Story at-a-glance

• Worldwide, 1 in 10 people suffers from lower back pain and it’s the No. 1 cause of job disability. In the U.S., $90 billion is spent on back pain each year
• Few people want to be told that their pain is psychological or emotional in origin, but there’s quite a bit of evidence that backs this up. Studies suggest that, to be effective, pain needs to be addressed from a biopsychosocial perspective
• The late Dr. John Sarno used mind-body techniques to treat patients with severe low back pain. He believed you unconsciously cause your own pain, and that pain is your brain’s response to unaddressed stress, anger or fear
• Pain acts as a distraction from the anger, fear or rage you don’t want to feel or think about, acting as a lid to keep unwanted emotions from erupting. Sarno believed most pain can be overcome by acknowledging its psychological roots
• Recent research supports Sarno’s ideas. In one recent study, emotion awareness and expression therapy reduced chronic musculoskeletal pain by 30 percent in two-thirds of patients; one-third of patients improved by 70 percent

Back pain is perhaps one of the most common health complaints across the globe. Worldwide, 1 in 10 people suffers from lower back pain, and it's the No. 1 cause of job disability. In the U.S., a whopping $90 billion is spent on back pain each year.1 Tragically, back pain is also a leading cause of opioid use, which now kills more Americans than car crashes.2

Seventy-five to 80 percent of back pain cases do resolve within two to four weeks,3 with or without treatment, although it's important to note that back pain can also be symptomatic of something else entirely, including an aortic aneurysm, appendicitis, gynecological issues, osteoporosis, arthritis and kidney stones,4 so if your back pain is not the result of an injury or strain, it's advisable to see a doctor for an assessment.

Few people want to be told that their pain is psychological or emotional in origin, but there's quite a bit of evidence that backs this up. As noted in a 2014 scientific review:5

"Specifically with regard to pain, studies pointed to the need for a model encompassing the complexity of the pain phenomenon. The biopsychosocial perspective closes this gap by confirming the existence of a dynamic relationship among biological changes, psychological status and social context.

The difficulty to accept the multidimensional nature of pain is largely linked to the widespread acceptance of Cartesian principles separating mind from body. Conversely, the biopsychosocial approach tries to consider physical, psychological, social and spiritual aspects not separately, but as an integrated whole … [S]everal studies show the major role of biopsychosocial factors in triggering chronic pain, in the process of acute pain chronicity and in patients' incapacity."

Back Pain — Is It All in Your Head?

The late Dr. John Sarno, a professor of rehabilitation medicine, used mind-body techniques to treat patients with severe low back pain. His specialty was those who have already had surgery for low back pain and did not get any relief. This is a tough group of patients, yet he claimed to have a greater than 80 percent success rate using techniques like the Emotional Freedom Techniques (EFT). A recent Vox article6 discusses Sarno's unconventional treatment strategies for back pain, citing feedback from enthusiastic patients:

"'Thousands of people, including myself and my husband, cured our chronic back pain using [Sarno's] methods,' wrote Karen Karvonen. Another Sarno devotee, Steven Schroeder, said the doctor changed his life. Schroeder's back pain flared whenever he was stressed — a busy time at work, an illness in his family.

After he absorbed Sarno's books, the discomfort mostly vanished. 'I still sometimes have pain now in times of stress — but I can literally make it go away with mental focus,' Schroeder, a lawyer in Chicago, wrote in an email. 'It is crazy.'

Though he may not be a household name, Sarno is probably America's most famous back pain doctor. Before his death on June 22, a day shy of his 94th birthday, he published four books and built a cult-like following of thousands of patients … Many of them claim to have been healed by Sarno, who essentially argued back pain was all in people's heads."

Before his death, Sarno was even the subject of a full-length documentary, "All the Rage: Saved by Sarno," produced through Kickstarter donations. The film is expected to become available on Netflix before the end of the year. He was also featured in a "20/20" segment in 1999 (below).

As noted by Sarno in "All the Rage" — a four-minute trailer of which is included above — "I tell [my patient] what's going on, and lo and behold, it stops hurting." The "what" that is going on is not a physical problem at all — it's emotions: anger; fear; frustration; rage.

