(For a compilation of peer reviewed abstracts in their entirety go to this page. There are currently about 40 abstracts looking at TMS, the mindbody connection for many chronic pain conditions and the efficiency of TMS techniques in pain reduction).
A 2007 peer reviewed study (1i) by researchers at the Seligman Medical Institute reported that they were able to reduce the pain levels of 51 chronic back pain patients (average pain duration 9 years) by over 50%. The methods used were journaling, informational reading, meditation and in some cases psychotherapy. As Dr. Schechter (the study’s Principal Investigator) said "The treatment program we used was completely non-invasive and non-pharmacological — and very inexpensive to administer. While educational approaches have always played a prominent role in the prevention of illness, we think they can also play an important role in their treatment, especially conditions such as chronic pain, where most conventional and treatments don’t seem to work that well."
Researchers used a standardized, self-reporting, pain scale to measure “least pain,” “worst pain,” and “average (typical) pain” before and after treatment. Scores improved by an average of 65%, 35%, and 52% respectively. (P<.0001). Medication use and mobility restriction likewise decreased significantly, while the scores for physical wellbeing also significantly improved. SMI Foundation Coordinator Arthur Smith, PhD, said “We do think we have enough anecdotal evidence here to justify more serious research on this approach. Most
Dr Sarno, who has been using the TMS diagnosis for a range of chronic pain conditions for over 25 years has documented two separate follow-up surveys of his patients. The first in 1982 drew 177 patients randomly from those that had been treated in the preceding 3 years. They were interviewed about their level of pain and functional ability. 76% were leading normal lives essentially free from pain, with only 16% considered treatment failures.(1) A second follow up study in 1987 limited the population surveyed to those with back pain, and of 109 randomly selected participants 88% were free of pain. These were on average patients with long histories of severe debilitating chronic pain, who reported immediate short term improvements, and whose improvements were maintained one to three years in the future.
Dr David Schechter retrospectively interviewed 85 patients treated for TMS between 1995 and 2000, with a finding of a 57% success rate, judged as significant long term improvement in terms of pain in patients with a long history (over a year) of chronic pain. (2). Amongst all patients he found 60% with significant long term improvement, 18% with some improvement and 21% with no improvement. Dr Howard Schubiner meanwhile has just finished an (as yet unpublished) study which compares a group of women with fibromylgia who received the TMS program with a control group who didn’t. He found that none of the women in the control group had improvements in pain, whilst the TMS group showed significant pain reduction both at a 6 week and 6 month follow up. (2i)
A small scale case study was conducted in the UK by physiotherapist Georgie Oldfield, surveying 24 of her patients treated between November 2007 and January 2008. Lower back pain, migraines and sciatica were the most common complaints, with the average length of symptoms over 3 years. The patients were surveyed in June 2008 and again in June 2009. Twenty of the patients reported an 80-100% improvement in June 2008, and although only twenty could be contacted in June 2009, 18 had maintained their progress or improved. As Georgie Oldfield says “Although not hard evidence and with relatively few patients, the results of this audit support Dr Sarno’s theory that the increasing epidemic of chronic pain may well be an emotionally induced phenomenon.” (3)
A number of studies have already underlined the fundamental psychological role in chronic pain. Robert Kerns, professor of psychiatry at Yale University, published a 2007 meta-analysis of 22 trials of psychological treatment for patients with chronic lower back pain. The results were that patients who learnt different methods of thinking about their pain (such as cognitive behavioural therapy or forms of meditation) could make that pain go away. Co-author of the report Benson Hoffman summed up the remarkable findings “These psychological treatments reduced the pain more than anything else.” (4)
Large scale population studies of back pain sufferers have also found that structural or physical factors are a poor predictor of the development of chronic pain. Poor posture or heavy lifting appear to have a negligible predictive effect. In studies of 3000 Boeing workers in the 1980s, and also in a study published by Stanford Professor of orthopaedic surgery Dr Eugene Carragee, the best predictor of chronic pain has been found to be emotional distress, stress or depression. As Dr Carragee noted “The structural problems were really overwhelmed by the psychosocial factors. People without mental risk factors were able to deal with their back pain. But for people with a psychological problem the pain was often crippling and catastrophic.” (5)(6)
Another notable study was undertaken by Schofferman et al. – which in a retrospective study of 86 patients who had undergone lumbar spine surgery found that there was a highly significant correlation between unsuccessful surgery and a history of childhood trauma. Patients with major childhood psychological traumas had an 85% likelihood of an unsuccessful surgical outcome. This contrasted with only a 5% incidence of failure amongst the patients with no childhood trauma. (6i)
There is also evidence that sufferers of some chronic pain conditions are interpreting pain signals abnormally. In a narrative review of fibromyalgia Abeles et al describe how the accumulating evidence suggests that the condition probably results from abnormal central pain processing rather than from a structural problem and conclude that sufferers actually perceive pain differently from the general population. (6ii)
But what about MRI structural diagnosis for conditions like back pain and sciatica? There have been a number of studies which have demonstrated that a large proportion of patients with no symptoms of back pain will nevertheless have an disc “abnormality” show up on MRI scans.(7) The conclusion for one such study of 98 asymptomatic people carried out by Maureen C Jensen et al. was that “given the high prevalence of these findings, the discovery by MRI of bulges or protrusions in people with lower back pain may frequently be coincidental.” (7i)
There is published evidence which speaks to the medical benefit gained by expressing emotions through journaling. Joshua Smyth et al.(8) conducted a study on rheumatoid arthritis and asthma sufferers. The experimental group wrote for 3 consecutive days a week on stressful experiences, the control group about their plans for the day. They found significant clinical improvements for both asthma and rheumatoid arthritis sufferers against the control group in objective measures.
