an ironically huge reduction in my invulnerability to emotional pain. This was efficiently followed by the emotional pain associated with losing my closest family members to death. Next was the disappointed exhaustion of losing 2 political races. And now, most recently, is mysterious, chronic, diffuse and severe physical pain. Bad pain all over, every day, with no clear origin. Pain which intensifies as I sleep, by the way, so that from 3:00 a.m. until waking most days I am tossing, turning and groaning. On one hand it catches me by surprise: "It really does happen!" The thing some of my patients have told me about over the years now has a first name as well as a last name. On another hand, it makes me kind of nervous: "Gee, what new kind of pain will I experience next?"

There's a whole other round of concern, as well. One problem with body/mind/spirit medicine is that it can seem like every health issue is the sufferer's fault: "Well, that's what happens when you don't process grief." This is where the sensitivity, maturity and humanity of the practitioner come into play. Yes, there is truth to "that's what happens when you don't process grief," but a humane, mature and sensitive person will understand that grief happens in life, sometimes unendurable grief. It is a cruel and unhelpful person who simply offers a generic observation, and it is a more useful one who tries to help you with your specific process. Even less helpful is the person who says "That's your karma." Maybe it is and maybe it isn't, but it certainly is useless, offensive and entirely presumptuous advice.

When you are in the middle of extended, severe pain, though, to some extent you do have a choice to make -- will you succumb to the pain and try everything in your power to retreat from it? Or will you try to learn from the pain and try everything in your power to work through it, even if you must do so over and over again, day after day? These are very personal questions and no one on the outside has any right to make any judgment or determination about the pain sufferer's answer. The answer may change, too, from day to day or week to week, and none has the right to judge those changes, either.

For now, my decision has been to try to understand my pain as well as I can, seek such assurance as I can that the pain doesn't herald some lethal condition, and seek the assistance of those whose opinions I value to help me with understanding the pain or (please God!) relieving it.

Pain, part 2

I was born to be a writer, and then there was some training involved. Daddy was an English professor and Mama was a newspaper editor. I always loved to read and write, but the thought of doing it for a job made me depressed, so I pursued dance, exercise therapy and acupuncture instead. I have to confess, I've always had a morbid fantasy that I will some day suffer an accident that leaves me physically disabled, leaving me no choice but to pursue writing. Little did I imagine that pain might be that disability.

I have been thinking of my pain as an internal bed of nails. Like the beds of nails used by fakirs, I hope that it will lead me to new understandings and new insight that I can use to help myself and my patients, but maybe I’m just a deluded masochist. I am willing to endure this pain fairly cheerfully in hopes of such an outcome, but at 4:00 a.m., when I roll over and am pierced for the third time by those internal nails, it's hard to be cheerful. I've only had this pain for 6 months -- in a year I may be begging for Oxycontin. You never know, and I hope I won't be judged for it, however things go.

There's this additional thing with chronic pain: it seems like the pain channels become burned in, as in “screen burn-in” on a monitor. It feels like our nervous systems, like LCD screens, undergo physical changes because of repeated and prolonged energetic transmissions across certain of our circuits. You don't become scarred by the internal bed of nails but rather get sores from it that are constantly inflamed and re-inflamed. In other words, we chronic pain sufferers may hyper-develop the physical channels associated with the pain response itself, ironically amplifying our sensitivity along those same damn channels.

Has anyone else noted that irony seems to be a by-product of pain?

So. Whaddaya do about pain?

Get ahead of it. This is a pretty standard idea with wide agreement among different practitioners. If you were my sister, I'd say, "Acupuncture, Advil, hot bath, massage, hypnotherapy -- whatever works. And try to stay ahead of it -- falling behind and getting back ahead is a lot more stressful than getting ahead and staying ahead." In addition to acupuncture, yoga and diet, I recently started using aspirin, myself. A temporary measure, but it helps me get by while I search out a more profound and permanent treatment.

Be open-minded. Hoo, boy, this is tough. Whatever direction your mind doesn't go? It may need to go there in dealing with your pain. Try to be patient.

Breathe. We could go into a LOT more detail about this, but if you can start a breath and finish a breath, the pain hasn't killed you yet. This is a starting place, and when all you can see is an undifferentiated sea of pain stretching in every direction, a starting place can be a kind of anchor.

