Healing back pain part. 1

The Manifestations of TMS.

I have never seen a patient with pain in the neck, shoulders, back
or buttocks who didnt believe that the pain was due to an injury, a
hurt brought on by some physical activity. I hurt myself while
running (playing basketball, tennis, bowling). The pain started
after I lifted my little girl or when I tried to open a stuck window.
Ten years ago I was involved in a hit-from-behind auto accident
and I have had recurrent back pain ever since.
The idea that pain means injury or damage is deeply ingrained
in the American consciousness. Of course, if the pain starts while
one is engaged in a physical activity its difficult not to attribute the
pain to the activity. (As we shall see later, that is often deceiving.)
But this pervasive concept of the vulnerability of the back, of ease
of injury, is nothing less than a medical catastrophe for the American
public, which now has an army of semidisabled men and women
whose lives are significantly restricted by the fear of doing further
damage or bringing on the dreaded pain again. One often hears,
Im afraid of hurting myself again so Im going to be very careful
of what I do.
In good faith, this idea has been fostered by the medical
profession and other healers for years. It has been assumed that
neck, shoulder, back and buttock pain is due to injury or disease of
the spine and associated structures or incompetence of muscles
and ligaments surrounding these structureswithout scientific
validation of these diagnostic concepts.
On the other hand, I have had gratifying success in the
treatment of these disorders for seventeen years based on a very
different diagnosis. It has been my observation that the majority of
these pain syndromes are the result of a condition in the muscles,
nerves, tendons and ligaments brought on by tension. And the point
has been proven by the very high rate of success achieved with a
treatment program that is simple, rapid and thorough.
Medicines preoccupation with the spine draws on fundamental
medical philosophy and training. Modern medicine has been
primarily mechanical and structural in orientation. The body is
viewed as an exceedingly complex machine and illness as a
malfunction in the machine brought about by infection, trauma,
inherited defects, degeneration and, of course, cancer. At the same
time medical science has had a love affair with the laboratory,
believing that nothing is valid unless it can be demonstrated in that
arena. No one would dispute the essential role the laboratory has
played in medical progress (witness penicillin and insulin for
example). Unfortunately, some things are difficult to study in the
laboratory. One of these is the mind and its organ, the brain. The
emotions do not lend themselves to test tube experiments and
measurement and so modern medical science has chosen to ignore
them, buttressed by the conviction that emotions have little to do
with health and illness anyway. Hence, the majority of practicing
physicians do not consider that emotions play a significant role in
causing physical disorders, though many would acknowledge that
they might aggravate a physically caused illness. In general,
physicians feel uncomfortable in dealing with a problem that is
related to the emotions. They tend to make a sharp division between
the things of the mind and the things of the body, and only feel
comfortable with the latter.

Peptic ulcer of the duodenum is a good example. Although
some physicians would dispute the idea, there is fairly wide
acceptance among practicing doctors that ulcers are caused
primarily by tension. Contrary to logic, however, the major focus
in treatment is medical, not psychological, and drugs are
prescribed to neutralize or prevent the secretion of acid. But failure
to treat the primary cause of the disorder is poor medicine; it is
symptomatic treatment, something we were warned about in
medical school. But since most physicians see their role only as
treating the body, the psychological part of the problem is neglected,
even though its the basic cause. In fairness, some physicians make
an attempt to say something about tension, but its often of a
superficial nature like, You ought to take it easy; youre working
too hard.
Pain syndromes look so physical it is particularly difficult for
doctors to consider the possibility that they might be caused by
psychological factors, and so they cling to the structural explanation.
In doing so, however, they are chiefly responsible for the pain
epidemic that now exists in this country.
If structural abnormalities dont cause pain in the neck,
shoulder, back and buttocks, what does? Studies and clinical
experience of many years suggest that these common pain
syndromes are the result of a physiologic alteration in certain
muscles, nerves, tendons and ligaments which is called the Tension
Myositis Syndrome (TMS). It is a harmless but potentially very
painful disorder that is the result of specific, common emotional
situations. It is the purpose of this book to describe TMS in detail.
The ensuing sections of this chapter will discuss who gets it, in
what parts of the body it occurs, the various patterns of pain and
the overall impact of TMS on peoples health and daily lives.
Following chapters will talk about the psychology of TMS (which
is where it all begins), its physiology and how it is treated.
Conventional diagnosis and treatment will be reviewed and I will
conclude with a chapter on the important interaction between mind
and body in matters of health and illness.

WHO GETS TMS ?

One might almost say that TMS is a cradle-to-grave disorder since
it does occur in children, though probably not until the age of five
or six. Its manifestation in children is, of course, different from
what occurs in adults. I am convinced that what are referred to as
growing pains in children are manifestations of TMS.
The cause of growing pains has never been identified but
physicians have always been comfortable in reassuring mothers
that the condition is harmless. It occurred to me one day while
listening to a young mother describe her daughters severe leg
pain in the middle of the night that what the child had experienced
was very much like an adult attack of sciatica, and since this was
clearly one of the most common manifestations of TMS, growing
pains might very well represent TMS in children.
Little wonder that no one has been able to explain the nature
of growing pains since TMS is a condition that usually leaves no
physical evidence of its presence. There is a temporary constriction
of blood vessels, bringing on the symptoms, and then all returns to
normal.
The emotional stimulus for the attack in children is no different
from that in adults anxiety. One might say that the attack in a
child is a paranightmare. It is a substitute for a nightmare, a command
decision by the mind to produce a physical reaction rather than
have the individual experience a painful emotion, which is what
happens in adults as well.
At the other end of the spectrum, I have seen the syndrome in
men and women in their eighties. There appears to be no age limit,
and why would there be? As long as one can generate emotions
one is susceptible to the disorder.

