Volume 2 Number7.1989

2nd International Montreux Congress on StressNovember 19-21, Hotel Excelsior, Montreux, Switzerland

State of the art presentations on Stress and Cardiovascular Disease include the Pathogenesis of Mitral Valve Prolapse in AnxietyDisorders and Stress, The Stress Connection to Sudden Death, Stress-Retated Cardiovascular Hyperreactivity in thePathogenesis of Atherosclerosis and Coronary Heart Disease, The Role of Stress and the Sympathetic Neruous System in thePathogenesis of Hypertmsion, and Hypertension as a Disorder of Communication. Other sessions are devoted to Stress,Emotions, Personality and Health, and include an update on Personality Traits As Predictors of Mortality from CardiovascularDisease and Cancer and the Beneficial Effects of Stress Reduction Strategies. Other segments are devoted to the StressReduction Effectsof Spa Therapy, How to Designand Deliver an Effective Stress Reduction Program, Psychophysiologic StressAssessment Techniques, etc, The concluding presentations are devoted to the Biobehavioral Effects of Low EmissionElectromagnetic EnerEt and their use in the treatment of insomnia, depression, anxiety and addictive disorders,

In reeponee to a nurnber of requectr, we will be devoting certaln iacuee of the Newrletter to cpecilictopicC. The forrnat will lnclude an introductory general overview followed by aumnary articlcareporting on recent relevant reeearch reportc. This iceue focuces on 9frecc and Afthrltio and LowBack Pain,

Stress and ArthritisThe word arthritis comes from the Greek, arthron0oint) and -itis (inflammation). The ape-man of twomillion years ago had evidence of chronic arthritis ofthe spine. Similar changes were also found in the Javaand Lansing skeletons, 500,000 years old and inEgyptian mummies dating from 8,000 B.C. Egyptianmanuscripts over 3,000 years old mention treatmentsfor gout and arthritis with various ointments, heat, orthe shock of an electric fish. Many of these sametherapies persisted into the present century in remoteAfrican villages. The Greeks used the term, rheuma

ALSO INCLUDED IN THIS ISSUE

Stress and Arthritis: Cause and Effect

What Kinds of Stress Cause Rheumatoid Arthritis? ..................3

Does Stress Trigger Arthritis? . . .3

Stress Reduction Therapy for Arthritis-... ......',..3

Self Help Redtrces Stress andArthritic Complaints ..............4

Pseudo.Arthritis and Stress r r r m l r r r r l m r r r *

The Lo.v Back Pain-Stress Connection.-. ....'.....5

(flowing) because they thought that rheumatism wasdue to the flowing of a watery substance into thejoints. Fifth century physicians believed that thecondition resulted as a "punishment by God fortransgressions" and prescribed purgatives, emetics,and leeches. In the twelfth century, a Persian writerattributed the disorder to an inability to expressaggression. At the end of the last century, Sir WilliamOsler commented on the association between arth'ritis and shock, worry, and grief.There are close to one hundred causes of arthritisincluding trauma, infections, metabolic and immunedisturbances and malignant growths. Females areaffected more than men and a majority over the age of65 have some form of arthritis that is symptomatic.About W" of the population, over the age of forty,show some X'ray changes of osteoarthritis, and it isthe greatest single caus€ of disability in the elderly'(Continued on page 2)

For further information on the original source of abstracts and otherreprints available on similar subjects, please send a self-addressedstamped envelope to: Reprint Division, American Institute of Stress,124 Park Avenue, Yonkers, NY 10703.

The Newsletter of THE AMERICAN INSTITUTE OF STRESSNEWSLETTER is published monthly byThe American Instituteof Stress. Subscription rates: $35.00 annually. Copyrighto 1987by The American Institute of Stress. All rights reserved.