Pain, part 3

A lot of eloquent, heartfelt and authoritative words have been written about pain, from every age and every culture on the planet. It takes real chutzpa to think I might be able to add anything to the extensive literature on pain. So let me start this section by telling a blond joke.

A blond went to his doctor and said, "Dr. G., you gotta help me! I've got pain all over my body! I don't know what's causing it and nothing makes it better! I can't sleep from the pain and from worrying about the pain! I'm at my wit's end! You gotta help me!"

Dr. G. knew his patient pretty well, and after sitting down and crossing his arms and legs he said, "Show me."

The blond lifted his trembling right hand to his forehead and touched it with his finger. Immediately, tears sprang to his eyes and he began to whimper. The doctor said, "Again." The blond repeated the same process, this time touching his left shoulder. Again the tears and whimpering, this time with a groan thrown in for good measure.

"One more time," said the doctor. The blond gingerly touched his knee with his finger and almost crumpled to the floor, weeping and gasping, his face white.

The doctor stood up, closed the blond's file and started out of the examination room. "It's very simple, Trey," he said as he walked out the door. "You broke your finger."

Funny but cruel, like most good humor. However, there's a lot of truth to the blond's predicament. We each have different tolerances for pain, as we have different tolerances for everything. When our tolerance is exceeded, things start to pour in and in the flood of sensation you can lose your bearings. I referred earlier to the "screen burn-in" phenomena of chronic pain, and when that pain is diffuse and of unknown origin, the "burn-in" can seem to permeate everything. Every perception becomes filtered through the burned-in lens of pain. Even if it IS only a broken finger, when all your perceptions come in through that avenue, as far as you can tell you have pain everywhere. And for a variety of reasons, it can be hard to develop new avenues of perception, especially when you are under siege by pain.

I have been clinically depressed before, and am familiar with its spiritual and psychological alienation, disorientation and isolation, but this physical pain response is something different. Although it is curious and provocative that anti-depressants are frequently prescribed for sufferers of chronic pain and seem to help somewhat... Still, clinical depression is associated with a lack or deficit (of connection, love, concern, energy, motivation), while the disorientation of chronic diffuse physical pain is due to an excess of sensation -- it's not just white noise, it's white noise amplified until you can't hear or see or feel anything else. Chronic physical pain tends to paralyze you, while depression makes you inert. In other words, chronic pain is an unbearably oppressive yang state, while depression is an unbearably passive yin state.

Yang, being active, has many faces and many personalities, while yin, being passive, is her own unmoving, cold-blooded self. Yin pain (depression) is itself, obviously and inevitably. Yang pain is every pain, and so is difficult to pin down. Do I have a Lyme flare, multiple spinal injuries or a combination of specific exacerbations to existing chronic injuries and dysfunctions? It feels like my right radial biceps tendon is ruptured, my left sacroiliac joint received a serious injury and my thoracic vertebra are all messed up. It also feels like I have polymyalgia rheumatica, or maybe fibromyalgia. My chronically painful knees haven't been anywhere close to right since last July. It feels like I have an aggressive crystalline blood stagnation borne of blood deficiency and exhaustion -- systemic gout, more or less. My hands hurt all the time, but especially in the morning -- I can hardly open jars, turn my car key or hold an acupuncture needle. All in the last 6 months. What I'm saying is: whatever it is, it's more pains than I can process. Maybe it's everything, or maybe it's four or five things and I can't tell the difference.

Fortunately, I am human. I can stop and consider my situation.

I can breathe.

I can get feedback from other people I trust.

Maybe I’ll learn something from my pain and maybe I won’t, but I'll deal with my pain and see you in the morning.

I mean, what else is a blond to do?

Pain, part 4

Hallelujah! I have relief from some of my pain! But more than that, I have had my first definitive, clear vision of the sources of my pain -- the curtain of oppressive yang sensation has been pulled aside so I can see what is bothering me, SO I KNOW WHAT TO DO!

