It hurts just to read the latest statistics on back pain. Every year, Americans spend an estimated $86 billion on back pain treatments, including pain pills, injections and surgery. And although about 800,000 surgical procedures are performed each year for back pain, in about 75% of those cases, the surgery doesn’t help.

That’s why David Hanscom, MD, an orthopedic spine surgeon at Swedish Medical Center in Seattle, does something that few surgeons would dream of—he talks most of his patients out of having surgery. Instead, he recommends a new six-step approach to treating chronic back pain that he finds far more effective than surgery for most people.


In this current environment of health-care reform, expensive yet ineffectual spine surgeries are a hot topic—but even decades ago, questions were being asked about whether too many were being performed. For example, back in 1989, Iowa Orthopaedic Journal published “Are We Performing Too Much Spinal Surgery?”…and the 2001 American Academy of Pain Medicine annual meeting presented the session “Failed Back Syndrome: The Disturbing Statistics.” New research continues to raise questions about the associated dangers, including a recent Stanford University study that linked spinal fusion surgery with a higher risk for stroke.

Dr. Hanscom acknowledged that overzealous surgeons and hospitals looking to maximize profits play a role in how many spine surgeries are performed. However, he said, it’s also important to realize that many surgeons are loath to turn away desperate patients who are begging for help. “These patients can’t work, they can’t sleep, they’re miserable—so they’re willing to try anything, even if there’s no guarantee that surgery will get rid of their pain,” he said.


The main reason why spine surgery so often doesn’t work, Dr. Hanscom said, is that an operation can relieve back pain only if there is a structural abnormality, such as a ruptured disk or pinched nerve. But the vast majority of chronic, severe back problems don’t fall into that category. Instead, the back pain is nonspecific, rooted in inflammation in the body’s soft tissues (ligaments, tendons, fascia, muscles). “These types of problems cannot be seen on imaging tests—and if you can’t see it, the best surgeon in the world won’t be able to fix it,” said Dr. Hanscom.

So when the problem is a soft-tissue issue, whether or not the patient undergoes surgery, his pain is likely to go on and on. Understandably, this leads to a lot of frustration (because nothing is helping) and fatigue (because pain is exhausting). A vicious cycle is created—pain leads to frustration and fatigue, and frustration and fatigue exacerbate pain.

The longer the pain continues, the worse the situation gets. “Long-lasting pain creates neurologic pathways that outlast the root cause,” Dr. Hanscom explained. “Once these pain pathways are formed and remembered, the cycle is established and the pain becomes chronic. So even after the soft-tissue problems are gone, the pain often isn’t. The only way to fix this type of chronic pain is to tackle the central nervous system’s response to pain.”


Dr. Hanscom knows firsthand whereof he speaks. His book Back In Control: A Spine Surgeon’s Roadmap Out of Chronic Pain describes his own battle with chronic pain—from tennis elbow, migraine headaches, burning feet syndrome and more—and the surprising strategy that he used to overcome it. Based on his personal and professional experience, he has developed a program—called Defined, Organized, Comprehensive Care (DOCC)—that he uses in treating his own patients and in training other surgeons. Its premise is that pain is a perception…and that understanding it gives you greater power to gain control over it. “Freedom from pain is not only possible, with the right tools it is probable,” he said.

Basically, the DOCC approach works by calming down the nervous system and allowing it to heal while also laying down new neurological pathways so the nervous system isn’t trapped in the endless loop of pain signals. Dr. Hanscom explained, “It’s not that you simply learn to live with the pain. Instead, your brain stops responding to the pain—so you literally do not feel it.” The DOCC program involves six basic steps…

Sleep. Getting at least eight hours of sleep per night is a cornerstone of the program. “If sleep issues aren’t addressed, nothing else will work,” Dr. Hanscom said. For people who have trouble sleeping due to their pain, prescription sleep medications are an option.

Stress management. Chronic stress creates a cascade of biological events that exacerbate inflammation and sleeplessness, which in turn perpetuate chronic pain. Managing stress requires a two-pronged approach—making time for activities that build up your energy reserves (exercise, hobbies, socializing, spending time alone)…and learning to deal more effectively with aspects of your life that drain your energy (things that make you anxious, angry or unhappy).

Pain medication. If you (or your doctor) have been leery of using pain medication for fear of its potential side effects, it is worth reconsidering this issue. Taking pain medication to achieve short-term relief while you work to resolve your chronic pain problem can help you halt that vicious cycle through which pain begets more pain, Dr. Hanscom said.

Physical therapy. Rehabilitation of soft tissues soothes inflammation and facilitates true healing.

Goal setting. Creating a detailed picture of what you are trying to achieve and devising a plan to work toward that goal helps you decrease anxiety, frustration and depression. This, in turn, calms the central nervous system and eases physical pain.

Retraining the brain. The DOCC program moves people from being reactive to being creative in their lives. Meditation, visualization and creative play are among the primary tools Dr. Hanscom recommends. Particularly helpful is writing, he said.

Example: Write down a situation that bothers you (for instance, “My spouse is always late and it stresses me out”). Then, on paper, examine your thought processes about this situation (such as, “When she’s late, I imagine that she’s been in a terrible accident…or that she just doesn’t care enough about me to be on time”). Next, look for errors in your thinking (“It’s highly unlikely that she’s had an accident…and she shows me in many ways every day that she loves me”). Finally, write about more rational ways in which to view the situation (“She’s just not good at budgeting her time. I’ll ask her to meet me 15 minutes earlier than necessary so that, by the time she arrives, we’ll be right on schedule”). Even though the problem or problems you write about might not seem to be related to your back pain, the writing exercises essentially help reprogram your nervous system to undo the old pain pathways, allowing your brain to lay down new, positive, pain-free neural pathways.

Helpful: Click here for a free download of an 82-page booklet called STOMP (Structuring Your Own Management of Pain), which Dr. Hanscom coauthored. It describes in more detail many of the concepts and pain-relieving strategies discussed above—so that you can take control of your pain instead of having it control you.