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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.

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