The Psychological Underpinnings of Pain

One of the most controversial aspects of Sarno's theory is that spine and disc abnormalities have no bearing on pain. In this 20/20 segment, Sarno dismisses these issues as "normal abnormalities" that are unrelated to any pain you may be experiencing. Many with back pain have no detectable abnormalities or structural problems while some that do have them suffer no pain.

According to Sarno, you unconsciously cause your own pain. In a nutshell, the pain you're experiencing is your brain's response to unaddressed stress, anger or fear. When these kinds of emotions are suppressed, your brain redirects the emotional impulses to restrict blood flow to certain parts of your body, such as your back, neck or shoulder, thereby triggering pain.

This pain acts as a distraction from the anger, fear or rage you don't want to feel or think about. The pain essentially acts as a lid, keeping unwanted emotions from erupting. You may feel anger at the pain, but you won't have to face the fact that you're actually angry at your spouse, your children or your best friend, or that you hate your job, or the fact that you feel taken advantage of.

As noted by Sarno, working hard and constantly trying to do everything perfectly to keep everybody around you happy, "is enraging to the unconscious mind." The term Sarno coined for this psychosomatic pain condition is "tension myoneural syndrome,"7 and he firmly believed most people can overcome their pain by acknowledging its psychological roots.

Even if you struggle to accept such a concept, the mere knowledge of it can have therapeutic power. In other words, by considering the idea that your problem is in fact rooted in stress factors opposed to a physical problem can allow the pain to dissipate.

While many of Sarno's patients got well without psychiatric help, he would often recommend seeking out a psychotherapist to explore repressed emotions, or to take up journaling to put your feelings on paper. Dr. David Hanscom, an orthopedic surgeon, also uses expressive writing as a primary treatment tool for back pain. To learn more about this, please see our 2015 interview linked above. Other dos and don'ts listed in Sarno's book, "Healing Back Pain," include:

Resume physical activity. It won't hurt you

Repress your anger or emotions

Talk to your brain: Tell it you won't take it anymore

Think of yourself as being injured. Psychological conditioning contributes to ongoing back pain

Stop all physical treatments for your back — they may be blocking your recovery

Be intimidated by back pain. You have the power to overcome it

Studies Support Mind-Body Connection in Painful Conditions

While many pain experts disagreed (and still disagree) with Sarno's theories, recent research supports the idea that pain, in many cases, has psychological underpinnings. A study8 published last year found emotion awareness and expression therapy (EAET) reduced chronic musculoskeletal pain by at least 30 percent in two-thirds of patients; one-third of patients improved by 70 percent.

More recently, a study9 published in the journal Pain concluded that treating fibromyalgia pain with EAET was more effective than cognitive behavioral therapy and general fibromyalgia education. Other recent research10 found that feelings of stiffness in the back "may represent a protective perceptual construct." Tasha Stanton, Ph.D., who investigates the neuroscience behind pain, explained her team's findings:11

"People with chronic back pain and stiffness overestimate how much force was being applied to their backs — they were more protective of their back. How much they overestimated this force related to how stiff their backs felt — the stiffer [it] felt, the more they overestimated force. This suggests the feelings of stiffness are a protective response, likely to avoid movement …

In theory, people who feel back stiffness should have a stiffer spine than those who do not. We found this was not the case in reality. Instead, we found that the amount they protected their back was a better predictor of how stiff their back felt. [We] found that these feelings could be modulated using different sounds.

The feeling of stiffness was worse with creaky door sounds and less with gentle whooshing sounds. This raises the possibility that we can clinically target stiffness without focusing on the joint itself but using other senses.

The brain uses information from numerous different sources including sound, touch, and vision, to create feelings such as stiffness. If we can manipulate those sources of information, we then potentially have the ability to manipulate feelings of stiffness. This opens the door for new treatment possibilities, which is incredibly exciting."

