There are a vari­ety of the­o­ries about the causes of stress related back pain. Impor­tantly, the over­rid­ing tenet in all of these the­o­ries is that psy­cho­log­i­cal and emo­tional fac­tors cause some type of phys­i­cal change result­ing in the back pain.

In most the­o­ries of stress related back pain, the pain cycle con­tin­ues and is exac­er­bated as the pain leads to the patient becom­ing timid and anx­ious about daily activ­i­ties. The pain cycle is char­ac­ter­ized by:

• The patient becomes unnec­es­sar­ily lim­ited in many func­tions of daily life, as well as leisure activities
• This decrease in activ­i­ties is due to the patient’s fear of the pain and injury
• This fear may be made worse by admo­ni­tions from doc­tors (and/or fam­ily and friends) to “take it easy” due to some struc­tural diag­no­sis (which may actu­ally have noth­ing to do with the back pain)
• The lim­i­ta­tions in move­ment and activ­ity lead to phys­i­cal de-conditioning and mus­cle weak­en­ing, which in turn leads to more back pain

Of course, this cycle results in more pain, more fear, and more phys­i­cal de-conditioning along with other reac­tions such as social iso­la­tion, depres­sion and anxiety.

Doc­tor Sarno’s theory

In Dr. Sarno’s for­mu­la­tion of TMS, the back pain is not attrib­uted to mechan­i­cal or phys­i­cal fac­tors, but rather due to the patient’s feel­ings, per­son­al­ity, and uncon­scious issues. Key emo­tions include uncon­scious anger and rage. In addi­tion he describes peo­ple who are likely to get TMS as being sim­i­lar to the type A per­son­al­ity, with char­ac­ter­is­tics such as:

• Hav­ing a strong inner drive to succeed
• Hav­ing a great sense of responsibility
• Being self-motivated and disciplined
• Being their own sever­est critics
• Being per­fec­tion­is­tic and compulsive

Dr. Sarno’s the­ory is that these per­son­al­ity char­ac­ter­is­tics inter­act with stress­ful life sit­u­a­tions to cause the back pain. He points out that the source of psy­cho­log­i­cal and emo­tional ten­sion is not always obvious.

Dr. Sarno’s the­ory of TMS describes a mech­a­nism whereby emo­tional ten­sion is pushed out of aware­ness by the mind into the uncon­scious. This uncon­scious ten­sion causes changes in the body’s ner­vous sys­tem. These changes include con­stric­tion in blood ves­sels and reduc­tion of blood flow to the var­i­ous soft tis­sues, includ­ing mus­cles, ten­dons, lig­a­ments, and nerves in the back. This causes a decrease in oxy­gen to the area as well as a buildup of bio­chem­i­cal waste prod­ucts in the mus­cles. In turn, this results in mus­cle ten­sion, spasm and back pain expe­ri­enced by the patient.

The diag­no­sis of stress-related back pain is often made by a thor­ough med­ical his­tory and phys­i­cal exam. Patients must be cau­tious in try­ing to self-diagnose stress related back pain, as there may be a seri­ous med­ical con­di­tion (such as a tumor or infec­tion) caus­ing the pain. A good med­ical exam­i­na­tion can usu­ally rule out the more seri­ous struc­tural causes of back pain in a great major­ity of patients.

For cases of stress-related back pain, the his­tory of onset of back pain is often quite vari­able. The pain may start with an iden­ti­fi­able inci­dent, or it may start insid­i­ously. For instance, it is not uncom­mon for the pain to start with an inci­dent such as a lower back sprain or strain, only to have it con­tinue as the result of emo­tional fac­tors long after the injury has healed.

In many cases there may be MRI find­ings such as a “disc bulge” or “degen­er­a­tive disc dis­ease” when stress-related back pain is the actual cul­prit. In these instances, the MRI find­ings are not clin­i­cally sig­nif­i­cant and ulti­mately deter­mined not to be the cause of the pain.

