Chapter Links

Join the Discussion

Read or add comments
on A Life Larger than Pain—click here

Recommend other books to readers of A Life Larger than Pain—click here

Editions and Rights

Please read and share this online version of the book but permission is not otherwise given to copy or download book content or to reproduce it in print or electronic form.

Inquiries regarding permissions or rights should be directed to Health Press NA Inc., P.O. Box 37470, Albuquerque, NM 87176, www.healthpress.com

A Life Larger than Pain

The Pathway from Resignation to Renewal

by Erv Hinds, M.D. (more about this book and author)

Chapter 4: The Three Dimensions of Pain Relief

The reductive, mechanistic view of the body grants no privilege to the "integrated whole." Modern medical science has evolved for most of this century as if the mind played no part in disease … even now, the mind is seen mostly as a kind of nuisance that can cause a placebo effect that has to be factored out of studies before the "real" impact of a drug or surgical technique can be determined.

–CHIP BROWN[27]

THE REMARKABLE STRIDES in mind-body understanding, complementary medicine, and holistic approaches to health have addressed the intersection of physiology and technology with psychology and spirituality. Materialistic, Western pragmatism has been tempered by Eastern mysticism. But this integration has yet to take root in the professional healthcare community in a significant way, especially in the pain specialty. Ironically, the treatment of pain is perhaps the area most in need of such multi-dimensional understanding.

When we presume that spiritual issues are relevant only for the religiously inclined, we marginalize a central aspect of what happens in the pain experience. Perhaps the failure to acknowledge the reality of the human spirit lies at the heart of what is missing in conventional medicine. In years to come, the specialty of pain medicine may well be the branch of medical science that reintroduces this fundamental reality to our understanding of how to treat illness and alleviate suffering. But right now we are in its infant years, far behind other cultures in affirming

the mysterious yet harmonious unity of the whole person. Our greatest strides in the next phase of medical science may well lie in discovering how crucial a role the human spirit plays in the healing of the whole person.

Advances in our understanding of the physiology of pain lend credence to the gathering evidence of the influence of spirit and mind on the body. It is far beyond the scope of this book to attempt a comprehensive overview of the physiology of pain. Rather, I want to broaden our understanding of how mind and body interact to show that our physiological experience of pain is a changing process rather than a static state. It is not set in stone. Fluid in nature, it is better characterized by the word "plasticity." This helps explain why certain kinds of pain often dismissed as "all in the mind" are in fact literal realities. It also affirms that pain patterns are not absolute, predetermined conditions: they are shaped not only by the kind of injury sustained, but also by an array of contributing factors. They can be intensified or modulated by an individual's responses to the pain.

Recent studies have established that prayer and meditation change the individual's response to pain. As I hope to suggest in exploring specific patterns in the physiology of pain, the interplay of the three dimensions of body, mind, and spirit is reality, not speculation. Our scientific understanding seems to be bringing us to the very boundaries of where body, mind, and spirit converge.

In its most elemental form, pain is the body's acknowledgment that injury has occurred. In this respect, all of us share a common recognition of pain. There are crucial differences, however, in how we experience pain as the message of injury is transmitted and interpreted. The best way to understand these differences lies in five key concepts: pain behavior, central sensitization, neurosignatures, the rebound trap, and brain plasticity.

pain behavior

Most of us are familiar with the pain of acute sunburn. The pain signal is transmitted from the surface of the skin to the spinal cord, where it

synapses (connects) with other nerves that transmit messages to the brain. Although the origin of the injury is the same from person to person, each individual recognizes the pain of the sunburn uniquely. This is due in part to physiological differences: one man's pathway will differ from another's simply because all aspects of his anatomy and physiology are unique to him and help define his individual identity. But differences in response to the injury may vary even more from one person to another because of the vastly different ways in which each of us responds to painful stimuli. You may shrug off a sunburn as a slight inconvenience while somebody else is consumed with its stinging pain and walks around stiffly for several days exclaiming, "Don't touch me!" These differing responses are varieties of pain behavior.