All Pain Is Regulated by Your Brain

It may be helpful to remember that while pain may be largely a product of your own mind, the pain is still "real." As noted by Dr. Mel Pohl,12 a clinical assistant professor in the department of psychiatry and behavioral sciences at the University of Nevada School of Medicine, "all pain is regulated by the brain — whether there is an actual nail in your thumb or an old injury that should have healed by now but inexplicably keeps hurting — in both cases it is nerve fibers that are sending messages to your brain that cause you to feel pain."

An acute injury doesn't have to have a psychological trigger, but if the pain persists long after the injury has healed, there may well be an emotional aspect involved. Pain can also carve figurative grooves in your brain. When pain is perceived over an extended period of time, the number of pain-causing neurotransmitters in your nervous system increase and your pain threshold tends to get lower. Essentially, you become more sensitized to pain.

Like Sarno, Hanscom and many others, Pohl also believes emotions are a primary cause of pain, triggering as much as 80 percent of all pain. This does not detract from its validity or intensity, however. Writing for Psychology Today, he says:13

"Based on studies conducted [in 2013] … published in the journal NatureNeuroscience, we now have conclusive evidence that the experience of chronic pain is strongly influenced by emotions. The emotional state of the brain can explain why different individuals do not respond the same way to similar injuries.

It was possible to predict with 85 percent accuracy whether an individual (out of a group of forty volunteers who each received four brain scans over the course of one year) would go on to develop chronic pain after an injury, or not.

These results echo other data and studies in the psychological and medical literature that confirm that changing one's attitudes — one's emotions — toward pain decreases the pain. I believe that one of the most important things people with chronic pain can do to help themselves is to notice what they are feeling."

Physical Movement Is a Crucial Treatment Component for Most Pain

Your body needs regular activity to remain pain free, and this applies even if you're currently in pain. Not only does prolonged sitting restrict blood flow, which may trigger or exacerbate pain, sitting may even be the cause of the pain in the first place. For example, when you sit for long periods of time, you typically end up shortening your iliacus, psoas and quadratus lumborum muscles that connect from your lumbar region to the top of your femur and pelvis.

When these muscles are shortened, it can cause severe pain upon standing, as they will effectively pull your lower back (lumbar) forward. When there's insufficient movement in your hip and thoracic spine, you also end up with excessive movement in your lower back. Most people tend to "baby" the pain and avoid moving about as much as possible, but in most cases, this is actually contraindicated. In fact, experts now agree that when it hurts the most, that's when you really need to get moving.14

A scientific review of 21 studies15 confirmed that not only is exercise the most effective way to prevent back pain in the first place, it's also the best way to prevent a relapse. Among people who had a history of back pain, those who exercised had a 25 percent to 40 percent lower risk of having another episode within a year than those who did not exercise.

Strength exercises, aerobics, flexibility training and stretching were all beneficial in lowering the risk of recurring pain. The video above, featuring Lisa Huck, demonstrates and explains the benefits of dynamic movement, and how it can help prevent and treat back pain.

New Treatment Guidelines for Back Pain Stress Nondrug Interventions

Fortunately, doctors are increasingly starting to prescribe activity in combination with a wait-and-watch approach for back pain patients.16 Dr. James Weinstein, a back pain specialist and chief executive of Dartmouth-Hitchcock Health System, told The New York Times:17

"What we need to do is to stop medicalizing symptoms. Pills are not going to make people better … [Y]oga and tai chi, all those things are wonderful, but why not just go back to your normal activities? I know your back hurts, but go run, be active, instead of taking a pill."

This view has now become the new norm. In fact, on February 14, 2017, the American College of Physicians issued updated treatment guidelines18,19 for acute, subacute and chronic low back pain, now sidestepping medication as a first-line treatment and recommending nondrug therapies instead. This is a significant change, and one that could potentially save thousands of lives by avoiding opioid addiction. The new guidelines include three primary recommendations:

1."Given that most patients with acute or subacute low back pain improve over time regardless of treatment, clinicians and patients should select nonpharmacologic treatment with superficial heat … massage, acupuncture, or spinal manipulation … If pharmacologic treatment is desired, clinicians and patients should select nonsteroidal anti-inflammatory drugs or skeletal muscle relaxants …

2.For patients with chronic low back pain, clinicians and patients should initially select nonpharmacologic treatment with exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction … tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation …

3.In patients with chronic low back pain who have had an inadequate response to nonpharmacologic therapy, clinicians and patients should consider pharmacologic treatment with nonsteroidal anti-inflammatory drugs as first-line therapy, or tramadol or duloxetine as second-line therapy.

