quote:

---

Dr. James R. Rochelle, M.D., Orthopedic surgeon

As a general orthopedic surgeon, I see patients with fractures, sports injuries, workers' compensation and personal injury problems, and many cases of acute and chronic low back and neck pain. I also see patients who need joint replacement surgery. Other common conditions are tendonitis of the knee and shoulder, rotator cuff pathology, chondromalacia of the patella, and carpal tunnel syndrome.

...

I have found that patients often seek out nonmedical practitioners on their own because of dissatisfaction with conventional medicine. Minor abnormalities of the spine are often treated with manipulation or other physical modalities. The results are mixed. In the light of what I have learned about acute and chronic pain, I believe that improvement in these cases may be due to the passage of time or a placebo reaction. The laying on of hands and a sympathetic, warm interaction between practitioner and patient can also contribute to symptomatic improvement.

Having surveyed the field of "chronic pain," I became convinced that no one had any long-term answers. I no longer wanted to refer patients for treatments that weren't working! I felt strongly that patients were actually being harmed by the attitude of their physicians. Many patients had become convinced that they had a "bad back" or a "bad neck." Doctors would encourage their patients to apply for Social Security disability benefits because they could see no other way of helping them. Some even told their patients that they might end up in a wheelchair. Andrew Weil, M.D., has referred to this negative conditioning as medical pessimism. With such gloomy prognoses, patients became disheartened and lost hope that they could live a normal life again. This negative conditioning is a major reason for the pain epidemic in the Western world today.

Another form of treatment of dubious value is surgery for the back and neck. There is now a large number of surgeons who specialize in such surgery. In addition to surgery to remove herniated disk material, spine fusions are now commonly done, though it has not been demonstrated that they are more effective than the simpler procedure. Indeed, experience treating TMS questions the need for any surgical procedure in most cases. Elaborate surgical hardware has been invented to provide stability for the spine, based on the idea that the back is unstable and, therefore, painful. There is nothing in the medical literature that supports this contention, despite which fusion surgery has increased dramatically in recent years.

One of the consequences of all this surgery is something called the failed back syndrome. Despite the technically well-informed spinal fusions with impressive x-rays, a large number of the operations end in failure! Most of the literature on failed back syndrome indicates that "psychological factors" are probably responsible for poor results, with failures approaching 30 to 50 percent. The exact nature of these "psychological factors" is poorly understood by spine surgeons, who are nevertheless undeterred in their enthusiasm to perform lumbar spine fusions. They obviously have strong financial and professional incentives to continue doing what they have been trained to do.

...

...

I referred some people for psychological evaluation. The referral process was a touchy subject because of the inference some people made about my request for an opinion about emotional issues. "Are you saying that this pain is all in my head?" my patients would ask. I explained that the pain was real and physical, but that emotional issues might possibly be part of the picture.

...

Obviously, something was missing in my understanding of "the psychology of chronic pain." What was I missing? I conducted an extensive literature search in the field of chronic pain, including the realm of alternative medicine. I read Dr. Andrew Weil's Natural Health, Natural Medicine. Dr. Weil strongly endorsed the concept of tension myositis syndrome (TMS). Dr. Weil wrote: "I am a great believer in TMS, having seen a great many cases of chronic back pain disappear as if by magic when people fall in love or otherwise make radical changes in their emotional and mental life." The possibility that chronic back pain is psychosomatic was intriguing to me.

On Dr. Weil's recommendation, I read The Mindbody Prescription by Dr. Sarno. The first thing that caught my attention was his discussion on ulcers. ... I came to understand that we are in the midst of an epidemic of pain caused by the psychological issues addressed by Dr. Sarno.

The psychological issues had not been adequately addressed by conventional medicine because there was no appreciation of the importance of the unconscious. Dr. Sarno gave primary credit to Freud for emphasizing the importance of the unconscious in all human behavior.

In order to learn more about incorporating TMS theory into my own practice, I visited Dr. Sarno at New York University in January 2002. I sat in on forty-five minute office visits with five of his new patients on each of two afternoons. I attended the two-hour lecture he presents on a weekly basis. On the second evening, I attended a small group follow-up session for those who were still having pain a month or so after attending a previous lecture.