What are the ages when it is most common, and can we learn
anything from those statistics? In a follow-up survey carried out in
1982, 177 patients were interviewed as to their then current status
following treatment for TMS. (See Follow-Up Surveys for results
of the survey.) We learned that 77 percent of the patients fell
between the ages of thirty and sixty, 9 percent were in their
twenties, and there were only four teenagers (2 percent). At the
other end of the spectrum, only 7 percent were in their sixties and
4 percent in their seventies.
These statistics suggest very strongly that the cause of most
back pain is emotional, for the years between thirty and sixty are
the ages that fall into what I would call the years of responsibility.
This is the period in ones life when one is under the most strain to
succeed, to provide and excel, and it is logical that this is when one
would experience the highest incidence of TMS. Further, if
degenerative changes in the spine (osteoarthritis, disc degeneration
and herniation, facet arthrosis and spinal stenosis, for instance)
were a primary cause of back pain, these statistics wouldnt fit at
all. In that case, a gradual increase in incidence from the twenties
on would occur, with the highest incidence in the oldest people. To
be sure, this is only circumstantial evidence, but it is highly suggestive.
So the answer to the question Who gets TMS? is Anybody.
But it is certainly most common in the middle years of life, the
years of responsibility. Lets now take a look at how TMS
manifests itself.

WHERE DOES TMS MANIFEST ITSELF?

Muscle.
The primary tissue involved in TMS is muscle, hence the original
name myositis (as mentioned, myo stands for muscle). The only
muscles in the body that are susceptible to TMS are those in the
back of the neck, the entire back, and the buttocks, known
collectively as postural muscles. They are so named because they
maintain the correct posture of the head and trunk and contribute
to the effective use of the arms.
Postural muscles have a higher proportion of slow twitch
muscle fibers than limb muscles, making them more efficient for
endurance activity, which is what is required of them. Whether or
not this is the reason why TMS is restricted to this group of muscles
we do not know. It is possible, though, since the muscles most
frequently involved have the most important jobs. These are the
buttock muscles, known anatomically as gluteal muscles. Their job
is to keep the trunk upright on the legs, to prevent it from falling
forward or to either side. Statistically, the low back–buttock area
is the most common location for TMS.
Just above the buttocks are the lumbar muscles (in the small
of the back), often involved simultaneously with buttock muscles.
Occasionally the gluteal or lumbar muscles are affected separately.
Roughly two-thirds of TMS patients will have their major pain in
this area.
Second in order of frequency of involvement are the neck and
shoulder muscles. The pain is usually in the side of the neck and
the top of the shoulder, in the upper trapezius muscle.
TMS can occur anywhere else in the back, between the
shoulders and low back, but does so far less frequently than in the
two areas mentioned.
Generally a patient will complain of pain in one of these prime
areas, as, for example, in the left buttock or the right shoulder, but
the physical examination will reveal something else of great interest
and importance. In virtually every patient with TMS one finds
tenderness when pressure is applied (palpation) to muscles in three
parts of the back: the outer aspect of both buttocks (and sometimes
to the entire buttock), the muscles in the lumbar area and both
upper trapezius (shoulder) muscles. This consistent pattern is
important because it supports the hypothesis that the pain syndrome
originates in the brain rather than in some structural abnormality of
the spine or incompetence of the muscle.

