Tension myositis syndrome

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Tension myositis syndrome (TMS) is a name given by Dr. John E. Sarno, to a condition characterized by a psychosomatic musculoskeletal and nerve pain. [1] [2] Sarno, Professor of Clinical Rehabilitation Medicine at New York University School of Medicine, and Attending Physician at The Rusk Institute of Rehabilitation Medicine at New York University Medical Center, has described TMS in three books [3] [4] [5] and has stated that the condition may be involved in other pain disorders as well. [6] Sarno's theories and management plan for back pain and other TMS equivalents have been widely publicized, including a segment on ABC's show 20/20 with John Stossel. Stossel stated he had been significantly helped by Sarno's method, but also that Sarno's diagnosis and method are not widely accepted by the conventional medical community. [7]. Sarno himself stated as well in a 2004 interview with Medscape Orthopaedics & Sports Medicine that "99.999% of the medical profession does not accept this diagnosis." [8]

Theory and symptoms

According to Dr. Sarno, TMS is a condition in which emotional stress causes physical pain. Most often this pain occurs in the back, neck, shoulders, and buttocks but may appear in other parts of the body as well. According to Sarno's theory, physiological reason for the pain is decreased blood flow, causing oxygen deprivation in the affected area(s) of the body, which may involve muscles, nerves, tendons or ligaments. This physical phenomenon, the decreased blood flow, is an aberration undertaken by the autonomic nervous system that causes increased pain(mild to intense) and tension in the affected tissues. This also manifests as muscle spasms, feelings of weakness, numbness, and other negative sensations.[6][8]

Sarno states that the underlying cause of the pain is the mind's defense mechanism against unconscious mental stress and emotions such as anger, anxiety and narcissistic rage, resulting in mild oxygen deprivation in muscles, nerves or tendons, thereby causing physical pain. The conscious mind is distracted by the physical pain, as the psychological repression process keeps the anger/rage contained in the unconscious and thereby prevented from entering conscious awareness. [9] TMS can be considered a psychosomatic condition and has been referred to as a "distraction pain syndrome". [10]

Sarno is a vocal critic of conventional medicine with regard to diagnosis and treatment of back pain, which is often treated by rest, physical therapy, exercise and/or surgery. [citation needed]

Treatment

Sarno states that the most important element of the treatment is education about the causes of the disorder, especially as he describes it, their psychological and emotional pressures. In the 2004 Medscape interview, he elaborated on this, saying "About 20% of the people who come to see me, who come into my program, cannot apparently get better until they've spent some time working with one of my psychologists. Psychotherapy is needed for about 20% of the patients."[8]

To exclude serious physical conditions, such as fractures, tumors, or infections that require conventional care, Sarno advises patients to first have a thorough physical examination by a qualified physician. He also considers that such examinations can help to identify symptoms typical of TMS, such as certain tender points that become painful when pressed. The remaining steps include firstly "Repudiate the physical and acknowledge the psychological aspect" which includes moving around and resuming normal activity as much as you can bear, without worrying about "re-injury". With TMS the only thing wrong with your back is that it hurts. Secondly "Drive the concept to your unconscious" by repeatedly focusing on exactly what your unconscious mind is attempting to repress - the sources of your anger. Dr. David Schechter, one of Sarno's former medical students and research assistants, has developed a 30-day, daily journal called "The MindBody Workbook"[11] to address the relative lack of treatment advice in Dr. Sarno’s book(s). In the workbook, the reader is encouraged to record emotionally significant events and make correlations between them and their physical pain. The point is to become aware of repressed emotions, which usually involves identifying their sources. The three major sources include one's childhood, personality type (self-critical, overly responsible, often perfectionist, prone to guilt) and life's challenges. The book describes personality types that are prone to TMS, and how TMS works. Once the mind understands the trick it is playing on itself, it gives up the ruse, and the symptoms will usually disappear after daily repetition.

