Friday, September 4, 2009

Tension Myositis Syndrome & Chronic Pain Myths

Chronic pain, especially nonspecific pain that is unexplained by structural or organic pathology, is a frustrating challenge for healthcare providers and patients alike. Tension Myositis Syndrome (TMS) — focusing on mind-body, psychosomatic pain related to unresolved emotional distress — has been proposed as a primary cause. However, whether TMS is more myth than reality and its clinical validity need careful consideration.

A New Paradigm of Chronic Pain Needed?
This subject came to our attention in a recent article titled “Treating Chronic Pain – There is a Better Way!” by Colleen Perry at the popular Huffington Post website [see article]. Perry, a marriage and family therapist in California, claims a new paradigm is needed when it comes to chronic pain and its treatment. She contends that many conditions are often mistakenly treated with drugs and/or surgery, including back pain, neck and shoulder pain, migraine headaches, fibromyalgia, carpal tunnel syndrome, repetitive strain injury, pelvic pain, irritable bowel syndrome, and others. For a better solution, she recommends a concept called Tension Myositis Syndrome, or TMS, which was originally proposed by John Sarno, MD, in the 1970s to describe disorders that appear to be purely physical but actually originate from distressful emotions. Perry asserts that “we cannot talk about reforming our healthcare system without taking into account the billions of dollars that are wasted by the American Medical Association's widespread refusal to recognize chronic pain as a mind-body disorder [which is the essence of TMS].”

Indeed, it does appear that TMS has not received serious recognition or study from mainstream medicine, even though Sarno — professor of Clinical Rehabilitation Medicine, New York University School of Medicine, and attending physician at the Rusk Institute of Rehabilitation Medicine — claims to have successfully treated thousands of patients merely by educating them on his beliefs of an emotional basis for their pain symptoms. His approach hinges on mind-body connections whereby pain arises from unresolved emotional issues; in effect, the brain causes the pain as a diversion or distraction from emotions that are threatening to the patient.

The phrase “Tension Myositis Syndrome” refers to the emotional disturbances behind the condition (tension), the involvement of skeletal muscles (myositis), and the multitude of symptoms (syndrome). Most recently, Sarno says the condition should be called “Tension Myoneural Syndrome” to include nervous system involvement, and others have suggested “The Mindbody Syndrome” as easier for the lay public to remember. TMS most clearly seems applicable to chronic pain without evidence of structural or organic pathology — nonspecific in nature; however, Sarno believes TMS should be considered even in cases where there is evident pathology, at least as a contributing factor.

Where is the evidence to support TMS?
Advocates claim there are inherent difficulties in performing clinical trials to validate psychosomatic characteristics of TMS, consequently there is very little supportive research literature. However, there is extensive popular literature on the subject (eg, see document here, or website here), and Sarno’s most recent book, The Divided Mind: The Epidemic of Mind Body Disorders (2006), and earlier works have sold very well. The “cure” for TMS requires identifying and managing underlying psychological stressors; in some persons, merely acknowledging the existence of threatening unconscious emotions allegedly has relieved all pain. Specific treatment modalities have included, reading books on the subject, cognitive behavioral therapy, hypnotic suggestion, and guided imagery. In one case-series report of 51 patients with chronic back pain diagnosed as TMS, treatment consisted of office visits, written and audio educational materials, guided journaling, and psychotherapy for select patients [Schecter et al. 2007]. During 3 to 12 months of followup there were significant decreases in pain scores and medication use, while physical health and activity scores increased significantly; however, reports such as these must be considered anecdotal.

