Seventy-five to 80 percent of back pain cases do resolve within two to four weeks, with or without treatment, although it's important to note that back pain can also be symptomatic of something else entirely, including an aortic aneurysm, appendicitis, gynecological issues, osteoporosis, arthritis and kidney stones, so if your back pain is not the result of an injury or strain, it's advisable to see a doctor for an assessment.
Few people want to be told that their pain is psychological or emotional in origin, but there's quite a bit of evidence that backs this up. As noted in a 2014 scientific review:
"Specifically with regard to pain, studies pointed to the need for a model encompassing the complexity of the pain phenomenon. The biopsychosocial perspective closes this gap by confirming the existence of a dynamic relationship among biological changes, psychological status and social context.
The difficulty to accept the multidimensional nature of pain is largely linked to the widespread acceptance of Cartesian principles separating mind from body. Conversely, the biopsychosocial approach tries to consider physical, psychological, social and spiritual aspects not separately, but as an integrated whole … [S]everal studies show the major role of biopsychosocial factors in triggering chronic pain, in the process of acute pain chronicity and in patients' incapacity."
Back Pain — Is It All in Your Head?
"'Thousands of people, including myself and my husband, cured our chronic back pain using [Sarno's] methods,' wrote Karen Karvonen. Another Sarno devotee, Steven Schroeder, said the doctor changed his life. Schroeder's back pain flared whenever he was stressed — a busy time at work, an illness in his family.
After he absorbed Sarno's books, the discomfort mostly vanished. 'I still sometimes have pain now in times of stress — but I can literally make it go away with mental focus,' Schroeder, a lawyer in Chicago, wrote in an email. 'It is crazy.'
Though he may not be a household name, Sarno is probably America's most famous back pain doctor. Before his death on June 22, a day shy of his 94th birthday, he published four books and built a cult-like following of thousands of patients … Many of them claim to have been healed by Sarno, who essentially argued back pain was all in people's heads."Before his death, Sarno was even the subject of a full-length documentary, "All the Rage: Saved by Sarno," produced through Kickstarter donations. The film is expected to become available on Netflix before the end of the year. He was also featured in a "20/20" segment in 1999 (below).
As noted by Sarno in "All the Rage" — a four-minute trailer of which is included above — "I tell [my patient] what's going on, and lo and behold, it stops hurting." The "what" that is going on is not a physical problem at all — it's emotions: anger; fear; frustration; rage.
The Psychological Underpinnings of Pain
According to Sarno, you unconsciously cause your own pain. In a nutshell, the pain you're experiencing is your brain's response to unaddressed stress, anger or fear. When these kinds of emotions are suppressed, your brain redirects the emotional impulses to restrict blood flow to certain parts of your body, such as your back, neck or shoulder, thereby triggering pain.
This pain acts as a distraction from the anger, fear or rage you don't want to feel or think about. The pain essentially acts as a lid, keeping unwanted emotions from erupting. You may feel anger at the pain, but you won't have to face the fact that you're actually angry at your spouse, your children or your best friend, or that you hate your job, or the fact that you feel taken advantage of.
As noted by Sarno, working hard and constantly trying to do everything perfectly to keep everybody around you happy, "is enraging to the unconscious mind." The term Sarno coined for this psychosomatic pain condition is "tension myoneural syndrome," and he firmly believed most people can overcome their pain by acknowledging its psychological roots.
Even if you struggle to accept such a concept, the mere knowledge of it can have therapeutic power. In other words, by considering the idea that your problem is in fact rooted in stress factors opposed to a physical problem can allow the pain to dissipate.
