坐骨神經痛是心病：緊張筯膜炎觀點
緊張筯膜炎(TMS)由沙諾(John E. Sarno)發明，用來描述心身肌肉骨格及神經症狀，通常是痛覺。
TMS的醫生包含了斯卻克特( David Schechter)、Andrew Weiland 及 Mehmet Oz。
症狀
背痛是常見的 TMS 症狀，但是沙諾定義更廣：
症狀類型：
根據沙諾的說法，TMS症狀包含疼痛、僵硬、刺痛及麻木及其它負面感覺。
發生部位：
除了背、沙諾陳述 TMS 可能發生在頸、膝、手臂、手腕或是身體其它部位。
斯卻克特(Schechter)表示症狀有轉移至身體其它部位的傾向，並認為症狀轉移可作為疼痛為TMS引發的證據。
診斷
根據沙諾及斯卻克特得出以下診斷TMS的法則：
沒有已知的病理因素：
沙諾及斯卻克特表示必須使用理學檢查、測試及影像來排出嚴重情形，如腫瘤。
沙諾表示椎間盤突出通常是無害的，因為症狀部位通常與突出部位沒有關聯。
壓痛點
通常醫師會用18個纖維肌痛壓痛點檢查出11個或以上的壓痛點作為纖維肌痛的診斷，沙諾則用6個主要壓痛點來診斷緊張筯膜炎：
2個在上斜方肌，2個在腰椎旁肌肉及2個在側上臀部。
這可找出99%的緊張筯膜炎病患。
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".[21]
教育
教育以會談、授課、書及錄音資料，内容包含緊張筯膜炎的心理及生理面向。
斯卻克特認為教育讓病患學習他們的生理狀態實際上是良性的，
任何失能是源自怕痛的恐懼及去除此狀態的心理，而不是實際再受傷的風險引起的。
Writing about emotional issues
Sarno states that each patient should set aside time daily to think and write about issues that could have led to the patient's repressed emotions. He recommends the following two writing tasks:
Writing a list of issues. Sarno states that each patient should try to list out all issues that might contribute to the patient's repressed emotions. He suggests looking in the following areas: (a) certain childhood experiences, such as abuse or lack of love, (b) personality traits such as perfectionism, conscientiousness and a strong need to be liked by everyone, (c) current life pressures, (d) aging and mortality and (e) situations in which the patient experiences conscious but unexpressed anger.
Writing essays. Sarno recommends that the patient write an essay for each item on the above list. He prefers longer essays because they force the patient to examine the emotional issues in depth.[6]
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 symptoms. According to Sarno and Schechter, daily repetition of the psychological process over time defeats the repression through conscious awareness.[22]
恢復正常生活型態
為了能恢復正常生活型態，病患應採取下列活動：
中斷物理治療：
沙諾建議病患停止使用整脊、物理治療及其它處置，因為通常這些處置會再增強慢性庝痛是因為結構問題的錯誤意識。
恢復正常活動
斯克卻特鼓勵病患漸近變得更為主動，並開始恢復正常活動。除外，鼓勵病患停止針對保養損傷背部的安全行為。
支持會議
沙諾讓未康復病患組成支持會議，使病患可以探索那些情緒可能引發症狀，
並復習早期教育之概念。
Psychotherapy
Sarno says that about 20% of his patients need psychotherapy. He states that he uses "short-term, dynamic, analytically oriented psychotherapy."[8] Schechter says that he uses psychotherapy for about 30% of his patients, and that six to ten sessions are needed per patient.[1]
Recovery Program
Alan Gordon, LCSW has created a TMS recovery program on the TMS Wiki, which includes various articles, exercises, and segments from sessions exemplifying therapeutic concepts.
While psychogenic pain and pain disorder are accepted diagnoses in the medical community, the TMS modality is more controversial.