The nervous system transmits the message of tissue injury to the brain. Differences in pain behavior emerge from the many different ways in which this perception is either downplayed or exaggerated. Some of these variables are traceable to psychosocial backgrounds. Your unwritten family rules may have instilled the belief that pain behavior is a shameful display of weakness. Somebody else's family may foster such outward displays as a way of regulating dynamics between family members. The greatest variables in how we respond to pain lie in the emotional and spiritual realm of suffering. In the crescendoing chain of events along the spectrum of pain, suffering is by far the most individualized response. We will look more closely at that dimension in later chapters, particularly chapter five, but first it is crucial to understand how the physiology of pain determines crucial differences in our responses.

The first step in the physical recognition of injury occurs at receptor sites (specialized cells that recognize injury) all over the body. When stimulated, the receptors send messages to the spinal cord, which will then transmit them to the brain (see fig. 4.1). Once the brain receives these messages of pain, it will send reply messages back through the spinal cord and out to the peripheral site of injury.

The central nervous system functions like a vast communications system, a comprehensive network connecting all parts of the organism with the brain. Incoming and outgoing pain messages are coordinated through a region of the spinal cord called the

dorsal horn (see fig. 4.2). The dorsal horn is a virtual corridor extending the length of the spinal cord, containing a "chemical soup" comprising receptors, synapses (connections between two nerve fibers), and chemical transmitters. It functions like a central railroad station between the body's superficial receptors and nerves and the headquarters of the brain. Depending on where in the body the injury occurs, the entry zone for the pain message into the dorsal horn occurs at a different point along the spine. If the injury occurred in the hands, for example, the pain message will enter the dorsal horn up in the cervical zone (neck areas) of the spine. When the feet are injured, the entry zone is the lower or mid back. This entry point serves as a kind of switching station, as the superficial nerves connect with the central nerves carrying messages directly to the brain.

The afferent (incoming) pain message

Messages flow two ways through the dorsal horn: bottom up, from the receptor sites to the brain; and top down, from the brain to the site of injury. Within the dorsal horn, these stimuli are modified and changed. Neurotransmitters (chemicals–such as epinephrine, norepinephrine, and serotonin–that transfer messages) form a chemical soup that can either intensify or diminish the pain signal. When the alarm is sounded that injury has occurred and the pain message races up to the brain, the brain will send messages back out to the dorsal horn to modify the incoming pain signals. There may be a dampening effect on the body's alarm over the injury as the brain's way of "down-regulating" the pain pathways–in contrast to a possible "up-regulating" from the injury site to the brain, intensifying the effect.

Neurotransmitters affect both the up-regulating and the down-regulating of pain pathways. We know that pain inhibitors–not just drugs, but a life-giving relationship, a workout that stimulates endorphins, or listening to soothing music–stimulate the pathways that modulate pain. The power of positive thinking and prayer on healing has been established clinically in numerous studies. "We always knew it helped; now we have the proof," people of faith have been commenting as the research has been publicized. But now we know the scientific basis for such behavioral techniques as hypnosis, biofeedback, and relaxation exercises–even prayer and meditation. Through our understanding of how neurotransmitters regulate pain messages in the dorsal horn, we are identifying the physiology of mind-body connections.

We are not as clear yet on the physiology of how depression, anxiety, and fear intensify pain. Perhaps they somehow rearrange the ingredients of the dorsal horn's chemical soup, preventing the pain-inhibiting pathways from being activated. We do know that they are pain intensifiers.

Chronic pain patients experience repetitive stimuli from pain fibers, heightening the sensitivity of the receptors to the same stimuli. When the stimuli occur over and over again, they create an "imprint" of the pain message on the central nervous system. With acute pain, the pain message

is established by the superficial nerves and eventually carried through the central nervous system to the brain, but it may be changed en route at the dorsal horn of the spinal cord. With chronic pain, the

same pain message repeated continually may create an imprint that is maintained by the central nervous system long after the original painful stimulus has stopped or markedly decreased–a phenomenon known as "central sensitization." Repetitive alteration of the chemical soup of neurotransmitters and receptor-stimulators changes the way the central nervous system handles pain messages.