There were three major eye-openers for me when I compared my own practice to that of Dr. Sarno. They related to the great significance he placed on:

1. The patient's social history

2. The findings of tenderness on physical examination

3. The importance of one diagnosis, one unifying concept: TMS



Social History

The most striking difference between my practice and that of Dr. Sarno was in the realm of history taking. Dr. Sarno spent a good deal of time obtaining the social history. This includes information about marital status, family history, siblings, and occupational information. Then he asked another question: "How was your childhood?" I had never asked that question of any patient in all my years of orthopedic surgery! Some people had good childhood experiences. Some people had experienced significant difficulties. Dr. Sarno allowed the patients to do most of the talking, trying to get a feel for different types of conflicts that people may have had in their childhood. If physical, emotional, or sexual abuse had occurred, we had a brief discussion about it's impact. Dr. Sarno tried to get a feel for what kind of relationship people had with their parents or guardians.

...

As I reflected on my experience in New York, I now realized one of the major reasons I hadn't understood the psychology of chronic pain. I had never asked people about these very important aspects of their lives. Why should I bother to ask people about their childhood? Did it really matter what kind of personality traits my patients had? Could issues of life stress really be all that important in causing the pain? After all, I was an orthopedic surgeon! I was too busy to take more than fifteen minutes to conduct an office visit for someone with chronic pain.

My previous attitude of neglect and ignorance of the importance of the social history is certainly typical of the vast majority of conventional doctors. I had never learned how to take a good social history. Like most doctors, I usually skipped over this vitally important source of information. ... Inadequate social history taking must be considered a primary reason that most doctors do not appreciate the true psychological factors that cause chronic pain.

Dr. Sarno's book provided a framework for understanding why these aspects of social history are important. He explained to his own patients that there are three sources for unpleasant emotions in the unconscious: childhood anger, emotional pain, and sadness; personality traits such as perfectionism and goodism; and the realities of life. He explained the mechanics of daily study as part of the treatment. People get better by developing a conscious awareness of the sources of unconscious rage and emotional pain.

Physical Exam: Tenderness

Dr. Sarno's physical exam was instructive. He did a complete musculoskeletal examination, with emphasis on findings of tenderness. I never realized how frequent the finding of tenderness on the outside of the thigh is in patients who have chronic low back pain. In Dr. Sarno's experience, this correlation is approximately 80 percent. Tenderness in the gluteal and lower lumbar region is almost universal in TMS, as is tenderness at the top of both shoulders. Many patients have paraspinal tenderness throughout the lumbar spine, extending sometimes into the thoracic area as well.

... This superficial tenderness indicates that deeper structures, such as the intervertebral disks, are not producing the pain.

[This is also what Dr. Richley told my wife.]

Before I knew about TMS, I tended to gloss over palpation of areas of tenderness in performing a physical examination. I usually had a predetermined notion that a person's chronic low back pain was caused by some degenerative condition in their back. Often, I relied on an MRI, assuming that some "structural abnormality" was the cause of the pain. These abnormalities are simply mentioned by the radiologists in their reports because it is their job to report everything they see. It is the job of the treating physician to put all the information together in arriving at a diagnosis. I had been too quick to jump to the conclusion that the reported "abnormalities" on the MRI were the cause of the patient's pain. I was dazzled by the clarity of the MRI technology. Like most physicians, I had a need to demonstrate that the cause of the pain was physical.

I had simply neglected the fact that these degenerative and bulging discs seen on the MRI are normal! We all get them as we get older. Even herniated discs seldom give rise to chronic pain syndromes because the swelling and inflammation from an acute herniation usually settles down within one to two weeks. I had not been doing an adequate examination for tenderness and, therefore, missed out on this most important physical finding. The diffuse tenderness that is present in TMS indicates that the central nervous system, the brain-mind, is involved. This is the only explanation that makes sense. It is anatomically impossible for disk abnormalities to produce tenderness in the iliotibial band, a tendon, and the gluteal, quadratus, lumborum, lumbar paraspinal, and upper trapezius muscles, as we see in chronic low back pain caused by TMS.

