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This Monday was a lot easier than last Monday!

As I wrote last week, I have proliferative diabetic retinopathy.  This is being treated by pan retinal photocoagulation (PRP), or lots of laser pulses to the retina. On my treatment last week, I was able to tolerate only 200 laser pulses.  I slept like I was drugged for the rest of the day and did not feel well the next day.

This week, I had 700 laser pulses.  My discomfort level after 700 was less than my discomfort level last week after the first 100!  After the treatment, I was full of energy, active through the remainder of the day, and felt fine the next day.

What has made the experience so difference this time?

There are three major changes between last week and this: physiology, medication, and preparation and mindfulness.

Physiologically, sensitivity of the retina is not uniform.  Some areas are nearer to nerves and some farther away.  It’s possible that the first treatment hit the most sensitive areas and the second treatment hit less sensitive areas.  While that’s possible, the doctor gave me no reason to believe that was a factor.

Last week, I took a Vicodin after the treatment to alleviate pain.  I don’t know that it did much.  This week, I tried one before going in for treatment.   Comparing the most intense pains from both weeks, I would say that the Vicodin may have dulled the pain slightly but that it was not a significant factor.  This agreed with the doctor’s observation that she had  not found Vicodin to be helpful.

I see preparation and mindfulness as the key changes.  Last week, I drove an hour to the appointment, so my mind was very busy before the procedure.  I was also complacent about the pain, having been through the experience twice before—forgetting that the first time was four years ago and I was sedated and numbed the second time. Last week, I paid no particular attention to my posture, breathing, or to the sensations.  Every laser pulse felt like pain—some of it very intense.

This time I did it very differently!  Teresa drove to the appointment while I listened first to a guided meditation on healing and then to an excellent talk by Gil Fronsdal on Pain.  When I sat in front of the machine, I arranged some back support and made my posture as erect as possible.

During the procedure itself, I had to stay very still and keep my eyes focused straight ahead.  I paid regular attention to my breath to be sure I was breathing regularly and deeply.  I watched my posture to be sure I didn’t curve my back and shoulders to slouch—postures that would reinforce feelings of pain and fear.

Most importantly, I watched carefully the sensations accompany each laser pulse.  I watched with a sense of curiosity, asking myself “what, exactly, is this sensation, and this one, and this one, and this one….” If you’ve ever had an eye exam with a slit viewer, you know how bright and uncomfortable a light can be.  Every laser pulse was a flash of ultra-bright light.  Most of the pulses were accompanied by a sensation I can best describe as the back of the eyeball being pricked with a needle; the experience was sometimes more intense than others.  Some of those pinpricks were accompanied by a strong shooting pain, like a lightning strike from the eye to the left forehead.  (I speculate that the shooting pain was the result of a pulse hitting on or very near a nerve.)

I had nowhere near the pain as I did a week ago.  We were able to do 700 laser pulses before the discomfort level made it seem advisable to stop.

Now that we have a cumulative total of 900 laser pulses, it’s time to wait and see how my eye responds.  My next appointment is in early January.  After an exam, we’ll decide whether more laser pulses or whether another shot of Avastin might be the better treatment.

What is pain, anyway?

This experience has led me to a new understanding of pain.

In the Bahiya Sutta, the Buddha says “let sensation simply be sensation….”  In other words, don’t add anything to the sensation.  It seems to me that what when we say pain, we always include an element of aversion.

Dharma talks typically distinguish between pain and suffering.  To me, it seems that the important distinction is between sensation and pain, with suffering just more mind accumulation around pain.  I now see pain as sensation plus the emotional experience that the sensation is unpleasant.

If you “let sensation simply be sensation,” then anything added is just mental proliferation.  Add unpleasant, and the sensation becomes pain.  Add pleasant and the sensation becomes pleasure.

Now that’s a thought with unexpected ramifications!  Is pleasure a mental proliferation just as pain is?

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Teresa and I drove to Sequim this morning.  Near Blyn we saw fields of grass glinting with a white covering of frost.  The frost reminded me of the crisp fall and winter mornings when I was growing up in Illinois.  I always loved walking in the snow in the woods—everything was so quiet and peaceful.  I felt my worries drop away from me.

Not much snow here!  It probably snows enough for a few inches of accumulation less than once a year here.  Each time it’s happened, we’ve been out of town on a winter vacation.  Maybe this year will be different?

We went to Sequim so that Teresa could be fitted for a new set of orthotics.  I have had intermittent problems with shooting pains in my ankles for several years.  Inserts customized by my now-retired podiatrist solved that.  This year I’ve also experienced some low back pain and minor knee problems.  On a day to day basis, I hardly notice it, but every few months it’s enough that I see the chiropractor.  Since these problems may all be related, I decided to be fitted for orthotics too, replacing my worn inserts.  I’ll get them in two weeks but it may be several months before I know for sure whether they alleviate these pains.

With respect to pain, mindfulness means an objective awareness of sensation and not getting caught up in it.  It means not letting the mind run amok with fear of all the possible consequences of the pain—from “I’ll never walk again” to “I’ll die tomorrow.”  Neither does it mean denying or ignoring the pain.  Both getting caught up in and denying the pain results in suffering needlessly.  The Middle Road would be to take action when appropriate.

The trick is to find that middle road!

Namasté.

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The Buddha said: “Let hearing simply be hearing, let seeing simply be seeing, let sensation simply be sensation….”  I find it more difficult to be equanamous about sensation when I consider it to be pain, especially when unexpected.

All the teachers say that the body deteriorates with age, and I know that to be true in my case.  I have proliferative diabetic retinopathy (PDR).  While there are some experimental medications to treat PDR, the “gold standard” of treatment is pan-retinal photocoagulation (PRP).  Or, in simpler words, blasting the retina with a laser.  Since my body was not responding adequately to the medication, PRP seemed the appropriate treatment to prevent vision loss.

I’ve had PRP twice before, in my right eye.  The first time was several years ago, and I remember some pain.  This  summer, I had further treatment but I was sedated and did not feel any pain.  Today, it was time to treat the left eye.  I think I had grown complacent—I had been through the treatment twice before with only minor discomfort, so I was prepared “to do it again.”  I wasn’t expecting or prepared for the pain.  I noticed that I was strongly resisting the sensation and could tolerate only 200 flashes of the laser (between 1,000 and 1,500 are planned).  Each flash felt like a pinprick on the back of the eye.  I wasn’t centered at the beginning and didn’t even think to try to regain my balance to experience the sensation differently.

When I am prepared for an uncomfortable situation, I at least have a chance to handle it well.  If not prepared, I am more likely just to react.  And reaction usually means suffering.

Further treatment is scheduled for next Monday.  My goal is to be calmer and more centered when the treatment begins, and to let the sensation simply be sensation and not something to recoil from.

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