Back Sense: A Revolutionary Approach to Halting the Cycle of Chronic Back Pain [NOOK Book]

Overview

Understand your back pain in a whole new way and break the cycle forever.

Back pain is a serious problem, disabling over 5 million Americans and costing society $20 to $50 billion annually. Until recently both doctors and patients have misunderstood its true causes and have unwittingly fostered the pain cycle. Back Sense is the groundbreaking book that promises to change the...
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Back Sense: A Revolutionary Approach to Halting the Cycle of Chronic Back Pain

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Overview

Understand your back pain in a whole new way and break the cycle forever.

Back pain is a serious problem, disabling over 5 million Americans and costing society $20 to $50 billion annually. Until recently both doctors and patients have misunderstood its true causes and have unwittingly fostered the pain cycle. Back Sense is the groundbreaking book that promises to change the way we approach the problem by proving that almost all chronic back pain is caused by stress and muscle tension, rather than by damage to the spine.

On occasion nearly everyone experiences short term back pain--from sore or strained muscles. But for many who come to treat their back gingerly because they fear further "injury," a cycle of worry and inactivity results, which actually increases muscle tightness and leads them to think of themselves as having a "bad back." In reality, most backs are strong and resilient--built to support our bodies for a lifetime. Contrary to popular belief, truly "bad backs" are extremely rare.

While seemingly abnormal disks and other parts of the back are, in fact, often present in those who suffer chronic back pain, they are also frequently found in those who have absolutely no pain whatsoever. Back Sense uses the latest scientific research to discredit the perfectly understandable, but counterproductive assumption that back pain is caused by these "abnormalities." Drawing on their work with patients and studies from major scientific journals and corporations such as Boeing, the authors have amassed conclusive evidence proving that stress and inactivity are actually to blame. Since conventional treatments of back problems encourage excessive caution, most sufferers get trapped in a vicious cycle in which concern about pain and physical limitations leads to heightened tension, more pain, and further distress.

The authors of Back Sense--all three are former chronic back pain sufferers themselves--have developed a revolutionary self-treatment approach that works. It allows patients to avoid the restrictions and expense of most other treatments. After showing readers how to rule out the possibility that a rare medical condition is the source of their problem, Back Sense clearly and convincingly explains how chronic back pain results from other factors. Building on this idea, the book systematically leads readers toward recapturing a life free of back pain.


From the Hardcover edition.
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Editorial Reviews

Publishers Weekly - Publisher's Weekly
Both clinical psychologist Ronald D. Siegel and market research consultant Michael H. Urdang have suffered from chronic back pain. They learned to treat their pain by using a new system of integrative medicine (a combination of East and West) and by staying physically active. In Back Sense: A Revolutionary Approach to Halting the Cycle of Chronic Back Pain, Siegel and Urdang team up with physician Douglas R. Johnson, a specialist in physical medicine and rehabilitation, to dispel misunderstandings by both sufferers and medical practitioners about the cause and treatment of back pain, based on their extensive research and success in treating thousands of patients. Agent, Ira Silverberg, Donadio & Olson. ( Apr. 17) Copyright 2001 Cahners Business Information.
From the Publisher
"I highly recommend this wonderful book to everyone with back pain. The first of my patients who read it got out of bed and off narcotics for the first time in months. We’re both thrilled."
–Christiane Northrup, M.D., author of Women’s Bodies, Women’s Wisdom and The Wisdom of Menopause

"Back Sense is a well-researched, well-written, and approachable book. I can testify to its efficacy, both as a patient and a practitioner: this approach works."
–David K. Urion, M.D., Associate Professor of Neurology, Harvard Medical School

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Product Details

  • ISBN-13: 9780767909716
  • Publisher: Crown Publishing Group
  • Publication date: 11/29/2001
  • Sold by: Random House
  • Format: eBook
  • Pages: 256
  • Sales rank: 519,676
  • File size: 723 KB

Meet the Author

Dr. Ronald D. Siegel is a licensed clinical psychologist and has been a member of the clinical faculty of the Harvard Medical School since 1984. In 1988, he was disabled by back pain. His personal experience led him to develop the treatments described in this book. He maintains a private practice in Massachusetts specializing in the treatment of chronic pain.