The Newsletter of THE AMERICAN INSTITUTE OF STRESS

THE AMERICAN INSTITUTE OT

Paul J. Bosch, M.D., F.A.C.P.Editor-in-Chief

Contributing Editorc from The Board of Truateee ofThe American Inetitute of Strese

Robert Ader, Ph.D., Rochester, NYHerbert Bencon, M.D., Boston, MANorman Coucinc, Los Angeles, CAMichael E. DeBakey, M.D., Houston, TXJoel Elkec, M.D., Louisville, KYJohn Laragh, M.D., New York, NYJames J. Lynch, Ph.D., Baltimore, MDKenneth R. Pelletier, Ph.D., M.D., Berkeley, CARay H. Roeenman, M.D., Menlo Park, CACharles F. Stroebel, Ph,D., M.D., Hartford, CTAlvin Toffler, New York, NYSue Thornac, RN, Ph.D., Baltimore, MD

Stress and Arthritis(Continued from page one)

Some studies suggest that rheumatoid arthritis ismore prevalent in blacks than whites and lower inJapanese and Eskimos. However, there have been noconsistent cultural, geographic, or climatic trends,although symptoms tend to be more severe inenvironments with lowbarometric pressures and highhumidity. Arthritis is responsible for the loss oftwenty-seven million work days annually, The averagepatient spends more than one thousand dollars eachyear on doctor visits and medication. Totalexpendi-tures are estimated to exceed 17 billion dollarsannually for these and other arthritis-related services.Rheumatoid arthritis is a common disorder that attimes may be crippling. Standard treatment con-sists of analgesics and anti-inflammatory drugs orphysical therapy to relieve pain and improve mobility.Over the past two decades, it has become increas-ingly clear that like lupus and other connectivetissue diseases, rheumatoid arthritis is an auto-immune disorder. For reasons still not clearlyunderstood, the body's immune system mistakenlyattacks its own tissues, in this case, certain joints,much as it would act to fight harmfulbacteria andviruses. Research has shown that a curious mole-cule called "Substance P," which is involved in thetransfer of pain signals between nerves, is present inhigh concentrations in those joints most ofteninvolved in rheumatoid inflammation. It has beenfound that certain cells of the immune systemwhichare involved in the inflammatory response, recog-nize "Substance P" and produce an inflammatoryreaction that results in pain, redness, swelling, andultimately deformity.

It has long been appreciated that flare-ups ofrheumatoid arthritis tend to occur during or follow-ing periods of severe emotional stress. Recentmedical research appears to support this relation-ship since it has been demonstrated that stress canintefiere with immune system function. Rheuma-toid arthritis is frequently associated with depres-sion, which also lowers immune defenses. In addition,everyday seemingly minor daily stresses or "has-

sles" also can reduce the immune system's ability tocombat disease causing agents and are similarlyassociated with flare-ups of rheumatoid arthritis.Newer drugs for treating resistant cases of rheuma-toid arthritis usually act by influencing immunesystem activities. A variety of stress-reductionmeasures seem to enhance such effects. As willbeseen in the following abstracts taken from therecent medical literature, there appears to be aclose connection between stress and the onset andclinical course of rheumatoid and other types ofarthritis. More importantly, stress-reduction strat-egies which foster a sense of control and self-efficacy can provide significant benefits throughother mechanisms still not completely understood.

"Man is distrubed not by things, but by his opinion aboutthings." - Epictetus

Stress and Arthritis:Cause of Effect?

Arthritis specialists differ in their opinion about therelationship between stress and arthritis. Somebelieve that it is a psychosomatic illness, which insome patients may stem from chronic repressedanger due to childhood rebellion against a coldauthoritarian parent, Others subscribe to the propo-sition that many of the associated personalitychanges are a result of this chronic painful illness.Psychiatrists speculate that as long as individualscan discharge their hostile impulses through accept-able muscular activities (sports, gardening, workingaround the house) they can relieve stress whichwould ordinarily cause excessive muscular tension.When the stress associated with suppressed angerbecomes excessive, it leads to increased muscletension and joint complaints. Patients sufferingfrom a debilitating form of arthritis may feel vulner-able and less able to express anger which could alsocontribute to increased tension and muscle spasm.Depression is another common manifestation ofrheumatoid arthritis and has been associated withdisturbances in immune system function that arethought to play a major role in the cause and courseof this disorder.

