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The treatment protocol for TMS includes education, writing about emotional issues and resumption of a normal lifestyle. For patients who do not recover quickly, the protocol also includes support groups and/or psychotherapy.
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".
- Education
Education may take the form of office visits, lectures and written and audio materials. The content of the education includes the psychological and physiological aspects of TMS. According to Schechter, the education allows the patients to "learn that their physical condition is actually benign and that any disability they have is a function of pain-related fear and deconditioning, not the actual risk of further 're-injury.'"
- 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.
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.
- Resumption of a normal lifestyle
To return to a normal lifestyle, patients are told to take the following actions:
- "Discontinuation of physical treatments -" Sarno advises patients to stop using spinal manipulation, physical therapy and other physical treatments because "they tend to reinforce erroneously a structural causation for the chronic pain."
- "Resumption of normal physical activity -" Schechter states that patients are encouraged to "gradually be more active, and begin to resume a normal life." In addition, patients are encouraged "to discontinue the safety behaviours aimed at protecting their 'damaged' backs".
- Support meetings
Sarno uses support meetings for patients who do not make a prompt recovery. Sarno states that the support meetings (a) allow the patients to explore emotional issues that may be causing their symptoms and (b) review concepts covered during the earlier education.
- Psychotherapy
Sarno says that about 20% of his patients need psychotherapy. He states that he uses "short-term, dynamic, analytically oriented psychotherapy." Schechter says that he uses psychotherapy for about 30% of his patients, and that six to ten sessions are needed per patient.
- 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.
A peer-reviewed 2007 study with Schechter, Smith and Stanley Azen, Professor and Co-Director of Biostatistics 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."
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).
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.
The most common medicines used to treat chronic (daily) headaches are called prophylactic medicines, which are used to prevent headaches. Such preventative medication is taken on a daily basis, even when a person may not have a headache. Prophylactic medicines are recommended for chronic headache patients because varied experiments prove that the medications "reduce the frequency, severity, and disability associated with daily headaches". A majority of the prophylactic medications work by inhibiting or increasing neurotransmissions in the brain, often preventing the brain from interpreting pain signals.
Preventative medicines include gabapentin (Neurontin), tizanidine (Zanaflex), fluoxetine (Prozac), amitriptyline (Elavil), and topiramate (Topamax). In testing, gabapentin was found to reduce the number of headache days a month by 9.1%. Tizanidine was found to decrease the average frequency of headaches per week, the headache intensity, and the mean headache duration. Through studies, Fluoxetine resulted in better mood ratings and "significant increases in headache-free days". Despite being associated with depression, antidepressants, such as amitriptyline, have been found to effectively treat "near-daily headaches" and numerous chronic pain conditions as well as improving mood and sleep—two possible triggers for chronic headache sufferers. One study found that the headache frequency over a 28-day period lowered for chronic headache patients on topiramate. Another medication to prevent headaches is botulinum toxin type A (BoNTA or BOTOX), which is given by injection instead of being taken orally. In a clinical study of botulinum toxin type A, patients participating in the 9-month treatment period with three treatments experienced headache frequency decreases up to 50%. As with all medications, the preventative medications may have side effects. Since different people respond to drugs differently, chronic headache sufferers may have to go through a "trial-and-error" period to find the right medications. The previously mentioned medicines can improve headaches, but physicians recommend multiple forms of treatments.
The most common chronic treatment method is the use of medicine. Many people try to seek pain relief from analgesic medicines (commonly termed pain killers), such as aspirin, acetaminophen, aspirin compounds, ibuprofen, and opioids. The long term use of opioids; however, appears to result in greater harm than benefit. Also, abortive medications can be used to "stop a headache once it has begun"; such drugs include ergotamine (Cafergot), triptans (Imitrex), and prednisone (Deltasone). However, medical professionals advise that abuse of analgesics and abortive medications can actually lead to an increase in headaches. The painkiller medicines help headaches temporarily, but as the "quick fix" wears off, headaches become more re-current and grow in intensity. These "rebound headaches" can actually make the body less responsive to preventive medication. The conditions keep worsening if one takes paracetamol, aspirin and non-steroidal anti-inflammatory drugs (NSAIDs) for 15 days a month or more. Therefore, analgesic and abortive medications are often advised for headaches that are not chronic in nature.