Michael H. Urdang is a qualitative market research consultant in Boston. He holds an M.Ed. in counseling psychology from the University of Massachusetts at Amherst. His bout with chronic back pain was resolved using the methods in this book. He currently lives in Arlington, Massachusetts.

Dr. Douglas Johnson is a physician and a board-certified specialist in physical medicine and rehabilitation. He is the medical director of the inpatient rehabilitation unit at Charlton Memorial Hospital and also maintains a private practice in physiatry. He lives in South Dartmouth, Massachusetts.


From the Hardcover edition.
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Read an Excerpt

CHAPTER
1
A New Approach to Back Pain

Back Pain Bulletin!
If you’ve been suffering with back pain, we don’t need to tell you just how bad it can get. It’s an ordeal. You suffer, your family suffers, your friends suffer, your work suffers. Your whole quality of life can take a nosedive. There are millions of other people with the same problem, but that doesn’t make it any easier to handle. We know that it’s hard to believe, but the book you hold in your hands can help–and help a lot. It’s about an exciting new approach to understanding and treating chronic back pain that integrates the very best from both “traditional” and “alternative” medicine so you can resume your normal life as soon as possible. It is based on an explosion of recent scientific research that leads to a whole new way of understanding and treating back pain that has become a chronic problem (lingered more than a couple of months).
Simply put, the book makes three major points:
1. The cause of most chronic back pain is generally misunderstood by both sufferers and the medical community. It is usually thought to be the result of damaged or defective parts in the back. This is a perfectly natural assumption, but, strange as this seems, it simply isn’t true. A great deal of scientific research has been done on chronic back pain, and the findings point in a completely different direction. So what does cause chronic back pain? The evidence tells us that while the problem may start with a physical injury or strain, those things usually heal quickly on their own. Tight muscles cause the pain to last, and stress is to blame for tight muscles–stress over pain, worries about the future, disappointments over unsuccessful cures, fears of surgery, anxieties about medical bills, problems at work, unhappiness over strained relationships. The pain is certainly not “all in your head.” We know that it is completely real. Muscle tension and spasms can cause intense pain.
2. Most current back pain treatment methods don’t work very well because they misunderstand the real cause of the pain. Again the research contradicts typical medical practice. If you are like most people, you’ve taken your back troubles to one or more doctors. You may have been told to rest, take medicine, or attend “back school.” Perhaps you’ve tried special cushions, braces, physical therapy, a chiropractor, or even surgery. You’re probably very careful to avoid reinjuring yourself. Some of these measures may have helped to a degree, but they probably haven’t solved your problem entirely or you wouldn’t be reading this book. Conventional treatments miss the real cause of most back trouble–they simply don’t address the stress and muscle pain problem.
Most treatments also emphasize “taking it easy,” “trying not to hurt yourself,” or waiting for the pain to go away before resuming activity. Yet all the research and our experience with patients show that a quick return to unrestricted physical movement is the fastest and surest way to recovery.
3. We have great news about your hurting back! Back Sense describes a new way to treat chronic back pain that is more effective and less expensive than conventional methods and allows you to resume full activity. Its goals are to help you understand the true causes of chronic back pain, reduce your stress, and restore your life. The especially exciting part is that you can heal yourself without special treatments and without having to accept disability and the loss of your favorite pastimes. The methods we describe have already helped thousands of back pain sufferers before you. They’re safe, too–low risk for almost everyone (we’ll tell you how to make sure they’re right for you).
We know that all of this is very hard to believe if you’ve been stuck with back pain for months or years. We were also extremely skeptical when we first heard about it. Please take a chance and read on. The news in this book can be your way out of pain.
Happy Ending: One Patient’s True Story
Up until now we have been talking about chronic back pain in general. Here is the story of one man’s struggle with the ailment–how he suffered and eventually got better. Your own story will be different, but you may find similarities to what you’ve experienced.