While many of Sarno's patients got well without psychiatric help, he would often recommend seeking out a psychotherapist to explore repressed emotions, or to take up journaling to put your feelings on paper. Dr. David Hanscom, an orthopedic surgeon, also uses expressive writing as a primary treatment tool for back pain. To learn more about this, please see our 2015 interview linked above. Other dos and don'ts listed in Sarno's book, "Healing Back Pain," include:
| Do: | Don't: |
|---|---|
| Resume physical activity. It won't hurt you | Repress your anger or emotions |
| Talk to your brain: Tell it you won't take it anymore | Think of yourself as being injured. Psychological conditioning contributes to ongoing back pain |
| Stop all physical treatments for your back — they may be blocking your recovery | Be intimidated by back pain. You have the power to overcome it |
Studies Support Mind-Body Connection in Painful Conditions
While many pain experts disagreed (and still disagree) with Sarno's theories, recent research supports the idea that pain, in many cases, has psychological underpinnings. A study published last year found emotion awareness and expression therapy (EAET) reduced chronic musculoskeletal pain by at least 30 percent in two-thirds of patients; one-third of patients improved by 70 percent.More recently, a study published in the journal Pain concluded that treating fibromyalgia pain with EAET was more effective than cognitive behavioral therapy and general fibromyalgia education. Other recent research found that feelings of stiffness in the back "may represent a protective perceptual construct." Tasha Stanton, Ph.D., who investigates the neuroscience behind pain, explained her team's findings:
"People with chronic back pain and stiffness overestimate how much force was being applied to their backs — they were more protective of their back. How much they overestimated this force related to how stiff their backs felt — the stiffer [it] felt, the more they overestimated force. This suggests the feelings of stiffness are a protective response, likely to avoid movement …
In theory, people who feel back stiffness should have a stiffer spine than those who do not. We found this was not the case in reality. Instead, we found that the amount they protected their back was a better predictor of how stiff their back felt. [We] found that these feelings could be modulated using different sounds.
The feeling of stiffness was worse with creaky door sounds and less with gentle whooshing sounds. This raises the possibility that we can clinically target stiffness without focusing on the joint itself but using other senses.
The brain uses information from numerous different sources including sound, touch, and vision, to create feelings such as stiffness. If we can manipulate those sources of information, we then potentially have the ability to manipulate feelings of stiffness. This opens the door for new treatment possibilities, which is incredibly exciting."
All Pain Is Regulated by Your Brain
It may be helpful to remember that while pain may be largely a product of your own mind, the pain is still "real." As noted by Dr. Mel Pohl, a clinical assistant professor in the department of psychiatry and behavioral sciences at the University of Nevada School of Medicine, "all pain is regulated by the brain — whether there is an actual nail in your thumb or an old injury that should have healed by now but inexplicably keeps hurting — in both cases it is nerve fibers that are sending messages to your brain that cause you to feel pain."An acute injury doesn't have to have a psychological trigger, but if the pain persists long after the injury has healed, there may well be an emotional aspect involved. Pain can also carve figurative grooves in your brain. When pain is perceived over an extended period of time, the number of pain-causing neurotransmitters in your nervous system increase and your pain threshold tends to get lower. Essentially, you become more sensitized to pain.
Like Sarno, Hanscom and many others, Pohl also believes emotions are a primary cause of pain, triggering as much as 80 percent of all pain. This does not detract from its validity or intensity, however. Writing for Psychology Today, he says:
"Based on studies conducted [in 2013] … published in the journal NatureNeuroscience, we now have conclusive evidence that the experience of chronic pain is strongly influenced by emotions. The emotional state of the brain can explain why different individuals do not respond the same way to similar injuries.
It was possible to predict with 85 percent accuracy whether an individual (out of a group of forty volunteers who each received four brain scans over the course of one year) would go on to develop chronic pain after an injury, or not.
These results echo other data and studies in the psychological and medical literature that confirm that changing one's attitudes — one's emotions — toward pain decreases the pain. I believe that one of the most important things people with chronic pain can do to help themselves is to notice what they are feeling."
Physical Movement Is a Crucial Treatment Component for Most Pain
When these muscles are shortened, it can cause severe pain upon standing, as they will effectively pull your lower back (lumbar) forward. When there's insufficient movement in your hip and thoracic spine, you also end up with excessive movement in your lower back. Most people tend to "baby" the pain and avoid moving about as much as possible, but in most cases, this is actually contraindicated. In fact, experts now agree that when it hurts the most, that's when you really need to get moving.