A non-peer-reviewed 2005 study by Schechter at the Seligman Medical Institute (SMI), co-authored with institute director Arthur Smith, found that treatment of TMS achieved a 57% success rate among patients with chronic back pain.[23]
A peer-reviewed[24] 2007 study with Schechter, Smith and Stanley Azen, Professor and Co-Director ofBiostatistics in the Department of Preventative Medicine at the USC Keck School of Medicine, found a 54% success rate for treatment of TMS (P<.00001). The treatment consisted of office visits, at-home educational materials, writing about emotional issues and psychotherapy. The average pain duration for the study's patients was 9 years. Patients with less than 6 months of back pain were excluded to "control for the confounder that most back pain episodes typically resolve on their own in a few weeks."[1]
Schechter, Smith and Azen also compared their results to the results of three studies of other psychological treatments for chronic back pain. The three non-TMS studies were selected because of (a) their quality, as judged by the Cochrane Collaboration, and (b) the similarity of their pain measurements to those used in the TMS study. Of the three non-TMS studies, only one (the Turner study) showed a statistically significant improvement. Compared to the 2007 TMS study, the Turner study had a lower success rate (26%-35%, depending on the type of psychological treatment) and a lower level of statistical significance (P<.05).[1]
Schechter, et al. state that one advantage of TMS treatment is that it avoids the risks associated with surgery and medication, but they caution that the risks of TMS treatment are somewhat unknown due to the relatively low number of patients studied so far.[1]
Theory[edit source | editbeta]
According to Sarno, TMS is a condition in which unconscious emotional issues (primarily rage) initiate a process that causes physical pain and other symptoms. His theory suggests that the unconscious mind uses the autonomic nervous system to decreases blood flow to muscles, nerves or tendons, resulting in oxygen deprivation, experienced as pain in the affected tissues.[2][8][25] 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.[7]
Sarno states that the underlying cause of the pain is the mind's defense mechanism against unconsciousmental 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.[19][26] Sarno believes that when patients recognize that the symptoms are only a distraction, the symptoms then serve no purpose, and they go away. TMS can be considered a psychosomatic condition and has been referred to as a "distraction pain syndrome".[20]
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.[5]
Notable patients[edit source | editbeta]
Notable patients who have been treated for TMS include the following:
Radio personality Howard Stern credited TMS treatment with the relief of his "excruciating back and shoulder pain",[17] as well as his obsessive-compulsive disorder.[17][27]
20/20 co-anchor John Stossel was treated by Sarno for his chronic debilitating back pain.[3] In a 20/20segment on his former doctor, Stossel stated his opinion that the TMS treatment "cured" his back pain, although he admitted that he continues to have relapses of pain.[10]
Television writer and producer Janette Barber said that for three years, she had been increasingly unable to walk, and eventually began to use a wheelchair, due to severe ankle pain originally diagnosed astendinitis.[11] She was later diagnosed and treated for TMS. According to Barber, she was "pain-free one week after [Sarno's] lecture" and able to walk and run within a few months,[10][11][28] notwithstanding her "occasional" relapses of pain.[11]
The late actress Anne Bancroft said that she saw several doctors for back pain, but only Sarno's TMS treatment helped her.[9][10]
Controversy[edit source | editbeta]