The over­all char­ac­ter­is­tics of stress-related back pain include symp­toms such as:

• Back pain and/or neck pain
• Dif­fuse mus­cle aches
• Mus­cle ten­der points
• Sleep dis­tur­bance and fatigue
• In many stress-related back pain cases, patients com­plain of the pain “mov­ing around”

In gen­eral, symp­toms of stress related back pain are sim­i­lar to those of fibromyalgia.

Accord­ing to Dr. Sarno, the diag­no­sis of TMS is made not only by rul­ing out other organic causes for the pain but also by pos­i­tively iden­ti­fy­ing the fea­tures of TMS.

Just as there are a vari­ety of the­o­ries about how stress and other emo­tional or psy­cho­log­i­cal fac­tors can cause back pain, there are a vari­ety of treat­ment approaches. The fol­low­ing out­lines two approaches:

Dr. Sarno’s approach to treat­ment of chronic pain

Dr. Sarno’s approach to patients with stress related back pain or TMS, is one of empha­siz­ing the psy­cho­log­i­cal and emo­tional fac­tors as causative and reas­sur­ing the patient as to t he impor­tance of a return to full phys­i­cal functioning.

Dr. Sarno’s approach focuses almost entirely on the repressed emo­tions of anger or rage as the causative fac­tors for the back pain. Once the diag­no­sis of TMS is made it is strongly rec­om­mended to the patient to “think psy­cho­log­i­cal, not phys­i­cal” when the pain occurs. In addi­tion, this treat­ment approach is gen­er­ally lim­ited to accept­ing the stress related back pain for what it is (through a series of edu­ca­tional lec­tures) and/or get­ting psy­chother­apy to address the uncon­scious issues.

This the­ory and approach is very dif­fer­ent than the way most physi­cians man­age patients with these back symptoms.

Multi-disciplinary treat­ment of stress related back pain

The multi-disciplinary (or inte­grated) approach defines and treats stress related back pain in some­what broader terms than Dr. Sarno’s con­cept of TMS. With the multi-disciplinary approach, the health care pro­fes­sion­als do not always see the well-defined per­son­al­ity char­ac­ter­is­tics that Dr. Sarno dis­cusses and do not focus on uncon­scious anger as the focal psy­cho­log­i­cal issue.

The multi-disciplinary approach to treat­ing stress related back pain includes eval­u­a­tion of phys­i­cal, emo­tional, cog­ni­tive and envi­ron­men­tal fac­tors in all types of back pain prob­lems and devel­ops treat­ments for each aspect. Thus, the multi-disciplinary for­mu­la­tion will look at the rel­a­tive con­tri­bu­tion of the fol­low­ing factors:

• Physical—including de-conditioned and weak mus­cles, nerve irri­ta­tion, etc.
• Emotional—including depres­sion, anx­i­ety, anger, etc.
• Cognitive—such as neg­a­tive thoughts, pes­simism, hope­less­ness, etc.
• Environmental—such as loss of job, finan­cial prob­lems, etc

This approach then devel­ops a treat­ment pro­gram based upon how much each fac­tor is thought to be influ­enc­ing the pain. A multi-disciplinary pro­gram may include such treat­ments as:

• Treat­ing the phys­i­cal fac­tors through re-activation ori­ented phys­i­cal ther­apy and/or pain medications
• Treat­ing the phys­i­cal and emo­tional fac­tors through appro­pri­ate med­ica­tions (often includ­ing anti-depressants or mus­cle relaxants)
• Treat­ing the emo­tional and cog­ni­tive fac­tors through psy­cho­log­i­cal pain man­age­ment tech­niques and biofeedback
• Treat­ing the envi­ron­men­tal fac­tors through coun­sel­ing or therapy

The idea of mul­ti­dis­ci­pli­nary treat­ment of back pain has been around for at least 25 years. It has been shown to be quite suc­cess­ful; although, the key fac­tor in treat­ment out­come is the moti­va­tion of the patient to com­plete a reha­bil­i­ta­tion approach.