I’m in my forties now, married, a professional. I was in my early thirties when the ordeal began. I was in decent shape and enjoyed outdoor sports. While on vacation visiting my brother, I decided to try out his cross-country ski machine. The next day, when my back started to ache, I figured that the machine had overstressed my muscles. Like most of us, I had gotten backaches before. But when I returned home from vacation, the pain was worse. I got a bit anxious when the pain moved into my leg, since I thought that this might indicate a nerve problem.
After a couple of weeks of pain I was starting to worry. Not only was the ache still there, but my toes went numb when I was walking. I went to my doctor, who looked worried herself. She sent me to see an orthopedic surgeon connected with a famous medical school. The surgeon ordered a CAT scan of my lower spine and told me to rest in bed until the results were known.
The CAT scan report brought dismal news. I was told that I had a herniated L5-S1 disk that was causing leg pain. The specialist reassured me that “many” patients recovered without surgery–provided they rested enough and avoided reinjuring their backs. I did not find this especially reassuring. I was given anti-inflammatory drugs, muscle relaxants, painkillers, and stern instructions to be careful. I grew dizzy, nauseated, and tired from the medicine.
Out of work, and lying in bed for hours at a time, I was bored and miserable. I had plenty of time to remember all sorts of things that hadn’t occurred to me in years. I recalled that my mom had been diagnosed with a “slipped disk” when I was young. I remembered that she had spent months in bed and was forced to use a bedpan. I realized that she had never fully returned to normalcy. I began to imagine life as a disabled person, and the idea filled me with dread.
Each morning, upon awakening, I tried to figure out if the pain was better or worse. There was no clear trend. Sometimes my spirits would lift for a few hours if the pain seemed less, only to crash again when it returned.
One day an idea occurred to me. Maybe a physician specializing in sports medicine might take a more optimistic and active position about my treatment. I called and made an appointment for a consult. This doctor took one look at the disk on the CAT scan and ordered me back to bed, threatening that if I did not heed his warning, I’d be “begging for surgery” in six months.
After weeks of bed rest, the pain and numbness were getting worse. I now imagined myself never being able to ride in the car or go for a simple walk around the block. Desperate, I consulted a chiropractor. Confirming the two doctors’ diagnosis, the chiropractor prescribed regular spinal manipulations, ultrasound stimulation, a back brace, and ice packs. I was excited to finally have a more active plan for getting better, and I followed the chiropractor’s advice religiously. Despite my hopes, it was not long before it became obvious that the pain and numbness were not really going away.
A couple of months later I began dragging myself to work, ignoring the dire warnings. I installed a bed in my office so that I could lie down most of the time. I couldn’t sit for more than ten minutes and couldn’t walk for more than a block. I wore a back brace, sat on special cushions, and leaned my car seat back to take the pressure off of my spine. More than once I almost got into an accident because I could hardly see through the windshield.
I now thought of little but my back and leg pain and was terrified of every movement. I became angry, depressed, and bitter. I had always hoped to have children, but I couldn’t even take care of myself now. My wife was depressed and exhausted, too, after months of caring for an invalid. One day my wife got fed up with me and suggested that I seemed to complain of more pain when I was emotionally agitated. I dismissed the idea as nonsense and angrily accused her of blaming me for a condition that was beyond my control. She clearly just didn’t understand.
A friend at work, hearing of my troubles, suggested that I look into the treatment methods of John Sarno, a famous doctor in New York. Dr. Sarno had supposedly helped a mutual acquaintance. Having read several medical books and seen three doctors, I felt that I already knew enough about back pain treatment to last a lifetime. I ignored the recommendation. The friend again pushed the idea a couple of months later. Fresh out of options, I gave in.
Dr. Sarno’s rather strange and improbable idea was that most chronic back pain, and the associated sciatic nerve symptoms, were not due to displaced disks or other structural problems at all. Rather, he insisted, these symptoms were caused by physical reactions to emotional stress. It can’t be true, I thought. The pain was too real. The CAT scan was too clear. The doctors and the books all agreed. There was that annoying observation from my wife, though, about my being in more pain when I was upset. Could there possibly be something to this guy’s theory? I wondered.
I called the woman who had supposedly benefited from seeing Dr. Sarno.
“How long have you been laid up?” she asked.
“About four months,” I replied.
“What are you doing now?” she asked.
“Lying down, of course–that’s all I ever do.”
“Why don’t you go out and buy groceries for the family–your wife will appreciate it.”
“Are you crazy?” I inquired.
“No–try it! I spent a year being completely crippled before figuring this out. I’ve been fine ever since.”
