I’ll have to start with my standard disclaimer that I’m not a medical doctor, nor do I play one on the internet. This post is lengthy, but reflects one of the most important transitions of my life. This story starts near the time of my birth. My earliest memories of my father involve his back pain. The restricted activities, the special chairs, ointments, gadgets and the lengthy daily ritual of corrective stretches on custom-shaped foam blocks. Oh, and the constant professional care. The doctors, chiropractors, surgeons, massage therapists, osteopaths, energy workers and acupuncturists. In 1970, my father was 28 years old and living the hippy artist life in the Potrero Hill district of San Francisco. My mother was pregnant with me, and against my father’s wishes, his very controlling mother decided it best to move in with both of them.
For the first time, and seemingly out of nowhere, he experienced a low back spasm and sciatica in his leg that was so intense that he passed out from the pain. By the time I was a year old, the pain had become chronic and the multitude of mentioned treatments began. In 1987, he was desperate and opted for back surgery after a MRI revealed a disc protrusion. Then, as often happens with back surgery, things got even worse. Today, my father would have just turned 80. Four years ago, what started as esophageal cancer, quickly spread throughout his bones. The medicinal cannabis definitely eased the discomfort of chemo for the last few months of his life, but I cannot help but wonder if four decades of daily pain medication to manage the chronic back pain played a part in the cancer.
I was never exposed to any team sports as a child, which I am certain had quite a lot to do with my father’s chronic back pain. By the time I was an underweight junior high student, team sports were mandatory for PE and the previous lack of history made for a horrible experience. Any kid who has been subject to intense bullying, especially back in the 80’s, knows the dread of PE. It’s no surprise that I became obsessed with weight training as a young adult, and eventually a trainer. My biggest fear? Hurting my lower back. For good reason, I held a belief system that the human spine is poorly designed and inherently fragile.
I always warmed up judiciously and wore my lumbar support belt like a sheath of armor. Yet I hurt my low back over and over again. Sometimes it would ache for a couple of days and other times for weeks. Heavy squats were my nemesis but I also tweaked it in odd and indirect ways, like on a supported leg-press sled or just racking heavy dumbbells. In 1994, when I was 24 years old, I too had a life-altering event. On a cold and rainy San Francisco morning, I began a workout with heavy bent-over barbell rows like I had so many times before. But this time on the first set, I felt an intense pop in my lower back and immediately fell to the floor. It was so painful to put on my shoes, let alone walk, that I spent most of the next two months lying down and contemplating how I’d get through the following day and continuing my career as personal trainer was unfathomable. At this point, I was convinced I had fulfilled my father’s legacy, and would be relegated to a life of chronic pain.
My father was quick to recommend several of the specialists he was seeing. I saw many chiropractors across various disciplines, massage therapists, accupressurists, and acupuncturists. Out of desperation, I even tried the energy workers. Nothing made it even marginally better. After two years of treatments and continued symptoms that ranged from needles in my feet to sub-scapular spasms, I finally succumbed to a MRI. Unsurprisingly, the scan revealed a disc herniation between L4 and L5. Three of my other discs showed severe degeneration and I also had degenerative osteoarthritis. The orthopedic surgeon recommended immediate surgery and flatly stated that I could no longer lift weights nor engage in any strenuous activity without the risk of making things much worse. Based on the outcome of my father’s back surgery, I was not quite sold but started contemplating the option. There were also things that did not make any sense about this injury. Sometimes the pain would vanish for a day or two at a time and then reappear without cause. I also did not understand why I was getting all of these other weird physical symptoms in places that had nothing to do with the nerves that were exposed to this specific disc protrusion shown in the MRI (I obsessed over nervous system diagrams in medical text books). Every care provider had a different but equally vague answer for this. The most common was, “The human spine is very complex, and we’re still learning a lot about how to treat it for injuries.” This was not a very comforting explanation when considering letting one of these guys cut me open.
About a year later, I was still in constant pain, but against the surgeon’s advice, I continued to exercise. I was just very, very careful. Most of it was seated, I always wore my trusty lumbar support belt and had also added a variety of salves, ointments and anti-inflammatories. It seemed that I was rarely in pain when I was actually exercising, though I would intuitively expect the opposite. My life was much different mow. I was no longer training people and instead wore a suit and tie, commuting to an office every day with my special carseat for added lumbar support. On one of these drives, I was listening to a guest named Dr. John Sarno on The Howard Stern Show, back in the days of terrestrial radio. Evidently, this wasn’t he first time he had been on since “curing” Howard’s chronic low back pain. I could not grasp exactly how he did it, but person after person called into the show with stories about how Sarno had also fixed their back pain.
