Since I first wrote the following piece in around 2010, there has been an explosion in the number of research papers into mindbody conditions. There are around 100 peer reviewed papers, annotated and linking to the original studies available to read on the TMSwiki here. For the medically inclined please check out that resource. For a basic introduction then read on!
It sounds too good to be true. So where is the evidence?
Unfortunately, the theory is unsuitable for double-blinded treatment trials. If you started with a group of chronic pain sufferers and randomly split them, 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 have a self selecting process, where you 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.
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 (2) Dr Howard Schubiner meanwhile has just finished an (as yet unpublished) study which compares a group of women with fibromylgia who received the TMS program with a control group who didn’t. He found that none of the women in the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.
A small scale retrospective 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)
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.” (7)
There is also published evidence which speaks to the medical benefit gained by expressing emotions through journaling. Joshua Smith 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 Dianne 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 writing about stressful events actually appeared to boost individuals’ immune system.
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. And some of the stories truly are remarkable. Hilary, a founding member of the TMS wiki (a website about TMS), 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. And this is not like the expensive “cures” promised to the desperate, there is no financial incentive behind those involved in running the TMS wiki – all the information people need is provided free online. It is simply former chronic pain sufferers trying to share their own positive experiences of recovery.
Unfortunately retrospective studies don’t meet the medical “gold standard” of clinical evidence and so 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 retrospective 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.
(1) (p xxv The Mindbody Prescription, Dr J. Sarno)
(3) “Clinical Audit reporting on outcomes of a Tension Myoneural Syndrome (TMS) Programme in a physiotherapy practice.” G. Oldfield. 2009.
(7) “Abnormal magnetic-resonance scans of the lumbar spine in asypmtomatic subjects. A prospective investigation.” SD Boden et al.
“Magnetic Resonance Imaging of the Lumbar Spine in People without Back Pain.” Maureen Jensen et al
(8) Joshua Smith et al published in the Journal of the American Medical Association: JAMA 4/14/99 vol 281 no 14 p1304-09
(9) Dianne Berry et al published in Psychotherapeutics and Psychosomatics 1993: 59: 11-19
(10) Journal of Consulting and Clinical Psychology, 1994, vol 62, no 1, 130-140.