Back pain persists as one of our culture’s most debilitating and costly health problems. Back and neck pain disable an estimated five million Americans, at an annual cost of $20 to $50 billion. In the U.S., back pain is listed second only to colds and flu as a primary reason for physician visits.
Given that our backs are designed to support us for a lifetime, I find these statistics staggering. And I know there must be a better way than the standard medical prescription of rest, drugs, and surgery.
Several years ago, I reported on the pioneering work of John Sarno, M.D., in my book, Women’s Bodies, Women’s Wisdom. Dr. Sarno identified the role of muscle tension and suppressed emotions in triggering the chronic pain cycle. Dr. Sarno, now in his seventies, has long taught that most cases of back pain and sciatica are related to tension myositis syndrome (TMS), a condition in which the back muscles become painfully tense. This cycle is often triggered by unrecognized or unresolved emotions such as anger or anxiety. I’ve long been an advocate of Dr. Sarno’s approach, as well as his book, Healing Back Pain: The Mind–Body Connection.
Now, I’m pleased to report that Dr. Sarno’s groundbreaking work has been acknowledged and taken to the next level by a team of Boston area medical professionals. They, too, are having success teaching patients to break the cycle of chronic back pain by following the program outlined in Back Sense: A Revolutionary Approach to Halting the Cycle of Chronic Back Pain, by Ronald D. Siegel, Psy.D., Michael H. Urdang, and Douglas R. Johnson, M.D.
I called Dr. Siegel to get the inside story on what had led him and his colleagues to write Back Sense, and also to see what services they now offered to those with back pain. Dr. Siegel developed his expertise in treating back pain through what I consider the most authentic means possible—by actually experiencing chronic back pain and turning it around through the approach outlined in Back Sense. He is a licensed clinical psychologist and member of the clinical faculty of Harvard Medical School. His practice in Lincoln, Massachusetts, is devoted to helping those with chronic back pain break the cycle that leads to its continuation. He refers patients when necessary to his co-author, Dr. Douglas Johnson, who is board-certified in physical medicine and rehabilitation, is the medical director of the inpatient rehab unit at Charlton Memorial Hospital, and maintains a private practice in physiatry.
Dr. Ronald Siegel was in his early thirties when his back pain ordeal started. He was in good shape and regularly enjoyed outdoor activities. While on vacation with his brother, he decided to try out a cross-country ski machine. The next day, his back started to ache. He figured it was from the exercise machine. But when he got home, the pain worsened and began radiating into his leg. After several weeks of pain, his toes became numb, so he went to see his doctor, who referred him to an orthopedic surgeon. A CAT scan was ordered, which showed a herniated disk at L5–S1, which supposedly explained the leg pain. He was told that many people can recover without surgery, and was sent home to rest in bed with painkillers, anti-inflammatory drugs, and instruction to be careful of his back.
Being forced to lie in bed from both the pain and the side effects from the drugs, Dr. Siegel remembered that his mother had had a slipped disc when he was a child, and she had never really returned to normal functioning afterward. He began to imagine himself as a similarly disabled person, which filled him with dread.
As he wasn’t getting any better, he decided to consult a sports medicine specialist. This physician took one look at the CAT scan and ordered him back in bed. With several more weeks in bed, his pain and numbness were getting worse. Desperate, he consulted a chiropractor, who began to perform regular spinal manipulations and ultrasound stimulation. He also prescribed a back brace and ice packs. Though Dr. Siegel followed this plan religiously, it didn’t really help.
After a couple of months, Dr. Siegel began dragging himself to work, despite dire warnings about what might happen to him. He had a bed installed in his office. He couldn’t sit for more than 10 minutes, couldn’t walk more than a block, wore a back brace, sat on special cushions, and had to adjust his car seat to take the pressure off his spine.
By this time, Dr. Siegel could think of little else besides his back and leg pain and he had also begun to get angry and depressed. One day his wife became fed up with him and pointed out that he seemed to complain of more pain when emotionally upset. Like many in his position, he dismissed her observation as nonsense, accusing her of blaming him for something over which he had no control.
