The scandal of cortisone injection material tainted with fungi has created a large burden of illness and death among a small proportion of individuals who received epidural injections for back pain. Calls for better regulation and oversight of compounding pharmacies are being made of the FDA and other governmental agencies. However, another story that may ultimately be more important needs to be highlighted. How many of these injections were indicated and how many were likely to be helpful to those receiving them? Unfortunately, studies demonstrate that the majority of these injections are not indicated and not effective.
In all medical decisions, it is incumbent upon the physician to calculate an analysis of the likely benefit of a given treatment versus the potential risk. This calculation is at the heart of all good medical practice. When a treatment is effective, doctors and patients are often willing to choose treatments that have a significant risk, such as is common in people with cancer. Another reason to tolerate treatment with significant risk is for conditions that are severely disabling, again as with cancer.
Medical decision-making for people with back pain has been very similar to that of cancer. Back pain is viewed by both doctors and patients as a severely disabling process that is likely to be chronic and unresponsive to simple interventions. Therefore, invasive treatments such as epidural and other injections, back surgery, and the use of opioid narcotic medications are commonly prescribed. The potential risk of these treatments is great as demonstrated by the fungal meningitis outbreak. In addition to this potential complication, the risks of surgery are well known, such as paralysis, infection, increased pain, and the need for re-operation. Opioids have been shown to have tremendous risk, having the potential for addiction, overdose and death, and the development of hyperalgesia, i.e., sensitizing the brain to actually experience more rather than less pain. Of course, the costs for back pain treatment are astounding, amounting to at least $100 billion per year in the U.S.
Speaking of the costs of treating back pain, the number of MRIs, injections, opiate prescriptions, and back surgeries has risen by 200-300% in the last decade or so, yet the rates of those with disabling back pain has also risen (by about 25%). What we are doing is clearly not working.
From my point if view, the problem is this: We are using the wrong approach for the majority of people with back pain. Only a small, proportion of back pain is caused by a clear pathological entity, such as a tumor, fracture, infection or obvious nerve root damage. These causes are estimated to comprise about 10-15% of those with back pain. The rest are likely caused by psycho-physiologic processes. This concept is so foreign to most people (and to most doctors) that it likely to be rejected out of hand. Yet, it is true. Minor “abnormalities” on MRIs are typically presumed to cause pain when there is no evidence that is the case. Abnormal MRIs occur in the majority of adults who have no back pain. Cutting edge neuroscience demonstrates that pain can be caused by the brain and that emotions lower the pain threshold. It is well known that the brain can create symptoms as severe as paralysis; this is called a conversion disorder.
What is not appreciated is that stress is the most common cause for chronic back pain (and other conditions such as chronic headaches, irritable bowel syndrome, and fibromyalgia). All pain is real — very real! Pain not caused by structural problems (e.g., fractures, tumors, infections) is caused by neural pathways that have been “learned” by the brain and create real physical pain. Careful histories of people with severe chronic pain uniformly uncover the underlying causes of the pain. Briefly, the situations that cause psycho-physiologic pain are those where an individual has been sensitized by stressful life events earlier in life (e.g., a controlling or abusive relative) and later a triggering event occurs such as a physical or emotional trauma that creates fear, anger, or guilt along with a sense of being trapped or feeling helpless. Severe pain develops as a reaction to these scenarios. The reason doctors never notice these connections is that they never take the time to look for them.
There is now an emerging body of literature showing that treatment of chronic back pain is effective when one uses a psycho-physiologic approach. We are in the process of publishing data showing that the majority of patients with severe chronic back pain can recover. This treatment approach is very cost-effective. In fact, it often only requires a change in how one views the cause of the pain and simple behavioral steps to change the nerve pathways causing pain. Dr. John Sarno has sold approximately a million books describing this model. From anecdotal reports, about 10% of those who have read one of these books have had rapid recoveries from chronic back pain. Can we learn something from 100,000 people? Most back pain (and other chronic painful conditions) can be cured. The current bio-technological approach of opiates, injections, and surgery is making us worse, rather than better. Millions of back pain sufferers need help and this help is closer than we think.
To your health,
Howard Schubiner, MD
The history of medicine consists of two major themes: development of new techniques to study the body and attempts to understand why illness occurs. Often these two themes lead to a synergism that creates a great advance, such as the development of the microscope so that we could actually see bacteria that cause disease. Before such technological breakthroughs occur, we are stuck trying to explain disease in the absence of being able to actually see the problem and therefore we develop theories on what is causing the problem. Sometimes these theories are correct, sometimes they are horribly wrong.
Ignaz Semmelweis was a Hungarian physician who noted that women who gave birth in the hospital setting had very high rates of post-partum infections (often fatal), while women who gave birth at home had much lower rates. The doctors at the time were doing autopsies and going from one procedure to another. Semmelweis thought that the doctors might be transmitting something to their patients thus causing the infections. He did an experiment to show that hand washing (using lime salts) actually did reduce the rates of death to below 1% (they were as high as 35%). However, he could not show why this worked and doctors didn’t believe him (despite being shown the research evidence). Sadly, Semmelweis ended up dying in an asylum in 1865 after becoming mentally ill. When one doesn’t understand the problem, the solution can be right in front of your face and yet you can’t see it.