Clinicians should only consider opioids as an option in patients who have failed the aforementioned treatments and only if the potential benefits outweigh the risks for individual patients and after a discussion of known risks and realistic benefits with patients … "

The guidelines stress that even in the rare case when an opioid is given, it should only be prescribed in the lowest dose and for the shortest duration possible. Steroid injections and acetaminophen are also discouraged, as studies suggest neither is helpful or beneficial. Acetaminophen does not lower inflammation, and a review of the research20 shows steroids are on par with placebo when it comes to treating back pain in the long term.

Nondrug Solutions for Pain Relief

I certainly believe that your emotional health and your ability to effectively address stress is an essential component of optimal health, and can have a major influence on whether or not you're effective in eliminating your pain. And so do many other doctors and scientists from various fields of medicine.

It's unfortunate that so many people dismiss these types of treatment strategies simply because they seem "too simple to be effective." We've been indoctrinated to believe that getting well involves radical, often painful treatment, when in most cases the complete opposite is true.

It's also important to be fully aware of the addictive potential of opioid drugs, and to seriously weigh your need for a narcotic pain killer. There are many other ways to address pain. Below is a long list of suggestions. If you are in pain that is bearable, please try these options first. If you need a pain reliever, consider an over-the-counter (OTC) option.

Research21 shows prescription-strength naproxen (Naprosyn, sold OTC in lower dosages as Aleve) provides the same pain relief as more dangerous narcotic painkillers. However, while naproxen may be a better alternative to narcotic painkillers, it still comes with a very long list of potential side effects,22 and the risks increase with frequency of use.

Eliminate or radically reduce most grains and sugars from your diet

Avoiding grains and sugars will lower your insulin and leptin levels and decrease insulin and leptin resistance, which is one of the most important reasons why inflammatory prostaglandins are produced. That is why stopping sugar and sweets is so important to controlling your pain and other types of chronic illnesses.

Take a high-quality, animal-based omega-3 fat

Omega-3 fats are precursors to mediators of inflammation called prostaglandins. (In fact, that is how anti-inflammatory painkillers work, by manipulating prostaglandins.) Good sources include wild caught Alaskan salmon, sardines and anchovies, which are all high in healthy omega-3s while being low in contaminants such as mercury. As for supplements, my favorite is krill oil, as it has a number of benefits superior to fish oil.

Optimize your sun exposure and production of vitamin D

Optimize your vitamin D by getting regular, appropriate sun exposure, which will work through a variety of different mechanisms to reduce your pain. Sun exposure also has anti-inflammatory and pain relieving effects that are unrelated to vitamin D production, and these benefits cannot be obtained from a vitamin D supplement.

Red, near-, mid- and far-infrared light therapy (photobiology) and/or infrared saunas may also be quite helpful as they promote and speed tissue healing, even deep inside the body.

Medical cannabis

Medical marijuana has a long history as a natural analgesic and is now legal in 28 states. You can learn more about the laws in your state on medicalmarijuana.procon.org.23

Kratom

Kratom (Mitragyna speciose) is another plant remedy that has become a popular opioid substitute.24In August 2016, the U.S. Drug Enforcement Administration issued a notice saying it was planning to ban kratom, listing it as Schedule 1 controlled substance. However, following massive outrage from kratom users who say opioids are their only alternative, the agency reversed its decision.25

Kratom is likely safer than an opioid for someone in serious and chronic pain. However, it's important to recognize that it is a psychoactive substance and should not be used carelessly. There's very little research showing how to use it safely and effectively, and it may have a very different effect from one person to the next.

Also, while it may be useful for weaning people off opioids, kratom is in itself addictive. So, while it appears to be a far safer alternative to opioids, it's still a powerful and potentially addictive substance. So please, do your own research before trying it.