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What Kinds of Stress CauseRheumatoid Arthritis?In one British study of female patients with arthritis,psychiatrists and rheumatologists working togetherfound that almost all had experienced a significantor new stressfulevent immediately before the onsetof their complaints. Sample items included: hus-band's firm went bankrupt, having a change at workto an unpleasant job, the abrupt end of a romanticrelationship, loss of a previously secure job, deathof a close friend, an only child getting marriedwithout parental participation in the event, etc.Scientists are generally skeptical about the sig'nificance of such anecdotalreports. Most of us, ifqueried about stressful events in the recent past,could probably come up with some or severalsituations that would fit that category. Such self-reports, which are after-the-fact must be evaluatedcarefully, However, the erratic course of rheum-atoid arthritis and its frequent relationship to emo'tional factors also suggest that stress may be animportant inciting influence. The disease may bequiescent for a long period of time and flare-ups areoften associated with personal problems, such asthe death or illness of a friend or family member.This is especially true when the patient has beeninvolved in a long-term relationship providing careor other self-sacrificing activities.

"Convictions are more dangerous enemies of truth thanlies'"

- Friedrich Nietzsche

Does StressTrigger Arthritis?

According to some specialists, the answer is adefinite yes. A recent round+able symposium entitled"Women and Arthritis" revealed that a significantnumber of sufferers had identified a significantlystressful event prior to the onset of their symptoms,which they felt was causally related. It may be thatstress does not actually cause the disease, butrather accelerates its development in those who aregenetically predisposed. Some experts believe thatcertain types of stress sustained during childhoodplay an important role in the development of thedisease decades later, More than a quarter ofchildren with juvenile rheumatoid arthritis werefound to have sustained a severe prior traumaticexperience. This was in sharp contrast to a controlgroup where only 10 percent reported such anevent. Similar findings were noted in a Londonstudy, where more than two out of three womenwith rheumatoid arthritis, had experienced a severe'ly stressful or traumatic incident in the year prior todevelopment of their symptoms. In contrast, only

one out of five in a carefully matched controlgroupreported similarly stressful situations.

"lt is easier to denature plutonium than to denature theevil spirit of man." - Albert Einstein

Stress Reduction TherapyFor Arthritis

It seems clear that in some patients, stress seems tobe a factor in the onset or recurrence of episodes ofrheumatoid arthritis. This is thought to be mediatedby effects on the immune system. Conversely,stress-reduction strategies can improve pain andfunction in many patients.More than 15,000 arthritis patients have now completeda twelve-hour patient-education course, first begunat the Stanford Arthritis Center in California in1979. lt was designed to help change patients'behavior and reduce their pain by providing inforrna-tion about their illness and ways to deal with it. Thecourse also provides education as wellas a supportgroup for osteoarthritis patients usingtrained leaders,most of whom have had arthritis, themselves.Patients learn relaxation techniques to reduce theiranxiety about the disease and to rclieve their pain.Leaders also encouraged patients to devise theirown exercises based on general principles, ratherthan following some specific prescribed routine. Asa result, the patients tend to feelmore in controloftheir illness and develop confidence in their abilityto dealwith their disease. Most usually find they cansoon get by with less pain medication and don'thave to depend as much on others to pursue theirdaily activities.Stress-reduction measures, including biofeedback,meditation, and visual imagery have also beenutilized to help arthritis sufferers, However, anybenefits may be due more to the feeling of controlengendered, rather than the specific intervention.Support from this comes from a study comparinghow well biofeedback training and self-efficacytraining could rclieve the pain of muscle tensionheadache. Patients received a careful explanationon how these headaches are caused by increasedtension in the muscles of the scalp and howbiofeedback could help them learn how to relaxthese muscles or significantly reduce pain, Half ofthe participants did receive this type of biofeedbacktraining and learned how to relax these muscleswhen they become tense. The control group receivedexactly the opposite feedback information so thatthe more they tensed their muscles, the more theybelieved that they were relaxing. Half of each groupwere told that they had been very successful inlearning the technique whereas the other half wereled to believe that they were only doing fairly well.(Continued on page 4)