I was completely stunned by this conversation. The woman was serious. As far as I knew, she wasn’t insane. My situation seemed so dire, yet I wanted to believe that there was a way out.
Summoning all my courage, I decided to try walking around the block. This seemed like a major expedition after all the months of bed rest. As I progressed, filled with the familiar fear, I noticed that my sciatic pain was now moving from one leg to the other. With a sudden shock I realized that this didn’t make any sense–the CAT scan clearly showed the disk protruding to one side. Only one leg should be hurting. If the pain was shifting sides, maybe it wasn’t being caused by the disk after all!
The following few weeks brought about a remarkable transformation. Gradually, despite my worries, I began moving again. I started to realize that more movement did not always lead to more pain. Sometimes the pain stayed the same, or even diminished, despite the fact that I was doing things that should irritate my damaged spine. Little by little I began acting more normally.
During this time I realized that I had suffered from medical problems in the past that might have been stress-related, including a persistent “pinched nerve” in my neck and chronic heartburn. There seemed to be a pattern here.
Increasingly convinced that my back trouble was probably caused by fear and muscle tension, I started working on regaining my range of motion and rebuilding lost muscle strength. There were ups and downs. When the pain intensified, I would get very discouraged. Still, doing more helped build my confidence, and as it grew, my pain began to diminish. I trained my friends to stop asking about my back and ask instead how I was doing with my fears. My depression and anxiety lifted as prospects of a normal life returned. Over the next several months I gradually returned to the full range of activities I had enjoyed before that fateful day on the cross-
country ski machine.
These events took place about ten years ago. This patient is important to us. That is not only because he was, in a sense, our first patient. It is because he is Dr. Ronald Siegel, a clinical psychologist and one of the authors of this book.
Dr. Siegel’s story illustrates several crucial points about chronic back pain. Note that even the best doctors may make errors in treating the problem. They are trapped by the same misconceptions about its cause and treatment as are patients. Also, the damaged spine theory of back pain seems so powerfully sensible that we tend to believe in it, even when the facts of our own situation don’t really fit. We have found that patients’ first major breakthrough in treatment often occurs when they notice for themselves that their symptoms aren’t entirely consistent with their diagnosis. Dr. Siegel’s experience of pain shifting from one leg to the other is just one example of how this happens. His story also shows that motivated, functional people can get caught in the intense downward spiral of the chronic back pain syndrome. In addition, it demonstrates how it is common for back pain patients to have suffered from other stress-related problems in the past. These can include headaches, digestive difficulties, rashes, jaw pain, grinding teeth, neck aches, joint pain, fatigue, and insomnia. Finally, the story illustrates how chronic back pain can rob people of the athletic, social, or other pursuits that they once used to relieve stress. This, of course, only compounds the problem.
You may be thinking that this is a strange and interesting story, and these are curious ideas, but they don’t apply to you. Your back really is damaged. Your thoughts and feelings couldn’t have anything to do with your back pain. Your pain is too severe to be the result of tight muscles. The plain fact is, muscle tension can produce tremendous pain, under the right circumstances. Unbelievable as it may seem, you too can leave your back pain behind.
Is This Book for You?
The Back Sense program is suitable for almost anyone suffering from pain in the back or neck, as well as related pain that is felt in the legs or arms, that has lasted for more than a couple of months. While we use the term back throughout the book, the treatment principles we outline apply equally well to most neck pain. We say “almost anyone” because there are a very small number of chronic back pain cases that are caused by some kind of underlying medical problem that requires special attention. This is an exception to the rule that affects only about one in two hundred people.
Health care professionals make a distinction between acute and chronic back pain. Usually acute refers to pain lasting less than two or three months, while chronic indicates it has lasted longer. Acute back pain may be thought of as primarily a bodily problem, whereas chronic back pain involves the mind and the body. Often, acute back pain is caused by common injuries such as muscle strains. These usually heal on their own in a month or two. While the principles we will be describing can help prevent acute back pain from turning into chronic back pain, they are designed especially for people whose pain has persisted. If your pain has lasted for at least two months and doesn’t seem to be getting better, you are probably getting caught in the chronic back pain syndrome caused by muscle tension.