Figuring anything was worth a try, I ordered Sarno’s book “Healing Back Pain” and carefully read through every page. In about two weeks, I was roughly 80% better. A couple of months later, I was completely symptom free. After years of pain, my pain was gone because I read a book. Here is where I will now humbly attempt to summarize a man’s life work in a blog post. Dr. Sarno earned his medical degree from Columbia University’s College of Physicians and Surgeons in 1950 and later became board certified in Rehabilitation Medicine. By the early 70’s, he realized that his patients who came in with back pain rarely improved. Here were some of the questions he began to ask about chronic back and neck pain:
- Why has lower back pain quickly reached epidemic proportions, ranking only second to the common cold as the reason for missed work?
- Why, after millions of years of evolution where humans have continually endured physical hardship, would we suddenly become unable to preform basic day-to day-functions without pain?
- If there are structural evolutionary inadequacies in our bodies, why is it that they have started causing chronic pain in only the last fifty years?
- Why would directly working the affected area with ultrasound, massage therapy and exercise often provide temporary relief for a structural injury as opposed to further aggravate it?
- Why is chronic back pain only prevalent in industrialized nations and why have the numbers climbed so dramatically in the last twenty years?
- How could the physiological structure responsible for protecting your central nervous system be completely devastated by something as innocuous as picking up a child or sleeping on a soft or hard surface?
- If your spine is injured, why would only very specific activities like sitting in a chair or standing cause pain in that area, but not other actions that involved the same area such as riding a bike or cooking? Or vice versa?
- When a MRI shows identical spine abnormalities in different patients (such as the exact same disc protrusion between L4 and L5), why are the symptoms so wildly different? They might include sciatica in the left leg and in others the right, even though the “injury” is identical. Some might have local pain while others get cramps in their calfs. Some have shooting pain in the buttocks and others have no symptoms at all.
- Why do most patients’ pain get considerably worse after a diagnosis supported by a X-Ray or MRI?
What Dr. Sarno discovered is a phenomenon called Tension Myositis Syndrome (TMS). Myositis simply means a physiological alteration of muscles. While this alteration is often incredibly painful, it is also harmless. The way TMS works physiologically is by acting out through the body’s autonomic nervous system. This is the part of the central nervous system responsible for all those involuntary functions of organs like your heart, stomach, lungs and liver. It also controls the circulation of blood. Most TMS manifestations are a mild restriction of blood flow to a target tissue, resulting in a lack of oxygen to that area. If that tissue is a muscle or tendon, this will cause a reaction that ranges from mild pain to severe spasming. If a nerve is involved in this area of oxygen deprivation, in addition to pain, there may also be numbness, tingling and weakness. This is why exercise usually helps relieve the symptoms — it is temporarily forcing oxygen rich blood to the target areas that are being deprived. In the case of an actual structural injury, say a torn ligament or muscle, this would not be the case.
So why would our autonomic nervous system do such a horrible thing to us? Well, that’s where things get really interesting. Believe it or not, it’s our unconscious mind trying to protect us through the old parlor trick of distraction. Over the accumulative years of our everyday lives, there are many things that make us angry and we are rarely consciously aware of most of it. Like a well that is slowly filled over time but never emptied, this anger accumulates and eventually forms into repressed rage. When the amount of rage in that well reaches a critical level and threatens to overflow over into conscious awareness, the brain might create this diversion of pain.
I know what you are likely thinking at this point — especially if you have had this in your life for a long time. That it makes no sense for your brain to cause debilitating, chronic physical pain just to avoid confronting some unconscious rage. To fully understand this, we need to go back to some of the roots of this work. Freud conceived of three components of the emotional mind, later labeled as the parent, adult and child. The parent and adult are found in both the conscious and unconscious mind and play a role in TMS, but it is the child that is the real culprit. Just like an actual child, this part of the unconscious is self-involved, dependent, charming and very often illogical and irrational. But unlike most actual children, it is also endlessly angry. This angry, irrational part of your unconscious would opt for you to deal with this incredibly painful distraction than what it deems to be an insurmountable volume of rage.
Sarno’s original book outlines the personality characteristics which are more prone to this disorder. I went down the checklist and felt as though I was reading my own profile. But nobody is immune to unconscious rage. Sarno believes most of it stems from three distinct sources:
- Rage that was generated during the time of infancy and childhood.
- The daily rage that comes from the pressure we put on ourselves to stay driven or be perfectionists.
- The rage that results from all of the little unacknowledged pressures of everyday life.
Although we are all subject to repressed rage from these sources, as mentioned, certain personality types have been shown to be more susceptible to TMS. Here are some of the traits that often tend to cause symptoms:
- Perfectionists: Projects have to be done perfectly, always needing to complete one task or another. Ignores own needs and feelings to complete tasks and putts well over 100% into everything they do. A clear picture of how everything should be and always has too much on their plate.
