The Somatic Connection  |   May 2014
How Much of Your Low Back Pain Is Really in Your Head?
Author Affiliations
  • Hollis H. King, DO, PhD
    University of Wisconsin School of Medicine and Public Health, Madison
Article Information
The Somatic Connection   |   May 2014
How Much of Your Low Back Pain Is Really in Your Head?
The Journal of the American Osteopathic Association, May 2014, Vol. 114, 406-407. doi:
The Journal of the American Osteopathic Association, May 2014, Vol. 114, 406-407. doi:
Bialosky JE, George SZ, Horn ME, Price DD, Staud R, Robinson ME. Spinal manipulative therapy-specific changes in pain sensitivity in individuals with low back pain [published online October 27, 2013]. J Pain. 2014;15(2):136-148. doi:10.1016/j.jpain.2013.10.005.  
Probably the most noted mind-body physician whose treatment for patients with low back pain is solely based on psychological interventions is John E. Sarno, MD.1,2 Sarno's treatment is a form of psychotherapy that requires the patient to confront any emotional issues associated with the pain. It is reported that patients who successfully complete his program become and remain pain free. The mind-body connection is also an important aspect of osteopathic medicine; the first tenet of osteopathic medical philosophy is, “The body is a unit; the person is a unity of body, mind, and spirit.”3 
A phenomenon closely related to the mind-body connection is the placebo effect. Researchers in the Department of Physical Therapy at the University of Florida have made strides toward understanding how the placebo effect may affect pain sensitivity. 
A total of 110 participants were recruited by means of advertisement. Participants were included in the study if they were experiencing low back pain with worse pain in the previous 24 hours rated as 4 or greater on a 0- to 10-point scale. Participants were randomly assigned to receive standard spinal manipulative therapy (SMT), placebo SMT, enhanced placebo SMT, or no treatment. In the SMT group, participants received a low back manipulation similar to the osteopathic manipulative treatment technique lumbar roll, which was applied bilaterally while the patient was in the lateral recumbent position. The placebo SMT participants received a maneuver involving a “thrust,” which was performed while the patient was supine in a neutral position. This maneuver was believed to have no beneficial effect. The participants in the standard SMT and placebo SMT groups were told that they would receive “either a studied SMT or a placebo intervention.” In the enhanced SMT group, the participants received the same placebo maneuver as the placebo SMT participants, but they were told, “The manual therapy technique you will receive has been shown to significantly reduce low back pain in some people.” The no-treatment control group sat silently for 5 minutes during the initial session. The standard SMT and placebo SMT interventions were repeated 6 times over a 2-week period. 
Outcome measures included mechanical pain sensitivity determined using pressure algometry, a visual analog scale, the Oswestri Disability Index, and thermal pain sensitivity. Immediately after intervention, the standard SMT participants demonstrated a reduction in pain sensitivity on most measures, with statistically significant differences found for thermal pain sensitivity (P≤.05). However, the outstanding finding and the focus of this research was an apparent central sensitization phenomenon, or preclinical effect: Compared with the other groups, the enhanced placebo SMT participants reported statistically significantly greater participant satisfaction. 
This study showed that suggestion enhanced perceived benefit of similar procedures and patient satisfaction. In a like manner, greater empathy is associated with positive clinical outcomes and patient satisfaction, and osteopathic medical students have been shown to have more empathy than other medical students.4 I contend from my clinical experience that osteopathic physicians also have high levels of empathy, which manifests in generally better clinical outcomes and constitutes a major element of the osteopathic difference. 
Sarno JE. Mind Over Back Pain. New York, NY: Berkley Trade; 1982.
Sarno JE. Healing Back Pain: The Mind-Body Connection. New York, NY: Grand Central Publishing; 1991.
Tenets of osteopathic medicine. American Osteopathic Association website. Accessed March 13, 2014.
Calabrese LH, Bianco JA, Mann D, Massello D, Hojat M. Correlates and changes in empathy and attitudes toward interprofessional collaboration in osteopathic medical students. J Am Osteopath Assoc. 2013;113(12):898-907. doi:10.7556/jaoa.2013.068. [CrossRef] [PubMed]