JOIN USWhen pain becomes chronic...
The Covid-19 pandemic has had residual deleterious effects on the mental and physical health of people across the world — headaches and muscle pain to name just a few. Pain is an abstract term and has a plethora of definitions across textbooks, dictionaries and the internet. Google simply defines pain as “physical suffering and discomfort caused by illness or injury.” Most people agree and relate this description to a feeling experienced when they fall off a bicycle or accidentally trip. Patients experiencing chronic physical pain attribute it to acute or immediate injuries. Medical jargon mandates that if there is an ‘acute’, there needs to be a ‘chronic’ as well. However, Johns Hopkins University, the top university in the US for health sciences, states that chronic pain is long-standing pain that persists beyond the usual recovery period or occurs along with a chronic health condition. Dr John E Sarno in the NYU School of Medicine coined the term Tension Myositis (or Myoneural) Syndrome (TMS) for physical pain (and other symptoms) which patients experience as a manifestation of repression of emotional stressors. To put it simply, the patient’s clever brain can sometimes interpret the psychological challenges that they face in the form of pain. Functional MRI studies show that as pain becomes chronic, the activity of the areas of the brain which are linked to emotions grow in strength. In the book Think Away Your Pain Dr Schechter states that “the source of chronic pain is often the nervous system and brain, not structural injury.” Reflecting this, most of the chronic patients that go to a doctor have already undergone all the diagnostic investigations and standard guidelines of treatment for their apparent structural condition. In most instances, nothing is clearly found at all.
If there’s something that physicians are missing it is the lack of a thorough review of the patients’ childhood and psycho-social history. These elements have been shown to play a vital role in making a diagnosis of TMS. In this condition, pain persists from transmutation or repression of psychological challenges in a patient’s inner or personal life. The physiological theory behind TMS is based on the principle that during a stressful event, the sympathetic nervous system is persistently activated, reducing the blood supply to muscles because of constriction of the blood vessels. Hence, the muscles (often neck and back) undergo spasms and there is perpetual pain.
What’s the cure?
The TMS approach focuses on the individual perception of pain and encourages ability, rather than disability which many diagnoses support. Education, meditation, positive affirmations, journaling, and individual or group psychotherapy have remodelled the idea of pain in patients diagnosed with TMS. It takes a different mental lifestyle to lessen the intensity of pain, keeping the mind-body connection in perspective.
Dr Schechter emphasises the psychosocial history, background, and context of the patient and their pain syndrome, once a clear structural or biochemical cause for pain has been ruled out.
So conducting diagnostic investigations to rule out structural causes of pain is done first. But a thorough insight into a patient’s psychosocial life is important as well, and that’s a bonus learning objective in taking the extra mile to help someone suffering from intractable pain. As Sir William Osler rightly said, “The good physician treats the disease, the great physician treats the patient who has the disease.” So every physician should be aware of TMS and include it in the treatment of chronic pain, after ruling out major structural diseases or problems. This will be beneficial to the numerous patients suffering as there is a new paradigm shift in chronic pain recognised by the medical fraternity. It may also improve the experience of doctors who will know their patients better and have more productive outcomes with chronic pain.
(The author is a doctor interning with a Manipal-based hospital while Dr David Schechter is a family & sports medicine physician.)