A friend at work then suggested that he look into the work of Dr. John Sarno. Reluctantly, he talked with a woman who had had chronic back pain for a year who had been healed by applying Dr. Sarno’s principles. She told him to go out and buy groceries—that his wife would appreciate it. So he did. And a funny thing happened. His pain didn’t automatically disappear. But what did happen is that his leg pain transferred to the other leg—which got his attention. How could that happen if all the pain were related to his slipped disc? As he started moving again, he began to realize that all movement did not lead to pain. Little by little he resumed normal activities.
During this time he had a revelation: He had suffered from medical problems in the past that were most likely stress-related: a “pinched nerve” in his neck and chronic heartburn. Increasingly, he became convinced that his back trouble was probably caused by fear and muscle tension. Over time, he worked on regaining his lost muscle strength and also trained his friends to stop asking him about his back pain. His depression and anxiety lifted as he realized he could have a normal life.
Dr. Siegel’s story is not unusual. I sent a friend of mine a copy of Back Sense when I learned that she had been in bed for more than a month with excruciating back pain, which she thought may have been triggered by injuries sustained in a car accident several years previously. She had had MRIs and was under the care of a neurosurgeon who had ordered bed rest and pain killers. But after reading through the book quickly, she put two and two together and realized that her pain had more to do with family and marital difficulties than anything else. Despite her doctor’s orders, she got out of bed and began to move around. Her pain gradually disappeared. She wrote me a note saying, “Thank you so much for sending Back Sense to me. It made lots of sense on so many levels.”
Many women begin to experience joint and back problems during peri-menopause. You must maintain your range of motion and also keep your spine well-aligned and stretched in order to keep the spinal nerves free from impingement, which can lead not only to back pain, but also to hip and shoulder pain. Pilates does this beautifully, and so does yoga. There’s also an ingenious at-home program anyone can do called The Core Program, developed by physical therapist Peggy Brill. The Core Program is a series of exercises that can be done in a small space with only a mat and some ankle weights.
What Causes This
The cause of most chronic back pain is generally misunderstood by both those who suffer from it and by the medical community. Although we’ve been taught that back pain results from damaged or defective tissues in the back, a great deal of scientific research has shown that this simply is not true.
For example, a landmark study reported in the New England Journal of Medicine pointed out that a full 64 percent of normal people with no back pain whatsoever had evidence of abnormal disks, 52 percent had a bulge of some type, 28 percent had some type of herniation, and 38 percent had an abnormality in more than one disk. In addition to disc “problems,” many other types of abnormal spine structures were found.
Unfortunately, each of these findings is regularly presented to back pain sufferers as the “cause” of their pain. Yet the evidence is clear that these findings are common and not evidence of injury or disease. Nejm1 The corollary is likewise true, that extensive testing on many others who suffer from chronic back pain fails to reveal any abnormalities whatsoever. Nejm21
What we do know is that acute physical injury or strain might begin the cycle of back pain, but acute injury heals quickly on its own. What keeps the pain going is chronic muscle tension (just what Dr. Sarno has been saying for years). And chronic muscle tension is the direct result of emotional stress that is not consciously acknowledged by the sufferer. Stress over the pain, worries about the future, the stress of living with a difficult spouse or family member, financial worries, etc., all add up to chronic muscular tension. This pain is not “all in your head.” It’s real. Chronic muscle tension hurts a great deal.
Back Sense contains an entire chapter on the anatomy of the back and explains why structural abnormalities are not the cause of most back pain. This is one area where research is far ahead of conventional practice. When you experience back pain, then an MRI reveals an abnormality, and your treating physician prescribes bed rest, drugs, and so forth, it is perfectly reasonable for you to assume that your problem is purely physical. And that’s a difficult belief to give up, given that it’s supported by so many physicians, chiropractors, physical therapists, and other doctors. Nevertheless, that belief is neither practical nor scientifically accurate, no matter how much you want to go along with it. If you doubt this, please read the book and studies that support its thesis. You have nothing to lose but your pain.
One of the first things that happens to all of us when we’re under stress is that we tense up—preparing to take action as part of the ancient fight-or-flight pathway in our body. When we can’t run or express our distress, and that distress is chronic, we tense even further. Interestingly, the words for emotional tension and muscle tension are the same. We feel tense emotionally and our muscles also tense up. And this is painful. Remember the last time you had a muscle cramp? You can’t move or think of anything else until that muscle relaxes. All manner of ordinary circumstances, such as fear of loneliness, financial failure, or having to deal with a difficult co-worker, child, or spouse can all result in muscle tension that we’re not even aware of. It’s not surprising that exactly the same class of drugs, the benzodiazepines (such as Valium and Ativan), can relax both muscles and anxiety. But these drugs don’t solve the problem; they merely mask it, and worse yet, they are highly addictive.