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Stress Reduction TherapyFor Arthritis(continued from page 3)The researchers found that there was a 53 percentreduction in headache pain in those patients whohad been led to believe that they had been verysuccessful. This included both those who reallylearned to relax and others who unknowingly hadactually learned to tense their muscles as a resuit ofbiofeedback training. The other group, which includedthose who had learned the technique quite cor-rectly, reported only a 26 percent reduction inheadache pain. Thus, it was not the technique itselfbut rather the patient's belief that they could exertsome control over the problem that providedbenefits. Some authorities feel that this may alsoapply to other stress-reduction strategies, such as,meditation, aerobic exercise, yoga, progressivemuscle relaxation, etc. While the stress-reductionbenefits of such activities can be explained by orattributed to physiologic and biochemical alter-ations, the important element may be the feeling ofself efficacy and control that the individual hasachieved. This could be an important factor in anytherapy for rheumatoid arthritis, including medi-cation, physiotherapy, moving to a differentclimate, or even faith in a specific physician, holywater, or shrine. The common denominator may bea placebo-like effect which reduces harmful andinjurious stress-related influences by encouragingthe feeling of self-efficacy and control,

"Dost thou love life? Then do not squander time, forthat's the stuff life is made of."

- Benjamin Franklin

Self Help Reduces StressAnd Arthritic Complaints

In one recently reported study, 48 patients weredivided in two "experimental" and two "control"

groups of 12 each. Four hour-long group sessionswere conducted weekly for20 weeks. The objectivesof these sessions were:1) to increase the patient's knowledge of biologicalprocesses in health and disease, with special refer-ence to rheumatoid arthritis, stress and coping skills.2) to increase the patient's self-awareness and anawareness of others; and to train them in constructiveself-observation on a day-to-day basis.3) to encourage patients to assume controloverstressful events in their life, mobilize their ownresources and skills, and to move themselvestowards self-actualization despite their chronicdisorder.4) to enrich the patient's personal, social, and

professional lives through their own initiative andfamily support.5) to measure, as far as possible ,the effect of theabove interventions on the subjective perception ofpain, discomfort, fatigue, functioning, and medica-tion requirements, as wellas by clinicalassessmentand laboratory studies.The group sessions included: education aboutrheumatoid arthritis, immune system function,psychophysiological effects of stress, and how toadapt or cope with stress. Patients were en-couraged to become aware of cognitive cues inthemselves and others, and to use them con-structively.Biofeedback was employed as a teaching andtraining device to demonstrate the ability to controlseemingly involuntary processes. Instruction wasgiven in relaxation training, guided imagery, anddecision-making techniques. The group leader wasa professionalrehabilitation counselor who had alsosuffered from arthritis for 20 years. Patients wereevaluated weekly with subjective reports and by avariety of questionnaires at the beginning, half waythrough, and at the end of the treatment program,with a follow-up one year after its termination.Despite its length, 39 out of the 40 patients con-tinued to the end of the trial, which in itself is a greattribute.Significant benefits were achieved in affect, per-sonal and social functioning and need for depen-dence on others. It was felt that the impaired abilityof many patients to recognize, experience, andexpress feelings may be related to early life stress,stresses operating at or about the onset of disease,and the ongoing stress arising from an attempt toadapt to a relentless, stubborn and unpredictablypainful, chronic disease. The benefit of this pro-fessional peer-led group in terms of social supportwas quite eident. At the end of the study, thepatients incorporated themselves into a non-profitself-helper's group, to continue their activities andprovide support for others. Further analysis of thedata may disclose whether or not a correlationexists between the degree of improvement andspecific endocrine and metabolic changes.

Pseudo-Arthritis and StressThere are all kinds of arthritis. The most common isosteoarthritis, which may be described as a wearand tear arthritis that accompanies the aging process,and affects up to 907o of elderly individuals. Rheuma-toid arthritis generally appears in younger agegroups, is more common in women, and is usually amore painful, and crippling disorder. There are alsoa variety of other forms of arthritis associated withsystemic disorders such as gout, psoriasis, andcertain inborn errors of metabolism.(continued on page 5)

