|Back Pain: An Unconventional Approach|
Back Pain: An Unconventional Approach
Jerome Greenberg, M.D.
A fifty-year-old woman presented with recurrent low back pain for the past two years, without any precipitating event. She had tried pain medication, physical therapy and a back brace without much help. She also had neck pain in the past, but not at present. On exam, there was pain on palpation in the lower lumbar paravertebral area, the buttocks and the upper trapezius muscles. Her neurologic exam was normal. Plain films showed some facet degenerative changes at L4-5. On questioning, she felt that stress may have played a role in her pain. Upon further discussion, she became tearful and related that she had been unhappy about being apart from her children and admitted to feeling angry that she had to move to Los Angeles several years ago from abroad, on account of her husband's job relocation.
Anger. At times, we all feel it and often we do our best not to show it. Many of us suppress it, until it comes out in some way —pain. Yes, we may relate the pain to some exercise we did or the way we slept or perhaps a little stress. Sometimes the pain goes away but sometimes it lingers. In some, the feeling of anger hovers just below the surface; in others it can be buried deeply, hidden under many layers. Take a moment to think about any suppressed anger in your own life—in relationships, work or past hurts.
Emotions have long been felt to be a contributing factor to pain syndromes, particularly with respect to depression and anxiety. Anger, too, has been examined in its relationship to pain. Some believe that anger in chronic pain patients has been due to a reaction to recalcitrant symptoms that have been unsubstantiated by objective medical findings or unrelieved by medical treatments.1 Denial of anger is also felt to be common among chronic pain patients, perhaps as a means of coping or because of the need to conform to social norms.2
Dr. John Sarno, a physiatrist affiliated with NYU Medical Center, in his book "Healing Back Pain: The Mind-Body Connection", describes his successful treatment of numerous patients with back pain by making patients aware of the connection between subconscious emotions and their pain. Anger, in his experience, may be more fundamental to the development of symptoms than any other emotion. Anger may come in many forms. As an example, it may stem "from our responsibility to those who are close to us like parents, spouses and children. Though we love them, they may burden us in many ways and the resultant anger is internalized. The combination of real concern and love for the family member and inner resentment of the deeds and responsibilities associated with the relationship are a source of deep conflict."3
Dr. Sarno has coined the term Tension Myositis Syndrome (TMS) which he believes is the major cause not only of lower back pain but pains involving many other areas, such as the neck and shoulder muscles. The concept deals with emotions such as anger, triggering regional pain via oxygen deprivation, causing both muscle and nerve pain. Though trained in physical medicine, Dr. Sarno came to view conventional treatment of most back pain as inappropriate. The belief that back pain is "physical" as opposed to "emotional" is what often perpetuates the patient's pain.
By prescribing physical therapy or performing trigger point injections, I believe we often provide little more than temporary help. These modalities—along with admonishing patients to be careful how they lift things or not to run again if they've had back pain—often merely push aside the real underlying source of pain: anger.
Of course, as primary care physicians, we should first exclude organic causes of back pain and I believe there is some role for physical therapy in a subset of patients. However, if one thinks about the many patients in one's practice where such organic causes have been excluded, one is left with numerous back pain patients (and patients with other regional pains syndromes) with no clear etiology. If one takes the time to probe for emotional factors, especially anger, one will be surprised how many of our patients can be helped in "unconventional" ways.
I used to ask patients with such pain syndromes if they felt they had a lot of stress in their lives. Yet, I came to realize this was too general a question.
Many patients would reply "my stress level has always been high" or that it's "not any more than usual." Interrogating further about hidden anger can often be of great value. Patients with suppressed anger are not often identified as easily as those who present with depression or anxiety. It must also be noted that those who harbor anger deep down do not necessarily come across as angry people, especially if their brain is diverting their anger to parts of their body. Eliciting such suppressed emotions can not only be cathartic but also diagnostic.
In the case of the fifty-year-old woman, after it was explained that there was nothing suggesting an organic cause for her back pain and that emotional factors were likely triggering her (real) pain, she was advised to read Dr. Sarno's book. A month later and without any other intervention, she reported that her pain had markedly diminished, and she felt she had control over her pain.
While this approach, in my experience, does not work for all patients, I have found it to be very useful. Once patients make themselves aware of a likely connection between anger and their pain, this understanding alone is often therapeutic. And of course, this approach need not be restricted to patients with musculoskeletal pains. It can be utilized to "treat" other pains without organic causes.