I saw a woman this week whose story is shocking. She had a great childhood with loving parents who taught her that people could be trusted, the world was good, and that she should act with kindness and caring towards all others. She learned to sweep emotions under the rug and work harder when problems arise. She did not learn to speak up for herself. Her life was great until high school when she started a 3-year relationship with a boyfriend who came from an abusive household. Over time, he became jealous and possessive. She continued to make excuses for him and tried to be a good girlfriend, thus acceding to his increasingly controlling ways. He pushed her away from her family and her friends. He didn’t let her go out unless he was there. He even hit her on two occasions. And she continued to make excuses for him and cover up her pain and distress. She tried to be an even better girlfriend and hoped he would change. He didn’t; and finally (with the help of her sister) she broke up with him. She went off to college and did well. Her life was back on track. She was an active athlete and even ran in marathons. In her first job, she desperately wanted to prove herself and become the best employee in the company. However, her boss was someone who took advantage of that attitude and her inability to speak up for herself. The boss piled more and more work onto her, causing her to work evenings and weekends. The boss did less and less. Yet my patient never spoke up to ask for some changes to be made. She felt trapped and her feelings were similar to how she felt when in a relationship with her abusive high school boyfriend. It was during this period in her life that her pain started.
Can tics be contagious?
The story from upstate New York doesn’t want to go away. There have been at least three national TV spots in the last few weeks about the 12 high school students who have developed tics. Neurologists consider tics and Tourette’s syndrome to be chronic neurologic disorders that are primarily inherited. The treatment consists of medications to attempt to control the abnormal movements and it is not generally believed that individuals can have any control over their tics.
However, the mini-epidemic in LeRoy High School near Buffalo is believed by excellent neurologists to be caused by a conversion disorder, i.e. a physical symptom that is not a pathological or structural process, but is caused by stress and unresolved emotions. In other words, this is a manifestation of Mind Body Syndrome (MBS) or a Psychophysiologic Disorder (PPD). (I will use these terms interchangeably.)
When one looks at the history of mini-epidemics of PPD, evidence abounds that PPD is a contagious disorder. There have been well-documented epidemics of repetitive stress injury, sick building syndrome, and psychogenic seizure-like activity (also known as pseudo-seizures). There is an interesting research article from Germany that demonstrates that back pain appeared to be contagious after the fall of the Berlin Wall. So, it isn’t really surprising that almost any symptom can be caused by MBS. Once a careful medical history, physical exam, and environmental evaluation rules out evidence for a pathological disorder, the diagnosis of MBS should be confirmed.
In the LeRoy High School situation, experts have done this and have concluded that the girls are suffering from PPD. However, this apparently hasn’t gone over very well with the patients, their parents, or many members of the community. Today’s report showed angry parents filling a meeting of the school board asking them to prove that their buildings are safe. Of course, they have a clean bill of building health from the state of New York and the CDC. Yet, a psychological explanation for physical symptoms doesn’t seem to ring true or satisfy most people.
Over the past few weeks, I have encountered several stories about tics and Tourette’s syndrome that suggest that it may not be as much of a neurological disease as we once thought. Story #1: A friend told me about a young man who suffered with Tourette’s for his whole childhood and adolescence. As an adult, he participated in an intensive psychological retreat during which he expressed and processed many emotional issues from his life. The tics resolved.
Story #2: I met a psychologist who told me that he cured a teenager of Tourette’s “by accident.” The young man was sitting in the psychologist’s office and while waiting, he was throwing some balls into a box over and over. When the psychologist entered, the boy apologized for his behavior and stopped. But the psychologist suggested that it was fine to throw these balls and encouraged him to continue to do so, which he did. During the course of a single one hour session, the boy expressed many issues that were bothering him and threw the balls more forcefully. Following the session, he seemed relieved. The tics disappeared and never returned.
Story #3: I was telling these stories to a friend. He immediately began to tell me his story. As a child, he was diagnosed with Tourette’s syndrome. The tics were incredibly embarrassing and humiliating to him. He hated them and vowed to stop them. He decided to resist them and spent many nights in bed holding his body against the urge to “tic.” After a few weeks of mental effort directed to stopping the tics, they went away and have not recurred.
I am not suggesting that all tics or all Tourette’s syndrome is caused by PPD, but it wouldn’t surprise me if many cases are. It is interesting that over time, people with Tourette’s tend to grimace and even swear uncontrollably. Grimacing and swearing, of course, are signs of anger. Could it be that some people with Tourette’s syndrome have unresolved resentment, anger, or rage? It would certainly be wonderful if there were a relatively simple solution to these horrible disorders. We need to do some studies to determine if tics and Tourette’s may respond to our usual MBS approach and treatment. If you know of people with these disorders who are interested, please have them contact me at firstname.lastname@example.org
It shouldn’t be too surprising that some neurological events are contagious. Patterns of speech are clearly neurological events. People who grow up in the south have different speech patterns and inflections than do those from the north. Phrases such as “like” and “you know” have become ubiquitous in the speech patterns of teenagers (and adults) in recent years. If these neurological events are contagious, why not tics?
To your health,
Howard Schubiner, MD