Mind Over Back Pain
- Back pain has reached epidemic proportions in the Western world. It is one of the most common disorders for which people seek medical help. The pattern of the patient's pain and the findings on physical examination could rarely be satisfactorily explained by the presumed pathology.
- Tension affected the circulation of blood to muscles and their associated nerves. The result was pain.
- Many doctors in my own specialty see the validity of the diagnosis but find it difficult to treat such patients. This is related directly to the fact that the disorder is not purely "physical."
- Since the late nineteenth century, medical thinking and training have been largely mechanical and structural in orientation. The body has been viewed as an exceedingly complex machine, and illness has been interpreted as malfunction in the machine brought about by many different factors, some of which come from outside the body, such as infection or trauma, some based on inherited defects and some caused by the degeneration of various organs and systems.
Conventional Treatment and Medical Mythology
- Among most victims of back pain, tension leads to a physical process involving the muscles and nerves of the neck, shoulders and back. I call this condition the Tension Myositis Syndrome (TMS).
- The change is circulatory; tension constricts the blood vessels feeding the involved muscles, and the resultant blood deprivation leads to painful muscle spasm and nerve pain. The consequences of TMS produce more anxiety; they increase internal tension and perpetuate the pain-producing process. Worst of all, fear is the back pain patient's constant companion: fear of physical deterioration.
- Numbness and tingling are symptoms of oxygen deprivation of nerves and are very common with TMS.
- An inflammation is an automatic reaction to almost any injury or disease; it is basically a protective, healing process. For example, germs that have gained access to the body will call forth an inflammation whose purpose it is to destroy them. Some inflammations, however, are the result of strange reactions that are not self-restorative, in which the body turns on itself. There is no demonstrable inflammation in patients with ordinary neck, shoulder or back pain.
- The body has wonderful recuperative powers. One should recover from a strain or a sprain in a few days or, at the most, two or three weeks. One of the worst aspects of the back pain problem is the tendency to become chronic, brought about first by incorrect diagnoses and second by the fear engendered by those diagnoses.
What Causes Back Pain?
- A placebo can reduce the pain in each of these examples by either or both of two mechanisms:
- Can reduce the tension temporarily by creating a belief in the patient's mind that he or she is going to be cured;
- Can reduce or abolish any kind of pain temporarily by stimulating the secretion of certain chemicals in the brain known as endorphins
- The placebo effect is almost always temporary. Furthermore, since the treatment did nothing to alleviate the underlying cause of the pain, it usually returns in exactly the same pattern.
- Muscle relaxants do not work directly on the muscle but exert whatever effect they may have in the brain. A number of medicinal substances are administered by injection. This is temporary and does not contribute to the basic solution of the problem.
- Another widely used technique for blocking the transmission of painful signals is transcutaneous nerve stimulation (TNS).
- The shocks are supposed to stimulate the nerves in the region and block the pain signal. Almost as many people were helped by a placebo nerve stimulator as by the real one.
- Biofeedback is a new treatment method occasionally used for these pain syndromes. The principle of this technique is that the patient will learn to reduce activity in the forehead muscle and in so doing bring about reflex relaxation all over the body. This does not solve the problem of TMS because it treats the symptom.
- Another widely used treatment for neck, shoulder and back pain is exercise. The proposition that the pain is due to weak muscles. It is very hard to reconcile with the facts that there are millions of sedentary people of both sexes and all ages who don't have back pain and that a fair proportion of the patients I have treated through the years have been healthy, strong young men and women.
- There is a place for exercise when TMS is the cause of pain, since exercise may improve the blood circulation to the involved muscles and nerves.
- Among other conventional treatments, manipulation techniques are widely used to restore proper alignment.
- Surgery is not a permanent solution. The majority develop pain again, often in a similar pattern to that which they had prior to surgery.
- The question is not whether discs degenerate and herniate; they do. What is at issue is whether disc abnormalities cause pain.
- Running, like swimming, is one of the best cardiovascular conditioners and ways of burning off tension. This is the great tragedy of prohibiting these vigorous activities; the individual loses an important means of dissipating accumulated tension while apprehension about his back compounds the tension.
The Manifestations of TMS
- Neck, shoulder and back pain is not a mechanical problem to be cured by mechanical means. It has to do with people's feelings, their personalities and the vicissitudes of life.
- Another great fear that serves to intensify and perpetuate TMS is that of physical activity. An acute attack invariably brings forth the prescription of bed rest. This is based on the concept that a structural abnormnality must be allowed to heal or an inflammatory process must be resolved.
- But still another set of psychological factors add to the reservoir of anxiety. Invariably the person begins to feel very inadequate.
- The mind develops a strategy designed to avoid the appearance of emotional difficulty. Quite unconsciously, the tension is channeled into the body, and a physical disorder is made to substitute for the emotional manifestation of tension. Such physical reactions are called psychophysiologic disorders—that is, physical changes caused by some emotional phenomenon.
- For some people with TMS, apparently the tension level rises while they sleep, and the result is an increase in pain. There appears to be a direct relationship between the level of tension and the degree of pain.
- The autonomic nervous system controls the circulation of blood all over the body.
- Changes in local circulation will occur as a result of such things as heat and cold, physical activity or fear and anxiety.