- People Pleasers: Usually adhere to what social, cultural or religious norms deem to be as “good” spouses, parents, children, employees, friends, etc., while failing to address their own needs. Often attempt to be the peacemakers during arguments, don’t speak their mind in confrontations and usually go along with others to avoid disagreements.
- Legalists: Always feel their view is right and tend to think the world would be better if more people thought like they did. Takes them a long time to make a decision because they are so worried about making the wrong choice.
- Stoics: Have a hard time expressing their emotions so they often hold them in. Embarrassed to cry in front of friends or family and feel a sense of control in their life when able to control their emotions.
- Driven by Anxiety & Fear: Always worried that a situation might yield the worst possible outcome. Nervous meeting new people, afraid people will reject them if what they were really all about were discovered. Fearful of the worst possible outcome of doctor’s visits.
- Low Self-Esteem: Question their ability to do things competently, get anxious in crowded rooms or when meeting new people. Do not feel like they are as well liked as others and do not feel like they deserve praise or compliments.
- Hostile and Aggressive: Low tolerance for those who make mistakes, easily subject to road-rage, little events make them react in an extreme manner. When involved in a conflict they are always convinced the problem is someone else’s as opposed to theirs.
- Dependents: Like it when other people make decisions for them. Being alone is frustrating and upsetting for them, prefer others to take the lead when making plans, avoid jobs that they know will be a challenge. End up in relationships where they are the one being taken care of.
So now you know why it happens and how it works. So how do you fix it? Well, you may have actually just started to. The foundation of a TMS cure is knowledge. The biggest pill to swallow is that you may very well not have any physiological problem, but instead a psychological one. Very often, once people truly accept and internalize this diagnosis, the unconscious mind’s charade begins to disintegrate, thus making the distraction of pain ineffective. It is as if you are saying to your brain, “Sorry, buddy. I know what you have been doing and the jig is up.” Many people, like myself, were cured just by reading the book. Others require more work, sometimes ongoing, and benefit greatly from talk therapy.
There are many factors that play into how hard TMS might try and hang on. The amount of repressed rage has a lot to do with it as does one’s willingness to mentally let go of the idea that there is something physically wrong with them. If they have lived with chronic pain for months, years, or even decades, this can be an incredibly difficult thing to reconcile. The pain and all the routines around it have become part of their identity. Some people’s pain comes out of nowhere, but usually there is what Sarno calls a “trigger” event. This is the occurrence that mentally anchors the original cause for the ongoing chronic pain. Some triggers make no sense at all. Why would the strongest bundle of muscles in the human body get “thrown out” from the act of picking up a child or lifting a box? Other triggers are more believable such as car accidents and sports injuries. In my case, I was totally convinced that lifting 315 lbs off the ground on a cold morning could absolutely crush one of my discs and cause pain for the rest of my life.
However, the fact remains that even if that was the cause of the herniated disc shown on the scan, the symptoms that resulted made no medical sense in relation to that specific injury. Actually, it is much more likely that the herniation was already there, along with all the degenerative discs that the scan revealed. The MRI only psychologically validated that I had a crippling injury, reinforcing the efficacy of the brain’s distraction tactic. The truth is that most people have disc protrusions but never have symptoms. A study at the University of Copenhagen compared X-rays of 238 patients that complained of back pain with those of 66 other patients that had no pain at all. The difference in the X-rays? None. Every single one had degeneration of the discs and the presence of spondylosis (bone spurs). In 1994, the New England Journal of Medicine published a report that showed disc bulges and protrusions on MRI’s in 64 out of 98 men and women who had never had back pain.
I am in no way saying that it isn’t possible to physically injure your back, but it is equally important to remember that the body has an amazing capacity to heal itself. Only five weeks after my wife sustained a transverse fracture on her fibula, she was back to walking, and was sleep-deprived while taking care of a one-year-old during the entire healing process. When months or years go by without relief after stepping off of the curb wrong way or sleeping on that soft mattress at your in-laws’ house, there is more likely a psychological cause at the root of things.
Aside from the reading and therapy, there are some other actions you can take. Most of them have to do with refraining from anything that cements the idea that you have a physiological problem. Have you stopped exercising for fear of re-injuring yourself? It’s time to start back up. Are there specific stretches and exercises you do for your back injury? Stop them all. Do you have a special lumbar support seat for your car or office chair? Get rid of it. Do you wear support belts or braces? Take them off. Dr. Sarno even eventually stopped recommending any physical therapy for his patients because he felt it was doing more harm than good by validating the idea of a physical problem.
Here are a few things to give a try:
- Contemplate Your Rage: The bummer about dealing with the unconscious is that you’ll never really know what’s lurking in there. However, you can make some good guesses and start to really be with those things that make you angry. This isn’t so easy when you’re in pain. The greater the pain, the harder it will be to concentrate on feelings, but that’s all part of the brain’s strategy.