The Newsletter of THE AMERICAN INSTITUTE OF STRESS

Pseudo-Arthritis and Stress The Low Back Pain.Stress(continued from page 4)Another commondisorderwhich mimics the symp-toms of arthritis is known as the myofascial syn-drome. It has been estimated that at least a third ofpatients who complain of symptoms attributed toarthritis are really suffering from myofascial pain,This appears particularly true of patients sufferingfrom low back pain. The real distinction betweenarthritis and myofascial syndrome is that arthritisprimarily involves the joints, whereas, myofascialpain refers to inflammation of soft tissues andmuscles. Another distinction is that myofascialpain, when correctly diagnosed is usually simple totreat. Many patients who suffer from myofascialpain are incorrectly labeled malingerers because ofthe lack of X-ray findings or laboratory studies toprovide objective proof of pathology. On examina-tion, there is none of the redness, inflammation, orsevere tenderness seen with other forms of arth-ritis, although the patient may be disabled becauseof severe or chronic pain,Muscle strain, poor posture and prior injury maycontribute to myofascial pain and some studiesreport an association with disruptive sleep patterns.However, most authorities agree that anxiety,tension, and stress aggravate symptoms. Somebelieve that stress is a major cause since it canproduce muscle spasm and nerve root irritation,thus resuliing in more muscle spasm, and perpetu-ating a vicious cycle,In some patients, there are sensitive "trigger points,"which can be treated with acupuncture, acupres-sure, or local anesthesia, Myofascial pain syndromeis thought to be responsible for a large majority ofiow back pain complaints, Several studies haveshown that the vast majority of these patients havea stress-related problem which has either caused oraggravated their condition. More importantly, acomprehensive program of stress reduction andexercise has proven eflective in providing completerecovery, even in patients scheduled for surgerybecause of a neurological deficit or radiologicevidence of severe disease. While muscle relaxants,physiotherapy, or the injection of a localanestheticcan break up the pain-muscle spasm-pain cycle,these may provide only temporary relief. Stress-reduction strategies seem to achieve the samebenefits in a more sustained fashion.

"Philosophy separated itself from Science when itasked the question: What type of knowledge of theworld and life makes man happiest? This hashappened in the Socratic schools. This point of view- happiness - ligated the artery of scientific inves-tigation - and it does it stilltoday."

.Nietzche

Connection: New CluesFor Causes and Cures

It is estimated that 80-90 percent of Americanssuffer from back pain at some time during theiradult life. 75 million currently list this as a significantcomplaint, and for two million, the problem is sopersistently severe, that they are unable to work.Low back pain represents the single largest cause ofworker absenteeism in the United States, Canada,Great Britain and Scandinavia. One large insurancecompany reports that back-related complaints accountfor one-third of its disability claims at a daily cost of$870,000. We spend close to 15 billion dollarsannually dealing with it and eight million newsufferers are added every year. The price tag ismuch higher when one considers the associateddepression, pain, and other mental and physicaldisabilities that severely dimnish the quality of lifefor affected individuals,Back pain is responsible for almost 20 million doctorvisits each year, and represents the leading cause ofrestricted activity in males under the age of 45. Inhalf of these, it tends to be a recurrent problem,severely disrupting work and leisure activities. Over200,000 patients undergo corrective back surgeryyearly, although in three out of five patients, theprocedure fails to provide ellective relief from pain,Given the magnitude of the situation, there hasbeen comparatively little research devoted to itsscientific study. That may be due to the fact thatbackaches are not life threatening, and that mostpatients improve spontaneously within a few weeks.However, the past decade has produced someexciting new theories and treatment approacheswhich challenge traditionalviews about cause andcure. Prominent among these is the suggestion thatlow back pain is primarily a stress-related "Disease

of Civilization." Based on this theory, therapeuticstrategies have been developed which have provento be surprisingly etfective in long-term studies.Some of the stronger links in the stress-back painchain of events were forged by Dr. John Sarno,when he was Director of Outpatient Services atNew York University Medical Center's prestigiousInstitute of Rehabilitation Medicine. He found thatalmost 90 percent of his patients with low backproblems also had a history of other stress-relatedcomplaints. These included tension and migraineheadaches, heartburn, peptic ulcers, colitis, spasticcolon, allergies and other stress-induced disorders.He reasoned that their muscle pain and spasmmight similarly be due to stress and tension, As hewrote in his book Mind Over Back Pain, 'When thattheory was put to the test, and patients weretreated accordingly, there was an obvious improve-ment in the results of treatment. In fact, it was(Continued on page 6)

