The Science

A revolution in understanding of the nature of chronic pain is underway, driven by compelling neuroscience.  For the layperson, the take-home message is that most chronic pain conditions can be effectively treated using a neuroplasticity approach.

Two recent papers summarise what is possible when a modern understanding of pain neuroscience is coupled with innovation in treatment, to include not just cognitive but also emotional aspects of brain function. In short, it’s compelling evidence that indicates that most chronic pain can be reduced or eliminated when treated correctly.

Lumley, M.A. & Schubiner, H. (2019). Psychological Therapy for Centralized Pain: An Integrative Assessment and Treatment Model. Psychosomatic Medicine, V 81, 114-124.

Lumley, M.A. & Schubiner, H. (2019). Emotional Awareness and Expression Therapy for Chronic Pain: Rationale, Principles and Techniques, Evidence, and Critical Review. Current Rheumatology Reports (2019) 21:30

 

The following is an illustrative case study of what is possible.  This case study addresses a diagnosis of fibromyalgia but we regularly observe similar outcomes in a broad range of pain syndromes (see list on the home page).

” ‘Nancy’ is a 52-year-old woman who sought treatment for fibromyalgia diagnosed 14 years earlier. Her past medical history was noted for eczema as a child, and irritable bowel syndrome as a young adult while working at a stressful job. In 1980, she had a motor vehicle accident and developed neck and back pain, which had persisted to the time of her presentation. In 1993, she was diagnosed with fibromyalgia, having developed gradual onset of muscle tenderness,fatigue, temporomandibular joint disorder, insomnia, and widespread pain. She was initially treated with medications,physical therapy, and massage therapy. Consultations included two rheumatologists and a pain management clinic, without lasting benefit. Three years prior to presentation,she was diagnosed with a cerebral hemangioblastoma that required surgery. Her pain persisted following the surgery, and she was prescribed Paxil (GlaxoSmithKline, London, England, UK) for persistent anxiety.

Nancy stated that she was in pain most of her adult life. As a homemaker, she had great difficulty doing housework or gardening and would have to lie down and rest in the afternoon. She could not participate in recreational activities with her family, including sitting at the movies.

Her social history was pertinent for being raised by a kind, loving father, and an uninvolved, nonsupportive mother. She became a legal assistant, married, then had two children. At the time of the development of her fibromyalgia and other symptoms, she was raising her children while building a new home. She was determined to be a“perfect” mother and wife, and endorsed being very stressed during this time. When asked what her mother was doing at the time, she started to cry, explaining that her mother was doing what she always did, i.e., taking care of herself and not meeting the needs of her daughter and now also her grandchildren. Nancy endorsed having very high expectations for herself and feeling overly responsible for things not in her control.

On examination, she met the criteria for fibromyalgia with many tender points. The rest of the exam was normal. Her average pain was a “6” out of 10 at the beginning of the MBM program; afterwards, it had decreased to a “1” and remained at that level by her 6-month follow-up appointment.She had no further interventions and was able to discontinue her Paxil. Nancy now reports that she is able to enjoy aquatic exercise and Hatha Yoga workouts, gardening, keeping up with her children and attending events with her family. She currently considers herself to be “cured”, with only an occasional stiff neck that she can easily dismiss. ” (Hsu and Schubiner, 2010: p978-9)

Nancy’s (not her real name) case is illustrative because it indicates the power of the mindbody connection to cause and cure severe pain (and anxiety) in certain people.

 

The scholarly reader is referred to the following papers, noting the two randomised controlled trials indicated significant treatment effect sizes for EAET.  The 2017 RCT demonstrated a superior effect size compared to expertly delivered CBT.

Lumley, M.A. & Schubiner, H., et al (2017). Emotional awareness and expression therapy, cognitive behavioral therapy, and education for fibromyalgia: a cluster randomized controlled trial. Pain. Dec 2017, 158(12):2354-2363.

Burger AJ, Lumley MA, Carty JN, et al. The Effects of a Novel Psychological Attribution and Emotional Awareness and Expression Therapy for Chronic Musculoskeletal Pain: A Preliminary, Uncontrolled Trial. Journal of psychosomatic research. 2016;81:1-8.

Michael C. Hsu, Howard Schubiner, Mark A. Lumley, John S. Stracks, Daniel J. Clauw and David A. Williams. 2010. “Sustained Pain Reduction Through Affective Self-awareness in Fibromyalgia: A Randomized Controlled Trial”. Journal of General Internal Medicine; Oct 2010, Vol. 25 Issue 10, p1064-1070.

