Category Archives: Miscellaneous

Back surgery: Caution is in order

Please check out my latest blog posted on the Psychology Today website:
Recent evidence suggests that expecting a cure for chronic back pain with back surgery is probably “wishful thinking.”
To your health,
Howard Schubiner, MD

Can an MRI hurt you? When a scan can become a scam.

Hi everyone. Please check out my new blog on the Psychology Today website.

Here’s the link:

To your health, Howard Schubiner, MD

New blogs on the Psychology Today website

Hello friends.

I’ve started writing a blog on the Psychology Today website. There are four posts so far. Here are the links for those blogs.

To your health,
Howard Schubiner, MD

Blog #37: Medical myopia and common sense

Deborah Amos, a reporter for National Public Radio, gave a talk recently about her work in the Middle East.  She was discussing the tense and contentious negotiations between the United States and Iraq regarding Iraq’s nuclear energy/nuclear bomb development program.  As an aside, Deborah noted that the Iraqi foreign minister developed acute back pain every time the negotiations hit a particularly tense spot.  The audience laughed and it seemed so obvious that this pain was causally related to the stress of the situation this man found himself in.  Simply common sense, it would seem.

Last month, there was a report on NPR’s Morning Edition about teenagers who are stressed.  The reporter described a growing trend of teenagers who are smart, highly motivated, and involved in many activities.  They tend to work very hard trying to obtain good grades in advanced placement classes, and are involved in several clubs, science projects, athletics, and volunteer work.  Unfortunately, they may develop signs of stress, such as headaches and stomach pains.  They are more likely to be young women who are conscientious, caring, and sensitive.  The report described one such young woman who decided to cut back on some of her activities and take fewer AP classes.  The result was that she felt better and her headaches and stomachaches went away.

These reports imply a relationship between stress and physical symptoms, such as back pain, headaches and stomachaches.  Simply common sense, it would seem.

Yet, when patients present to physicians with chronic symptoms, the concept that stress may be the primary culprit is not entertained, despite evidence to the contrary.

A report from the Kansas City Star this month described a growing trend of a disorder known as widespread pain disorder in young women.  This syndrome describes pain in one part of the body that spreads to many parts.  There is no known medical cause and there is no evidence of tissue damage.  The young women described in the article tend to be teenagers who are highly motivated, overly committed, and “stressed out.”  The article described a treatment program that centers on exercise and physical therapy, although it does include some family counseling.  These programs cost tens of thousands of dollars.  The physicians however are careful not to imply to the patients and families that this syndrome is caused by stress.

Similarly, an article in the New York Times this week described the syndrome of chronic pelvic pain that is being treated with an electrical wand that applies stimulation to trigger points in the muscles of the pelvis.  The wand must be applied through the rectum in men; and sometimes through the vagina in women.  Interestingly, the title of the article is “A fix for stress-related pelvic pain” and patients can buy the wand for $800 and learn how to apply it to themselves for $4300.  The protocol includes relaxation exercises, but avoids looking at the stress in their patients’ lives as a cause for the symptoms.

Finally, an article was recently published in the Journal of the American Medical Association on children with migraine headaches.  The research compared using medication plus cognitive behavioral therapy (CBT) to medication without CBT.  The study found that those who got CBT had fewer migraines than those who didn’t.  In an accompanying editorial, this comment seemed to sum up the view of modern medicine to these stress-related illnesses:

“Unless communicated carefully, suggesting a child see a therapist for headache treatment could inadvertently imply that the origin of chronic migraine is psychological.”

Modern medicine is myopic when it comes to stress-related illness.  Even when the evidence clearly points to stress as the cause of physical symptoms, we are loath to use common sense.  We attempt to avoid the simple explanation that stress causes real physical reactions in the body; that stress causes real pain.  Avoiding this concept leads to treatments that are expensive and don’t specifically target the cause.  Even if the patient gets better (it is interesting to note that none of the young women interviewed in the article on widespread pain syndrome were pain-free), they are not likely to develop the understanding and self-knowledge that they will need to deal with both current and future stressful situations.  They are also not likely to understand that physical symptoms that may arise in the future can also be stress-related, which is critical to avoiding costly and misleading medical workups.

If physicians and other health professionals used common sense, they would be more likely to help patients identify stress-related illnesses as being simply that: stress-related illnesses.  They could help their patients understand this and get treatment specifically directed at understanding the relationship between the mind and the body and dealing with thoughts and emotions that trigger pain and other symptoms.  Simply common sense, it would seem.

To your health,

Howard Schubiner, MD


Blog #36: The bio-technological approach to back pain: Dangerous road ahead

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