Nerve.
The second type of tissue to be implicated in this syndrome is
nerve, specifically what are known as peripheral nerves. Those
most frequently affected are located, as might be expected, in close
proximity to the muscles that are involved most often.
The sciatic nerve is located deep in the buttock muscle (one
on each side); lumbar spinal nerves are under the lumbar para-
spinal muscles; the cervical spinal nerves and brachial plexus are
under the upper trapezius (shoulder) muscles. These are the nerves
most frequently affected in TMS.
In fact, TMS looks like a regional process, rather than one
aimed at specific structures. So when it affects a given area, all
the tissues suffer oxygen deprivation so that one may experience
both muscle and nerve pain.
Varying kinds of pain may result when muscle and/or nerve
are affected. It may be sharp, aching, burning, shocklike, or it may
feel like pressure. In addition to pain, nerve involvement may
produce feelings of pins and needles, tingling and/or numbness,
and sometimes sensations of weakness in the legs or arms. In
some cases there is measurable muscle weakness. The latter can
be documented with electromyographic studies (EMG). EMG
abnormalities are often cited as evidence of nerve damage due to
structural compression, but in fact EMG changes are very common
in TMS and usually reveal involvement of many more nerves than
could be explained by a structural abnormality.
Lumbar spinal and sciatic nerve symptoms are in the legs, for
that is where those nerves are going. Involvement of cervical spinal
nerves and brachial plexus cause symptoms in the arms and hands.
Traditional diagnoses attribute leg pain to a herniated disc and arm
pain to a pinched nerve. (See chapter 5.)
TMS may involve any of the nerves in the neck, shoulders,
back and buttocks, sometimes producing unusual pain patterns.
One of the most frightening is chest pain. One immediately thinks
of the heart when there is chest pain and, indeed, it is always
important to be sure that there is nothing wrong with that organ.
Once having done so, one should keep in mind that spinal nerves in
the upper back may be suffering mild oxygen deprivation because
of TMS and that this may be the source of the pain. These nerves
serve the front of the trunk as well as the back, hence the chest
pain.
Remember: Always consult a regular physician in order to
rule out serious disorders. This book is not intended as a guide to
self-diagnosis. Its purpose is to describe a clinical entity, TMS.
One may suspect the presence of nerve involvement in TMS
through the patients history, the physical examination or both. Sciatic
pain may affect any part of the leg except the upper, front thigh.
There is considerable variability depending on how much of the
nerve trunk is affected by oxygen debt. As noted above, the person
may also complain of other strange feeings and of weakness.
On physical examination the tendon reflexes and muscle
strength are tested to determine whether oxygen deprivation has
irritated the nerve sufficiently to interfere with the transmission of
motor impulses. Similarly, sensory tests are done (for example,
ability to feel a pinprick) to determine the integrity of the sensory
fibers in the involved nerve. The major virtue of documenting
sensory or motor deficits is to be able to discuss them with patients
and reassure them that feelings of weakness, numbness or tingling
are quite harmless.
The so-called straight leg–raising test is always done when a
patient is examined, though for different reasons, depending on the
examiner. If there is a great deal of soreness in the buttocks, the
patient will be unable to elevate the straightened leg very far and
then only with a great deal of pain. The pain may be due to the
muscle, the sciatic nerve or both. What the sign does not mean in
the majority of cases is that there is a herniated disc pressing on
the sciatic nerve, as patients are often told.
When there is a shoulder-arm pain syndrome, one does similar
tests on the arm and hand.
Sometimes patients have pain on two sides; this is of no
particular significance. People will also often report that in addition
to having the major pain in the right buttock and leg, for example,
they have some intermittent pain in the neck or one of the shoulders.
This is not unexpected since TMS may involve any or all of the
postural muscles.

Tendons and Ligaments.

Following the publication of my first book describing TMS, I
gradually became aware that a variety of tendonalgias (pain in
tendons or ligaments) were probably part of the syndrome of tension
myositis. The term myositis was fast becoming obsolete, it having
been determined many years before that nerves could be implicated
in TMS, as just described. Now I was beginning to realize that still
another type of tissue might be part of the process; and as time
went by this conclusion became more and more inescapable.
What first attracted attention were reports from treated patients:
In addition to the disappearance of back pain, their tendon pain
(for example, tennis elbow) often left as well. As is well known,
tennis elbow is one of the most common of the disorders called
tendonitis. Generally, it is assumed that these painful tendons are
inflamed, presumably because of excessive activity. The routine
treatment is anti-inflammatory medication and activity restriction.
Having been alerted to the possibility that these painful tendons
might be part of TMS, I began to suggest to patients that their
tendonitis might also disappear if they allowed it to occupy the
same place in their thinking as the back pain. The results were
encouraging and over time my confidence in the diagnosis
increased. I am now prepared to say that tendonalgia is often an
integral part of TMS and in some cases is its primary manifestation.
It has become apparent that the elbow is not the most common
site of tendonalgia. In my experience, the knee has that distinction.
Some of the usual diagnoses for knee pain are chondromalacia,
unstable knee cap and trauma. However, the examination discloses
that there is tenderness of one or more of the tendons and ligaments
surrounding the knee joint and the pain usually disappears along
with the back pain.
Another common place is the foot and ankle, either the top or
bottom of the foot, or the Achilles tendon. Common foot diagnoses
are neuroma, bone spur, plantar fasciitis, flat feet and trauma due
to excessive physical activity.
The shoulder is another location for TMS tendonalgia; the usual
structural diagnosis is bursitis or rotator cuff disorder. Again, there
is usually easily identified tenderness on palpation of a tendon in
the shoulder. Wrist tendons are not uncommonly involved. It is
possible that what is known as carpal tunnel syndrome may also
be part of TMS but this cannot be stated without further observation
and study.
Recently I saw a patient who had developed pain in a new
location after a minor accident. She said the pain was in her hip
and that X rays showed that there was arthritis of the hip joints,
more on the side where she was having pain, and she had been
told that this was the cause of her pain. She had proven to be
highly susceptible to TMS in the past so I suggested she come in
for an examination. The X rays showed a very modest amount of
arthritic change in the joint in question, about what would be
expected in someone of her age. She had excellent range of motion
of the joint and no pain on weight bearing or movement of the leg.
When I asked her to touch the exact spot where she felt the pain
she identified a small area where the tendon of a muscle attaches
to bone, well above the hip joint; it was tender to pressure. I told
her I thought she had TMS tendonalgia and the pain left in a few
days.
Hip tendonalgia is most commonly attributed to what is called
trochanteric bursitis. That diagnosis was not made on this occasion
because the location of pain was above the trochanter, the bony
prominence that can be felt at the upper, outer aspect of the hip.
TMS can manifest itself in a variety of locations and it tends to
move around, particularly if something is being done to combat the
disorder. Patients often report pain in a new location as the old one
gets better. It is as though the brain is unwilling to give up this
convenient strategy for diverting attention away from the realm of
the emotions. It is, therefore, particularly important for the patient
to know where all the possible locations of pain are. My patients
are routinely instructed to call me when they develop new pain so
that we can determine whether it is part of TMS.
In summary, TMS involves three types of tissue: muscle, nerve
and tendon-ligaments. Let us now look at how TMS manifests
itself.