In an interesting controlled clinical trial published several months ago in JAMA [Kroenke et al. 2009], researchers randomly assigned patients diagnosed with depression and chronic pain (back, hip, or knee) to either usual care (n=127; standard antidepressants and analgesics) or an experimental intervention (n=123; including the usual analgesics plus optimized antidepressant medication regimens and a multi-session pain self-management program consisting of an examination of negative emotions, relaxation techniques, behavioral modification, and other approaches for increasing self-efficacy). Compared with usual care, the intervention group experienced significantly greater reductions in both depression and pain. Unfortunately, there was no third group receiving usual care plus the self-management program; that is, to separate out effects of enhanced antidepressant therapies that could have, themselves, manifested pain relief. Still, in a sense, the intervention might be considered a form of “medication-assisted TMS-management therapy,” and it seems to support the value of attending to possible psychosomatic influences as a component of chronic pain management.

Inherent Dangers & Caveats
Other research seems to contradict TMS interpretations of chronic pain. An extensive systematic review examining the influence of psychological factors on the onset and continuation of complex regional pain syndrome (CRPS, also known as reflex sympathetic dystrophy, or RSD) found that, while many patients with CRPS are stigmatized as being psychologically different, there was no evidence of psychosomatic effects [Beerthuizen et al. 2009]. European investigators have recently expressed concerns about inappropriately attributing somatic pain complaints having no evident clinical pathology to purely psychological origins, or “psychologization,” which could serve as a barrier to effective pain management [Crombez et al. 2009].

Some researchers, such as Norton M. Hadler, MD, have for many years described psychosomatic aspects of chronic pain disorders in pejorative terms [eg, Hadler 1978; Hadler et al. 2007]. For example, Hadler and colleagues consider work-related cumulative strain disorders and backache as mere “surrogate complaints” reflecting psychological distress over poor working conditions and unrewarding work rather than as bona fide maladies. They write: “No physician, employer, human resource professional, claims adjuster, or worker is likely to realize that the backache is intolerable and disabling because the job is intolerable, unsatisfying, or insecure” [Hadler et al. 2007]. The implication in Hadler’s publications through the years is that many persons with pain complaints are psychologically unfit malingerers hoping to take advantage of workers’ compensation or other assistance for bogus conditions having no basis in structural or organic pathology. And, while he does not specifically name tension myositis syndrome, concepts of TMS used inappropriately would appear to bolster Hadler’s arguments opposing physical origins of the complaints.

Therefore, a final concern is whether treatment of TMS would be covered by health insurance and/or other compensation systems. Especially, since it appears that the psychological basis of the disorder opens the door for a variety of alternative therapies, often delivered by nonmedical practitioners. So, there may be dangers in broadly accepting TMS unless its scientific validity can be confirmed. Even if TMS is more myth than reality, as with all myths there still may be some innate truth behind it since pain is a subjective experience and emotional discord may exacerbate pain perception. However, whether or not mind-body connections play a central or peripheral role in chronic pain, and the extent to which discovering and managing emotional underpinnings can have remedial effects, requires more investigation. Any opinions? Post your comments below.

> Beerthuizen A, van’t Spijker A, Huygen F, Klein J, de Wit R. Is there an association between psychological factors and the complex regional pain syndrome type 1 (CRPS1) in adults? A systematic review. Pain. 2009;145(1-2):52-59.
> Crombez G, Beirens K, Van Damme S, et al. The unbearable lightness of somatization: a systematic review of the concept of somatization in empirical studies of pain. Pain. 2009;145(1-2):31-35.
> Hadler NM. Legal ramifications of the medical definition of back disease. Ann Intern Med. 1978;89(6):992-999.
> Hadler, NM, Tait RC, Chibnall JT. Back pain in the workplace. JAMA. 2007;297(14):1594-1596.
> Kroenke K, Bair MJ, Damush TM, et al. Optimized antidepressant therapy and pain self-management in primary care patients with depression and musculoskeletal pain: a randomized controlled trial. JAMA. 2009;301(20):2099-2110.
> Schechter D, Smith AP, Beck J, et al. Outcomes of a mind-body treatment program for chronic back pain with no distinct structural pathology – a case series of patients diagnosed and treated as tension myositis syndrome. Altern Ther Health Med. 2007;13(5):26-35.