Healing Back Pain

I've put off writing this post for many years because I know it will be controversial.  But we're a few days from Christmas, and I also know this post will be a wonderful gift for some people.

Chronic or intermittent pain, often located in the back, neck, and/or buttocks, is a major driver of personal suffering and reduced productivity in the US and other affluent nations.  While pain can obviously have a variety of structural causes, such as sprained ankles or bruising, garden-variety back pain usually doesn't.  I've come to believe that such pain is usually psychosomatic in nature-- in other words, caused by the brain but resulting in physical signs and symptoms in the body.  It's widely accepted that a person's mental state can affect pain perception, but this idea goes further.  Pain isn't just exacerbated by a person's mental state; it's often entirely caused by it.


Conventional medicine is not very effective at treating this kind of pain, which is often attributed to spinal features like slipped or herniated disks that are supposedly irritating or compressing spinal nerves.  Yet these spinal features are common in people without pain, are inconsistently associated with pain (1), and surgery to correct them is often no more effective than "placebo surgery" in which an incision is made but the features aren't corrected (2).  Injection of powerful anti-inflammatory drugs into the area of the spine that is supposedly causing pain is also no more effective than injecting saline (3).  Nearly everyone shows some degree of disc degeneration by the age of 20-- it's evidently normal.  Furthermore, a neurologist will tell you that the signs and symptoms of garden-variety back pain are usually difficult to reconcile with a diagnosis of spinal nerve compression.

In other words, there is not much evidence that garden-variety pain in the back, neck, and buttocks is related to structural features of the body, or that typical treatments offer anything better than a placebo effect.  The idea that our pain is caused by structural features is an assumption we make because it seems logical (i.e., we feel pain when we injure ourselves, therefore back pain must be due to some sort of injury).  This assumption is not supported by the evidence.

The idea that pain often has a psychosomatic origin was pioneered by John E. Sarno, MD, professor of rehabilitation medicine at New York University School of Medicine and attending physician at the Howard A. Rusk Institute of Rehabilitation Medicine at the NYU Medical Center (retired).  He has coined a name for this extremely common psychosomatic pain syndrome: tension myoneural syndrome (TMS).  Over the years, he has successfully treated thousands of patients for TMS by 1) ruling out structural causes for their pain, 2) giving them the right diagnosis, and 3) addressing the psychosomatic problem directly.  The fastest and most effective treatment is simply to become aware of the nature of the problem, after which it tends to resolve quickly.

Here's the idea in a nutshell.  In our everyday lives, we generate negative emotions like anger, irritation, and anxiety.  That can result from little things like being annoyed about having to do the dishes, listening to a boring speech by your boss, disagreeing with a spouse, and in some cases more serious things like memories of abuse.  Most of us try to express our negative emotions in constructive ways rather than throwing things and punching people, so we find other ways to cope with them.  We fidget with our fingers, we tap our feet, distract ourselves with music, go jogging or lift weights, bite our nails, and some people do more serious self-harm like self-cutting.

In some people, one of the ways the brain copes with negative emotions is by substituting physical pain.  This is a completely non-conscious process, meaning that people aren't usually aware that the brain is substituting physical pain for emotional pain, and they are also not aware of the emotion that has been replaced.  It doesn't require deep, dark emotions-- for many people, the tension generated by ordinary everyday stressors is enough.

Here is my personal story.  I've had mild-to-moderate chronic pain for as long as I can remember-- even as a child.  In middle school, the postural muscles in my back and neck would become tired and painful when I sat in a chair for too long, so I'd study laying down on my bed.  I had periodic muscle spasms affecting my neck and upper back (attributed to "pinched nerve" or torticollis), which were not only painful but would produce an asymmetrical head and neck posture that I had to live with for days.

In high school, the chronic pain in my back and neck was rarely severe, usually just a dull, annoying, distracting presence.  I was pretty hard on my body with wrestling, cross country, track, and frequent strength training, so I attributed my pain to that.  College was about the same.

In graduate school, the chronic pain became more severe and began to spread to other locations, such as my jaw (diagnosed as temporomandibular joint syndrome) and my buttocks and hips (diagnosed as sciatica).  I was baffled that a healthy, athletic young man could have so many physical problems.

