JOHN E. SARNO, M.D., treats backs.
He is not an orthopedist; he is not a neurologist nor a surgeon nor a neurosurgeon. Sarno is professor of clinical rehabilitation at the New York University School of Medicine.
For the most part his back patients have already been through the specialists and the specialists' specialties, including multiple back surgeries. Many have done all the rounds: chiropracters, an assortment of physical therapists, acupuncturists, osteopaths, psychics, faith healers, but their backs or necks--or both--still hurt. The average duration of symptoms in one group of 177 of Sarno's patients was eight years before they came to him.
Most of them "know" what they "have"--herniated or "slipped" discs, pinched nerves, degenerative back disease . . . and they often come armed with X-rays and myelograms.
"Most of them believe," says Sarno, "they themselves have done something to injure their backs. Everyone has been taught that through the years, and they are absolutely, totally and completely brainwashed into thinking the back is a fragile structure and that back troubles are caused by things you do."
There are many differences between the way Sarno approaches, diagnoses and treats backs and the way the "specialists" do, and Sarno concedes that his approach is often regarded as "rank heresy."
But there is one big difference: Most of Sarno's patients get well.
"I HAD SOME mild back pain," the New York psychoanalyst was saying, "so I had my back X-rayed and I brought the X-ray into the radiologist myself. "He looked at it and said 'normal.' But as soon as I said 'yes, but my back hurts,' he looked again and said, 'hmmm, well maybe there is something about the space between this disc and that disc . . .' The orthopedist told me to go to bed for two weeks. That didn't help very much, and he said go to bed for two more weeks . . .
"I'm a doctor myself, after all, and when I get sick I listen to doctors . . . He gave me some medicine for pain . . . and then an anti-inflammatory drug . . . Then I talked to a friend of mine at the hospital who is an emergency-room physician and she said, 'My God, you have a disc problem, you better stay in bed because last night in the E.R. I treated someone with a disc problem and he became paralyzed right there . . .'
"So I stayed flat on my back. It was very messy. Our orthopedist said if I wasn't better in another two or three weeks, well, there was surgery . . .
"Then I got a call from a cousin and she said, 'Listen, Dolly, I have a doctor who told me my back pain was emotional and I listened to him and I got better.'
"I was a real smart aleck and I said, 'Well, I'm listening to you.' Then a week later she called back and I said, 'Listen, I know I'm under a lot of tension and it's psychosomatic, but I'm no better.' She said, 'You have to go and see him.' "
"By this time," said the psychoanalyst, "I had reached my limit of listening to doctors talk about surgery . . . so I called my cousin's doctor, Dr. Sarno.
"The day I went to see him I was so weak from being in bed all the time two people had to walk me into the cab and stay with me so they could walk me into his office."
She paused in her narrative, then learned forward and said, "Listen, don't use my name . . . how would it look to my patients to know their psychiatrist had a psychosomatic illness?"
That was about four years ago. Today, her back is fine.
"PSYCHOSOMATIC" is not a word John Sarno likes to use. "People simply do not understand what it means. They usually think it means imaginary, and of course it is pejorative to most people.
"In fact, it is simply any physical process induced by any psychological phenomenon--rapid heart beat and perspiring induced by fear or excitement, for example."
Nevertheless, says Sarno, "this back pain is a real physiologic process. It may be initiated by tension, as most of it is." But, as he tells his patients, "There is something going on back there. It is just not what is generally thought to be the something that is going on."
In the "vast majority" of patients he sees--such an enormous percentage even he cannot bring himself to admit how vast--the pain is not being caused by disc disease, whether or not X-rays indicate herniated discs. It is not caused by "degeneration" of the spine or bone spurs. It is not caused by pinched nerves. No X-rays or myelograms or CAT scans can picture a nerve being pinched or pressured.
"In other words," says Sarno, "it is not a structural abnormality of the spine."
What Sarno's 18 years of experience and developing technique suggest, first, is that a group of small blood vessels constricts, restricting local circulation. The constriction results in:
* The creation of a condition called "ischemia," in which insufficient blood is carried to the muscle, causing painful spasms.
* The accumulation of chemical wastes, also painful.
* Deprivation of the normal supply of oxygen to the nerves, which then cause extreme pain themselves.
"So," says Sarno, "you have three mechanisms of pain. These can involve any or all of the postural muscles starting at the back of the neck all the way down to the buttocks. At the same time, if you realize that any of the nerve structures that traverse these areas are involved, then you can have pain and other symptoms like numbness and tingling in arms and legs."