Chronic back pain comes in many forms. Some of our patients have suffered with the problem for just a few months, while others have struggled with pain for several decades. For some it has been merely annoying, for others completely disabling.
We want to emphasize the fact that stress-related chronic back pain often begins with an acute physical injury. This can be due to an accident, overuse of muscles, or strain. Sometimes, however, the pain begins during an unremarkable action such as cleaning the house or playing a sport. For a surprising number of people, the pain seems to begin “out of the blue” and isn’t directly connected to any single event. Even though there may not be a clear-cut event that caused the pain, people try hard to make sense of their pain and tend to search exhaustively for anything damaging that they have engaged in.
People with chronic back pain come from all walks of life. Some have worked at jobs that require physical exertion, while others have sat at desks for many years. Some have been truly athletic, while others were never unusually strong or physically fit.
The diagnoses we see are also varied. Many have been told that they have a “slipped,” “bulging,” “herniated,” or “degenerated” disk. Others have been told that they have arthritis in the spine or that their spine is misaligned (subluxations), curved (scoliosis) or otherwise malformed, damaged, or weak. Some of our patients have been told that nothing is wrong with them physically, and they must be imagining their pain. They may have been informed that the tests “didn’t find anything” or been given a diagnosis such as “idiopathic back pain,” which means the same thing. Many of them are simply given pain medication, tranquilizers, or antidepressants and sent on their way. They are often left thinking that their doctor hasn’t looked hard enough to find what is really wrong with them.
However your pain began, and whatever your diagnosis, chances are that your pain is not due to damage to your spine. Even the fact that tests may have shown something to be out of place or “degenerated” need not be cause for alarm. Similarly, observations about misalignment or bad posture may have nothing to do with your pain. We will show you in the pages ahead how concerns about being damaged, along with other sources of stress and tension, are enough to cause and maintain your pain. Again, this does not mean that the problem is just psychological. Rather, you will learn how certain beliefs and emotional attitudes can cause you to unknowingly tense muscles and how muscle tightness and spasms can cause the pain you experience.
It is important to recognize that everyone has stress and tension, and anyone can get caught in the cycle of pain, worry, and stress that causes chronic back pain. The demands of modern life subject all of us to an astounding variety of stressors. While we emphasize the role of stress in the problem, it is important to realize that we are not suggesting that you need to avoid or eliminate stress to succeed with the program. Instead we teach you ways to cope effectively with the inevitable pressures of life in our society.
Whatever your diagnosis or history, if you find yourself frustrated by your lack of progress in overcoming chronic back pain, this book is indeed for you.
Why Hasn’t My Doctor Told Me About This?
At this point, alarm bells may be going off in your mind in response to all this supposedly good news. You may be thinking: If these methods are such a “breakthrough,” why doesn’t my doctor know about them? He or she is pretty smart. He or she went to an excellent medical school. We understand these questions because we would be thinking the same things. After all, people have been selling crackpot science and quack cures for years. The complete answer will resolve your concerns, but it’s complicated. For that reason we address it at length in chapter 3.
The short answer is that advances in medical treatment usually take a long time to be accepted. That is often not such a bad thing. You want to be careful when you are dealing with someone’s health. Luckily we are not talking about brain surgery. The risks in this case are tiny, and the conventional treatments themselves actually involve a good deal of risk. Many of them actually make things worse!
The self-treatment methods we will show you involve both the body and the mind. Most doctors simply haven’t been trained to think this way. Study after study finds that chronic pain is often unrelated to the condition of the spine. Study after study also shows stress to be the most important predictor of who gets back pain. Most health professionals working with chronic pain do accept the idea that this plays some role in how intense the pain seems to patients. They are generally unaware, however, of the research demonstrating that the mind can be potent enough to actually cause the problem by increasing tension in the body.
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Table of Contents