The agent (or angel) of this revelation is my old friend Frania Zins, PT and Feldenkrais practitioner extraordinaire. I took a hellacious fall last summer while hurriedly building a rabbit hutch for my five-year old's birthday bunnies. I was lucky I didn't die, honestly, and the lesson is clear: no matter how big a hurry you're in, go get a ladder instead of standing on top of something dangerously inappropriate (a sliding board, in my case)! I knew I was badly hurt right away, and craved Frania's experienced, knowledgeable hands right away, too. But she's in New York, I'm in Central PA, I had a practice to run, kids to raise, an election to lose, yadda yadda yadda. Besides, I did what I could and my immediate pain went away after about 6 weeks. It wasn't for another month or so that I started awaking in pain. And I certainly had Lyme disease, gout and other real reasons to worry about some other, systemic origin for my comprehensive pain pattern.

Still, after starting to write about my situation (and after listening to my wife, Amy, in more and more exasperation tell me for five months to go get myself some help!), I made arrangements to meet Frania for a Feldenkrais/acupuncture swap. One of the things that is amazing about Frania is that her hands can make your body understand directly what is happening to it, and as soon as I felt them on my lumbar, thoracic and cervical spine, I knew, "Oh, damn. That's hurt bad." See, after the initial six weeks of lower back pain from landing on my left butt cheek, I never perceived my back as hurting -- I perceived the pain as starting at my hips and shoulders and radiating outward from there -- this was part of the incomplete, flawed perception that my sea of pain obscured. But it was clear from Frania's hands that, Lyme disease or no, I definitely had hurt my spine pretty badly in three different regions.

I would be lying if I said I leapt up off her table, right as rain, but I did get up slowly, with my hands and shoulders hurting a lot, knowing a lot more about my situation than I did when I laid down. Furthermore, Frania gave me one simple anatomical/kinesthetic concept to fool with, and one week later, while lying in bed on a Saturday morning, something big let loose in my deep right hip (piriformis, maybe?), a place where I had never had any particularly intense pain, and by the next day my legs and lower back worked again and were essentially pain-free. I mean, pain-free for an out-of-shape 50 year-old with chronic knee problems.

Now don't get me wrong -- I am not going to play soccer or perform ballet again, and the absence of that lower body pain brought my upper body pain into much sharper relief -- but I can get up out of a chair now and walk, I can roll over in bed, and I can clearly feel the pain in my neck and upper back that is tied to the pain in my shoulders and hands. I still awake at 3:00 a.m. most days in pain, but since it is only half of me that hurts, I can re-position myself more easily, or hell, get up and take some more aspirin if I need to. The thought of getting out of bed and walking to and from the bathroom is no longer the scary ordeal it was a few weeks ago. That's the most important thing -- my pain level is back within my thresholds, so I am no longer held in thrall by it.

Yes, Amy and everybody else, I am going back to see Frania again next weekend, and I am really looking forward to making some headway against my upper body pain. And if I had health insurance I probably would have gotten an orthopedic or neurological consult that would have revealed my ruptured discs or fractured vertebra 9 months ago. But I would have missed this opportunity to experience and understand a new, debilitating and terrifying pain, the sort of pain that so many of my patients endure.

By the way, I will probably follow through with getting a neurological examination, with MRI and all, but I would bet $100 that it will show ruptured discs in my lumbar and cervical spine, fracture or ligamentous damage in my thoracic spine and a fully torn supraspinatus muscle in my right shoulder. More damage accumulated in this animated carcass to go along with all the other injuries, illnesses and iatrogenic mishandling. I will probably have to be careful about lifting for the rest of my life, and my head- and handstand days are probably over. But that leaves a lot I can still do, and even if my neck, shoulder and hand pain don't get any better than they currently are, I am not paralyzed by pain as I was. Hallelujah!

Tuesday, April 26, 2011

Another analogy, for chronic health issues

What I have striven to do as an acupuncturist is to help people with chronic problems find the end of a piece of energetic string that they can follow out of their maze. Sometimes you pick up and drop many ends of string before you find one that leads somewhere. Sometimes the string leads you in a bad direction and you have to retreat. And sometimes it's just a big ball of knots and you have no choice but to sit there, picking and picking at the knots to try to get the line to run free.

For awhile now I have used the image of an old-fashioned fishing reel to describe the process of dealing with a chronic health issue. Some people talk about an onion, and describe how you have to peel away layers to get at what's underneath, but I find that a detestable metaphor -- onions are nothing BUT layers! The implication is that there is nothing to life BUT pathology, and when you get under the layers which are currently tormenting you there will be new layers beneath for you to peel. Ugh. I'd step in front of a truck if I believed that.