PATIENT CONCEPTS OF CAUSE AND TYPE OF ONSET.

When first seen most people are under the impression that they
have been suffering from the long-term results of an injury, a
degenerative process, a congenital abnormality or some deficiency
in the strength or flexibility of their muscles. The idea of injury is
probably the most pervasive. This often ties in with the
circumstances under which the pain begins.

According to a survey we did a number of years ago, 40 percent
of a typical group of patients reported that the pain began in
association with some kind of physical incident. For some it was a
minor automobile accident, usually the hit-from-behind type. Falls,
on the ice or down steps, were common. Lifting a heavy object or
straining was another; and, of course, running, tennis, golf or
basketball were often blamed. The pain began anywhere from
minutes to hours or days after the incident, raising some important
questions about the nature of the pain. Some of the reported
incidents were trivial, such as bending over to pick up a toothbrush
or twisting to reach into a cupboard, but the ensuing pain might be
just as excruciating as that experienced by someone who was trying
to lift a refrigerator.
I recall a young man who was sitting at his office desk writing
and experienced a spasm in his low back so severe and persistent
that he had to be taken home by ambulance. The next forty-eight
hours were agonizing; he couldnt move without setting off a new
wave of spasm.
How can such excruciating pain be set off by this great variety
of physical incidents? In view of the different degrees of severity
of the physical incidents and the great variation in when the pain
begins after the incident, the conclusion is that the physical
happening was not the cause of the pain but was merely a trigger.
Many patients apparently dont need a trigger; the pain just comes
on gradually or they awaken with it in the morning. In the survey
mentioned above, 60 percent fell into that category.
The idea that physical incidents are triggers is reinforced by
the fact that there is no way to distinguish between those pains
that start gradually and those that begin dramatically in terms of
subsequent severity or longevity of the attack. All of this makes
perfect sense when one considers the nature of TMS. Despite the
perception of injury, patients are not injured. The physical
occurrence has given the brain the opportunity to begin an attack
of TMS.
There is another reason to doubt the role of injury in these
attacks of back pain. One of the most powerful systems that has
evolved over the millions of years of life on this planet is the biologic
capacity for healing, for restoration. Our body parts tend to heal
very quickly when they are injured. Even the largest bone in the
body, the femur, only takes six weeks to heal. And during that
process there is pain for only a very short time. It is illogical to
think that an injury that occurred two months ago might still be
causing pain, not to mention one of two or ten years ago. And yet
people have been so thoroughly indoctrinated with the idea of
persistent injury that they accept it without question.
Invariably those patients who have a gradual onset of pain will
attribute it to a physical incident that may have occurred years
before, like an automobile or skiing accident. Because in their minds
back pain is physical, that is, structural, it must be due to an
injury. As far as they are concerned there has to be a physical
cause.
This idea is one of the great impediments in the way of recovery.
It must be resolved in the patients mind or the pain will persist.
Gradually, patients need to begin to think psychologically; and,
indeed, once the diagnosis of TMS is made, it is common for patients
to begin to recall all of the psychological things that were going on
in their lives when acute attacks occurred, like starting a new job,
getting married, an illness in the family, a financial crisis and so on.
Or the patient will acknowledge that he or she has always been a
worrier, overly conscientious and responsible, compulsive and
perfectionistic. This is the beginning of wisdom, the start of the
process of putting things into proper perspective. In this case, it is
the recognition that there are physical disorders that play a
psychological role in human biology. Not to be aware of that fact is
to doom oneself to perpetual pain and disability.

THE CHARACTER OF ONSET.

The Acute Attack.
Perhaps the most common, and undoubtedly the most frightening,
manifestation of TMS is the acute attack. It usually comes out of
the blue and the pain is often excruciating, as described in the case
of the young man above. The most common location for these
attacks is the low back, involving the lumbar (small of the back)
muscles, the buttock muscles or both. Any movement brings on a
new wave of terrible pain so the condition is very upsetting, to say
the least. It is clear that the involved muscles have gone into spasm.
Spasm is a state of extreme contraction (tightening, tensing) of the
muscles, an abnormal condition that may be horrifically painful.
Most everyone has experienced a leg or foot cramp (charley horse),
which is the same thing, except that the cramp will stop as soon as
the involved muscle is stretched. The spasm of an attack of TMS
does not let up. When it begins to ease, any movement can start it
up again.
As will be described in the physiology chapter (see The
Physiology of TMS), I believe that oxygen deprivation is
responsible for the spasm as well as other kinds of pain characteristic
of TMS. It is likely that common leg cramps also result from oxygen
deprivation, which is why they usually occur in bed when the
circulation of blood is slowed down and there is liable to be a
temporary, minor state of reduced oxygenation in the leg muscles.
Blood flow can be quickly restored to normal with muscle
contraction. With TMS, however, reduced blood flow is continued
by action of the autonomic nerves, and the abnormal muscle state
persists.
People often report that at the moment of onset they hear
some kind of noise, a crack, a snap or a pop. Patients often use the
phrase My back went out. They are sure that something has
broken. In fact, nothing breaks, but the patient will swear that there
has been some kind of structural damage. The noise is a mystery.
It may be that it is similar to the noise elicited by a manipulation of
the spine, which is a kind of cracking the knuckles of the joints
of the spinal bones. One thing is clearthe noise indicates nothing
harmful.