Chronic back pain results from stressful thoughts or emotions that aren’t released fully but instead are held in the form of chronic muscle tension. If you then believe that your back is damaged, you may begin to brace yourself, or begin assuming positions to guard against potential damage. This behavior and the beliefs that fuel it then trap you in a vicious cycle of pain and fear. The longer this goes on, the more it leads to psychological conditioning that deceives you into fearing physical activity. It has been found that fear of pain, especially in back pain sufferers, plays a very important role in the perception of pain. Frustration, anger, and depression further deepen the cycle.
When people first hear that their back pain isn’t caused by a damaged spine, they may be relieved. But others are unhappy, and even angry. Being told that their level of pain is caused by stress leads some to misinterpret this as being told, “It’s all in your head. You are causing this pain, or faking it, or imagining it.” And that feels very invalidating. Let’s face it; it’s much easier to believe that we’re injured than it is to believe that we have an emotional problem! Our society doesn’t help this common attitude at all. We are taught from childhood on to believe that physical illness or injury is outside our control, while emotional issues are a sign of weakness. This is especially true if you are suffering, but nothing shows up on your tests. Then you are apt to be told that your pain is “all in your head.” In Back Sense, the authors explain:
We want to repeat that we are not in any way suggesting that chronic back pain is fake, imaginary, an illusion, invented, or all in your head. We are simply saying that, just like other physical disorders that have psychological roots, most chronic back pain is caused by the body’s natural response to excessive stress. This response includes muscle tension, and this can produce an amazing variety of authentic problems. (See Back Sense, page 41.)
I couldn’t agree more. With 30 years of research in mind-body medicine behind us, it’s truly time to put the power of the mind-body connection to work for us, rather than against us. The evidence is irrefutable: Our emotional state profoundly affects our physical body. And our thoughts profoundly influence our emotions.
While it may be hard to believe that your stress level is high enough to cause so much pain, the research in this area is compelling and voluminous. For example, a study done by Boeing Aircraft Company followed over 3,000 healthy people without back problems for four years—long enough to see which ones became disabled with back pain. Of the original group, almost 300 employees developed disabling back pain during the study period. The investigators found that psychological stress from a variety of sources predicted back pain more than any physical measure such as strength, flexibility, height, weight, or the results of physical examinations. And interestingly, psychological stress was a far more important predictor of back pain than how physically demanding an employee’s job was. Workpain2 Numerous other studies have shown that dissatisfaction, stress, raising children, working in a war zone, or lack of support either at home or work can cause disabling back pain. These studies have been done all over the world and in all lines of work.
First, get a thorough medical evaluation. Serious conditions such as rheumatoid arthritis, osteoporosis, ankylosing spondylitis, infections, tumors, and kidney stones can cause back pain—but not very often. It’s important to keep in mind that such conditions are both rare and unusual, accounting for less than one percent of all cases of back pain. Warning signs of such a condition include the following:
Unexplained weight loss, fevers, chills
- Recent urinary tract or other infection
- IV drug abuse
- Immune suppression from HIV, a transplant, or steroids
- Recent major injury
- Numbness in the groin or buttocks
- Difficulty controlling bowels
- Extreme weakness in the legs that rapidly worsens Bigos3
Once you’ve gotten the medical “all clear,” it’s important to see a physician who will support you in resuming exercise and activity, even if your tests do show evidence of a bulging disc or other common “abnormality.” The best way to do this is to go to a physiatrist—a physician who specializes in rehabilitation and understands the role of activity in recovering from back pain.