Emotional Freedom Techniques (EFT)

EFT is a drug-free approach for pain management of all kinds. EFT borrows from the principles of acupuncture in that it helps you balance out your subtle energy system. It helps resolve underlying, often subconscious and negative emotions that may be exacerbating your physical pain. By stimulating (tapping) well-established acupuncture points with your fingertips, you rebalance your energy system, which tends to dissipate pain.

Meditation and Mindfulness Training

Among volunteers who had never meditated before, those who attended four 20-minute classes to learn a meditation technique called focused attention (a form of mindfulness meditation) experienced significant pain relief — a 40 percent reduction in pain intensity and a 57 percent reduction in pain unpleasantness.26

Chiropractic

Many studies have confirmed that chiropractic management is much safer and less expensive than allopathic medical treatments, especially when used for pain such as low back pain.

Qualified chiropractic, osteopathic and naturopathic physicians are reliable, as they have received extensive training in the management of musculoskeletal disorders during their course of graduate health care training, which lasts between four to six years. These health experts have comprehensive training in musculoskeletal management.

Acupuncture

Research has discovered a "clear and robust" effect of acupuncture in the treatment of back, neck and shoulder pain, and osteoarthritis and headaches.

Physical therapy

Physical therapy has been shown to be as good as surgery for painful conditions such as torn cartilage and arthritis.

Foundation Training

Foundation training is an innovative method developed by Dr. Eric Goodman to treat his own chronic low back pain. It's an excellent alternative to painkillers and surgery, as it actually addresses the cause of the problem.

Massage

A systematic review and meta-analysis published in the journal Pain Medicine included 60 high-quality and seven low-quality studies that looked into the use of massage for various types of pain, including muscle and bone pain, headaches, deep internal pain, fibromyalgia pain and spinal cord pain.27

The review revealed massage therapy relieves pain better than getting no treatment at all. When compared to other pain treatments like acupuncture and physical therapy, massage therapy still proved beneficial and had few side effects. In addition to relieving pain, massage therapy also improved anxiety and health-related quality of life.

Astaxanthin

Astaxanthin is one of the most effective fat-soluble antioxidants known. It has very potent anti-inflammatory properties and in many cases works far more effectively than anti-inflammatory drugs. Higher doses are typically required and you may need 8 milligrams (mg) or more per day to achieve this benefit.

Ginger

This herb has potent anti-inflammatory activity and offers pain relief and stomach-settling properties. Fresh ginger works well steeped in boiling water as a tea or grated into vegetable juice.

Curcumin

In a study of osteoarthritis patients, those who added 200 mg of curcumin a day to their treatment plan had reduced pain and increased mobility. A past study also found that a turmeric extract composed of curcuminoids blocked inflammatory pathways, effectively preventing the overproduction of a protein that triggers swelling and pain.28

Boswellia

Also known as boswellin or "Indian frankincense," this herb contains specific active anti-inflammatory ingredients.

Bromelain

This enzyme, found in pineapples, is a natural anti-inflammatory. It can be taken in supplement form but eating fresh pineapple, including some of the bromelain-rich stem, may also be helpful.

Cetyl Myristoleate (CMO)

This oil, found in fish and dairy butter, acts as a joint lubricant and anti-inflammatory. I have used this for myself to relieve ganglion cysts and carpal tunnel syndrome. I used a topical preparation for this.

Evening Primrose, Black Currant and Borage Oils

These contain the essential fatty acid gamma-linolenic acid (GLA), which is particularly useful for treating arthritic pain.

Cayenne Cream

Also called capsaicin cream, this spice comes from dried hot peppers. It alleviates pain by depleting the body's supply of substance P, a chemical component of nerve cells that transmits pain signals to your brain.

Methods such as hot and cold packs, aquatic therapy, yoga, various mind-body techniques and cognitive behavioral therapy29 can also result in astonishing pain relief without drugs.

Grounding

Walking barefoot on the earth may also provide a certain measure of pain relief by combating inflammation.