Sarno's protocol for treatment of TMS is used by the Harvard-Radcliffe RSI Action Group as part of their preventative education and support program for people with RSI.[12]

Back pain

Back pain is one of humanity's most frequent complaints. In the U.S., acute low back pain (also called lumbago) is the fifth most common reason for all physician visits. About nine out of ten adults experience back pain at some point in their life, and five out of ten working adults have back pain every year.[13]

The most common diagnoses of back pain, lumbar disc herniation or degenerative disc disease, have not been shown to be more prevalent among those in pain than among the general population. The mechanisms by which these conditions might cause pain are not known. [14] [15] [16][17] Much back pain (an estimated 85% of cases) has no known physiological cause, beyond the persistent muscle tension that is usually associated with it. [18][19]

According to Sarno, patients often report that back pain seems to move around, up and down the spine, or from side to side, which according to his theory implies that the pain is not caused by a physical deformity or injury.[20] In some cases, psychosocial factors, such as on-the-job stress and dysfunctional family relationships correlate much more closely with back pain than structural abnormalities revealed in x-rays and other medical imaging scans. [21] [22] [23][24] Statistically, back pain peaks at midlife and diminishes to the point of being relatively rare among the elderly.[25]

Controversy

His critics in mainstream medicine argue that neither the theory of TMS nor the effectiveness of the treatment has been proven in a properly controlled clinical trial. Sarno's TMS success stories, which, along with those of his colleagues who use this approach, are now estimated to number in the tens of thousands, could be due to either the placebo effect or the natural ebb and flow of back pain. Most people (estimated at 85 – 90%) recover from a back pain episode on their own in a matter of weeks without any mechanical intervention at all.[26] Also, because patients typically see their doctor when the pain is at its worst, pain chart scores will probably improve with time on account of the normal fluctuation cycle of pain. Sarno's supporters counter that his approach works almost as well with chronic patients (those who have been in pain for three to six months or more) as it does with acute patients, making it less likely that the improvement is due to the normal, cyclical nature of back pain.[27] Also, the effects seem to be permanent, reducing the likelihood of a placebo effect, which is usually more temporary,[28][29] or the normal fluctuation cycle of chronic pain. Conducting proper scientific tests of Sarno's approach presents many challenges, not the least of which is financing the study.