Though the low back is the most common location for an acute
attack, it can occur anywhere in the neck, shoulders or upper and
lower back. Wherever it occurs, it is the most painful thing I know
of in clinical medicine, which is ironic because it is completely
harmless.
Not uncommonly the trunk is distorted by one of these attacks.
It may be bent forward or to the side, or a bit of both. The precise
reason for and mechanism of this is not known. Naturally, its very
disturbing but it has no special significance.
These episodes last for varying periods of time and invariably
leave the person with a sense of dread and apprehension. The
common perception is that something terrible has happened and
that it is important to be very careful not to do anything that will
injure the back and bring on another attack.
If the low back pain is accompanied by pain in the leg, or
sciatica, there is even greater concern and apprehension, for this
raises the spectre of the herniated disc and the possibility of surgery.
In this media-dominated age very few people have not heard of
herniated discs and the idea arouses great anxiety, resulting in
greater pain. If, in the course of medical investigation, imaging
studies show a herniation, the apprehension is multiplied even
further. And if there should be feelings of numbness or tingling in
the leg or foot and/or weakness, all of which can occur with TMS,
because of burgeoning fear, the conditions for a very protracted
episode of pain are defined. As will be discussed later, herniated
discs are rarely the cause of the pain (see Herniated Disc).
There is not a great deal one can do to speed the resolution of
such an episode. If the person is fortunate enough to know what is
going on, that this is only a muscle spasm and there is nothing
structurally wrong, the attack will be short-lived. But this is rarely
the case. I advise my patients to remain quietly in bed, perhaps
take a strong painkiller, and not agonize over what has happened.
They are further instructed to keep testing their ability to move
around and not assume they are going to be immobilized for days
or weeks. If one can overcome ones apprehension, the duration
of the attack will be considerably shorter.

The Slow Onset of Pain.

In over half the cases of TMS the pain begins graduallythere is
no dramatic episode. In some cases there is no physical incident to
which one can attribute the pain. In others onset of pain may follow
a physical happening, but hours, days or even weeks later. This
pattern is fairly common after a so-called whiplash incident. A car
is struck from behind and your head snaps back. Examination and
X rays do not reveal a fracture or dislocation but sometime
thereafter pain begins, usually in the neck and shoulders, occasionally
in the mid or low back. Pain in an arm or hand may also occur and,
like sciatica, arouses a great deal of anxiety. Sometimes the pain
begins in the neck and shoulders and then moves down to involve
the rest of the back. If one knows that this is TMS, the course may
be relatively brief. If some sort of structural diagnosis is made,
symptoms may continue for many months, despite treatment.

THE TIMING OF ONSET.
Acute attack or slow onset, why does the pain begin when it
does? Remember, the physical incident, no matter how dramatic,
is a trigger. The answer, of course, is to be found in ones
psychological state. Sometimes the reason is obviousa financial
or health crisis, or something one ordinarily thinks of as a happy
occasion, like getting married or the birth of a child. I have had a
number of highly competitive people whose pain began in the course
of athletic competition, like a tennis match. Naturally, they assumed
that they had hurt themselves. When they realized they had TMS,
they admitted how very anxious they had been about the
competition.
It is not the occasion itself but the degree of anxiety or anger
which it generates that determines if there will be a physical reaction.
The important thing is the emotion generated and repressed, for
we have a built-in tendency to repress unpleasant, painful or
embarrassing emotions. These repressed feelings are the stimulus
for TMS and other disorders like it. Anxiety and anger are two of
those undesirable emotions that we would rather not be aware of,
and so the mind keeps them in the subterranean precincts of the
subconscious if it possibly can. All of this is discussed in detail in
the psychology chapter.
Then theres the person who says, There was absolutely
nothing going on in my life when this began. But when we begin
to discuss the trials and tribulations of daily life it is usually clear
that this person is generating anxiety all the time. I think there is a
gradual buildup in such people until a threshold is reached, at which
point the symptoms begin. Once it is pointed out to them, these
patients have little trouble recognizing that they are the kind of
perfectionist, highly responsible people who generate a lot of
subconscious anger and anxiety in response to the pressures of
everyday life.

The Delayed Onset Reaction.