A scientific review of 21 studies confirmed that not only is exercise the most effective way to prevent back pain in the first place, it's also the best way to prevent a relapse. Among people who had a history of back pain, those who exercised had a 25 percent to 40 percent lower risk of having another episode within a year than those who did not exercise.
Strength exercises, aerobics, flexibility training and stretching were all beneficial in lowering the risk of recurring pain. The video above, featuring Lisa Huck, demonstrates and explains the benefits of dynamic movement, and how it can help prevent and treat back pain.
New Treatment Guidelines for Back Pain Stress Nondrug Interventions
Fortunately, doctors are increasingly starting to prescribe activity in combination with a wait-and-watch approach for back pain patients. Dr. James Weinstein, a back pain specialist and chief executive of Dartmouth-Hitchcock Health System, told The New York Times:"What we need to do is to stop medicalizing symptoms. Pills are not going to make people better … [Y]oga and tai chi, all those things are wonderful, but why not just go back to your normal activities? I know your back hurts, but go run, be active, instead of taking a pill."This view has now become the new norm. In fact, on February 14, 2017, the American College of Physicians issued updated treatment guidelines for acute, subacute and chronic low back pain, now sidestepping medication as a first-line treatment and recommending nondrug therapies instead. This is a significant change, and one that could potentially save thousands of lives by avoiding opioid addiction. The new guidelines include three primary recommendations:
1. "Given that most patients with
acute or subacute low back pain improve over time regardless of
treatment, clinicians and patients should select nonpharmacologic
treatment with superficial heat … massage, acupuncture, or spinal
manipulation … If pharmacologic treatment is desired, clinicians and
patients should select nonsteroidal anti-inflammatory drugs or skeletal
muscle relaxants …
2. For patients with chronic low back pain, clinicians and patients should initially select nonpharmacologic treatment with exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction … tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation …
3. In patients with chronic low back pain who have had an inadequate response to nonpharmacologic therapy, clinicians and patients should consider pharmacologic treatment with nonsteroidal anti-inflammatory drugs as first-line therapy, or tramadol or duloxetine as second-line therapy.
Clinicians should only consider opioids as an option in patients who have failed the aforementioned treatments and only if the potential benefits outweigh the risks for individual patients and after a discussion of known risks and realistic benefits with patients … "
The guidelines stress that even in the rare case when an opioid is
given, it should only be prescribed in the lowest dose and for the
shortest duration possible. Steroid injections and acetaminophen are
also discouraged, as studies suggest neither is helpful or beneficial.
Acetaminophen does not lower inflammation, and a review of the research shows steroids are on par with placebo when it comes to treating back pain in the long term.2. For patients with chronic low back pain, clinicians and patients should initially select nonpharmacologic treatment with exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction … tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation …
3. In patients with chronic low back pain who have had an inadequate response to nonpharmacologic therapy, clinicians and patients should consider pharmacologic treatment with nonsteroidal anti-inflammatory drugs as first-line therapy, or tramadol or duloxetine as second-line therapy.
Clinicians should only consider opioids as an option in patients who have failed the aforementioned treatments and only if the potential benefits outweigh the risks for individual patients and after a discussion of known risks and realistic benefits with patients … "
Nondrug Solutions for Pain Relief
I certainly believe that your emotional health and your ability to effectively address stress is an essential component of optimal health, and can have a major influence on whether or not you're effective in eliminating your pain. And so do many other doctors and scientists from various fields of medicine.It's unfortunate that so many people dismiss these types of treatment strategies simply because they seem "too simple to be effective." We've been indoctrinated to believe that getting well involves radical, often painful treatment, when in most cases the complete opposite is true.
It's also important to be fully aware of the addictive potential of opioid drugs, and to seriously weigh your need for a narcotic pain killer. There are many other ways to address pain. Below is a long list of suggestions. If you are in pain that is bearable, please try these options first. If you need a pain reliever, consider an over-the-counter (OTC) option.
Research shows prescription-strength naproxen (Naprosyn, sold OTC in lower dosages as Aleve) provides the same pain relief as more dangerous narcotic painkillers. However, while naproxen may be a better alternative to narcotic painkillers, it still comes with a very long list of potential side effects, and the risks increase with frequency of use.
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