- Self-Talk: This is a matter of your conscious mind addressing your unconscious mind. Do not be afraid to speak out loud and tell your brain that you are on to its shenanigans. Demand that it increases the oxygenated supply of blood to the areas that are in pain. Be forceful and even try yelling out loud. Remember, you are dealing with a selfish and irrational part of your emotional mind.
- List it Out: Get all that rage out on paper. Make a list of all the pressures you feel and manifestations of the personality traits I listed earlier. Life is beautiful, but it is also often infuriating. Your partner and children might be the greatest source of joy in your conscious life, yet the greatest causes of rage in your unconscious mind. It is very difficult to admit you might resent your own children to the point of rage, but it is also much more common that you would believe.
- Journaling and Meditation: Are you too busy to write for a few minutes each day or just sit in silence? Then this one is especially important for you to try. The alleviation of TMS is based on your ability to think your way out of it. If you do not have the mental space in your life for a little introspection, this will be incredibly difficult to achieve. Create some protected time for you to work through this and it will pay dividends.
Over the years, I’ve had some reoccurrences of back pain, some worse than others. Some people never experience pain again after fully embracing the cause of TMS, but I seem to need some gentle reminding now and then. A few years ago on winter break, I was at the gym just hours before flying out to spend time with my wife’s family in Utah. It was going to be a long trip in order to cover her family and my own in San Francisco. My wife was in a cast with a broken ankle, and we were traveling with our baby and daughter. I did not finish all the work that I had intended to before leaving, and I get stressed out as it is when going home to visit my family. As I contemplated all of this during my first set of deadlifts, I felt a sharp spasm in my low back. By the time I arrived at my in-laws, it hurt to breathe. I spent all night unable to sleep and drenched in a cold sweat. For three days, I popped muscle relaxers and pain pills and even tried lying in the snow to relieve the spasming. I was so convinced that I hurt myself deadlifting, that I forgot all about TMS. But the pain started shifting into all sorts of weird places that didn’t make physiological sense. That night, I opened up my Kindle and downloaded Sarno’s more clinical dive into the syndrome, The Mindbody Prescription. I got about a third into the book that night and in the morning, the pain was gone.
I just cannot fully describe how insane of an experience it is to go from that level of pain and then have it just turn off. The transformation was just as mind blowing as it had been twenty years prior. As fate would have it, I ended up marrying a psychotherapist who specializes in pain psychology. Just a few weeks after the last incident, I started getting spasms in my my back after another tough workout. This time, I insisted to my wife that it was TMS, and she began leading me through a series of questions when I suddenly exclaimed, “I’m just so f’ing angry that I understand what is causing this, but it still happens anyhow! I know there’s nothing physically wrong with me, yet I keep falling for this trick that my brain plays on me!” I immediately felt a rush of warmth into the spasmed area and the pain vanished. I actually felt it, as if someone opened up a valve in my lower back. This experience really validated how valuable talk therapy can be for this syndrome.
In Sarno’s later work, he identifies many other medically mysterious chronic disorders that are most likely varieties of TMS, operating under the same psychological premise. Some chronic ailments on that list include shoulder, neck and arm pain, gastrointestinal disorders, arthritis, chronic fatigue syndrome, carpal tunnel syndrome, plantar fasciitis, migraine headaches and even some skin disorders. If the cause and effect of your problem is murky in medical logic and wrought with contradicting remedies, it is worth examining TMS as the possible culprit. Location substitution is fairly common with tougher TMS cases. This is when pain stops in one area only to start in another. This is the brain’s attempt at continuing to distract you from the unconscious rage by moving the pain to another area or even spinning up a completely new malady. Some patients speak of how they underwent a shoulder surgery only to have pain appear in their “good” shoulder shortly afterwards. Others report to be free of their chronic back pain only to get an ulcer later in the year. After my most recent experiences, a psychological cause for a physical ailment is now my default consideration as opposed to my last.
The financial momentum behind back and neck pain remedies alone is staggering. Between 1997 and 2005, the aggregate cost of treatment increased 65%, reaching $86 billion a year. The larger category of chronic pain affects over 100 million American adults. This is more than the number affected by the combined cases of heart disease, cancer and diabetes. If the work around mind-body practices and self-healing gained even incremental traction, the suffering of millions of people could be eliminated. If you have suffered from chronic low back pain, I sincerely hope this helps you as much as it did me. Keep in mind that everybody’s recovery looks different. Do not give up if it is taking a while. Although it is very hard to believe while in severe pain, TMS and its many equivalents are essentially harmless. Please do not take a single diagnosis as the final word of your fate. It has now been proven without doubt that structural abnormalities in the spine are massively common, yet seldom painful. Things can and will get better. You can be free of pain again.