This mechanism for persistently repeated pain is similar to what people suffer in so-called phantom limb syndrome–they continue to feel pain in an arm or a leg that is no longer there. Phantom limb is a good model for understanding the physiology of chronic pain: the message is not imagined, because it is actually imprinted on the brain. The nervous system is still interpreting an incoming (afferent) barrage of impulses–bottom-up messages from the periphery to the center. By contrast, outgoing messages (efferent) are a top-down array of impulses carried from the central nervous system back out to the peripheries. Thus the cliché "it's all in your head" is literally true, when the phenomenon of central sensitization and imprinting have occurred. To the brain, the pain is all too real.

central sensitization

When a traumatic event happens, it triggers a barrage of painful impulses. Repetitive incoming signals increase the intensity and frequency of the pain message in the "wind-up phenomenon," sometimes leading to an imprint on the brain. This is the process of central sensitization. The nervous system retains a physiological memory of the damage it has sustained, even if the pain impulse has been withdrawn.

That's the bad news. The good news is that understanding this physiological condition teaches us that we have control. For example, those who suffer from the disease of Raynaud's Syndrome, in which the hands are painfully cold, can learn through biofeedback to raise the temperature of their hands. They can learn to control vasodilation (expansion of the blood vessels) and constriction through therapy affecting their modulatory pathways and neurotransmitters.

Spinal cord, shown in cross section

An example of how we can benefit from understanding central sensitization is operations involving amputations. Sound research exists demonstrating that when the extremity of painful sensation is anesthetized (such as with a spinal or epidural block) before the amputation, it may markedly decrease the amount of phantom limb pain the patient eventually experiences. This is because the incoming barrage of pain signals, sent from the periphery to the central nervous system, has been blocked. Therefore, the central sensitization that might otherwise have developed, creating a blueprint of the event in the patient's brain, is markedly decreased or even eliminated. The central nervous system never receives the original message from the periphery; the wind-up phenomenon is defused before it develops; and the imprint is not allowed to form. Otherwise, without the anesthetic block, the patient's body might continue to perceive the painful injury of amputation for years to come.

Those who have had an amputation and now suffer from phantom limb pain can stimulate the inhibitory pathways through cognitive skills such as hypnosis or invoking spiritual practices to decrease the body's perception of pain.

When stimuli from our brain move down the central nervous system through the dorsal horn of the spinal cord, the perception of pain from the body's periphery can be changed. Biofeedback, hypnosis, relaxation exercises, meditative responses, and prayer come top-down from the brain to the central nervous system and can inhibit pain at the dorsal horn of the spinal cord. Instead of winding up, the pain winds down. This is a relatively simple concept, yet it is not widely known. It provides the scientific explanation for the positive effects of cognitive therapy and spiritual practices.

The wind-up phenomenon explains why people who continue to suffer from chronic pain are not just mired in a negative body-mind dynamic. They may also be experiencing pain via central sensitization. The science of neurophysiology (the study of how the nervous system functions in carrying messages from the periphery to the brain and back again) is beginning to identify specific areas of the brain and the spinal cord that are stimulated by positive, rhythmical, or repetitive thoughts. Inhibitory pathways and neurotransmitters that modulate or decrease the perception of pain have been identified in the dorsal horn of the spinal cord and other parts of the brain. It has also become clear that in parts of the nervous system, there is the capacity for change, stimulated by prayer and cognitive therapies.