Treatment may involve investigation, reassurance and explanation, and possibly specialist treatment such as antidepressants or cognitive behavioral therapy.
Anumonye reported treatment success with lorazepam; others found benefit with antidepressants and relaxation exercises.
Treatment varies. In most cases, the best treatment is to remove the cause of compression by modifying patient behavior, in combination with medical treatment to relieve inflammation and pain. Whatever the cause, typical treatment takes several weeks to months—depending on the degree of nerve damage. Typical treatment options include:
- Active Release Technique (ART) soft tissue treatment
- Wearing looser clothing and suspenders rather than belts
- Weight loss if obesity is present
- Non-steroidal anti-inflammatory drugs (NSAIDs) to reduce inflammatory pain if pain level limits motion and prevents sleep
- Reducing physical activity in relation to pain level. Acute pain may require absolute bed rest
- Deep tissue massage to reduce tension in the gluteal muscles, most commonly the gluteus maximus. The tensor fasciae latae may also be implicated.
The lateral cutaneous nerve of the thigh can occasionally be damaged during laparoscopic hernia repair, or scarring from the operation can lead to meralgia paraesthetica.
For lower pain levels, treatment may involve having the patient:
- Seek appropriate physical therapy, such as stretching and massage, which plays a large role in the management of pain
- Learn to perform inguinal ligament stretching (from a physical therapist or from a YouTube video) which can rapidly relieve symptoms
- Use rest periods to interrupt long periods of standing, walking, cycling, or other aggravating activity
- Lose weight, and exercise to strengthen abdominal muscles
- Wear clothing that is loose at the upper front hip area
- Apply heat, ice, or electrical stimulation
- Take nonsteroidal anti-inflammatory medications for 7–10 days
- Remove hair in affected area (shave)
- Lidocaine patches (must shave area first)
- Titanium dioxide patches to interfere with the electrostatic effect of the nerves on the surface of the skin
Pain may take significant time (weeks) to stop and, in some cases, numbness persists despite treatment. In severe cases, the physician might perform a local nerve block at the inguinal ligament, using a combination of local anaesthetic (lidocaine) and corticosteroids to provide relief that may last several weeks. Pain modifier drugs for neuralgic pain (such as amitriptyline, carbamazepine or gabapentin) may be tried, but are often not as helpful in the majority of patients.
Persistent and severe cases may require surgery to decompress the nerve or, as a last resort, to resect the nerve. The latter treatment leaves permanent numbness in the area.
Over-the-counter drugs, like acetaminophen, aspirin, or ibuprofen, can be effective but tend to only be helpful as a treatment for a few times in a week at most. Analgesic/sedative combinations are widely used (e.g., analgesic/antihistamine combinations like Syndol, Mersyndol and Percogesic, analgesic/barbiturate combinations such as Fiorinal). Frequent use of analgesics may, however, lead to medication overuse headache.
Botulinum toxin does not appear to be helpful.
Sudden cessation of high-dose corticosteroids, opioids, barbiturates, benzodiazepines, caffeine or alcohol can induce myalgia in many respects.
People who have 15 or more headaches in a month may be treated with certain types of daily antidepressants which act to prevent continued tension headaches from occurring. In those who are predisposed to tension type headaches the first-line preventative treatment is amitriptyline, whereas mirtazapine and venlafaxine are second-line treatment options. Tricyclic antidepressants appear to be useful for prevention. Tricyclic antidepressants have been found to be more effective than SSRIs but have greater side effects. Evidence is poor for the use of SSRIs, propranolol, and muscle relaxants for prevention of tension headaches.
Patients are typically sent to therapy for BII phobia in order to receive therapeutic treatments to calm their levels of anxiety and stress. Therapists use a combination of psychological and physical measures, such as applying muscle tension, in order to help the patient to be aware that there is certainly a needle in front of them.