I prefer the fishing reel image because when it gets a backlash (a big tangle of knotted fishing line which keeps the reel from working correctly) you have no choice but to untangle the knot on the surface, then the next knot you come to, then the next knot until the line runs free. At that point you can reel in the line and resume fishing. Yes, it also works to just cut the whole mess of tangled line out of the reel and fish from there, but you can only do that a couple times before you run out of line entirely and have to quit fishing. "Fishing" standing in for "living" in this metaphor, I plainly think it is worthwhile to try the patient knot-picking approach for some time before resorting to surgery. It's also a good idea to work on your cast ("cast" being synonymous with "lifestyle"), but when you've got a big ol' backlash staring at you it's not the time to lecture about casting technique.

When there is an auto-immune, latent or hyper-sensitive component to the chronic health issue, I add to the backlash image a layer of glue (dampness, in Chinese pathological terms). The glue is made up of painkillers, steroids, antibiotics, alcohol, sugar, fat and other substances we use to comfort ourselves, but which are all suppressive, in Chinese energetic terms. The glue holds the knots in place, allowing you to reel up whatever line you have on top of the backlash and continue fishing, but your cast is greatly limited and you're going to be in big trouble if you catch a big one and need to let out some line. Furthermore, as you fish you are constantly losing a little line here and there, tying on lures and whatnot, and it's only a matter of time before you work your way down to the level of the original problem. When you finally get down to untangling the backlash, you will find that the glue has cemented the knots in place and has spread to deeper and more superficial layers of the line, expanding the boundaries of the original backlash in a very discouraging way.

I think this is a pretty good analogy, but now that I have spent 6 months considering chronic, diffuse pain from the inside, I would add another factor to the puzzle: it can happen that you don't know which way to turn the reel's handle. This means that until you find a productive end of line to pull on and then watch to see which way the handle turns in response, you don't know, literally, which way to turn. Your choice is to either thrash about in a panic, almost certainly making the knots worse, or to wait calmly until you get a clue, which can look like denial, indecision or self-destruction from the outside and which feels like paralysis from the inside.

This is where the assistance of an experienced, sensitive and trusted practitioner comes into play. Their distance provides some context for pointing out to you the way to turn. In this situation, the practitioner is not just helping you find an end of string -- he or she is throwing you a lifeline.

One of my drawbacks as a practitioner is perhaps too much deference to my patients. Some of it has to do with maintaining clear boundaries and avoiding fostering dependence, some has to do with avoiding making a reputation for myself as someone who just wants you to come back for another treatment, and some has to do with sincere philosophical belief -- who the hell am I to tell anyone else how to live? But some of my stand-off-ishness may have to do with a kind of cowardice -- the kind of cowardice that allowed me as a young man to enter into romantic liaisons with a disclaimer that I wouldn't commit to the relationship. It took me far too long to realize the shamefulness of that trick -- I pretty much had to be on the receiving end before I understood the dishonesty, cruelty and sophistry of such words. Although I started in a decent place, not wanting to manipulate anyone, I proceeded in a cowardly and dishonest fashion, denying involvement or entanglement in spite of the evidence provided by tangled limbs and complicated schedules.

Now, having been on the receiving end of a lifeline thrown by my honest, loving and brave friend Frania, I am beginning to realize an additional layer of responsibility and commitment I owe to my patients. No, I can't help everyone, and no, I don't want to have certain types of reputation, but I am more self-serving, less brave and less generous than I care to admit when I hold myself aloof. Having caught this lifeline and felt the relief, hope and restored confidence that had been so drowned by my sea of pain, I realize now how little my concerns about professional boundaries matter. I wouldn't have minded if my butt was bared in public, would have paid all the money I have and would have endured any kind of lecture (and believe me -- Frania can lecture!) in return for that lifeline.

It is a small but terrifying step to go from standing at a patient's side, helping them look for the end of a piece of string, to going out on a limb, looking them full in the face and giving it your best shot, throwing with all your heart in hopes that they will be able to catch hold and start to pull themselves out of their torrent of pain or dysfunction. It is a step that I will be taking from now on, and it is a huge part of what I have been able to learn from my ordeal.

If I intend to keep writing I'm going to have to find another disability to blame, or maybe scrap that whole morbid need for an excuse to write and simply write because I can. And because my writing may act as a lifeline for someone who reads it and needs it.