...

One Diagnosis

There is a strong tendency for pain loci in TMS to move from one place to another. I used to see patients with back pain for several months. After resolution of the back pain, I would see them later for shoulder tendinitis and still later for neck pain. I now realize they were having location substitution. This is typical of TMS; Dr. Sarno refers to it as the symptom imperative, meaning that if the psychological need for physical symptoms continues, the brain will continue to produce them until the psychological situation changes for the better.

This is an important revelation for both patient and doctor. Many people spend a lot of time and money seeing super-specialists for each different area of the body. They often get the impression that they are falling apart physically. They are at the point of near exhaustion from all the various diagnoses and treatments.

Many specialists tend to see the patient only in terms of his herniated disk, his shoulder impingement, or his carpal tunnel syndrome. There is a woeful trend toward "body parts medicine" that fails to see people as individuals. ... This cookbook approach to treatment may serve the interests of the managed care bureaucracy, but it drives a wedge between patient and doctor. There is very little appreciation of the whole person and no understanding of the mindbody connection. There is little wonder that many people seek alternative treatments for the many different conditions diagnosed by conventional allopathic physicians.

...

Most important, the knowledge that a person has one condition, TMS, and not several different and unrelated diagnoses is a huge benefit. There is no need to spend time and money on multiple diagnostic exams and visits to specialists. There is no need to pursue different chemical or physical treatments.

Patients can be reassured when they have TMS that their back is normal; their neck is normal; their arms and their legs are normal. Reassurance is powerful medicine. People can stop worrying that their next attack of severe neck pain is just around the corner. They will realize that they don't have a permanently "bad back." They can work to reverse the powerful negative conditioning the medical establishment has foisted on them over the years. They can rediscover faith and hope in the future.

It's really a question of diagnosis. That's the heart of the matter, Dr. Sarno has stated. The TMS diagnosis is liberating and empowering for patients. It gives chronic pain sufferers their best opportunity to live a full and rewarding life, free of pain.

Implementing TMS in My Practice

The approach to each person needs to be individualized to address the issues that are relevant to their particular presentation of TMS. Some people need a lot of discussion about structural abnormalities that may have been diagnosed by other doctors. Many people have significant fear about certain activities that cause pain. Other people have a hard time believing that unpleasant emotions can cause physical symptoms.

I tell people to give the educational program a try. It's natural to have reservations about a concept that is so different from orthodox medical diagnosis and treatment. It's my job to educate them about TMS and to address their individual concerns. Many people agree to adopt an open attitude, and they usually accept my initial invitation to attend the TMS lecture.

... Most people state their intention to come when they see me for the initial visit, while a small number state that they are not coming because they reject the concept of TMS. I expect that half or more of my patients will eventually reject the diagnosis. This should not be a source of irritation or hard feelings. I tell people who reject the diagnosis that I respect their opinion, and I wish them good luck, presumably with another physician.

... Some people who reject the diagnosis are looking for a more conventional treatment. Some people want a "quick fix." Many people want me to prescribe a medication or perform an injection or operation that will cure their pain problem. I can't magically get rid of their pain for them. It is only those who are willing to take responsibility for learning about their condition and doing the daily study program who will be cured of TMS.

As a physician, I have always prided myself on being able to help the large majority of my patients. It is quite frustrating for someone like me to accept that half or more of my patients will reject my diagnosis and treatment. Some patients take offense at the suggestion that their condition is psychosomatic. I avoid using this "P-word" during the initial interview (unless specifically asked about it) because some people believe that psychosomatic means that the pain is "all in my head." I strongly emphasize that their pain is real and physical. The pain is in the body. Despite my best efforts to clarify this point, some people seem afflicted with selected hearing. They hear that the mind is involved in TMS. They seem to believe that I am implying they have some sort of mental illness, and they reject the diagnosis.

---