Most current approaches to back pain don’t work well because they don’t treat the root cause of the pain. Most people with back pain see several doctors and are told to rest, take medicine, or use a variety of devices to “protect” their backs. The bad back industry is now so huge that entire businesses are devoted to selling a variety of chairs, furnishings, and other devices designed to help you protect your back. Surgery is often recommended, as well. And far too often, this can make the problem worse, if the underlying cause is not addressed. Most treatments involve taking it easy and trying to avoid injuring yourself. This approach just weakens your other muscles. Both research and patient experience show that the fastest and surest way to recover from back pain is to return quickly to unrestricted physical activity. Malmivaara4
Spiritual and Holistic Options
Back Sense describes a new way to treat chronic back pain that is more effective and less expensive than conventional methods. It helps you heal yourself without special treatments, disability, or loss of your favorite activities. Although this approach is not standard (yet), it is perfectly safe and well worth a try. You can expect a return to full physical functioning instead of years of disability and pain because the Back Sense approach gets to the heart of chronic back pain and helps you learn to reduce your stress and restore yourself to living fully.
To get over chronic back pain, you have to understand that excessive emotional stress that goes unexpressed or unreleased generates further stress. Change of all kinds leads to stress, which can make pain worse, but change is an inevitable condition of life. Back Sense lists the following life events, both positive and negative, that researchers have found to be most stressful. Go down the list and see if you can relate to any of them:
- Death of a friend or loved one
- Marital separation of divorce
- Personal injury or illness
- Getting married
- Being fired at work
- Marital reconciliation
- Sexual difficulties
- Changing jobs
- Getting a mortgage
- Child leaving home
- Trouble with relatives
- Beginning or ending school
- Other changes in daily routines
- Taking a vacation
You can learn how to work consciously and effectively with your stressors. If any of the events on this list seems relevant, take out a piece of paper. Answer the following:
- How did I feel when…happened to me?
- What was going on at the time?
- Who else was involved?
- What fears or emotions did this bring up?
- Did I feel the emotion fully?
- Did I try to hold it in?
- How do I usually cope with difficult emotions?
- Did I talk to anyone about this?
You may be surprised at what other feelings or insights come up during this exercise. Write down any other insights you might have about the situation.
Remember, it isn’t difficult events per se that lead to physical problems. It’s our perception of their meaning that can have adverse consequences, leading to a chain of physical reactions that adversely affect our health. Back Sense includes many different suggestions for learning how to identify, express, and release difficult emotions fully instead of trying to control them.
To begin healing and reverse the cycle, the Back Sense authors advise that you begin to accept and experience your emotions more directly. This simple act will begin the process of relaxation and relief. Here are a few more suggestions to enhance the recovery cycle:
- Mindfulness (the practice of bringing your attention into the present): If you are walking, for example, notice how the ground feels under your feet, what your surroundings look like, whether it’s cool or warm or windy. When your thoughts wander, gently bring them back to the present.
This works because anxiety about back pain (or any other pain) is usually connected to thoughts about the future—fear of loss of normal function and activities or imagining the worst-case scenario. By keeping yourself tuned in to the present, you take your attention off your sore back and neutralize negative thoughts about the future. Kabatzinn5
- Journal Writing: Set aside 15 minutes per day to write in a diary. Try writing every day for the first several days, then once per week. Write continuously without self-editing, and let it flow. Write about your emotions, including fear, hurt, sadness, anger—whatever shows up for you. Remember, it’s private, so don’t hold back.
Studies have shown that writing about your emotional “hot buttons” enhances immune function and health and reduces stress. In fact, journal writing has long been part of my core program for creating health daily. I recommend it for every woman, regardless of whether you are experiencing back pain. Francis6
- Exercise: This is critical to full recovery because chronic back pain is often due to muscular tension and disuse. The keys to regaining freedom of movement include flexibility (stretching), strength (weight), and endurance (aerobic) training. Back Sense includes a comprehensive, illustrated section on regaining full physical function with plenty of charts to record your progress. Malmivaara27
It’s also helpful to listen to phrases people routinely use that reinforce beliefs that do not serve them. When it comes to back pain, examples would be:
“I can’t stand this.”
“My back is killing me.”
“I don’t get any support.”
“I’m falling apart.”
“I can’t get them off my back.”
“I feel backed into a corner.”
“I won’t back down.”
And so forth. Practice listening to your own dialogue with others to see if you can hear any implications of outmoded belief systems; then practice revising these internally, then in your external conversations. And ask your friends and family to practice this with you, as well. When enlisting their help, you might say something like this: “I’m really working on strengthening my back and my life in every way. Please don’t treat me as if I’m special or remind me that I have a bad back.” There is immense power in words.