A popular method of treatment for BII phobics is Cognitive-Behavior Therapy (CBT), which is a technique that allows the patient to become immune to their fear by being exposed to it. For BII phobics, patients are given pictures of needles or blood, they are also asked to draw pictures of these needles and speak about it. Afterwards, they are given an actual needle, and the goal is: by that point, that the patient is to be comfortable enough with their fear of needles and blood.
Some patients may refuse professional help for their phobia. Instead, a different type of treatment solely revolves around motivation and whether or not the patient is willing to undergo through treating their phobia with self-help. Similar to CBT, patients treat themselves by completing exercises to become immune to their fear. This requires no professional assistance and merely relies on the person.
Research on hypnotherapy has been looked upon to treat patients with BII phobia. Hypnotherapists are known for using relaxing therapies towards individuals with common anxiety issues. A form of therapy given to patients with BII phobia include the “Applied Tension” method, which was developed by Lars-Göran Öst and his colleagues at the University of Uppsala in Sweden. This “coping method involves creating tension on a person’s arms, legs, and chest until they start to feel their body temperature rising,” (Robertson) which usually occurs within 10 to 20 seconds. These sessions of muscle tension is repeated 5 times with 20 to 30 second breaks. Patients should complete this form of therapy over the course of 5 weeks. This helps to prevent the patient from fainting by applying tension to the body, the blood pressure steadily rises, preventing any sudden drop until their vaccination is complete. By using this treatment, there was a noticeable improvement by 90% of patients with BII phobia. Compared to patients that only used the relaxation methods, where only 60% showed noticeable improvement.
Along with muscle tension,there are several methods of physical maneuvers that can help with the treatment of BII phobia. Therapists suggest that while being injected, patients should perform movements, such as: leg crossing, muscle tensing, and holding in the breath. Patients are instructed by their therapist to perform these maneuvers simultaneously while being injected with a needle. It’s also recommended that the patient stays seated with their head lowered while performing these movements.
One treatment methodogy that is very promising for the treatment of camptocormia is deep brain stimulation. Previously, deep brain stimulation and bilateral stimulation of the subthalamic nucleus and/or globus pallidus internus have been used to treat patients with Parkinson's disease. Studies have shown that similar treatments could be used on patients with severe camptocormia. By using the Burke-Fahn-Marsden Dystonia Rating Scale before and after treatment, it was found that patients experienced significant functional improvement in the ability to walk.
Cognitive behavioral therapy (CBT) has been shown to be effective in PMS and is suggested as a successful adjunct to SSRI treatment. CBT is an evidence-based treatment approach for treating depression and focuses on the link between mood, thoughts, and actions to help patients address current issues and symptoms. When CBT was compared to SSRI alone or in combination with SSRI, groups receiving CBT had significant improvement of PMS symptoms. Through the practice of CBT, patients are better able to recognize and modify recurrent issues as well as thought and behavior patterns that interfere with functioning well or that make depressive symptoms worse.
There have been some nutritional supplements that have been shown to help alleviate the symptoms of PMDD. In 1998, a placebo-controlled, randomized trial of 720 people with PMDD found that calcium carbonate demonstrated up to a 50% reduction in symptoms, compared with a 30% reduction in the control group. Herbal treatments that have shown promise in PMDD include chasteberry ("Vitex agnus castus"), St. John's wort ("Hypericum perforatum"), and ginkgo ("Ginkgo biloba)". Studies have been conducted on the efficacy of chasteberry and gingko, but as of this writing, no randomized controlled trial has been conducted on the efficacy of St. John's wort in alleviating PMDD symptoms.
Initial line of treatment is with anti-inflammatory drugs or cortisone injections. There have been trials with gloves which help protect the ulnar nerve from compression. The most radical treatment option is surgery to relieve tension in the volar carpal ligament which forms the roof of Guyon's canal, thereby reducing compression on the ulnar nerve.
The place of chiropractic-, physical-, occupational-, massage- and osteopathic therapy was not confirmed in scientific studies. These treatments can be both expensive as well as dangerous (causing permanent damage when performed wrongly).