The TMS diagnosis and treatment protocol are not accepted by the mainstream medical community.[9][10]Sarno himself stated in a 2004 interview with Medscape Orthopaedics & Sports Medicine that "99.999% of the medical profession does not accept this diagnosis."[2] Although the vast majority of medical doctors do not accept TMS, there are prominent doctors who accept it. Andrew Weil, a notable medical doctor and alternative medicine proponent, endorses TMS treatment for back pain.[14][15] Mehmet Oz, a television personality and Professor of Surgery at Columbia University, includes TMS treatment in his four recommendations for treating back pain.[16] Richard E. Sall, a medical doctor who authored a book on worker's compensation, includes TMS in a list of conditions he considers possible causes of back pain resulting in missed work days that increase the costs of worker's compensation programs.[29]
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,[6] citing the placebo effect and regression to the mean as possible explanations for its success. Patients typically see their doctor when the pain is at its worst and pain chart scores statistically improve over time even if left untreated; most people recover from an episode of back pain within weeks without any medical intervention at all.[30] The TMS theory has also been criticized as too simplistic to account for the complexity of pain syndromes.[10] James Rainville, a medical doctor at New England Baptist Hospital, said that while TMS treatment works for some patients, Sarno mistakenly uses the TMS diagnosis for other patients who have real physical problems.[31]
Sarno responds that he has had success with many patients who have exhausted every other means of treatment, which he says is proof that regression to the mean is not the cause.[10]
TMS的醫生包含了斯卻克特( David Schechter)、Andrew Weiland 及 Mehmet Oz。
症狀
背痛是常見的 TMS 症狀，但是沙諾定義更廣：
症狀類型：
根據沙諾的說法，TMS症狀包含疼痛、僵硬、刺痛及麻木及其它負面感覺。
發生部位：
除了背、沙諾陳述 TMS 可能發生在頸、膝、手臂、手腕或是身體其它部位。
斯卻克特(Schechter)表示症狀有轉移至身體其它部位的傾向，並認為症狀轉移可作為疼痛為TMS引發的證據。
診斷
根據沙諾及斯卻克特得出以下診斷TMS的法則：
沒有已知的病理因素：
沙諾及斯卻克特表示必須使用理學檢查、測試及影像來排出嚴重情形，如腫瘤。
沙諾表示椎間盤突出通常是無害的，因為症狀部位通常與突出部位沒有關聯。
壓痛點
通常醫師會用18個纖維肌痛壓痛點檢查出11個或以上的壓痛點作為纖維肌痛的診斷，沙諾則用6個主要壓痛點來診斷緊張筯膜炎：
2個在上斜方肌，2個在腰椎旁肌肉及2個在側上臀部。
這可找出99%的緊張筯膜炎病患。
患有身心症史：
沙諾及斯卻克特認為若身心症史，則可作為緊張筯膜炎的指標，如腸躁症及緊張性頭痛。
沙諾及斯卻克特表示病人無法找到有受過TMS訓練的醫師，則應該去看傳統醫師來排除骨折、腫瘤及感染等因素。
治療
治療
治療協議
TMS治療協議包含教育、撰寫情緒議題及回復至正常的生活型態。無法立該回彼的病患，也包含支持團體及心理治療。
TMS治療協議包含教育、撰寫情緒議題及回復至正常的生活型態。無法立該回彼的病患，也包含支持團體及心理治療。
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".[21]
教育
教育以會談、授課、書及錄音資料，内容包含緊張筯膜炎的心理及生理面向。
斯卻克特認為教育讓病患學習他們的生理狀態實際上是良性的，
任何失能是源自怕痛的恐懼及去除此狀態的心理，而不是實際再受傷的風險引起的。
Writing about emotional issues
Sarno states that each patient should set aside time daily to think and write about issues that could have led to the patient's repressed emotions. He recommends the following two writing tasks:
Writing a list of issues. Sarno states that each patient should try to list out all issues that might contribute to the patient's repressed emotions. He suggests looking in the following areas: (a) certain childhood experiences, such as abuse or lack of love, (b) personality traits such as perfectionism, conscientiousness and a strong need to be liked by everyone, (c) current life pressures, (d) aging and mortality and (e) situations in which the patient experiences conscious but unexpressed anger.
Writing essays. Sarno recommends that the patient write an essay for each item on the above list. He prefers longer essays because they force the patient to examine the emotional issues in depth.[6]
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 symptoms. According to Sarno and Schechter, daily repetition of the psychological process over time defeats the repression through conscious awareness.[22]
恢復正常生活型態
為了能恢復正常生活型態，病患應採取下列活動：
中斷物理治療：
沙諾建議病患停止使用整脊、物理治療及其它處置，因為通常這些處置會再增強慢性庝痛是因為結構問題的錯誤意識。
恢復正常活動
斯克卻特鼓勵病患漸近變得更為主動，並開始恢復正常活動。除外，鼓勵病患停止針對保養損傷背部的安全行為。
支持會議
沙諾讓未康復病患組成支持會議，使病患可以探索那些情緒可能引發症狀，
並復習早期教育之概念。
Psychotherapy
Sarno says that about 20% of his patients need psychotherapy. He states that he uses "short-term, dynamic, analytically oriented psychotherapy."[8] Schechter says that he uses psychotherapy for about 30% of his patients, and that six to ten sessions are needed per patient.[1]
Recovery Program
Alan Gordon, LCSW has created a TMS recovery program on the TMS Wiki, which includes various articles, exercises, and segments from sessions exemplifying therapeutic concepts.
醫學證據
While psychogenic pain and pain disorder are accepted diagnoses in the medical community, the TMS modality is more controversial.