There is another interesting pattern that we see very often. In
these cases patients go through a highly stressful period that may
last for weeks or months, such as an illness in the family or a
financial crisis. They are physically fine as they live through the
trouble, but one or two weeks after its all over they have an attack
of back pain, either acute or slow onset. It seems as though they
18
rise to the occasion and do whatever they have to do to deal with
the trouble, but once its over the accumulated anxiety threatens to
overwhelm them, and so the pain begins.
Another way of looking at it is that they dont have time to be
sick during the crisis; all of their emotional energy goes into coping
with the trouble.
A third possibility is that the crisis or stressful situation is
providing enough emotional pain and distraction that a physical
pain isnt necessary. The pain syndrome seems to function to divert
the persons attention away from repressed undesirable emotions
like anxiety and anger. When one is living through a crisis there is
more than enough unpleasantness going on and one has no need
for a distraction.
Whatever the psychological explanation, this is a common
pattern and it is important to recognize it so that the back pain will
not be blamed on some physical condition.

The Weekend-Vacation Syndrome.

When we generate anxiety depends mostly on the details of our
personality structure. Not uncommonly people will report that they
almost always have an attack of pain when they are on vacation,
or if they already have pain that it gets worse on weekends. For
some the reason is obvious. They are very anxious about their
work or business when they are away from it. Its a bit like the
delayed reaction; as long as they are on the job they may be burning
up the anxiety but when they are away from it, supposedly relaxing,
the anxiety accumulates.
Speaking of relaxing, one often hears the advice Relax, as
though thats something one can do voluntarily. There are also
numerous techniques around for promoting relaxation, like drugs,
meditation and biofeedback, to name a few. However, unless the
relaxation process succeeds in reducing repressed anxiety and
anger, people will develop things like TMS and tension headaches
despite the attempt to induce relaxation. Some people dont know
how to leave their daily concerns behind them and shift attention
to something pleasurable. I remember a patient who said that her
pain would invariably begin when she got herself a drink and sat
down to relax.
Recently I saw a young man who illustrated the vacation
syndrome very well. He described having been under a lot of stress
for a long time, but without any back pain. It wasnt until he was
on his honeymoon that he was awakened one night with a
nightmarish dream followed immediately by a severe back spasm
in which, he said, my back went completely out. Of course, it
might have been due to the stresses and strains of being newly
married, but he was an extremely conscientious type and I was
inclined to connect it with his work.
He was still having symptoms when I saw him three months
later, no doubt due to the fact that an MRI had shown a disc
herniation at the lower end of the spine and the possibility of surgery
had been discussed. (An MRI, or magnetic resonance imaging, is
an advanced diagnostic procedure that is capable of producing an
image of body soft tissues allowing one to detect the presence of
such things as tumors or herniated discs.)
However, he read my book on TMS, thought that he was typical
of the patients described, and came in to see me. The examination
was conclusive for TMS. In fact, it showed that his symptoms
could not be due to the herniated disc, for he had weakness in two
sets of muscles in his leg, something that the herniated disc could
not have caused. Only involvement of the sciatic nerve, as is typical
in TMS, could have produced this neurological picture. At any rate,
he was delighted to learn that TMS was the basis for his back
troubles and had a rapid recovery.
Another explanation, often difficult for people to admit to
themselves, is that there are great sources of anxiety and anger in
their personal lives, like a bad marriage, trouble with children, having
to care for an elderly parent. We have seen numerous examples
of this: women trapped in bad marriages that they cannot stand
and yet unable to break out because of their emotional and/or
financial dependence on their husbands; people who feel perfectly
competent at what they do for a living but who cannot deal with a
difficult spouse or child.
I recall a woman with a persistent pain problem who lived
with a very difficult brother. Despite psychotherapy the pain
continued. One day she told me that she had done a very unusual
thing; she had gotten furious at her brother, had shouted and ranted
at him and stormed out of the house. And with thatthe pain
disappeared. Unfortunately, she could not maintain her strong
posture and the pain returned.

The Holiday Syndrome.

One often hears or reads that holidays may be stressful. What
should be a time of relaxation and fun often turns out to be
unpleasant for some people. I have been struck by the fact that
many patients will report the onset of attacks of TMS before, during
or shortly after major holidays.
The reason is obvious: big holidays usually mean a lot of work,
particularly for women, who take the responsibility in our culture
for organizing and carrying out the festivities. And, of course, society
demands that this be done cheerfully, with a smile. Usually the
women are completely unaware that they are generating great
quantities of resentment, and the onset of pain comes as a complete
surprise.

THE NATURAL HISTORY OF TMS.

What are the common patterns of TMS? What happens over time
if one continues to be plagued by this disorder?

Conditioning.

