Evidence based chronic pain treatment

Dr John Sarno’s Tension Myositis Syndrome (TMS)  / PsychoPhysical Disorder (PPD) approach to the diagnosis and treatment of a range of mindbody conditions  has been the subject of a number of peer reviewed studies.  Whilst undertaking my psychology degree at ANU I had the opportunity to read many of Sarno’s original research studies as well as his books (the latter being generally oriented more towards the sufferer who is trying to get well rather than the academic reader).

In recent years Sarno’s approach has been adopted by a new generation of mind-body oriented physicians and therapists. Encouragingly other authors have also published peer reviewed journal articles on his approach. Whilst there are still relatively few articles written specifically about TMS / PPD theory, there is a substantial mainstream literature exploring the connection between pain presentation and psychosocial factors.  Unfortunately many of these articles only explore cognitive based approaches to pain management. These can be very useful in managing pain levels in many circumstances.  However, the emerging mindbody literature is increasingly demonstrating that a significant subset of pain sufferers will be able to make a complete recovery if they are prepared to work with the unconscious aspects of emotion, which are not the subject of cognitive treatments.

Of the TMS / PPD studies I have reviewed personally all have indicated significant effect sizes for given treatment groups.  This, in combination together with my own clinical experience leads me to conclude that Sarno’s approach is highly effective for the subgroup of patients who can accept the mind-body aspects of their condition.

The scholarly reader, practitioner or interested layperson is referred to the following papers as a starting point:

Dr Jeff Axelbank’s excellent annotated bibliography of peer reviewed studies

Michael C. Hsu, Howard Schubiner, Mark A. Lumley, John S. Stracks, Daniel J. Clauw and David A. Williams. 2010. “Sustained Pain Reduction Through Affective Self-awareness in Fibromyalgia: A Randomized Controlled Trial”. Journal of General Internal Medicine; Oct 2010, Vol. 25 Issue 10, p1064-1070.

Hsu, Michael C., Schubiner, Howard. 2010. “Recovery from Chronic Musculoskeletal Pain with Psychodynamic Consultation and Brief Intervention: A Report of Three Illustrative Cases”. Pain Medicine; Jun 2010, Vol. 11 Issue 6, p977-980.

Gordon, Alan. 2010. “Miracles of mindbody medicine”. Healthcare Counselling & Psychotherapy Journal; Jan2010, Vol. 10 Issue 1, p13-18.

 

Alan Gordon in the article listed above comments on a retrospective analysis of treatment success using the TMS / PPD  framework:

“Sarno conducted three formal retrospective studies at the Rusk Institute in 1982, 1987, and 1999 to assess the effectiveness of TMS treatment. In all, 371 randomly selected chronic pain clients were interviewed six months to three years after treatment to determine their level of pain and functional ability. A total of 72 per cent reported being free or nearly free of pain with unrestricted activity, while 16 per cent reported some improvement, and 12 per cent little to no improvement.  One of these three studies was unique in that it included only clients with documented herniated discs. Over a third had been previously advised by physicians to undergo surgery. However, when interviewed between one and three years after TMS treatment, a remarkable 88 per cent of these clients reported being free or nearly free of pain.” (Gordon 2010: p17)

 

The following is an illustrative case study reported by Hsu and Schubiner:

” ‘Nancy’ is a 52-year-old woman who sought treatment for fibromyalgia diagnosed 14 years earlier. Her past medical history was noted for eczema as a child, and irritable bowel syndrome as a young adult while working at a stressful job. In 1980, she had a motor vehicle accident and developed neck and back pain, which had persisted to the time of her presentation. In 1993, she was diagnosed with fibromyalgia, having developed gradual onset of muscle tenderness,fatigue, temporomandibular joint disorder, insomnia, and widespread pain. She was initially treated with medications,physical therapy, and massage therapy. Consultations included two rheumatologists and a pain management clinic, without lasting benefit. Three years prior to presentation,she was diagnosed with a cerebral hemangioblastoma that required surgery. Her pain persisted following the surgery, and she was prescribed Paxil (GlaxoSmithKline, London, England, UK) for persistent anxiety.

Nancy stated that she was in pain most of her adult life. As a homemaker, she had great difficulty doing housework or gardening and would have to lie down and rest in the afternoon. She could not participate in recreational activities with her family, including sitting at the movies.

