How Much Pain Is in the Mind?

More than three decades ago, John E. Sarno, MD, published Healing Back Pain, a popular book that garnered something of a cult following. Looking at his own practice, Sarno, a rehabilitation medicine specialist in New York City, saw that most of his patients with chronic pain did not have evidence of acute injury or degenerative disk disease. Their persistent pain appeared to be independent of any structural damage to the spine. Sarno attributed the pain to what he called tension myoneural syndrome (TNS), or the body’s reaction to suppressed stress and emotional turmoil. Resolving that psychological conflict, Sarno believed, would lead to an improvement in pain.

Dr Ira Rashbaum

Sarno’s theory has met skepticism from the mainstream community, but glowing testimonies from patients who say they benefitted from his strategies fill the internet. Sarno wrote several books on his ideas before his death in 2017. But he published only one peer-reviewed study, a 2003 review in the Archives of Physical Medicine and Rehabilitation co-authored by Ira Rashbaum, MD.

Medscape Medical News spoke recently with Rashbaum, a physiatrist and chief of tension myoneural syndrome at NYU Langone Health, New York City, about TNS and how he manages patients with chronic pain.

This interview has been edited for length and clarity.

Medscape:  What is your theory of back pain?

Rashbaum: My null hypothesis is that back pain is not due to psychological issues, so as to not be a biased doctor, I try to accept the null hypothesis or reject the null hypothesis. In most cases chronic back pain is not due to structural etiology. My sense is it’s a mind-body issue — the avoidance of feeling strong emotions like anger, rage, sadness, fear, shame, and guilt. Patients can embrace psycho-educational programs and if they don’t get better, we work with a psychotherapist or a or licensed mental health counselor to help work through the patient’s feelings. That’s my experience over a number of years.

Medscape:  How do you determine if a patient has back pain from a mind-body issue or another cause?

Rashbaum: I do a very careful medical history, including a physical examination and review of any diagnostic studies they’ve undergone. In most situations, there’s not really a medical cause of the back pain. For instance, a lot of asymptomatic individuals have all sorts of horrible findings on medical imaging like CTs and MRIs, and the reverse is also true — many people with negative findings on imaging tests experience significant pain. My job as a diagnostician is to see how much of this is really a mind-body problem or something that stems from structural pathology.

Medscape:  How well do your patients react to being told that their back pain is, in a way, “in their head”?

Rashbaum: I have a skewed population. I’m sort of like a guru in mind-body back pain, so the people who come to me are already thinking along those lines. I ask, “What’s going on in your life?” Maybe there are job issues, marital issues, health issues, and I’d say that it’s certainly possible that stress can be causing this back pain.

Sometimes when I see a patient referred from another physician, I’m a bit hesitant to ask about what’s going on in their life. Even earlier today, I’d seen a patient with back pain and I had a sense that they were not really going to be open to a mind-body approach. So I said, do physical therapy.

Medscape:  What do you recommend primary care clinicians do with patients with back pain?

Rashbaum: You have to do a proper neurological examination and musculoskeletal examination. It’s a tough situation because doctors in primary care have limited time to take care of patients. It’s difficult to have a deeper dive just to kind of see what’s going on in their life. But you can recommend useful agents like acetaminophen and muscle relaxants, which are sometimes okay.

Medscape:  What sorts of things do you tell patients to say to themselves when they’re experiencing pain? 

Rashbaum: If the pain is severe, I recommend they take medication — over-the-counter analgesics or a muscle relaxant, if they have them — and take a warm shower or bath. I prefer acetaminophen up to three times per day, if that’s OK with the patient’s primary care physician, over nonsteroidal anti-inflammatory drugs because most pain is non-inflammatory in nature. Once the pain is more manageable, patients should journal about what’s going on in their lives and/or meditate, and try to feel any strong emotions, such as anger, sadness, or fear.

Medscape:  What do you say to clinicians who are dismissive of the notion that chronic pain may stem from emotional repression, and that addressing the latter can resolve the former — particularly those who point to a lack of peer-reviewed data for such a link?

Rashbaum: I would tell them they could be looking harder for that evidence. For example, in a patient page from JAMA from April 24, 2013, on low back pain, often the cause of back pain is unknown. There are data in spine surgical journals that patients with psychological issues do worse with spine surgery. And in 2016 JAMA published a study from Cherkin et al which found that among adults with chronic low back pain, treatment with mindfulness-based stress reduction or cognitive behavioral therapy resulted in greater improvement in back pain and functional limitations at 26 weeks compared with usual care.

My feeling is that these psychosocial interventions are easy to try, relatively inexpensive, noninvasive, and, in my experience, often can lead to marked improvements. I believe that, for the vast majority of people with chronic pain, it makes much more sense to start by addressing mind-body issues than turning to that approach as a last resort.

Rashbaum reports no relevant financial relationships.

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