- TMS is the result of tension-induced alterations in local circulation resulting in blood deprivation, called ischemia.
- This blood deprivation is not sufficient to damage the muscles and nerves except infrequently. The resultant pain is due, first, to an accumulation of chemical waste products in the muscle. Second, reduced circulation means that insufficient oxygen reaches the muscle, causing it to spasm. Third, reduced circulation results in reduced oxygen to nerves such as the sciatic.
- The response of nerves to lowered levels of oxygen is pain; if the oxygen level is lower still, there may be feelings of numbness, "pins and needles" and even reduced strength in muscles.
The Treatment of TMS
- Physical incidents did not cause the pain but acted as a trigger. The process of TMS probably exists in back muscles for months or years before the pain begins, but in a milder state.
- The importance of this pain on pressure cannot be overemphasized. Muscle tenderness on pressure is the hallmark of TMS. It explains the "trigger points" that doctors have been talking about for years, which can now be recognized as the central zone of a wider area of muscle pain induced by blood deprivation.
- Only the postural muscles and their associated nerves are targets for TMS; This is a clinical fact, similar to the fact that the stomach or colon may be a target organ for tension.
- The pain of TMS varies widely in quality, since there are three reasons for it: muscle spasm, accumulated chemical wastes and nerve irritation.
- The accumulation of chemical wastes causes pain of a duller, aching quality that will also persist as long as the circulatory insufficiency remains, though varying in intensity. Nerve pain may be burning, aching or shooting.
- Patients with TMS consistently report that moist heat (moist packs, hot shower, hot tub) relieves pain and sometimes dispels it completely for short periods of time. This supports the concept that TMS is due to reduced blood circulation, since heat probably works by improving the local circulation. Conversely, cold generally increases pain in TMS muscles by further slowing the circulation.
- Data confirms that degenerative processes have nothing to do with most back pain. Degeneration is progressive and relentless.
- In patients with very severe TMS, it has been observed that there is often a reciprocal relationship between the awareness of tension and the pain. That is to say, if the patient was aware of feeling very tense on a particular day, he or she had less pain.
- We teach our patients to think of their pain in psychological terms, for if they can do that, the tension will cease to produce a physical reaction.
- Psychophysiologic reactions such as ulcer, migraine and TMS seem to be an attempt by the mind to discharge excess tension in a way that masks or hides the tension. This subterfuge is necessary because obvious manifestations of tension are acceptable neither to the individual nor to society. Quite unconsciously, we prefer not to be considered nervous or jittery.
- Whatever the brain mechanism, it is quite clear that the knowledge of what is going on prevents the autonomic nervous system from transmitting nerve messages that constrict the blood vessels and cause muscle and nerve pain.
- Reducing the tension in one's life is very difficult if not impossible, because tension is so much the result of personality traits and temperament. Tension is also due to stressful life circumstances.
- Meditation, Yoga, relaxation exercise or aerobic exercise reduce TMS, but in my experience not nearly enough to eliminate it.
- Logic suggests to patients yet another possibility. Perhaps as their back pain departs, the tension will find a different target and cause some other physical disorder, such as an ulcer. We found that this did not happen either, though it is quite common when symptoms are removed by other forms of treatment; this is known as symptom substitution.
- We found that understanding and accepting the diagnosis of TMS was equivalent to "cure" in the majority of cases.
- Dr. René Jules Dubos, a world-famous medical scientist who participated in some of the most fundamental medical discoveries of this century. In his later years Dr. Dubos is quoted as having said, "I have an enormous belief that practically everything in the body is governed by the mind, that the mind is much more important than anything else in the body."
- The unconscious acceptance of an idea is similar to the placebo reaction, with the important difference that the result appears to be permanent when the belief is based on a logical, rational concept.
- The structural-mechanistic philosophy of medical practice is unfortunate; patients see themselves as passive recipients of whatever fate brings.
- If the person in pain is at the same time frightened, depressed, angry or frustrated, the pain will be more severe.
- A permanent "cure" for TMS requires that the patient understand what it is, how it works and develops the confidence that through this understanding the process will cease. No drug will accomplish that.
- Currently udnerstanding about chronic pain is fundamentally erroneous. There are two major fallacies in its conceptualization:
- There is an underlying structural disorder that represents the basis for continuing pain.
- This pain is perpetuated and aggravated by an unconscious desire for "secondary gain."
- There is no underlying structural disorder in the majority of these patients; most of them suffer from TMS, which is physical but not structural, a central tenet of this book.
- "Secondary gain" is not the motivating psychological force behind the pain syndrome but anxiety, depression and psychological conflict. "Secondary gain" undoubtedly exists but represents a small part of the psychological process and should not be the major thrust of psychotherapy.
- The initial diagnosis of the tension myositis syndrome the patient should be immediately reassured that the process is not the result of a hidden desire to be in pain.
- All doctors should be practitioners of holistic medicine in the sense that they recognize the interaction between mind and body.
- Though the cause of TMS is tension, the diagnosis is made on physical and not psychological grounds, in the tradition of clinical medicine.
These notes were taken from John Sarno's book Mind Over Back Pain: A Radically New Approach to the Diagnosis and Treatment of Back Pain