Her social history was pertinent for being raised by a kind, loving father, and an uninvolved, nonsupportive mother. She became a legal assistant, married, then had two children. At the time of the development of her fibromyalgia and other symptoms, she was raising her children while building a new home. She was determined to be a“perfect” mother and wife, and endorsed being very stressed during this time. When asked what her mother was doing at the time, she started to cry, explaining that her mother was doing what she always did, i.e., taking care of herself and not meeting the needs of her daughter and now also her grandchildren. Nancy endorsed having very high expectations for herself and feeling overly responsible for things not in her control.

On examination, she met the criteria for fibromyalgia with many tender points. The rest of the exam was normal. Her average pain was a “6” out of 10 at the beginning of the MBM program; afterwards, it had decreased to a “1” and remained at that level by her 6-month follow-up appointment.She had no further interventions and was able to discontinue her Paxil. Nancy now reports that she is able to enjoy aquatic exercise and Hatha Yoga workouts, gardening, keeping up with her children and attending events with her family. She currently considers herself to be“cured”, with only an occasional stiff neck that she can easily dismiss. ” (Hsu and Schubiner, 2010: p978-9)

Nancy’s (not her real name) case is illustrative because it indicates the power of the mindbody connection to cause and cure severe pain (and anxiety) in certain people.

 

Sarno’s primary research was published in a number of papers including:

Sarno, John. 1981. “Etiology of Neck and Back Pain: An Autonomic Myoneuralgia?”.  Journal of Nervous and Mental Disease Vol 169 No 1  p55-59.

Sarno, John. 1977. “Psychosomatic back ache”. Journal of Family Practice Vol 5: p353-357.

Sarno, John. 1976. “Chronic back pain and psychic conflict”. Scandinavian Journal of Rehabilitation Medicine Vol 8: p143-153.

 

Sarnos monographs are also recommended, particularly his later works “The MindBody Prescription” and “The Divided Mind”:

Sarno J. The mindbody prescription: Healing the body, healing the pain. New York: Warner Books; 1998.

Sarno J. The divided mind: The epidemic of mindbody disorders. New York: Harper Collins Publishers Inc; 2006.

“The MindBody Prescription” also contains a section for the academic reader with further explication of Sarno’s position on the psychodynamics of pain syndromes.

 

Some other peer reviewed journal articles which lend support to the notion that mindbody factors are important in chronic pain treatment:

 

Schweinhardt, P et al. 2012. ‘Fibromyalgia as a disorder related to distress and its therapeutic implications’Pain Research and Treatment, vol. 2012

Häuser WSchmutzer GBrähler EGlaesmer H. 2009.  “A cluster within the continuum of biopsychosocial distress can be labeled “fibromyalgia syndrome”–evidence from a representative German population survey.” J Rheumatol. 2009 Dec;36(12):2806-12

Robert Kerns, Benson Hoffman. 2007. “Meta-analysis of psychological interventions for chronic back pain”.  Health Psychology, Vol. 26 (1),1-9.

Rashbaum Ira, Sarno John. 2003. “Psychosomatic Concepts in Chronic Pain”.  Archives of Physical Medicine and Rehabilitation.  Volume 84, Supplement 1 Pages S76-S80.

David Schechter, AP Smith, J Beck, J Roach, R Karim, S Azen. 2007. “Outcomes of a Mind-Body Treatment Program for Chronic Back Pain with No Distinct Structural Pathology-A Case Series of Patients Diagnosed and Treated as Tension Myositis Syndrome “. Alternative Therapies in Health and Medicine. 2007. Vol. 13 (5): 26–35

Burns JW, Quartana PJ, Bruehl S. 2008. “Anger inhibition and pain: conceptualizations, evidence and new directions.” J Behav Med. 2008 Jun;31(3):259-79

Burns JW, Quartana P, Gilliam W, Gray E, Matsuura J, Nappi C, Wolfe B, Lofland K. 2008. “Effects of anger suppression on pain severity and pain behaviors among chronic pain patients: evaluation of an ironic process model.” Health Psychol. 2008 Sep;27(5):645-52.

Berry DS, Pennebaker JW. 1993. “Nonverbal and verbal emotional expression and health.”. Psychother Psychosom. 1993;59(1):11-9.

 

 

The reader is also referred to the evidence summary and substantial bibliographies contained in the “Medical evidence” section of the TMS Wiki website.

 

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