Even things like tennis elbow may be related. "When you clear up the neck or shoulder pain," says Sarno, "the tendinitis often goes away in the elbow."
It is tension, however, that initiates the process, causing the initial constriction of blood flow, and Sarno has named the condition Tension Myositis Syndrome: TMS.
WHEN A NEW back (neck, leg or shoulder) patient comes to see Sarno, he palpates muscle groups in the shoulder, mid-back and lower back. Muscle tenderness usually suggests the patient has TMS.
A long chat and a case-history search often reveals one or more of such tension-related conditions as asthma, headaches, peptic ulcers, allergies, skin problems or digestive problems. In a study of 100 consecutive patients diagnosed as suffering from TMS, "88 of them," says Sarno, "had a history of one or more, and some--28 percent--had a history of four or more, of these other things."
Once the diagnosis is made, Sarno--whose basic fee is $250--attempts to help the patient understand the crucial link to tension.
"If you can get the patient to correlate tension in general--it doesn't have to be about a specific situation--with the existence of this phenomenon, it will stop."
It is so dazzling in its simplicity that even Sarno calls it "an incredible thing." But it works.
JOHN SARNO, also an attending physician at the world-famous Institute of Rehabilitative Medicine (the so-called Rusk Institute), conducts two 2-hour teaching sessions--for his back patients, partners and families--and he considers the sessions "critical" to their recovery.
Many patients are also sent to specific physical therapists who work closely with Sarno and provide exactly the kind and degree of therapy he prescribes.
The lecture sessions, on consecutive Mondays, are basically intensive courses on how mind is linked to body, on how and why the body works to produce tension myositis pain and on the latest scientific developments related to Sarno's thesis.
Participants are encouraged to ask questions at any point. Former patients are encouraged to return for "refresher" courses. (Even the psychoanalyst comes back to the lectures about once a year.)
For most patients real improvement shows up within four to eight weeks. A very few patients "who have substantial psychological conflicts," says Sarno, may be referred for psychotherapy.
Last summer Sarno and his staff followed up on 200 patients treated 12 to 42 months before. Of the 177 they reached, 76 percent said they were cured of any back problem whatsoever. Eight percent said they were improved. Of the 16 percent who said they were not helped, virtually all told Sarno they had not accepted his diagnosis.
SARNO LIKES to recall humorist Russell Baker's column a few years ago called, "Where Have All the Ulcers Gone?"
Sarno is certain he knows: Right down the back.
Ulcers came to be known as the ultimate in disorders produced by tension, stress and anxiety. The kind of person whose unconscious mind tends to direct tension into physical symptoms--rather than express it directly--could no longer "hide" anxiety in an ulcer. The cover, as it were, was blown.
But because we are taught from childhood that "it is not acceptable to express anxiety, to be considered uptight, nervous, the brain at an unconscious level has only one alternative," says Sarno, "to direct the anxiety someplace into the body."
The TMS candidate is usually hard-working, compulsively perfectionist, often his or her own severest critic, similar (but not identical) to the cardiologists' Type-A personality. Psychological conflicts--such as a working mother's pull between job and family--will increase the generation of tension.
Before this tension results in pain, it must reach a certain level. Sarno sees it working its way through a series of tension zones. Finally, an accident involving the back may be the trigger for all the tension to be shunted there. Or to catapult an individual into a high enough tension zone to produce the symptoms of a back that has "gone out."
A back or shoulder injury itself is probably healed in a few days or weeks. But if it has served as a trigger, says Sarno, it will become the ideal place for the brain to hide the anxiety so that subsequent "accidents" will more easily produce episodes of crippling back pain.
Pain is itself tension-producing, and the fear of "degenerative spinal disease" causes even more.
"All of these," says Sarno, "feed right into the cycle, along with worries about collapse of the spine and paralysis and having to be in a wheelchair . . . not being able to support a family, or to have sexual relations . . . These are all very real factors, and they feed into increasing the tension--which of course increases the pain--and you go around and around and around."
Sarno believes his success rate is so high because "taking this process and exposing it to the light of day makes people aware of what is going on. I am changing the ground rules very drastically, giving the patients a feeling of control rather than victimization and intimidation."
During the period of four to eight weeks, Sarno says, "What you learn about TMS filters down from conscious to subconscious mind . . . What we're doing is mobilizing your own inner resources to solve this problem.
"We're telling our brains, in effect, we're on to you. We know what you're doing. We didn't realize before what was happening. We are," he says, "telling our brain that that we no longer want our anxieties expressed physically."