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The Low Back Pain-StressConnection: New CluesFor Causes and Cures(continued from page 5)possible now to predict which patients would do welland which might not."Dr. Sarno suspected tht the pain problem in thesepatients was not caused by the usual excuse of abulging disc or arthritic spur pressing on a nerve. Itseemed much more likely that the realreason was adecrease in the flow of blood to the affected area. It iswell known that stress can produce constriction ofblood vessels, resulting in pain in the affected tissuesbecause of lack of oxygen.A vivid example of this is seen in patients with angina,who frequently experience severe chest pain whenthey are angry or tense. Such emotional stress canprovoke spasm of the coronary arteries, severelyrestricting the flow of blood and oxygen to the heart,precipitating an attack of angna. Similarly, a signifcantreduction in the flow of blood to an extremity willproduce intense pain. In both instances, the discom-fort is due to the decreased delivery of oxygen to theaftected muscles. Low back pain and muscle spasmmay thus also be a consequence of the diminishedsupply of blood and oxygen.Further support for this theory comes from electronmicroscopy studies. This technique provides suchmagnificent magnification of tissues, that it is possibleto study what is going on inside each individualcomponent cell. When biopsies were obtained fromthe affected muscles of patients suffering from backpain, nothing startling was noted using a regularmicroscope. However, the electron microscolx clearlyrevealed changes in those muscle cells consistent withoxygen starvation. Based on this confirmation, atherapeutic program was developed utilizing appropri'ate exercises and stress-reduction measures designedto reduce spasm and increase the suppbof bloodandoxygen to the involved muscles. It proved to beextremely successful and the results were far superiorto the conventional treatment of complete bed restwith traction or surgery. Although these findings wererepeatedly reported in the medical literature, mostphysicians appeared to ignore or reject them. Some,however, had reached a similar conclusion based ontheir own clinical expeience. Interestingly enough,two of these were well known neurosurgeons withextensive experience in low back surgery.Dr. C. Norman Shealy became disenchanted with theresults of surgery for low back pain and realized thatthe cause and cure of the problem lay elsewhere.Hewas the first to use transcutaneous electrical nervestimulation (TENS) for the treatment of back pain,and subsequently developed a holistic treatmentapproach to the problem that emphasized stressreducton and exercise treatment modalities. That

was almost two decades ago and nowhis comprehen'sive pain and treatment center, has been expandedand relocated in Springfield, Missouri, to include otherstress-related pain disorders.Dr. Hubert Rosomoff, Chairman of the Departmentof Neurological Surgery at the University of Miami,pioneered the neurosurgical rhizotomy treatment forlow back pain utilizing an instrument very similar to apiano wire to pick off the involved pain pathwaytraveling up the spinalcord to the brain. Although thiswas less hazardous than major spinalsurgery, he alsodiscovered that he could achieve better results withnon-invasive rehabiiitative techniques. This required amultidisciplinary approach which included exercise,psychological counseling, and occupational and avoca-tional therapy aimed at reducing stress. In a recentinterview, he noted that in one review evaluation ofsome 45,000 patients, only 17" of them truly reallyrequired surgery, and that "by and large . . . we aretalking about a non surgicaldisease." 15 years ago heand his colleagues started a four-bed ward at theUniversity of Miami's Comprehensive Pain and Rehab'ilitation Center for patients with low back pain. Sincethen it has steadily expanded and thousands ofpatients originally scheduled for surgery haveobtained relief. In view of the fact that a significantnumber of these represent severe or "end stageproblems" resistant to conventional therapy, the ffiY"success rate of this multimodal approach is quiteimpressive.A prime example was the mother of two children whocame to the clinic as a last resort. "For 14 years shehad been mostly bedridden; to dealwith the pain sheeven had to eat her meals on a stretcher and wastaking five times the recommended quantity of mor-phine." Although she was able to retum to a normalroutine after treatment at the center, her initialreaction was anger at the medicalsystem in general,because "She flet that she had lost 14 years of her lifefor no good reason." Another 67-year-old man with amyelogram showing severe constriction of the spinalcord and suffering from bilateral foot-drop wouldsurely have been operated on immediately at mostmedical centers. Dr. Rosomoff noted that he was"fully recovered after six weeks and on the golf courseat eight weeks. He's been thercever since." Like Dr.Samo, he also came to the conclusion that it was not aherniated disk that was responsible for most of hispatients'pain, but rather soft tissue and muscle injurythat could best be alleviated by exercise and stressreduction efforts designed to reduce vascular andmuscle spasm,Hans Kraus, a New York physiatrist, who treatedJohn F. Kennedy's back pain when he was President,was one of the first to recognize the stress-lwo backpain connection. More than zl0 years ago, he andothercolleagues were involvedinan unique back painclinic at Columbia University. It included ortho'(Continued on page 7)