When our thoughts and desires wander far away from our spiritual beliefs, medical problems become more dominant and oppressive. Health problems seem to cause less anxiety and fear if we do not feel alone with our pain. Without a spiritual context for providing an awareness of transcendence, it is all too easy for individuals to feel stuck in their pain, isolated from everything and everyone, and focused only on the reality of the pain. When they feel the freedom to turn the pain over to a source greater than themselves, they inevitably find some relief from the oppressive weight of constant suffering. This is not just an emotional response; physiologically, prayer stimulates inhibitory nerve fibers that effectively turn down the volume of pain.

neurosignatures

Pain behavior and central sensitization are two important concepts for understanding how we experience pain. A third is "neurosignature,"

which refers to a particular pattern of nerve pathways unique to each individual. These recurring and highly individualized pathways are formed by our early life experiences, our attitudes, and our beliefs. In a self-perpetuating way, our neurosignature influences our emotions and behavior. It may be a blueprint for illness or wellness, for weakness or strength, for headaches and nausea, or for curiosity and pleasure.

Our neurosignature can either downgrade or upgrade painful impulses coming in from the periphery, depending in part on the nature of our pathways as they have developed over time. Like a bad habit, or conversely like a good habit, recurring impulses from the brain, along with their corresponding emotions, engage our brain's previously used nerve pathways to instruct the body. This is how our thoughts become self-fulfilling prophecies. When we are flexible enough to change our minds, we do a great deal to improve our health. Our bodies and minds are a composite of genetic predisposition and experiential adaptation. Nature versus nurture, predestination versus free will–all commingle in the unique wiring of our brains that enables us to contemplate our bodies and our existence.

Perhaps the best way to handle pain includes blending sound medical techniques with appropriate spiritual and psychological intervention. The process of applying anesthesia to a body part before the intrusion of a painful stimulus is called preemptive analgesia (to preempt the pain). This procedure is useful across many medical disciplines, including the treatment of pain patients. Otherwise, if preemptive treatment is not possible, the repeated pain message may create an imprint. Once this damage has occurred, the focus must then shift from preventing to inhibiting the pain.

the rebound trap

The rebound trap occurs when the very medication or treatment designed to alleviate pain ironically causes it to recur. We refer to this as a biphasic response–the medicine goes out to help, but then it loops back to entrench the patient in further pain. This pattern occurs most frequently with headache pain.

For example, taking too much cafergot or narcotics or even non-steroidal anti-inflammatories can lock patients into a continual headache pattern. The medication itself becomes part of the reason for the headache in a reverberating cycle, not unlike an itch from an insect bite. The more you scratch it, because it feels so good to do so, the more you irritate the skin. In place of the original itch you have now created a new pain, which may escalate in intensity beyond the original problem.

Rebound headaches can be worse than the original headache the medication was designed to eliminate, because the treatment resets the receptor sites in the brain and becomes part of the problem instead of providing the solution. We are not sure why this happens, but we think it has to do with the saturation of the receptor sites. In order to break out of the rebound trap, the patient needs help withdrawing from the medication so that the receptor sites can be desaturated. The result will usually be an ultimate decrease in pain. Once the medication is discontinued long enough for the receptor sites to reset, it may again be helpful if appropriately reintroduced. Sometimes it is necessary to help individuals discontinue use of the medication entirely. If this does not provide a physiological solution, it may help them ease their intense focus on managing the pain and turn instead to a growing confidence in the mystery of healing.

The rebound phenomenon may be expanded beyond pharmacology more broadly to a body-mind interaction. When patients give all their attention to the pain and worry compulsively about all its varied manifestations, they get bogged down in reverberating thought patterns that simply make the pain worse. In their earnest attempt to understand their pain, their focus becomes entirely somatic (of the body). This constant preoccupation intensifies their pain. Like the pharmacological rebound, the receptors may be reset, increasing the pain, plunging the sufferer further into anxiety and perpetuating the vicious cycle.

