Gerry Gajadharsingh writes:
I remember reading Dr John Sano’s, excellent book “Healing Back Pain” over 30 years ago, which at the time, really challenged my paradigm in regard to the diagnosis of musculoskeletal (MSK) pain, especially back pain and therefore it’s treatment. As a specialist in rehabilitation in New York, Sarno’s conclusions, after many years in clinical practice, was that most of his chronic pain patients did not have evidence of acute injury or defined pathology to account for their chronic back pain. His conclusion was that the patient’s pain was a reaction to suppress stress and emotional turmoil, and therefore resolving that psychological conflict would lead to an improvement in pain.
At the time, this view was immensely controversial, and not generally accepted by patients, nor many clinicians. Of course, clinicians in functional medical practices of which my professional Osteopathy is probably one of the oldest in the world, would point out that there are often are a variety of functional factors as opposed to obvious pathological factors, driving the pain. In many cases, this is true, however in my subsequent years of practice, it has become quite evident to me that psychology plays an important part and for some patients, the major part for their ongoing pain. The challenge sometimes is convincing the patient that this is the case.
The language that clinicians use is often important, terms such as “it’s all in your mind” and “it’s a stress related condition” simply doesn’t wash with patients. It’s almost as if they are making it up, and therefore their symptoms are not worthy of proper attention. All this is going to do is to entrench the vicious circle and continue their ongoing pain (although it doesn’t mean that the cause of the pain is not mediated via the mind and stress processes).
These are themes continued by other authors, such as Dr Suzanne, O’Sullivan, who is a consultant neurologist in the UK, and her excellent book was called “It’s all in your head”. Note, she uses the term head not mind. She suggests that at least a third of patients presenting to GPs are thought to have so-called medically unexplained symptoms. In most of these cases an emotional root is suspected, however, this is the last thing that patients want to hear and it’s the last thing that doctors want to say. I remember looking at the Google reviews for her book to find that they were either all 5 stars or all 1 star, it was really a polarising book. Many clinicians may well have read Oliver Sacks, another eminent neurologist from the UK but working in the USA, who wrote “The man who mistook his wife for a hat”, again, at the time a ground-breaking book, looking at the causes of patients presenting with neurological conditions, and realising there is much more going on than just pathology!
Much of my caseload is with complex patients, many of them with complex pain syndromes. I think what has been very helpful in managing these patients is a very detailed case history, my patients often comment that no one previously has ever asked in such detail, regarding their symptoms, history, past medical history, medications, dosages of medications, when are they taking them, supplements, diet, stress management, strategies, family, history, work and family dynamics et cetera. I think case history taking is an art and it is not easy to learn. As an undergraduate it’s very formulaic and I understand why that needs to be. However, as a postgraduate clinician and one’s experience expands, everything the patient has to say is relevant. When I was an undergraduate a lot of the patient had to say was put down to so-called “red herrings”, i.e., much what they said had minimal or no impact on their symptoms, “keep the patients on track” I’ve come to learn that this is a very naïve way of looking at things. Even in the modern-day NHS, the approach is to keep the patient just concentrating on one symptom at each patient appointment!
I think everything the patient has to say it’s relevant. The job of an experienced clinician is to gently explore, with the patient going down different pathways through the history, and some of the things that you can discover can often become a “lightbulb moment” for the patient when they come to realise that this may well have been contributory toward the ongoing symptoms especially in relation to chronology, which I believe, is vitally important. The why and how a patient has developed their problem is as important as to what the problem actually is. As the why and how will often will lead to better patient management and compliance of whatever treatment and management strategy that you have to offer the patient.
The second part Is a very detailed clinical examination, although the history may be suggestive of numerous psychosocial factors, clinicians have a duty to physically examine a patient, which can cover various systems of the body, obviously MSK, which is what we’re talking about today, often screening of other systems such as cardiovascular, respiratory neurological etc. Sometimes important findings are found but sometimes it’s reassuring to the patient to know you have taken them seriously even though your clinical findings on physical examination may well be normal.
Secondary investigations such as imaging blood tests et cetera can be useful, but I believe this needs to be done carefully as there are many patients out there who have seen numerous clinicians had numerous imaging, blood tests et cetera, all to be told there is still “nothing wrong”. Patients find this incredulous, that despite normal medical investigations their still hasn’t been a cause of their pain which has been found.
Sometimes this is to do with the interpretation of whatever investigations have been done, and I have a passion for the functional interpretation of blood tests as opposed to the standard medical interpretation (which of course is still important to do to rule out obvious medical problems). Functional interpretation of blood test is still in its infancy but more and more clinicians and the research community are starting to look at blood test reference ranges and realising that there are problems that can be clinically relevant to patients at the lower end or higher end of the standard medical reference ranges.
http://www.thehealthequation.co.uk/lung-cancer-risk-rises-with-increasing-blood-glucose/
http://www.thehealthequation.co.uk/want-a-longer-and-healthier-life-keep-drinking-the-water/
The big one of course Is psychology, both conscious and subconscious patterns, and how stress affects our physiology. Because patients hate being told that stress has a part to play in the problem, what I will do is to examine their breathing bahaviour via capnometry and measure their autonomic nervous system response (90% of brain and nervous system control). It is very common for patients to have a very switched-on stress part of the autonomic nervous system (sympathetic upregulation) and so when I talk to patients when I talk about stress, I show them that I’m measuring their physiological response to stress. So, in a way what we are doing is giving them an explanation as to how stress can affect their minds and bodies and it is much easier for patients to then accept that part of the solution may be adoption of techniques and behaviours to manage the stress and psychological components to their problems.
A very useful concept, especially with chronic pain because central nervous system sensitisation. Again, helping patients understand what this means, almost always universally helpful in managing and treating patients with chronic pain.
http://www.thehealthequation.co.uk/pain-reprocessing-therapy-helps-with-chronic-back-pain/
Medscape
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 disc 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 (TMS), or the body’s reaction to suppressed stress and emotional turmoil. Resolving that psychological conflict, Sarno believed would lead to an improvement in pain.
Sarno’s theory has met scepticism 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 TMS and how he manages patients with chronic pain.
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 (paracetamol) 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, non-invasive, 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 (spine surgery) as a last resort.