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The Low Back Pain-StressConnection: New CluesFor Causes and Cures(continued from page 5)pedists, neurosurgeons, neurologists, internists,rheumatologists, psychiastrists, radiologists andspecialists in physical medicine, thus attracting awide assortment of patients with this complaint.They also concluded that more than 807o had nodemonstrable ogranic delect, and that the vastmajority could be cured by a combination ofexercise and stress reduction and relaxation exer-cises. This treatment program provided the basisfor the national YMCA Healthy Back Programwhich was introduced in l976inover 1000 facilities.Twice a week, for six weeks, patients received anhour of instruction in exercises and stress-reduc-tion techniques which they were encouraged tocontinue at home on a daily basis. By 1980, over200,000 participants had completed the programwith one-third achieving complete freedom fromback pain, An additional507o reported "significant

improvement in both pain relief and freedom ofmovement," The underlying philosophy of the pro-gram was stated in the New York State JournalofMedicine in 1977 as follows:"Any plan of treatment for back pain to be suc-cessful must correlate with its etiologic element.Our interest focuses on back pain that does notrequire surgical intervention for its correction andthat in the main results from underexercice andoverctresg.

Etiologically, back pain often reflects the impactof our present-day mechanized society, one inwhich physical activity is unneeded and frequentlydifficult to obtain. Also, it denotes a society in whichmany mental tension-producing stimulioverstress cusceptible individualc. "

Stress activates widespread automatic activitiesthat can affect everv organ and tissue in the body.However, the major effect and magnitude of thesevariegated responses differs for each of us. Suchreflex reactions have been exquisitely refined overhundreds of thousands of years of evolution topermit survival. The classic "flight or flight"response to acute stress was obviously advanta-geous to primitive man, suddenly confronted by aferocious foe. Elevation of the blood sugar provideda quick source of energy, increased heart rate andblood pressure produced a greater flow of blood tothe brain for decision making, dilation of the pupilsof the eye improved vision, quicker blood clotting,reduced blood loss from internal hemorrhage orlaceration, etc. And there was also a shunting ofblood away from the gut, where it was not immedi-ately needed for digestive purpos€s, to the largemuscles of the torso and limbs. This facilitatedincreased muscle tension to improve strength

in combat or a greater ability to escape from alife-threatening situation. However, the nature ofstress for modern man is not a physicalencounterwith a ferocious foe once or twice a month, butrather a host of emotional threats and challengesthat often occur severaltimes a day. Unfortunately,our automatic defensive ingrained responses arenow not only no longer purposeful or useful, butpotentially dangerous. Repeatedly invokedn it is nothard to see how they could contribute to diabetes,hypertension, stroke, heart attack, peptic ulcer,muscle spasm and other stress-related "Diseases ofCivilization."Stress is an unavoidable consequence of life, and islikely to become more intense in our increasinglycompetitive culture. Our individual responses tostress differ, which explains why some people blushbut others get pale. Headache, pain in the neck,chest or stomach pain, diarrhea, and tremblinghands are frequent complaints. Most of these aredue to spasm in various muscle groups or the bloodvessels that nourish them. It should come as nosurprise, therefore, that similar reactions mayresult in low back pain and muscle spasm. It iscrucial to recognize that it is often not the externalstimulus or event which determines our response tostress, but rather our own preconceived perceptionof its significance. Often this is a result of psy-chosocialinfluences that influence our attitude andbehavior. Some research studies suggest that patientssuffering from chronic back pain tend to conform totheir social environment to an excessive degree.Consequently, there is a frequent tendency tosuppress emotions such as anger and agression,and these feelings are expressed in terms of in-creased muscle spasm.Changing the way we perceive and prioritizepoten-tially threatening challenges and other behavioralmodification strategies are the best ways to elim-inate the adverse effects of stress. Exercise mayalso be etfeclive in reducing muscle spasm and painby increasing the circulation to the affected area,Some studies interestingly reveal that the cardio-protective and other benefits of exercise may resultmore from their associated stress-reduction prop-erties, rather than purely physical conditioning,These and other observations are providing newinsights into the relationship between stress andlow back pain, in terms of both probable causes,and practical cures.