Hsu, Michael C., Schubiner, Howard. 2010. “Recovery from Chronic Musculoskeletal Pain with Psychodynamic Consultation and Brief Intervention: A Report of Three Illustrative Cases”. Pain Medicine; Jun 2010, Vol. 11 Issue 6, p977-980.

Gordon, Alan. 2010. “Miracles of mindbody medicine”. Healthcare Counselling & Psychotherapy Journal; Jan2010, Vol. 10 Issue 1, p13-18.

Dr Jeff Axelbank’s excellent annotated bibliography of peer reviewed studies

 

Alan Gordon in the article listed above comments on a retrospective analysis of treatment success using the TMS / PPD framework:

“Sarno conducted three formal retrospective studies at the Rusk Institute in 1982, 1987, and 1999 to assess the effectiveness of TMS treatment. In all, 371 randomly selected chronic pain clients were interviewed six months to three years after treatment to determine their level of pain and functional ability. A total of 72 per cent reported being free or nearly free of pain with unrestricted activity, while 16 per cent reported some improvement, and 12 per cent little to no improvement. One of these three studies was unique in that it included only clients with documented herniated discs. Over a third had been previously advised by physicians to undergo surgery. However, when interviewed between one and three years after TMS treatment, a remarkable 88 per cent of these clients reported being free or nearly free of pain.” (Gordon 2010: p17)

 

At the present moment, there is an over reliance on treatments lacking evidence, some with significant harm risks, for common conditions like back pain.  This is a significant study describing the problem published last year in arguably the world’s most prestigious medical journal The Lancet.

Hartvigsen, J., et. al. (2018). What low back pain is and why we need to pay attention”. Lancet, 03/2018 http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)30480-X/fulltext

• Excerpt: “For nearly all people with low back pain, it is not possible to identify a specific nociceptive cause. Only a small proportion of people have a well understood pathological cause eg, a vertebral fracture, malignancy, or infection. People with physically demanding jobs, physical and mental comorbidities, smokers, and obese individuals are at greatest risk of reporting low back pain. Disabling low back pain is over-represented among people with low socioeconomic status. Most people with new episodes of low back pain recover quickly; however, recurrence is common and in a small proportion of people, low back pain becomes persistent and disabling. Initial high pain intensity, psychological distress, and accompanying pain at multiple body sites increases the risk of persistent disabling low back pain. Increasing evidence shows that central pain-modulating mechanisms and pain cognitions have important roles in the development of persistent disabling low back pain.”

Carragee, E.J., Lincoln, T., Parmar, V.S., & Alamin, T. (2006). A Gold standard evaluation of the “discogenic pain” diagnosis as determined by provocative discography. Spine, 31(18), 2115-2123.

• Summary: This is a prospective study comparing a group of patients having spinal fusion surgery and a strictly matched control group with similar disc pathology. The surgical group had a success rate of 27%, while the control group had a success rate of 72% after five years. The authors conclude that discography is not a good indicator of need for surgery.

 

For a more substantial exploration of key issues in the science of treatment of chronic pain conditions the scholarly reader is referred to the PPD Association‘s comprehensive  Annotated Bibliography for Psychophysiologic Disorders and Chronic Pain.

1. Evidence for the benefit of psychological treatment for persistent physical symptoms, particularly for Emotional Awareness & Expression Therapy and Intensive Short-Term Dynamic Psychotherapy with lesser effect size from Cognitive Behavioral Therapy, Acceptance & Commitment Therapy and Educational Techniques.
Abbass, (2009). Baikie KA. (2012). Burger AJ. (2016). Burton, C. (2003). Cherkin et al (2016). Clarke DD (2016). Drossman DA, Ringel Y, et al (2003). Edwards TM, Stern A, Clarke, DD et al. (2010). Engel, GL (1977). Escobar, J. I. et al (2007). Fors EA et al. (2002). Geenenyz, R. & Bijlsm J.W.J. (2010). Gordon, A. (2010). Guthrie, E., Creed, F. et al (1993). Hann KEJ, McCracken LM. (2014). Hannibal & Bishop (2014). Hsu MC et al. (2010). Hsu, M.C. and Schubiner, H. (2010). Kroenke K., Swindle R. (2000). Laird KT, Tanner-Smith EE et al (2016). Lumley, M.A. & Schubiner, H., et al (2017). Lumley, M.A. & Schubiner, H. (2019) x2. Moseley GL, Butler DS (2015). Peabody, F. (1927). Powers SW, Kashikar-Zuck SM (2013). Rasmussen, N. H., Furst, J. W.,et al (2006). Schechter D et al. (2007). Smith, R. C., Lein, C., Collins et al. (2003). Speckens, A. E. M., van Hemert, et al (1995). US Dept of HHS Pain Report (2019). Williams AC, Eccleston C, Morley S. (2012). Ziadni MS et al (2018).