It is advised to consult a physician beforehand starting any therapy, albeit an alternative approach, to avoid any permanent nerve damage.
Due to the wide range of causes of camptocormia, there is no one treatment that suits all patients. In addition, there is no specific pharmacological treatment for primary BSS. The use of analgesic drugs depends entirely on the intensity of the back pain. Muscular-origin BSS can be alleviated by positive lifestyle changes, including physical activity, walking with a cane, a nutritious diet, and weight loss. Worsening of symptoms is possible but rare in occurrence.
Treatment of the underlying cause of the disease can alleviate the condition in some individuals with secondary BSS. Other treatment options include drugs, injections of botulinum toxin, electroconvulsive therapy, deep brain stimulation, and surgical correction. Unfortunately, many of the elderly individuals affected by the BSS are not treated surgically due to age-related physical ailments and the long postoperative recovery period.
In severe cases of PM and DM with systemic signs, an initial three to five days on intravenous corticosteroid (methylprednisolone) may be used; but normally treatment begins with a single daily (after breakfast) high dose of oral corticosteroid (prednisone). After a month or so the strength of every second day's dose is very gradually reduced over three to four months, to minimize the negative effects of the prednisone. When a high dose of prednisone cannot be reduced without losing muscle strength, or when prednisone is effective but it is producing significant complications, "steroid sparing" oral immunosuppressants such as azathioprine, mycophenolate mofetil, methotrexate and cyclosporine, may be used in combination with reduced prednisone. Some of these steroid sparing drugs can take several months to demonstrate an effect.
To minimize side effects, patients on corticosteroids should follow a strict high-protein, low-carbohydrate, low-salt diet; and with long-term corticosteroid use a daily calcium supplement and weekly vitamin D supplement (and a weekly dose of Fosamax for postmenopausal women) should be considered.
For patients not responding to this approach there is weak evidence supporting the use of intravenous immunoglobulin, ciclosporin, tacrolimus, mycophenolate mofetil and other agents; and trials of rituximab have indicated a potential therapeutic effect.
Encouraging the use of proper ergonomics not only includes matching the physical ability of the worker with the correct job, but it deals with designing equipment that is correct for the task. Limiting heavy lifting, training, and reporting early signs of injury are examples that can prevent MSD. Employers can provide support for employees in order to prevent MSD in the workplace by involving the employees in planning, assessing, and developing standards of procedures that will support proper ergonomics and prevent injury.
One focus of ergonomic principles is maintaining neutral postures, which are postures in which muscles are at their normal length and able to generate the most force, while reducing stress and possible injury to muscles, tendons, nerves, and bones- therefore, in the workplace or in everyday life, it is ideal for muscles and joints to maintain neutral positions. Additionally, to prevent hand, wrist, and finger injuries, understanding when to use pinch grips (best for fine motor control and precise movements with low force) and power grips (best for high-force movements done repeatedly) is important for employees and general tasks outside the workplace. The choice of tools should match that of the proper grip and be conducive to neutral postures, which is important for employers to consider when purchasing equipment. In order to reduce injuries to the low back and spine, it is recommended to reduce weight and frequency of lifting cycles as well as decreasing the distance between the body and the load to reduce the torque force on the back for workers and individuals doing repeated lifting to avoid fatigue failure of the spine. The shape of objects being lifted should also be considered, especially by employers, because objects which are easier to grip, lift, and access present less stress on the spine and back muscles than objects which are awkwardly shaped and difficult to access.
The National Institute of Occupational Safety and Health (NIOSH) has published ergonomic recommendations for several industries, including construction, mining, agriculture, healthcare, and retail, among others.
Groups who are at particular risk can be identified, and modifications to the physical and psychosocial environment can be made. Approaches to prevention in workplace settings include matching the person's physical abilities to the tasks, increasing the person's capabilities, changing how tasks are performed, or changing the tasks. Employers can also utilize engineering controls and administrative controls to prevent injury happening on the job. Implementation of engineering controls is the process of designing or redesigning the workplace to account for strengths, weaknesses, and needs of the working population- examples would be workstation layout changes to be more efficient or reducing bending over, or moving necessary tools within shorter reach of the worker's station. Employers may also utilize administrative controls like reducing number of hours in a certain position, limiting overtime, or including more breaks during shifts in order to reduce amount of time at risk for each worker.