A separate study by Diane Berry et al.(9) reviewed studies into the expression of verbal and non verbal emotion, and concluded that such activities led to immediate reductions in autonomic nervous system activity, and led to improved physical health, an enhanced immune function and were associated with fewer medical visits.
Researchers from the University of Miami researchers undertook a similar study (10). They also concluded that both writing about and talking about stressful events actually appeared to boost individuals’ immune system.
There is also evidence demonstrating how stress causes changes areas the brain, which then affects susceptibility to and sensitivity to pain. In a recent small study, the MRI scans of 14 fibromyalgia (FM) patients and 14 healthy patients were compared. The FM group were found to have reduced grey matter in the parts of the brain responsible for pain-processing. The question was whether this reduction had caused the chronic pain, or whether it was the result of chronic pain. To address this, the researchers looked at the link between levels of grey matter reduction and length of FM symptoms. They found no link - suggesting that the reduced grey matter was present prior to development of FM symptoms, and was a potential causal factor. Other studies have shown the same relationship between grey matter reduction and post-traumatic stress disorder, implying that life stresses could be responsible for this reduction, leading to greater pain sensitivity and susceptibly to chronic pain conditions. (11)
A study by Fadel Zeidan et al into the effectiveness of mindful meditation found that even a brief 3 day meditation program was successful in reducing pain ratings and anxiety scores compared to baseline measurements. He says, "We knew already that meditation has significant effects on pain perception in long-term practitioners whose brains seem to have been completely changed -- we didn't know that you could do this in just three days, with just 20 minutes a day. All you have to do is use your mind, change the way you look at the perception of pain and that, ultimately, might help alleviate the feeling of that pain." (12) (13)
There is already a flourishing internet community of hundreds of former chronic pain sufferers who all credit Dr Sarno and the TMS diagnosis as the key to becoming pain free. The TMShelp Forum has over 2000 members and the TMS wiki has upwards of 200 pages of information on the theory. Some of the stories truly are remarkable. Hilary, a founding member of the TMS wiki, suffered from RSI for 13 years. She says of her recovery: “After having been completely dependent on voice recognition software for many years to do my IT job I am now completely cured and have no problems using the keyboard and mouse for as long as I like.”
And her story is just one amongst scores. Chronic back pain, RSI, neck pain and migraines. Seriously debilitating conditions which former long term sufferers give testimony to overcoming within weeks, and sometimes within hours or days of reading about TMS. This is more powerful than any concept of placebo – which cannot in any case cure what are, according to conventional medical thinking, supposedly structural deficits.
Unfortunately, the TMS theory is unsuitable for double-blinded treatment trials. It is likely that a majority of the “treatment” group would downright reject the psychosomatic diagnosis - it would be like having a drug trial where the majority of the “treatment” group refused to take their medication. The only alternative is therefore to simply measure the progress of the people who do accept a psychosomatic process. This is not ideal because perhaps those that are amenable to such a diagnosis really are different from other chronic pain sufferers. Nevertheless such studies can demonstrate that a subset of chronic pain sufferers (i.e. those willing to accept the TMS concept) can benefit from TMS theory.
Despite the mounting scientific evidence of the benefits of employing TMS techniques to alleviate chronic pain, for now the concept of TMS remains outside the mainstream. But the compelling nature of the numerous success stories online, the impressive success reported in small scale studies and the growing body of medical evidence attesting to the fundamental role of the psyche in chronic pain, all suggest something far more substantial than either statistical fluke or placebo. Perhaps there are psychosomatic roots to a range of chronic pain conditions and in neglecting this concept in favour of structural diagnosis we are consigning large number of people unnecessarily to years of pain. At the very least further research is desperately needed, and for chronic pain there needs to be a much greater emphasis on treating the mind as well as the body.