Contrast this pain-centered focus with the responses of those in less technologically advanced cultures. I have seen Navajo women with congenital hip problems working just as hard as other women with healthy joints. Cultures that are more grounded in the natural rhythms of everyday life do not share our view of a direct association between pain and impairment. In our society, we are accustomed to popping pills

at the onset of a bodily ache because we expect the instantaneous gratification of relief. We are ill-prepared for learning how to take our limitations along with us to the job or learning to turn our focus away from the pain toward a positive direction. The renowned behavioral psychologist Dr. Wilbert Fordyce observed that if you have something better to do, you hurt less.[28]

At the heart of the rebound trap is a paradox: the very thing you think is helping you is hurting you. If you are desperate for relief, you will naturally clutch at whatever you think is going to make the pain go away. If the results are slow in coming, you are likely to grab all the harder–taking three pills instead of one, escalating your conviction that something has to be done now, and intensifying your distress signals to everyone around you. Your very attempts to get help may pitch you deeper into a spiral of despair and more pain. Lifeguards know that a panicked person in the water, flailing around for the nearest thing to keep him above the surface, is likely to put a choke-hold around the neck of his would-be protector and take them both down. This is an extreme example, but it graphically illustrates what happens when desperation shuts out all other perspectives on reality and turns counterproductive.

Despair and fatigue often blind us to the truth that reality is larger than our immediate framework. Pain tends to narrow our perspective, making it harder for us to look beyond the confines of our struggle. Even the intense desire to conquer the pain can be a form of rebound, because it so easily leads to a negative preoccupation.

If you are obsessed with resolving a problem, finding a way to release your preoccupation can break your reverberating mental cycle. Let's say you leave the office with your mind racing again and again over the same issue. You begin driving home and realize that you can't remember pulling out of the parking lot because your mind has been so preoccupied. I've got to stop thinking about this for a while, you tell yourself, because it's getting me nowhere and if I'm not more careful I'll end up in an accident because of it. You turn on some music and two miles later, while you're sitting at a red light, a solution to the problem suddenly pops into your mind. You have just experienced breaking out of the rebound trap.

Athletes know that there is an optimum intensity beyond which it is counter-productive, or even destructive, to push their bodies. Intuitively, they know when they reach this level. Pain patients often have this intuitive knowledge as well, but they need help in stepping back to recognize that level and refocus their attention. Once they learn how to act on this awareness, they can reverse the escalating intensity of their suffering.

Physiologically, we know that receptor sites are saturated with neurotransmitters, and we can begin to reset them by something as simple as taking a deep breath. Many religious traditions prescribe spiritual practices that in one way or another involve breathing or meditating exercises that calm body and mind. Now we understand why these practices are so effective in breaking the cycle of pain and anxiety: they have a direct effect on how the body responds to stimuli. In the Christian tradition of the Lord's Prayer, the petition "Thy will be done" is essentially a letting go of the world's evils, turning them over to a higher source. Appropriating this prayer by taking a deep breath, sitting back from the pain, and turning it over to a transcendent power is a form of reversing the rebound cycle.

Breaking the rebound trap, however, cannot be reduced to the level of mind-body science. Although we know that receptor sites play a critical role in escalating or de-escalating pain, there is much we don't know about the body's healing power. The rebound concept plunges us into psychological and spiritual mysteries, which warrant our respect even as we strive to identify and understand them.

brain plasticity

One of the physiological reasons why we are able to break out of the rebound trap is the concept of brain plasticity: the ability of the central nervous system to change the way it operates. Remarkably, the body has built-in power to reverse its own self-destructive patterns and make the physiological changes necessary to move toward healing.

It is amazing to discover just how malleable the brain and the nervous system are. Much like a computer, the brain has hardware and software.

We appear to be hard-wired for certain neurologic responses. For example, stimulating the brain in a particular zone (the emetic) causes nausea and vomiting. Researchers have identified specific zones in the brain that, when stimulated by practices such as contemplative prayer and meditation, produce a sense of spiritual transcendence and awe.