2. Evidence regarding the link between adverse life experiences (child or adult) and persistent physical symptoms.
Anderberg UM et al. (2000). Aybek S et al. (2014). Davis DA, Leucken L, Zautra AJ. (2005). Drossman, DA, Talley, NJ; et al (1995). Egloff N et al. (2013). Felitti VI. (1998). Goldberg RT et al. (1999). Gupta, M. A. (2013). Harrop-Griffiths J, Katon W, et al. (2009). Kessler RC et al (2010). Lane, R.D. et al (2018). Nicol AL et al (2016). Sachs-Ericsson, N.J., Sheffler, J.L et al (2017). Schofferman, J., Anderson, D., et al (1992). Sheinberg R et al (2019). You, D.S. & Meagher, M.W. (2018).

3. Evidence that psychological factors can change pain perception.
Bardin et al (2009). Berna et al (2010). Campbell, C.M. et al. (2015). Carroll, L.J. et al (2004). Carson, J.W. et al (2007). Castro WH et al. (2001). Chou, E.Y. et al (2016). Costa et al (2005). Eisenberger, N.I. (2012). Eisenberger, N.I. (2015). Gracely RH. (2015). Harvard Medical School, (2010). Hellman, N., Kuhn, B.L. et al(2018). Kross E et al. (2011). Kulkarni, B et al. (2007). Mcbeth et al (2005). Quartana, P.J., Burns, JW. (2007). Rhudy& Meagher (2000). Rivat et al (2010). Suarez-Roca et al (2008). Von Houdenhove B et al (2001). Wager, T.D., Rilling et al. (2004). Wiech, K et al. (2009). Wise, B.L., Niu, J, et al (2010).

4. Evidence that objective measures of organ disease or structural abnormality (such as imaging studies) are not good predictors of persistent symptoms and/or that psychological factors are better predictors.
Bedson, J. and Croft,P.R. (2008). Bigos, S.J. et al (1992). Boos, N et al. (1995). Borenstein D.G. et al. (2001). W. Brinjikji et al (2015). Burton T, Farley D, and Rhea A. (2009). Carragee, E. et al (2006). Carragee, E.J., Lincoln, T., et al (2006). et al. (2003). Christensen JO et al. (2012). Elliott J et al (2010). Englund, M. et al. (2008). Feyer AM et al. (2000). Jensen, M.C., Brant-Zawadzki, et al. (1994). Kaplan LD et al. (2005). Karppinen J. (2001). Kim SJ et al. (2013). Lederman E. (2011). Masselin-Dubois, A., Attal, N.,et al (2013). Matsumoto M et al. (2013). Simotas AC. (2005). Silvis ML et al. (2011). Widhe T et al. (2001). Wise, B.L., Niu, J, et al (2010). Young, A.K., Young, B.K, et al. (2014). Young Casey C et al. (2008)Connor PM et al. (2003). Christensen JO et al. (2012). Elliott J et al (2010). Englund, M. et al. (2008). Feyer AM et al. (2000). Jensen, M.C., Brant-Zawadzki, et al. (1994). Kaplan LD et al. (2005). Karppinen J. (2001). Kim SJ et al. (2013). Lederman E. (2011). Masselin-Dubois, A., Attal, N.,et al (2013). Matsumoto M et al. (2013). Simotas AC. (2005). Silvis ML et al. (2011). Widhe T et al. (2001). Wise, B.L., Niu, J, et al (2010). Young, A.K., Young, B.K, et al. (2014). Young Casey C et al. (2008)