Essential to an understanding of this subject is knowledge about a
very important phenomenon known as conditioning. A more
modern term meaning the same thing is programming. All animals,
including humans, are conditionable. The phenomenon is best known
by the experiment reported by the Russian physiologist Pavlov,
who is credited with the discovery of conditioning. His experiment
demonstrated that animals develop associations which can produce
automatic and reproducible physical reactions. In the research study
he rang a bell each time he fed a group of dogs. After repeating
this a few times he found that the dogs would salivate if he rang
the bell even without the presentation of food. They had become
conditioned to have a physical reaction at the sound of the bell.
The process of conditioning, or programming, seems to be very
important in determining when the person with TMS will have pain.
For example, a common complaint of people with low back pain is
that it is invariably brought on by sitting. This is such a benign
activity one is mystified by the fact that it initiates pain. But
conditioning occurs when two things go on simultaneously, so it is
easy to imagine that at some point early in the course of the TMS
experience the person happens to be having pain while sitting. The
brain makes the association between sitting and the presence of
pain and that person is now programmed to expect pain with sitting.
In other words, the pain occurs because of its subconscious
association with sitting, not because sitting is bad for the back.
That is one way a conditioned response may be established. There
must be others I am unaware of since sitting is such a common
problem for people with low back pain. Car seats have a bad
reputation, so a person expects to have pain when he or she gets
into a car.
Often people are programmed to have pain because of things
they have heard or been told by a practitioner. Never bend at the
waist means the onset of pain is a sure thing when they bend
from then on, although it may never have caused pain before.
Someone says that sitting compresses the lower end of the spine
so, of course, its got to hurt when you sit. Standing in one place,
lifting, carryingall have a bad reputation and will quickly be
conditioned into a patients pattern.
Many people report that the pain is relieved by walking; others
say that walking brings it on. Some have a great deal of pain at
night and cannot sleep. One man worked hard all day long with a
fair amount of heavy lifting and never a twinge of pain. Every
night he would wake up about 3:00 A.M. with severe pain that
persisted until he got out of bed. Clearly a conditioned reaction.
Others report that they sleep well but develop pain as soon as
they wake up and get out of bed. In these patients the pain usually
increases in severity as the day goes on.
Based on history and physical examination, all of these people
have TMS but are programmed to believe they suffer from
something else. What gives strong support to the idea that these
reactions are conditioned is that they disappear within a few weeks
as patients go through my treatment program. If they were
structurally based they would not go away after treatment
(consisting primarily of lecture seminars), which is what happens
with successfully treated patients. The conditioning is broken by
the educational process.
One cannot overemphasize the importance of conditioning in
TMS for it explains many of the reactions that patients dont
understand. If someone says, I can lift a very light weight but
anything over five pounds will cause pain, the pain cant be based
on structural grounds. Or this example: a woman who could bend
over and touch her palms to the floor without pain but told me she
always felt pain when she put her shoes on!
Many of these conditioned responses stem from the fear that
people develop when they have back pain, especially in the low
back. They have been told and they have read that the back is
fragile, vulnerable and easily injured, so if they try to do something
vigorous, like jog or swim or vacuum the floor, their backs begin to
hurt. They have learned to associate activity with pain; they expect
it, so it happens. That is conditioning.
The specific posture or activity that brings on the pain is not
important per se. What is essential is to know that it has been
programmed in as a part of the TMS and is, therefore, of
psychological rather than physical significance.

Common Patterns of TMS.

Perhaps the most common pattern is for the person to have
recurrent acute attacks of the kind described earlier. These may
last from days to weeks or even months, with the most acute pain
subsiding after a few days. They are traditionally treated with bed
rest, painkillers and anti-inflammatory drugs, administered by mouth
or by injection. If the patient is hospitalized, traction is often
employed, though its purpose is to immobilize the patient and not to
pull the spinal bones apart since this could not be done with the
weights used. I do not instruct my patients what to do for an acute
attack, for it is the goal of this program to see that the attacks
dont occurto prevent them. However, occasionally I am called
upon to advise someone having an acute attack; as stated earlier
in the chapter, its essentially a question of waiting it out. I may
prescribe a strong painkiller but not an anti-inflammatory drug, since
there is no inflammation.