Notes

  1. ^ Greenberg, Jerome (2000-02-01). "Back Pain: An Unconventional Approach". Proceedings of UCLA Healthcare. UCLA Department of Medicine. Retrieved 2007-09-12.
  2. ^ McGrath, Mike (2004-11-03). "When Back Pain Starts in Your Head: Is repressed anger is causing your back pain?". Prevention.com. Rodale Inc. Retrieved 2007-09-12.
  3. ^ Healing Back Pain: The Mind-Body Connection, By John E Sarno, M.D, Warner Books, 2001, ISBN 0759592225
  4. ^ The Divided Mind: The Epidemic of Mindbody Disorders, By John E. Sarno and contributor Ira Rashbaum, HarperCollins, 2007, ISBN 0061174300
  5. ^ The Mindbody Prescription: Healing the Body, Healing the Pain, Grand Central Publishing, 1999, ISBN 0446675156
  6. ^ a b "An Expert Interview With Dr. John Sarno, Part I: Back Pain Is a State of Mind", by Pippa Wysong, Medscape Orthopaedics & Sports Medicine, 06/07/2004
  7. ^ Interview by John Stossel, ABC 20/20 segment, 1999
  8. ^ a b c "An Expert Interview With Dr. John Sarno, Part II: Back Pain Is a State of Mind", by Pippa Wysong, Medscape Orthopaedics & Sports Medicine, 06/07/2004
  9. ^ Stanley J. Coen, M.D. and John E. Sarno, M.D., Psychosomatic avoidance of conflict in back pain. Journal of the American Academy of Psychoanalysis. 1989 Fall; 17(3):359–76.
  10. ^ Schechter D, Smith AP. (2005). "Back pain as a distraction pain syndrome (DPS): A window to a whole new dynamic in integrative medicine". Evidence Based Integrative Medicine. 2 (1): 3–8.
  11. ^ Schechter D. The MindBody Workbook. Los Angeles: MindBody Medicine Publications, 1999, ISBN 1929997051.
  12. ^ Harvard-Radcliffe RSI Action Group: handout document, and website
  13. ^ A.T. Patel, A.A. Ogle. "Diagnosis and Management of Acute Low Back Pain". American Academy of Family Physicians. Retrieved March 12, 2007.
  14. ^ Borenstein DG, O'Mara JW Jr, Boden SD, et al. The value of magnetic resonance imaging of the lumbar spine to predict low-back pain in asymptomatic subjects: a seven-year follow-up study. The Journal of Bone and Joint Surgery. American Volume. 2001; 83–A(9):1306–11.
  15. ^ Savage RA, Whitehouse GH, Roberts N. The relationship between the magnetic resonance imaging appearance of the lumbar spine and low back pain, age and occupation in males. European Spine Journal. 1997; 6(2):106–14.
  16. ^ "Conclusions: On MRI examination of the lumbar spine, many people without back pain have disk bulges or protrusions but not extrusions. Given the high prevalence of these findings and of back pain, the discovery by MRI of bulges or protrusions in people with low back pain may frequently be coincidental." Jensen MC, Brant-Zawadzki MN, Obuchowski N, Modic MT, Malkasian D, Ross JS. Magnetic resonance imaging of the lumbar spine in people without back pain. New England Journal of Medicine. 1994; 331(2):69–73.
  17. ^ 6. Kleinstuck F, Dvorak J, Mannion AF. Are "structural abnormalities" on magnetic resonance imaging a contraindication to the successful conservative treatment of chronic nonspecific low back pain? Spine. 2006 Sep 1;31(19):2250-7.
  18. ^ White AA 3rd, Gordon SL. Synopsis: workshop on idiopathic low-back pain. Spine. 1982; 7(2):141–9.
  19. ^ van den Bosch MA, Hollingworth W, Kinmonth AL, Dixon AK. Evidence against the use of lumbar spine radiography for low back pain. Clinical Radiology. 2004 Jan; 59(1):69-76.
  20. ^ Sarno JE. The Mindbody Prescription: Healing the Body, Healing the Pain. New York: Warner Books, 2000:86-89.
  21. ^ Burton AK, Tillotson KM, Main CJ, Hollis S. Psychosocial predictors of outcome in acute and subacute low back trouble. Spine. 1995; 20:722–8.
  22. ^ Carragee EJ, Alamin TF, Miller JL, Carragee JM. Discographic, MRI and psychosocial determinants of low back pain disability and remission: a prospective study in subjects with benign persistent back pain. The Spine Journal. 2005; 5:24–35.
  23. ^ Hurwitz EL, Morgenstern H, Yu F. Cross-sectional and longitudinal associations of low-back pain and related disability with psychological distress among patients enrolled in the UCLA Low-Back Pain Study. Journal of Clinical Epidemiology. 2003; 56:463–71.
  24. ^ Dionne CE. Psychological distress confirmed as predictor of long-term back-related functional limitations in primary care settings. Journal of Clinical Epidemiology. 2005 Jul; 58(7):714–8.
  25. ^ Kopec JA, Sayre EC, Esdaile JM. 2004. Predictors of back pain in a general population cohort. Spine. 2004 Jan 1; 29(1):70-7; discussion 77-8.
  26. ^ Pengel LH, Herbert RD, Maher CG, Refshauge KM. Acute low back pain: systematic review of its prognosis. British Medical Journal. 2003 Aug 9; 327(7410): 323.
  27. ^ Schechter D, Smith AP (2005). "Long-Term Outcome of Back Pain Patients Treated by a Psychologically Based Program (Abstract #1112)" (PDF). Psychosomatic Medicine. 67 (1): A-101. Retrieved 2006-09-05.
  28. ^ Hansen BJ, Meyhoff HH, Nordling J, Mensink HJ, Mogensen P, Larsen EH. Placebo effects in the pharmacological treatment of uncomplicated benign prostatic hyperplasia. The ALFECH Study Group. Scandinavian Journal of Urology and Nephrology. 1996 Oct; 30(5):373-7.
  29. ^ Montgomery SA: Efficacy in long-term treatment of depression. Journal of Clinical Psychiatry 1996; 57(suppl 2): 24–30.

External links

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