5. Evidence that invasive treatment, non-invasive non-psychological treatment and opioids are ineffective for chronic pain.
Berthelot JM. (2015). Buchbinder R, (2009). Carragee, E.J., Lincoln, T., et al (2006). Carreon, L.Y. et al (2010). Chaparro LE. (2014). Chou R., Baisden, J., et al. (2009). Chou R. (2015). Deyo RA et al (2009). Franklin, G.M.,Haug, et al (1994). Fritzell, P., Ha ̈gg, O. et al (2001). Geiss A. (2005). Hadler, N.M. (2003). Kallmes DF et al (2009). Keller A et al. (2007). Khan, M., Evaniew, N., et al (2014). Kirkley A, et al. (2008). Lian, J., Mohamadi, A et al (2018). Mirza, S.K. and Deyo, R.A. (2007). Nguyen TH. (2011). Staal JB. (2009). Thordarson, D., Ebramzadeh, E. et al (2005). Traeger AC et al. (2019). Verbeek JH. (2012).

6. Studies of the neuroscience of chronic pain including the key role of altered nerve pathways in the brain.
Apkarian AV et al. (2005). Aybek S et al. (2014). Brown CA et al. (2014). Derbyshire SW et al. (2004). Drossman, D. A., Ringel, Y., et al (2003). Eisenberger NI et al.(2003). Eisenberger, N.I. (2012). Eisenberger, N.I. (2015). Gündel, H., Valet, M. et al (2008). Harper, M. (2012). Hashmi JA. (2013). Kim J, Loggia ML, et al (2015). Kindler LL. (2011). Kivimäki M et al. (2004. Kulkarni, B et al. (2007). Lamm C et al. (2011). Lorenz J. (2003). McEwen BS & Kalia M. (2010). Wager, T.D., Rilling, et al. (2004).

7. Evidence for the benefits of expressive writing, reappraisal of arousal and exercise.
Gortner EM et al. (2006). Graham JE, Lobel M, Glass P, Lokshina I. (2008). Jamieson JP et al. (2012). Jamieson JP et al. (2013). Smyth JM et al. (1999). Streeter et al (2010).

8. The economic impact of PPD.
Barsky, AJ et al (2005). Deyo RA et al (2009). Gaskin DJ, Richard P. (2012). Henderson M. (2005). Landa, A. et al. (2012). Nimnuan C. (2001).

Dr John Sarno’s Tension Myositis Syndrome (TMS) / PsychoPhysical Disorder (PPD) approach to the diagnosis and treatment of a range of mindbody conditions has been the subject of a number of peer reviewed studies.

Whilst undertaking my psychology degree at ANU, I (Hal) had the opportunity to read many of Sarno’s original research studies as well as his books (the latter being generally oriented more towards the sufferer who is trying to get well rather than the academic reader).

In recent years Sarno’s approach has been adopted by a new generation of mind-body oriented physicians and therapists. Encouragingly other authors have also published peer reviewed journal articles on his approach. Whilst there are still relatively few articles written specifically about TMS / PPD theory, there is a substantial mainstream literature exploring the connection between pain presentation and psychosocial factors. Unfortunately many of these articles only explore cognitive based approaches to pain management. These can be very useful in managing pain levels in many circumstances. However, the emerging mindbody literature is increasingly demonstrating that a significant subset of pain sufferers will be able to make a complete recovery if they are prepared to work with the unconscious aspects of emotion, which are not the subject of cognitive treatments.

Of the TMS / PPD studies I have reviewed personally all have indicated significant effect sizes for given treatment groups. This, in combination together with my own clinical experience leads me to conclude that Sarno’s approach is highly effective for the subgroup of patients who can accept the mind-body aspects of their condition.

 

Dr John Sarno’s primary research was published in a number of papers including:

Sarno, John. 1981. “Etiology of Neck and Back Pain: An Autonomic Myoneuralgia?”. Journal of Nervous and Mental Disease Vol 169 No 1 p55-59.

Sarno, John. 1977. “Psychosomatic back ache”. Journal of Family Practice Vol 5: p353-357.

Sarno, John. 1976. “Chronic back pain and psychic conflict”. Scandinavian Journal of Rehabilitation Medicine Vol 8: p143-153.

Sarnos monographs are also recommended, particularly his later works “The MindBody Prescription” and “The Divided Mind”:

Sarno J. The mindbody prescription: Healing the body, healing the pain. New York: Warner Books; 1998.

Sarno J. The divided mind: The epidemic of mindbody disorders. New York: Harper Collins Publishers Inc; 2006.

“The MindBody Prescription” also contains a section for the academic reader with further explication of Sarno’s position on the psychodynamics of pain syndromes.