A non-peer-reviewed 2005 study by Schechter at the Seligman Medical Institute (SMI), co-authored with institute director Arthur Smith, found that treatment of TMS achieved a 57% success rate among patients with chronic back pain.[23]
A peer-reviewed[24] 2007 study with Schechter, Smith and Stanley Azen, Professor and Co-Director ofBiostatistics in the Department of Preventative Medicine at the USC Keck School of Medicine, found a 54% success rate for treatment of TMS (P<.00001). The treatment consisted of office visits, at-home educational materials, writing about emotional issues and psychotherapy. The average pain duration for the study's patients was 9 years. Patients with less than 6 months of back pain were excluded to "control for the confounder that most back pain episodes typically resolve on their own in a few weeks."[1]
Schechter, Smith and Azen also compared their results to the results of three studies of other psychological treatments for chronic back pain. The three non-TMS studies were selected because of (a) their quality, as judged by the Cochrane Collaboration, and (b) the similarity of their pain measurements to those used in the TMS study. Of the three non-TMS studies, only one (the Turner study) showed a statistically significant improvement. Compared to the 2007 TMS study, the Turner study had a lower success rate (26%-35%, depending on the type of psychological treatment) and a lower level of statistical significance (P<.05).[1]
Schechter, et al. state that one advantage of TMS treatment is that it avoids the risks associated with surgery and medication, but they caution that the risks of TMS treatment are somewhat unknown due to the relatively low number of patients studied so far.[1]
Theory[edit source | editbeta]
According to Sarno, TMS is a condition in which unconscious emotional issues (primarily rage) initiate a process that causes physical pain and other symptoms. His theory suggests that the unconscious mind uses the autonomic nervous system to decreases blood flow to muscles, nerves or tendons, resulting in oxygen deprivation, experienced as pain in the affected tissues.[2][8][25] 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.[7]
Sarno states that the underlying cause of the pain is the mind's defense mechanism against unconsciousmental 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.[19][26] Sarno believes that when patients recognize that the symptoms are only a distraction, the symptoms then serve no purpose, and they go away. TMS can be considered a psychosomatic condition and has been referred to as a "distraction pain syndrome".[20]
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.[5]
Notable patients[edit source | editbeta]
Notable patients who have been treated for TMS include the following:
Radio personality Howard Stern credited TMS treatment with the relief of his "excruciating back and shoulder pain",[17] as well as his obsessive-compulsive disorder.[17][27]
20/20 co-anchor John Stossel was treated by Sarno for his chronic debilitating back pain.[3] In a 20/20segment on his former doctor, Stossel stated his opinion that the TMS treatment "cured" his back pain, although he admitted that he continues to have relapses of pain.[10]
Television writer and producer Janette Barber said that for three years, she had been increasingly unable to walk, and eventually began to use a wheelchair, due to severe ankle pain originally diagnosed astendinitis.[11] She was later diagnosed and treated for TMS. According to Barber, she was "pain-free one week after [Sarno's] lecture" and able to walk and run within a few months,[10][11][28] notwithstanding her "occasional" relapses of pain.[11]
The late actress Anne Bancroft said that she saw several doctors for back pain, but only Sarno's TMS treatment helped her.[9][10]
Controversy[edit source | editbeta]
The TMS diagnosis and treatment protocol are not accepted by the mainstream medical community.[9][10]Sarno himself stated in a 2004 interview with Medscape Orthopaedics & Sports Medicine that "99.999% of the medical profession does not accept this diagnosis."[2] Although the vast majority of medical doctors do not accept TMS, there are prominent doctors who accept it. Andrew Weil, a notable medical doctor and alternative medicine proponent, endorses TMS treatment for back pain.[14][15] Mehmet Oz, a television personality and Professor of Surgery at Columbia University, includes TMS treatment in his four recommendations for treating back pain.[16] Richard E. Sall, a medical doctor who authored a book on worker's compensation, includes TMS in a list of conditions he considers possible causes of back pain resulting in missed work days that increase the costs of worker's compensation programs.[29]
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,[6] citing the placebo effect and regression to the mean as possible explanations for its success. Patients typically see their doctor when the pain is at its worst and pain chart scores statistically improve over time even if left untreated; most people recover from an episode of back pain within weeks without any medical intervention at all.[30] The TMS theory has also been criticized as too simplistic to account for the complexity of pain syndromes.[10] James Rainville, a medical doctor at New England Baptist Hospital, said that while TMS treatment works for some patients, Sarno mistakenly uses the TMS diagnosis for other patients who have real physical problems.[31]
Sarno responds that he has had success with many patients who have exhausted every other means of treatment, which he says is proof that regression to the mean is not the cause.[10]
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