(1i) “Outcomes of a Mind-Body Treatment Program for Chronic Back Pain With No Distinct Structural Pathology.” David Schechter et al. In Alternative Therapies, September, 2007 - VOL. 13, NO. 5.
Journal abstract: http://www.ncbi.nlm.nih.gov/pubmed/17900039
(1i) Study press release: http://www.mmdnewswire.com/study-shows-chronic-back-pain-can-be-successfully-treated-by-educational-and-psychological-program-2155.html
(1) The Mindbody Prescription, Dr J. Sarno. Warner Books Inc: New York, 1998.
(2) David Schechter, M.D. Presentation at The American Psychosomatic Society 63rd Annual Meeting Vancouver, Canada – March 2-5, 2005 http://www.psychosomatic.org/events/2005meetingabstracts.pdf (p101): Abstract also available to read here: http://tmswiki.wetpaint.com/page/Annotated+Bibliography
(2i) “Unlearn Your Pain.” Dr. Schubiner.
(3) “Clinical Audit reporting on outcomes of a Tension Myoneural Syndrome (TMS) Programme in a physiotherapy practice.” G. Oldfield. 2009. http://tmswiki.net/misc/OldfieldTMSCaseSeries2008-9.pdf
(4) Meta-analysis of psychological interventions for chronic low back pain. Journal of Health psychology. 2007, vol. 26, no1, pp. 1-9 HOFFMAN et al.
http://cat.inist.fr/?aModele=afficheN&cpsidt=18442167
(5) Carragee EJ et al. Prospective controlled study of the development of lower back pain in previously asymptomatic subjects undergoing experimental discography. Spine 2004 May 15; 29(10):1112-7
Quote from http://www.medicalnewstoday.com/articles/8342.php
Discussed in http://www.scientificamerican.com/article.cfm?id=psychological-stress-bett and http://www.medscape.com/viewarticle/537798
(6) Bigos SJ et al. Clinical Otheopedics and related Research 1992 Jun;(279):21-34. A longitudinal, prospective study of industrial back injury reporting. http://www.ncbi.nlm.nih.gov/pubmed/1534722
6i Schofferman J et al. Spine 1992 Jun;17(6 Suppl):S138-44. Childhood psychological trauma correlates with unsuccessful lumbar spine surgery. http://www.ncbi.nlm.nih.gov/pubmed/1385898
(6ii) Abeles et al “Narrative Review: The Pathophysiology of Fibromyalgia” Annals of Internal Medicine Volume 146 • Number 10 727-735. 15 May 2007
http://www.annals.org/content/146/10/726.full.pdf
(7) Boden SD et al. The Journal of Joint and Bone Surgery. 1990 Mar;72(3):403-8. Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. A prospective investigation. http://www.ncbi.nlm.nih.gov/pubmed/2312537
(7i) Jensen M et al. “Magnetic Resonance Imaging of the Lumbar Spine in People without Back Pain.” The New England Journal of Medicine. Vol. 331:69-73. July 14 1994. Number 2. http://content.nejm.org/cgi/content/full/331/2/69
(8) Joshua M. Smyth et al. Effects of Writing About Stressful Experiences on Symptom Reduction in Patients With Asthma or Rheumatoid Arthritis: A Randomized Trial. JAMA, Apr 1999; 281: 1304 - 1309.
http://jama.ama-assn.org/cgi/content/abstract/281/14/1304?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=oshua+Smith+et+al.%288%29+conducted+a+study+on+rheumatoid+arthritis+and+asthma+sufferers&searchid=1&FIRSTINDEX=0&resourcetype=HWCIT
(9) Berry D et al. Nonverbal and verbal emotional expression and health. Psychotherapy and Psychosomatics. Vol 59(1), 1993, 11-19.
http://cat.inist.fr/?aModele=afficheN&cpsidt=4542927
and http://www.ncbi.nlm.nih.gov/pubmed/8441791
(10) Esterling et al. Journal of Consulting and Clinical Psychology, 1994, vol 62, no 1, 130-140. Emotional disclosure through writing or speaking modulates latent Epstein-Barr virus antibody titers. http://www.ncbi.nlm.nih.gov/pubmed/8034815
(11) Burgmer, M et al. “Decreased Gray Matter Volumes in the Cingulo-Frontal Cortex and the Amygdala in Patients with Fibromyalgia.” Psychosomatic Medicine 71:566-573, 2009. From Munster, Germany.
http://www.psychosomaticmedicine.org/cgi/content/abstract/71/5/566
Summary here: http://www.stressillness.com/blog/?p=170
(12) Zeidan F et al. The Effects of Brief Mindfulness Meditation Training on Experimentally Induced Pain. The Journal of Pain (published online 23 October 2009).
http://www.jpain.org/article/S1526-5900(09)00691-9/abstract
(13) Quotes from University of North Carolina at Charlotte press release, printed at http://www.physorg.com/news177058708.html
