Tension myositis syndrome

Tension myositis syndrome (abbreviated TMS ) is a name given by Dr. John E. Sarno to a condition he describes as characterized by a psychosomatic musculoskeletal and nerve pain. Sarno, a Professor of Clinical Rehabilitation Medicine at New York University School of Medicine and Attending Physician at The Rusk Institute of Rehabilitation Medicine at New York University Medical Center, has described TMS in four books,   and has stated that the condition may be involved in other pain disorders as well. Tension myositis syndrome and Sarno's treatment methods have received some attention, including a segment on ABC's 20/20, in which John Stossel stated he felt that Sarno's protocol helped reduce his previously chronic debilitating back pain ; and articles in Newsweek, the Seattle Times, and the New York Times. However, the TMS diagnosis and treatment protocol are not widely accepted by the conventional medical community; this is stated by Stossel in the show segment, and Sarno himself stated in a 2004 interview with Medscape Orthopaedics & Sports Medicine that "99.999% of the medical profession does not accept this diagnosis." Notable patients treated for tension myositis syndrome include Howard Stern and Anne Bancroft. Author Richard E. Sall, MD includes TMS in a list of conditions he considers to be possible causes of back pain resulting in missed work days that increase the costs of worker's compensation programs.

Theory and symptoms
According to Sarno, TMS is a condition in which emotional stress causes physical pain, most often in the back, neck, shoulders, buttocks and in some cases, other parts of the body. His theory suggests that the autonomic nervous system decreases blood flow to muscles, nerves, tendons or ligaments, resulting in oxygen deprivation, experienced as pain and tension in the affected tissues. This can manifest as muscle spasms, feelings of weakness, numbness, and other negative sensations. Sarno theorizes that because patients often report that back pain seems to move around, up and down the spine, or from side to side, that this implies the pain may not be caused by a physical deformity or injury.

Sarno states that the underlying cause of the pain is the mind's defense mechanism against unconscious mental stress and emotions such as anger, anxiety and narcissistic rage. The conscious mind is distracted by the physical pain, as the psychological repression process keeps the anger/rage contained in the unconscious and thereby prevented from entering conscious awareness. TMS can be considered a psychosomatic condition and has been referred to as a "distraction pain syndrome".

Sarno is a vocal critic of conventional medicine with regard to diagnosis and treatment of back pain, which is often treated by rest, physical therapy, exercise and/or surgery.

Diagnosis
Below is a list of criteria for diagnosing TMS, according to Dr. David Schechter (Sarno's former medical student and research assistant) and Sarno:
 * Lack of known physical cause: Schechter and Sarno state that a physical examination, tests and imaging studies may be needed to rule out serious conditions, such as tumors.    Sarno considers spinal disc herniations to generally be harmless, because the symptom location does not correlate to the herniation location.
 * Tender points: While medical doctors use eleven of eighteen tender points as a diagnostic criteria for fibromyalgia, Sarno states that he uses six main tender points to diagnose TMS:  two tender points in the upper trapezius muscles, two in the lumbar paraspinal muscles and two in the lateral upper buttocks. He states that these are found in 99% of TMS patients.
 * Change of symptoms over time: Schechter and Sarno state that movement of pain to other parts of the body may indicate that the patient has TMS.
 * History of other psychosomatic disorders: Schechter and Sarno consider a prior history of other psychosomatic disorders to be an indication that the patient may have TMS.  They list irritable bowel syndrome and tension headache as examples of psychosomatic disorders.

Schechter and Sarno state that if a patient is unable to visit a medical doctor who is trained in TMS, then the patient should see a traditional medical doctor to rule out serious disorders, such as fractures, tumors and infections.

Treatment
Sarno states that the most important element of the treatment is education about the causes of the disorder, especially as he describes it, their psychological and emotional pressures. In the 2004 Medscape interview, he elaborated on this, saying "About 20% of the people who come to see me, who come into my program, cannot apparently get better until they've spent some time working with one of my psychologists. Psychotherapy is needed for about 20% of the patients."

The treatment protocol emphasizes acknowledging the psychological aspect along with resuming normal movement activity as much possible, without excessive concern about "re-injury". The psychological process includes learning to focus on sources of anger that had previously been repressed. Schechter developed a 30-day daily journal called "The MindBody Workbook" to assist the patient in recording emotionally significant events and making correlations between those events and their physical pain. According to Sarno and Schechter, daily repetition of the psychological process over time defeats the repression through conscious awareness, resulting in remission of the symptoms.

A non-peer-reviewed 2005 study by Schecter at the Seligman Medical Institute, co-authored with the institute's director, found that treatment of TMS using journaling, home educational program, an office-based seminar, and psychotherapy, and other methods, achieved a 57% success rate among the study participants identified as patients with chronic persistent back pain. The study's conclusion described the treatment as "relatively inexpensive, non-invasive, and non-pharmacological" and suggested further research using brain imaging, other neurological correlations and clinical methods. In 2007, the same authors published a second (peer-reviewed ) study on the same treatment mode, in which pain scores of 51 chronic patients (minimum of 6 months, average 9 years of pain before treatment) were reduced by over half. (P < .0001)

Sarno's protocol for treatment of TMS is used by the Harvard RSI Action Group, a student volunteer organization, as part of their preventative education and support program for people with repetitive strain injury, also referred to as "RSI".

Controversy
Critics in mainstream medicine state that neither the theory of TMS nor the effectiveness of the treatment has been proven in a properly controlled clinical trial. They state that TMS success stories could be due to either the placebo effect or regression to the mean, and that because patients typically see their doctor when the pain is at its worst, pain chart scores statistically improve over time even if left untreated. Most people (estimated at 85 – 90%) recover from a back pain episode on their own in a matter of weeks without any mechanical intervention at all. Sarno himself states that "Even the majority of psychiatrists don't accept this diagnosis either."