The irony of the usual experience with one of these attacks is
that most patients would be better off if they consulted no one.
This is unwise, however, because every once in a while there may
be something physiologically important going on and so one must
be examined by a physician. Assuming nothing truly serious, like a
tumor, is present, the usual diagnosis is some spinal structural
abnormality. A scary diagnosis (degenerative disc disease, herniated
disc, arthritis, spinal stenosis or facet syndrome) plus the dire
warnings of what will happen if the patient doesnt take sufficient
bed rest and cautioning about never again jogging or using a vacuum
cleaner or bowling or playing tennis is the perfect combination for
multiplied and persistent pain.
But the human spirit is more or less indomitable and eventually
the symptoms fade, leaving someone who is essentially free of
pain but permanently scarred, not physically but emotionally. Except
for the very brave few, most people who have had such an attack
never again engage in vigorous physical activity with an easy mind.
They have been sensitized by the experience and all that it is
supposed to imply and they see themselves, to a greater or lesser
degree, as permanently altered. They fear another attack and
eventually it comes. It may be six months or a year later but the
prophecy is fulfilled and the dreaded event occurs again. As before,
the person usually attributes the attack to some physical incident.
This time there may be leg pain as well as back pain and now
there is talk of surgery should a herniated disc be found on MRI or
CT scan. (CT, or computed tomography, is an advanced X-ray
technique that can, like the MRI, give information about soft tissues
as well as bone.) This further increases anxiety and the pain may
become even more severe.
This pattern of recurrence of acute attacks is very common.
As time goes on the attacks tend to come more frequently, to be
more severe and to last longer. And with each new attack the fear
increases and there is an increased tendency to limit physical
activities. Some patients become virtually disabled as time goes
on.
In my view physical restrictions and the fear of physical activity
represent the worst aspect of these pain syndromes. They are
ever present, though the pain may come and go. They have a
profound effect on all aspects of life: work, family, leisure time.
Indeed, I have known patients with TMS who were much more
disabled in terms of their daily lives than patients who were
paralyzed in both legs. Many of the latter go to work every day on
their own, raise families and in every way lead normal lives, except
that they are in wheelchairs. The severe TMS patient may have to
stay in bed most of the day because of the pain.
Eventually most people who have recurrent attacks will develop
a chronic pattern. They will begin to have some pain all the time,
usually mild, but exacerbated by a variety of activities or postures
to which they have become conditioned. I can lie on my left side
but not on my right; I must always have a pillow between my
knees in bed; I never go anywhere without my seat cushion;
My body corset (or neck collar) is absolutely essential if I am to
remain free of pain; If I sit for more than five minutes I get
severe pain; The only chair I can sit on has to have a hard seat
and a straight back; and on and on.
And to some the pain becomes the primary focus of their lives.
It is not uncommon to hear people say that the pain is the first thing
they are aware of when they awaken in the morning and the last
thing they think about when they go to sleep. They become
obsessed with it.
There is great variety in . There
are those who have a little pain all the time with varying degrees of
physical restriction. Others have occasional acute attacks but live
essentially normal lives in between with little or no restriction.
What I have been describing are the more common
manifestations of TMS and the most dramatic, those in the low
back and legs. However, a severe episode involving the neck,
shoulders and arms can be very dramatic tooand just as physically
restricting. Here is a typical example.
The patient was a middle-aged man who had been having
recurrent attacks of pain in the neck and shoulders and pain,
numbness and tingling in his hands for about three years prior to
the time I saw him. The episode that brought him to me had begun
about eight months previously with pain in the left arm. He saw
two neurologists, had a variety of sophisticated tests and was told
that the pain was the result of a disc problem in the neck. There
was debate whether he should have immediate surgery; he was
warned that he might become paralyzed if he didnt. Not
surprisingly, the pain spread from his arm to his neck and back; he
was unable to ski or play tennis, two of his favorite sports. He was
very frightened.
My examination disclosed that he had TMS and that there
were no neurological abnormalities. Fortunately, a third neurologist
concluded that there was no structural basis for his pain so he was
able to accept the diagnosis of TMS with an easy mind. He went
through the program and in a few weeks was free of pain and able
to resume his usual athletic activities. He has not had a recurrence.
Sometimes the shoulder is the site of the trouble or the knee.
To anyone who tries to be physically active, knee pain can be very
debilitating. I have had such an episode and can attest to the fact
that it can be scary, persistent and restricting. Any of the tendons
and ligaments in the arms and legs and any of the muscles and
nerves of the neck, shoulders, back and buttocks can be involved
in TMS.
Though we must identify the structures involved in each case,
this is the least important part of the consultation. Each encounter
with a patient is an excursion into that persons life. After we have
established which body parts are involved that information must
be put aside, for we do not work on the muscles, nerves and
ligaments directly. Something in that persons emotional life that
might have played a role in producing the symptoms must be
addressed.

There comes to mind the case of a man who had found himself
financially well-off enough to retire from business at an early age
and who shortly thereafter developed the pain syndrome for which
I saw him. As we talked it became apparent that since his retirement
he had become preoccupied with a number of family problems,
there had been a number of deaths in the family, he was worried
about the health of the business he had left (in the hands of relatives),
and he had begun to wonder what his life was all about now that
he was retired and was thinking about aging and mortality for the
first time. His concern about these matters, considered consciously
and unconsciously, had produced sufficient anxiety (and anger) to
precipitate the TMS. Conventional medicine had attributed his pain
to an aging spine, and treatment for that had, naturally, failed. He
had TMS; his troubles were not in his spinethey were in his life.
To summarize, TMS may involve postural muscles, nerves that
are in and around those muscles, and a variety of tendons and
ligaments in the arms and legs. In the areas involved, the patient
has pain, possibly feelings of pins and needles and/or weakness.
There are many different patterns and locations of symptoms and
considerable variation in severity, ranging from mild annoyance to
almost total disability.
Recurrent attacks, fear of recurrence and physical activity,
and failure to find successful treatment characterize TMS.
The symptoms of pain, numbness, tingling and weakness are
intended by the brain to suggest that something is physically wrong.
To most people, practitioners and laymen alike, physically wrong
means injury, weakness, incompetence and degeneration, singly or
in combination. To further this view of the symptoms, the pain
often begins in association with some physical activity, the more
vigorous the better. The patient cant help but conclude that
something has been injured or displaced. My back went out is a
common description of the event.
Also very important to advancing the idea of structural
incompetence is the powerful tendency for people to become
programmed to fear a variety of simple, common things like sitting,
standing in one place, bending and lifting.
The net effect of symptoms, fears and alterations in life-style
and daily activities is to produce someone whose attention is strongly
focused on the body. As shall be seen in succeeding chapters, that
is the purpose of the syndrometo create a distraction so that
undesirable emotions can be avoided. It seems a heavy price to
pay, but then the inner workings of the mind are not really known,
and we can only suspect its deep aversion to frightening, painful
feelings.