Learn More — Additional Resources
- Back Sense, by Ronald D. Siegel, Psy.D., Michael H. Urdang, and Douglas R. Johnson, M.D.
- Healing Back Pain: The Mind–Body Connection by Dr. John Sarno
- The Core Program: Fifteen Minutes a Day That Can Change Your Life, by Peggy W. Brill
- Healing Mind, Healthy Woman: Using the Mind-Body Connection to Manage Stress and Take Control of Your Life, by Alice D Domar & Henry Dreher
- The Relaxation Response, by Herbert Benson, M.D., president of the Mind/Body Medical Institute.
- Women’s Bodies, Women’s Wisdom, by Christiane Northrup, M.D., Chapter 15, “Steps for Creating Vibrant Health”
- The Wisdom of Menopause, by Christiane Northrup, M.D., Chapter 12, “Standing Tall for Life: Building Healthy Bones”
- The audiotape program Anger Releasing by Louise Hay
- Jensen, M.C., Brant-Zawadzki, M. D., Obucowski, N., Modic, M. T., Malkasian, D., & Ross. J. S. (1994). Magnetic resonance imaging of the lumbar spine in people without back pain, NEJM, 331 (2), 69-73. See also: Wiesel, S. W., Tsourmas, N., Feffer, H. L., Citrin, C. M., & Patronas, N. (1984). A study of computer-assisted tomography. I. The incidence of positive CAT scans in an asymptomatic group of patients. Spine, 9 (6), 549-551;
- Stadnik, T. W., Lee, R. R., Coen, H. L., Neirynck, E. C., Buisseret, T. S., & Osteaux, M. J. (1998). Annular tears and disk herniation: Prevalence and contrast enhancement on MR images in the absence of low back pain or sciatica. Radiology, 206(1), 49-55;
- Boden, S. D., Davis, D. O., Dina, T. S., Patronas, N. J., & Wiesel, S. W. (1990). Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. A prospective investigation. J. Bone Joint Surg. [Am.], 72 (3), 403-408.
- Frymoyer, J. W. (1988). Back pain and sciatica. NEJM, 318 (5), 291-300; Spangforte, E. V. (1972). The lumbar disk herniation: A computer aided analysis of 2504 operations. Acta Orthop. Scand., 142 (Supp.), 1-95.
- Bigos, S. J., Battie, M. C., Spengler, D.M., Fisher, L. D., Fordyce, W. E., Hansson, T. H., Nachemson, A. L., & Wortley, M. D. (1991). A prospective study of work perceptions and psychosocial factors affecting the report of back injury. Spine, 16 (1), 1-6. [Published erratum appears in Spine (1991), 16 (6), 688].
- Bigos, S., Bowyer, O., Braen, G., et al. (1994). Acute low back problems in adults. Clinical Practice Guideline No. 14. AHCPR Publication No. 95-0642. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services;
- Deyo, R. A., & Diehl, A. K. (1988). Cancer as a cause of back pain: Frequency, clinical presentation, and diagnostic strategies. J. Gen. Intern. Med., 3 (3), 230-238;
- Deyo, R. A., Rainville, J., & Kent, D. L. (1992). What can the history and physical examination tell us about low back pain? JAMA, 268 (6), 760-765;
- Waddell, G., Main, C. J., Morris, E. W., Venner, R. M., Rae, P. S., Sharmy, S. H., & Galloway, H. (1982). Normality and reliability in the clinical assessment of backache. Br. Med. J. (Clin. Res. Ed.), 284 (6328), 1519-1523.
- Malmivaara, A., Hakkinen, U., Aro, T., Heinrichs, M. L., Koskenniemi, L., Kuosma, E., Lappi, S., Paloheimo, R., Servo, C., Vaaranen, V., et al. (1995). The treatment of acute low back pain – Bed rest, exercises, or ordinary activity? NEJM, 332 (6), 351-355; Mitchell, R. I., & Carmen, G. M. (1990). Results of a multicenter trial using an intensive active exercise program for the treatment of acute soft tissue and back injuries. Spine, 15 (6), 514-521;
- Waddell, G., Feder, G., & Lewis, M. (1997). Systematic reviews of bed rest and advice to stay active for acute low back pain. Br. J. Gen. Pract., 47 (423), 647-652.