But we are also soft-wired for certain things, enabling us to learn new skills and adapt thought and behavior accordingly, such as changing our ways of responding to stress with hypnosis or relaxation techniques. Brain plasticity empowers us to benefit from positive expectations. The brain is a living, changing member of our organic self. Cognitive therapy, spiritual awareness, remembered wellness, and intuitive thoughts can literally change our minds.

Herbert Benson introduced the term "remembered wellness" to replace the term "placebo effect."[29] The placebo effect tends to have negative connotations, such as the arbitrary dismissal of some recurring problems as being "all in your head." Remembered wellness is a powerful, positive term describing how we want to feel. It is rooted in our strong, natural desire for health and wholeness. "All of us project our intense desire for wellness onto the medicine we take," Benson observes. "Remembered wellness isn't particularly mysterious."[30]

Armond Trousseau, a nineteenth century French physician, advised his contemporaries to treat as many patients as possible with new drugs while the drugs still had the power to heal. Expectations of health are powerful–witness the surge of interest in herbal remedies such as melatonin and St. John's wort. Once word got around, people ran out to the store and found that melatonin helped them sleep better and St. John's wort eased their depression. To some degree, these effective results are rooted in the power of remembered wellness.

In the era when the polio vaccine and penicillin were new, we thought the power to stamp out disease was in the palm of our hands. However, epidemics such as AIDS and the increasing incidence of breast and prostate cancers humble us in the realization that we do not have the power we presumed. They return us to a more holistic, less technique-oriented way of exploring our vulnerability to disease and searching for

resources with which to fight it. Technological advances have wrought wonders, but they have also tended to narrow our focus to discrete parts of the human body. We study the minute details of individual trees in disregard of their place in the forest. In our legitimate quest for the advance of medical science, we forget that until a hundred years ago the placebo effect, spiritual beliefs, and remembered wellness were the treatments of choice.

three-dimensional pain management

Because studies of the brain are yielding new evidence of how the mind controls and affects the body, the mind-body loop is easier to understand and accept. But the existence of the spirit is scientifically debatable. The spirit-body loop is observable in its manifestations: a peace that surpasses comprehension; joy in the midst of suffering and sorrow; the vital spark evident in a person whose body is rapidly deteriorating; the strong sense of a person's presence continuing after she has died; the sudden and sometimes overwhelming transformation of personality when nothing external has changed; the movement away from bitterness and anger toward forgiveness and love. When I watch the miracle of relinquishment, of turning over helplessness to trust, I witness the miracle of the human spirit coming alive.

The beauty of spirit is that we can't get our hands around it to document it. If we could, we would be all over it. How freeing it is simply to yield to its mystery in recognition that we are not able to control it. For healthcare providers and for family and close friends, there is relief in knowing that at a certain point you have done everything you can, and any further healing will be accomplished only by the mysterious power of the spirit.

Scientific advances in our understanding of how mind and body interrelate have perhaps inadvertently reduced our view of pain to a two-dimensional reality: the body experiences it, and the mind perceives it. Then a paradigm shift occurred: if you can change how the mind perceives it, then you can change how the body experiences it. This reversal is true. The body's responses to painful stimuli can be intensified or moderated by thought patterns, as cognitive therapies for pain treatment attest.

Entrenchment in chronic pain, however, can drain off energy and initiative to such a degree that nothing short of wholesale reactivation will reverse the downward spiral and turn the individual toward healing. Accomplishing this reversal requires far more than boosting willpower and adopting positive thinking. It necessitates a transformation from within. I am convinced that this inner work takes place in the realm of the spirit.

"Man lives in three dimensions: the somatic, the mental, and the spiritual," declared Dr. Viktor Frankl, a therapist who endured the catastrophic suffering of the Holocaust. "The spiritual dimension cannot be ignored, for it is what makes us human."[32] Regardless of religious convictions, most of us would agree that at the core of the human person there is a unique essence that is not reducible to mind and body alone. Frankl's third dimension describes what we mean when we say that the "spirit" of someone lives on after death, whether in the memories of others or in some perceived form of afterlife.