Acknowledgments ix
Part 1 Understanding Chronic Back Pain 1
Chapter 1 A New Approach to Back Pain 3
Chapter 2 What Is the Program? 14
Chapter 3 Bad Back? 22
Chapter 4 Ruling Out Truly Serious Medical Conditions 34
Chapter 5 Mind and Body in Chronic Back Pain 39
Chapter 6 The Chronic Back Pain Cycle 49
Part 2 Relieving Chronic Back Pain 69
Chapter 7 Belief and the Body 71
Chapter 8 Restoring Your Life 82
Chapter 9 The Emotional Toll 107
Chapter 10 Think Psychologically 117
Chapter 11 Common Pitfalls 138
Chapter 12 A Guide to Mindfulness 151
Chapter 13 A Guide to Regaining Fitness 162
Chapter 14 Final Thoughts 187
Appendix 1 Medical Diagnosis of Back Pain 190
Appendix 2 Medical Treatment of Back Pain 202
Appendix 3 Resources 210
References 215
Index 239
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Customer Reviews

Average Rating 4.5
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Sort by: Showing all of 5 Customer Reviews
  • Anonymous

    Posted January 4, 2002

    This book gave me 'my life' back again!

    After a fall, I suffered from chronic leg pain for a period of 20 months before finding this book. For 20 months I spent countless hours seeing doctors, physical therapists, chiropractors, message therapists, and other health practitioners, including acupuncture. I was desperate to get well. I had made progress, but I still felt it very difficult to walk or move normally--I was still in essence 'crippled,' and I feared my life might never been normal again. Then I found this remarkable book. In the period of time it took me to read the first few chapters, I knew what the authors were suggesting would work for me. I was able to immediately implement the principles. I got up from where I was reading and began to walk completely normally for the first time in over a year and a half. Soon thereafter, I found myself bounding up stairs and skipping with joy. Three months later, I'm still doing great. I¿m so happy to be 'Free At Last!' If you suffer from chronic back, neck, or leg pain, I urge you to read this book. It may not have the same effect on you, but you have nothing to lose but your pain!

    2 out of 2 people found this review helpful.

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  • Anonymous

    Posted October 26, 2001

    This book makes Sense of the Pain. Try It!

    I have had mild to moderate, with occasional severe, back pain for many years. Generally, the pain started when I was in graduate school. I thought that the long hours of sitting in class, reading and studying was damaging my ¿weak¿ back. After reading this book, I started to realize how much stress was a major factor in my back pain. Just before I read the book I was visiting my chiropractor every week and getting a massage a couple times a month. I loved the treatments, but I was getting increasingly concerned that I had a serious problem with my back that was going to disable me, sooner, rather than later. After finishing Backsense, I have stopped stressing about every twinge, tight muscle or pain in my back---and the pain has been much less and less frequent! I now enjoy my gym activities and play time with my children, knowing that my back is strong and healthy. Backsense gave me a better understanding and confidence in the strength and durability of my back. It was easy to read and understand. Anyone searching for relief from back pain should read this book.

    1 out of 1 people found this review helpful.

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  • Anonymous

    Posted September 26, 2001

    I urge you to read this book.

    I was a skeptic. After many years of spending thousands of dollars and countless hours with medical doctors and chiropractors, I could not believe that changing the way I thought about my pain could help me conquer the crippling spasms that had wracked my life for nearly 20 years. I had tried special exercises, surgical consults, CAT scans, and powerful medications¿ nothing could take away those episodes that left me in agony, tilting to one side as if severely wounded. These spasms attacked me repeatedly, leaving me incapacitated for weeks and months. What I discovered through the Back Sense approach, was that the cure lay in three areas: The first, and most important, is the awareness that I should not fear the pain as something that was about to cripple me as it had done in the past. Nor should I react by favoring my back or avoiding normal activities that I worried might have strained it in the past. Finally, root causes of the pain invariably were in how I managed my own feelings, especially stress, worry, and sometimes anger. I am now free of spasms and no longer worry about my back. I urge you to read this book.

    1 out of 1 people found this review helpful.

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  • Anonymous

    Posted August 10, 2001

    When it seemed that nobody had any answers for me, I found them in this book.

    For close to a year I had been experiencing debilitating back and hip pain. I am a very active person, and in addition to suffering from the constant pain, I was beginning to become severely depressed as the level of my physical activity decreased. The book was able to provide answers to my questions as to what was happening to me, and also provide a method for reducing the pain and learning to deal with the causes. Neither of which had been forthcoming from doctors or physical therapists. The book was easy to read and very simply laid out. The reasoning behind their recommendations appeared to be based on good science, and the scientific references that they provided added to the credibility of the statements. I also liked the fact that they emphasized the need for going through the usual diagnostic tests. The authors are then able to provide reasons for the pain and ways to work to reduce the pain and 'get your life back'. Most specialists will admit that surgery for a herniated disc will not reduce the pain. However, it seems that many doctors can provide their patients with no further direction or assistance. The book made so much sense - and it has turned my life around. I would recommend it for anyone who has chronic back pain (or for that matter, any muscular/nerve-based pain). The same philosophy could be applied to any part of the body. I rate this book very highly

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    Posted January 2, 2011

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