Healing Back Pain : The Mind-Body Connection
By John E. Sarno, M.D.
The primary tissue involved in TMS is muscle, hence the original name myositis (as mentioned, myo stands for "muscle"). The only muscles in the body that are susceptible to TMS are those in the back of the neck, the entire back, and the buttocks, known collectively as postural muscles. They are so named because they maintain the correct posture of the head and trunk and contribute to the effective use of the arms.
Postural muscles have a higher proportion of "slow twitch" muscle fibers than limb muscles, making them more efficient for endurance activity, which is what is required of them. Whether or not this is the reason why TMS is restricted to this group of muscles we do not know. It is possible, though, since the muscles most frequently involved have the most important jobs. These are the buttock muscles, known anatomically as gluteal muscles. Their job is to keep the trunk upright on the legs, to prevent it from falling forward or to either side. Statistically, the low back-buttock area is the most common location for TMS.
Just above the buttocks are the lumbar muscles (in the small of the back), often involved simultaneously with buttock muscles. Occasionally the gluteal or lumbar muscles are affected separately. Roughly two-thirds of TMS patients will have their major pain in this area.
Second in order of frequency of involvement are the neck and shoulder muscles. The pain is usually in the side of the neck and the top of the shoulder, in the upper trapezius muscle.
TMS can occur anywhere else in the back, between the shoulders and low back, but does so far less frequently than in the two areas mentioned.
Generally a patient will complain of pain in one of these prime areas, as, for example, in the left buttock or the right shoulder, but the physical examination will reveal something else of great interest and importance. In virtually every patient with TMS one finds tenderness when pressure is applied (palpation) to muscles in three parts of the back: the outer aspect of both buttocks (and sometimes to the entire buttock), the muscles in the lumbar area and both upper trapezius (shoulder) muscles. This consistent pattern is important because it supports the hypothesis that the pain syndrome originates in the brain rather than in some structural abnormality of the spine or incompetence of the muscle.
The second type of tissue to be implicated in this syndrome is nerve, specifically what are known as peripheral nerves. Those most frequently affected are located, as might be expected, in close proximity to the muscles that are involved most often.
The sciatic nerve is located deep in the buttock muscle (one on each side); lumbar spinal nerves are under the lumbar para-spinal muscles; the cervical spinal nerves and brachial plexus are under the upper trapezius (shoulder) muscles. These are the nerves most frequently affected in TMS.
In fact, TMS looks like a regional process, rather than one aimed at specific structures. So when it affects a given area, all the tissues suffer oxygen deprivation so that one may experience both muscle and nerve pain.
Varying kinds of pain may result when muscle and/or nerve are affected. It may be sharp, aching, burning, shock like, or it may feel like pressure. In addition to pain, nerve involvement may produce feelings of pins and needles, tingling and/or numbness, and sometimes sensations of weakness in the legs or arms. In some cases there is measurable muscle weakness. The latter can be documented with electromyographic studies (EMG). EMG abnormalities are often cited as evidence of nerve damage due to structural compression, but in fact EMG changes are very common in TMS and usually reveal involvement of many more nerves than could be explained by a structural abnormality.
Lumbar spinal and sciatic nerve symptoms are in the legs, for that is where those nerves are going. Involvement of cervical spinal nerves and brachial plexus cause symptoms in the arms and hands. Traditional diagnoses attribute leg pain to a herniated disc and arm pain to a "pinched nerve".
TMS may involve any of the nerves in the neck, shoulders, back and buttocks, sometimes producing unusual pain patterns. One of the most frightening is chest pain. One immediately thinks of the heart when there is chest pain and, indeed, it is always important to be sure that there is nothing wrong with that organ. Once having done so, one should keep in mind that spinal nerves in the upper back may be suffering mild oxygen deprivation because of TMS and that this may be the source of the pain. These nerves serve the front of the trunk as well as the back, hence the chest pain.
Remember: Always consult a regular physician in order to rule out serious disorders. This book is not intended as a guide to self-diagnosis. Its purpose is to describe a clinical entity, TMS.
One may suspect the presence of nerve involvement in TMS through the patient's history, the physical examination or both. Sciatic pain may affect any part of the leg except the upper, front thigh. There is considerable variability depending on how much of the nerve trunk is affected by oxygen debt. As noted above, the person may also complain of other strange feelings and of weakness.
On physical examination the tendon reflexes and muscle strength are tested to determine whether oxygen deprivation has irritated the nerve sufficiently to interfere with the transmission of motor impulses. Similarly, sensory tests are done (for example, ability to feel a pinprick) to determine the integrity of the sensory fibers in the involved nerve. The major virtue of documenting sensory or motor deficits is to be able to discuss them with patients and reassure them that feelings of weakness, numbness or tingling are quite harmless.
The so-called straight leg-raising test is always done when a patient is examined, though for different reasons, depending on the examiner. If there is a great deal of soreness in the buttocks, the patient will be unable to elevate the straightened leg very far and then only with a great deal of pain. The pain may be due to the muscle, the sciatic nerve or both. What the sign does not mean in the majority of eases is that there is a herniated disc "pressing on the sciatic nerve," as patients are often told.
When there is a shoulder-arm pain syndrome, one does similar tests on the arm and hand.
Sometimes patients have pain on two sides; this is of no particular significance. People will also often report that in addition to having the major pain in the right buttock and leg, for example, they have some intermittent pain in the neck or one of the shoulders. This is not unexpected since TMS may involve any or all of the postural muscles.