Here's a list of all the chronic pain locations I've cataloged in myself over the years.  These are all typical of TMS, which tends to affect postural muscles in the back and neck, the trapezius muscles, the outer aspect of the buttocks, almost any tendon (commonly knee, hip, foot, shoulder, elbow, wrist, hand (e.g., carpal tunnel syndrome)), and certain nerves like the sciatic nerve and the brachial plexus.  I'll start from the top and work my way down:

• Jaw (temporomandibular joint syndrome)
• Sides and back of neck
• Trapezius
• Upper, middle, and lower back, near the spine
• Outer aspect of buttocks
• Sciatic nerve (sciatica)
• Anterior hip
• Knees
• Arch of foot (plantar fasciitis)
• Ball of foot (Morton's neuroma)

While still in graduate school, I looked everywhere for solutions.  I did yoga for two years, which helped a little bit but didn't solve the problem.

I saw a sports medicine doctor at the University of Washington, who ordered X-rays and pronounced my back to be in excellent shape.  He actually came very close to putting his finger on the problem.  He clearly saw a lot of patients like me, because he had a diagnostic routine that immediately identified weakness and tension in my hip abductors.  He said it was due to psychological stress, and recommended an abductor stretching routine and meditation.  The stretching helped, but not the meditation, because I was already doing it every day!  Yet although the stretching routine helped my abductors, the pain just recurred somewhere else.

I was ready to try almost anything, even therapies of which I was skeptical.  I saw a chiropractor for months, which helped a little bit but didn't solve the problem.  I saw an acupuncturist for months, which was pleasant but didn't affect the pain.

Finally, while looking for new ideas, I stumbled across John Sarno's book, Healing Back Pain.  I saw that he was an MD in rehabilitation medicine, but his ideas seemed pretty far out.  I read Amazon.com reviews for his book, which basically consist of 1,200 people going on and on about how it cured their long-standing pain, turned their lives around, etc.  I had never read anything quite like those reviews.  I saw that I could buy a used copy of his book for $2.  Why not?

I read his book, and immediately recognized myself in the pages.  His description of the primary pain locations and characteristics were specific yet matched mine precisely.  A month later, the inexplicable pain that had troubled me for as long as I could remember-- the pain that I had tried everything to get rid of-- was 80 percent gone.  It's been nearly a decade since I first read Healing Back Pain, and the pain is now closer to 90 percent gone, with occasional flare-ups.  I have repeatedly and successfully treated flare-ups by applying his methods*.

I've bought more than ten copies of Healing Back Pain over the years, and whenever one of my friends develops chronic pain that could be TMS, I give them a copy.  In almost all cases, they experience a rapid resolution of symptoms.  Usually, they keep the book.  If you have chronic pain and you're on the fence, just read it.  It's so cheap and short that you have nothing to lose.

Scientific evidence supporting the approach is mostly limited to a large number of patient follow-ups that Sarno and his colleagues have conducted, most of which is published in his book, and some of which is published in peer-reviewed journals.  Although his methods aren't particularly rigorous, the results do suggest that his approach is extremely effective.  A 2007 study by Sarno's colleagues found that the approach is effective for long-standing (greater than 6 months) chronic back pain, particularly pain that has been present for more than 3 years.  The results suggest that this treatment is substantially more effective than typical medical therapies.  The reason they focused on long-standing pain is to anticipate the critique that the effect is simply due to the spontaneous resolution of symptoms that often occurs in pain syndromes (or regression to the mean).

I acknowledge that the scientific evidence supporting the approach, and particularly the mechanism, is not strong.  It has received very little interest from the medical and research communities, so there's hardly any research at this point.  I think this presents an excellent opportunity for the biomedical research community to explore a hypothesis that may have the potential to help a lot of people.

If you've read Healing Back Pain, please share your experience (whether positive or negative) in the comments.

* Usually, this involves some new location for the pain, such as knee pain, which I initially assume is due to a repetitive stress injury like tendonitis.  I give myself some rest.  When the pain doesn't subside and persists for longer than it should have taken the injury to heal, I start to think it's TMS.  Then, I'll go back to Sarno's book and see that the location is one of those that can be affected by TMS.  The pain usually disappears within minutes, and I immediately resume vigorous exercise without further pain.