In the nineteenth century it was understood that what happened with the bedside doctor included care for the human spirit as well as treatment of the body. In the last hundred years, we have witnessed a split of this care into twin disciplines for healing–physical care with the doctor and spiritual care with the priest. Care of the whole person was further segmented into a third discipline, psychological dynamics, in the so-called therapeutic age. Until the very recent trend toward holistic medicine, conventional disciplines have treated body, mind, and spirit separately. What used to be one river has divided into three separate streams, none of which flows in confluence with the others.

Frankl recognized that the three disciplines belonged together. To separate them was to violate the unity of the human person. His experiences in Nazi concentration camps shaped his conviction that an individual's "will to meaning" was necessary for survival and therefore an essential dimension of human existence. He arrived at this body-mind-spirit understanding not because he was trying to explain the persistence of religion, but because he had observed something critical to our survival that is irreducible to mind or body.

Fundamental to what it means to be human, Frankl declared, is the search for meaning. This will-to-meaning is not a mere symptom of a restless mind, but an absolutely vital part of existence–the distinguishing characteristic of humans in contrast to animals. Animals do not agonize over the meaning of their existence. Yet without a sense of this meaning, humans cannot survive when all else has been stripped from them. Frankl pleaded with his contemporaries not to ignore this fundamental reality by dismissing it as a religious invention superimposed onto materialistic reality.

Other researchers have studied the human person in an attempt to identify the spiritual dimension without defining it in religious terms. Daniel Helminiak, a psychotherapist and educator, describes the human mind as a "double" reality of psyche and spirit. Therefore, human beings are spiritual by nature. The whole person is not simply body and mind or body and soul, but, organism, psyche, and spirit.[33]

In the past thirty years, medicine has changed as rapidly as the computer industry. Yet patients still have the same physical problems, the same psychological and emotional needs, the same restless longings. Technological and pharmaceutical advances may have increased life spans and decreased physical pain, but they have been far less effective in diminishing patient suffering or nurturing a sense of individual worth in the context of a caring community. It is crucial that we complement our scientific and therapeutic expertise on the physiological level with corresponding attention to the effects of pain on mental, emotional, and spiritual levels.

STEPS FOR THE PATH:

observe the interplay of body-mind-spirit

1.	Today, I would rate my general pain level as:
0		1	2	3	4	5		6	7	8	9	10
pain free							excruciating pain

2.	How do you find yourself triggering the rebound phenomenon in dealing with your pain?

3.	Pain behavior is manifested in actions such as wincing, limping, or constant complaining. How do you notice this behavior in others?

	How do you notice it in yourself?

4.	Brain plasticity confirms that physiological patterns are not set in stone. Pain and suffering can be changed through the interaction of mind, body, and spirit. How do techniques or practices such as relaxation, biofeedback, hypnosis, or meditative prayer affect your experience of pain?

5.	Finding a path to improved coping involves a personalized balance of the interplay of mind, body, and spirit. What are the next few steps in your journey of integrating the three dimensions of pain relief?

[27] Chip Brown, Afterwards, You’re a Genius: Faith, Medicine, and the Metaphysics of Healing, New York: Riverhead/Penguin Putnam, 1998, p. 47.

[28] Fordyce, Wilbert. Psychologist at University of Washington Medical School Pain Center, Seattle.

[29] Herbert Benson. Timeless Healing. The Power and Biology of Belief. Simon and Schuster, 1997.

[30] Ibid., p. 20.

[31] Ibid., p. 20.

[32] Viktor E. Frankl. The Doctor and the Soul, second ed. New York: Vintage, 1986, pp. xv-xvi.

[33] Daniel A. Helminiak. The Human Core of Spirituality: Mind as Psyche and Spirit. Albany, NY: State University of New York Press, 1996, see esp. pp. 6, 24-25.

prev: Pain Does Not Equal Sufferingnext: Heartache: The Pain We Neglect