Habit reversal training (HRT) has the highest rate of success in treating trichotillomania. HRT has been shown to be a successful adjunct to medication as a way to treat trichotillomania. With HRT, the individual is trained to learn to recognize their impulse to pull and also teach them to redirect this impulse. In comparisons of behavioral versus pharmacologic treatment, cognitive behavioral therapy (including HRT) have shown significant improvement over medication alone. It has also proven effective in treating children. Biofeedback, cognitive-behavioral methods, and hypnosis may improve symptoms. Acceptance and Commitment Therapy (ACT) is also demonstrating promise in trichotillomania treatment. A 2012 review found tentative evidence for "movement decoupling".
Despite its very similar clinical presentation to PM, IBM does not respond to the drugs that effectively treat PM, and there is no proven effective therapy for IBM. Alemtuzumab is being studied but as of May 2013 it had not demonstrated clinical effectiveness in IBM. Dysphagia (difficulty swallowing) may be improved by intravenous immunoglobulin, though more trials are needed. Non-fatiguing, systematic strength-building exercise has demonstrated benefit. Occupational and rehabilitation therapists can offer good advice on walking without falling and performing fine motor tasks, and can provide appropriate canes, braces and wheelchairs. Speech pathologists can provide advice on preventing choking episodes and reducing the anxiety of an immanent aspiration for both patients and carers.
There is no standard course of treatment to slow or stop the progression of the disease. sIBM patients do not reliably respond to the anti-inflammatory, immunosuppressant, or immunomodulatory medications. Management is symptomatic. Prevention of falls is an important consideration. Specialized exercise therapy may supplement treatment to enhance quality of life. Physical therapy is recommended to teach the patient a home exercise program, to teach how to compensate during mobility-gait training with an assistive device, transfers and bed mobility.
The United States Food and Drug Administration (FDA) has not approved any medications for trichotillomania treatment.
Medications can be used to treat trichotillomania. Treatment with clomipramine, a tricyclic antidepressant, was shown in a small double-blind study to improve symptoms, but results of other studies on clomipramine for treating trichotillomania have been inconsistent. Naltrexone may be a viable treatment. Fluoxetine and other selective serotonin reuptake inhibitors (SSRIs) have limited usefulness in treating trichotillomania, and can often have significant side effects. Behavioral therapy has proven more effective when compared to fluoxetine or control groups. There is little research on the effectiveness of both behavioral therapy together with medication, and robust evidence from high-quality studies is lacking. Acetylcysteine treatment stemmed from an understanding of glutamate's role in regulation of impulse control.
Many medications, depending on individuality, may increase hair pulling.
Medical and surgical treatments have been recommended to treat organic dysphonias. An effective treatment for spasmodic dysphonia (hoarseness resulting from periodic breaks in phonation due to hyperadduction of the vocal folds) is botulinum toxin injection. The toxin acts by blocking acetylcholine release at the thyro-arytenoid muscle. Although the use of botlinum toxin injections is considered relatively safe, patients' responses to treatment differ in the initial stages; some have reported experiencing swallowing problems and breathy voice quality as a side-effect to the injections. Breathiness may last for a longer period of time for males than females.
Surgeries involve myoectomies of the laryngeal muscles to reduce voice breaks, and laryngoplasties, in which laryngeal cartilage is altered to reduce tension.
Tension-type headaches can usually be managed with NSAIDs (ibuprofen, naproxen), acetaminophen or aspirin. Triptans are not helpful in tension-type headaches unless the person also has migraines. For chronic tension type headaches, amitriptyline is the only medication proven to help. Amitriptyline is a medication which treats depression and also independently treats pain. It works by blocking the reuptake of serotonin and norepinephrine, and also reduces muscle tenderness by a separate mechanism. Studies evaluating acupuncture for tension-type headaches have been mixed. Overall, they show that acupuncture is probably not helpful for tension-type headaches.