Book Reviews o Meetings and Items of InterestChicago, IL 60660. (3121 784-2025.Oct. 27-30, Fifth Annual Meeting of the Society for TraumaticStress Studies "Leaming from Victim/Survivors: Insights forPrevention, Intervention, and Care," San Francisco, CA. TheSociety for Traumatic Stress Studies, P.O. Box 1564, Lancaster,PA 17603.Nov. 2-4, Cardiac Wellness and Rehabilitation, St. Thomas, VI.Medical Education Resources, (800) 421-3756.Nov. 2-4, Neuroimmunology M: The State of the Art, Chicago,IL. University of Chicago School of Medicine. (372) 7C2'1056.Nov. 2-5, 1989 23rd Annual Convention of the Association forAdvancement of Behavior Therapy, Washington, DC' (2I2)279.7970.Nov. 4-5, Teaching Humanistic Medicine: An Exploration ofGoals, Techniques and Experiences, New York, NY, NYU PostGraduase School. (2L2) 340-5295.Nov. 5-19, Topics in Psychopharmacology and BiologicjrlPsychiatry Moscow, Samarkand, Tashkent, Leningrad, USSR.Professional Seminar Consultants, Inc. (800) 365-5357.Nov. 9-11, Addiction Medicine: State of the Art CaliforniaSociety for the Treatment of Alcohoism and Drug Addiction, SanDieqo. CA. &l5l 428-9091.trloi,. 1Z-ZO, Z6ih Annuat Psychiatric Institute on Group Behaviorand Group Leadership, Peachtree City, GA, Emory UniversitySchool of Medicine. (404\ 727 -5695.Nov. 19-21, Second Annual Intemational Montreux Congresson Stress, Montreux, Switzerland. American Institute of Stress(914) %3-1200.Dec. 3-7, Intemational Round Table on Silent MyocardialIschemia. For detailed information contact the Congress Secre-tariat, Tel Aviv; contact Kenes Ltd., P.O. Box 50006, Tel Aviv51500.Dec. 7-9, Cardiac Wellness and Rehabilitation, Acapulco,Mexico. Medical Education Resources (see above for details-same as August 4.)Dec. 1&e0, Wellness and lts Relationship to Heakh Promotion,Protection and Disease Prevention (Cruise Rio De Janeiro toBuenos Aires, Argentina). Seminars and Symposia Inc. (212)sfi-7sn.Feb. 25-Mar 2, lgg0 rAmerican Journal of Health Promotion,Cancun, Mexico. (313) 258-3754.Mar. 29-Apt. l, 199O, American Society of ContemporaryMedicine and Surgery (Stress and Hypertension), Phoenix,Arizona.

Book ReviewThe Woman'e World, Furst, M.L. and Moree, D.R.,(eds.). AMS Press, New York, 1988' 146 pp.' $32.50.This is another volume in the AMS Stress and Modern Societyseries. The authors had published a previous volume on thesame subject in 1982 at the height of the Woman's LiberationMovement and, in some r€spects, this represents an update orfollow-up. It begins with a brief overview of the stress conc€pt,tracing its relationship to a variety of signs, symptoms, anddiseases. A subsequent section deals with common stressesencountered by various classes of modern women, particularlythose in the workplace. The concluding chapters are devoted tosuggestions on how to identify stress and to manage it effectively.This includes psychological and physical coping mechanisms,the role of nutrition, social diversions, as well as standard stressmanagement techniques such as muscular relaxation and medita'tion are discussed. Distinctions between the nature of stress andstress responses between males and females are emphasized.However, surprisingly little discussion was devoted to Type Abehavior which seems to be increasing in females who have tocompete in a male-dominated work force where they still do nothave equal rights. Many authorities believe that this may be amajor cause of the significant increase in cardiovascular diseaseseen in certain female occupational settings. This volume is wellindexed and referenced, and its easy to read conversational styleappears to be directed primarily towards a lay audience ratherthan health professionals.

Meetings and ltems of Interest

Sept. 24, Healthy Pleasures, Boston, MA (M.l.T.) Institute for the Studyof Human Knowledge. Contact Margaret Caudili, M.D., ISHK/Boston. Box 1062, Cambridge, MA 02238.Oct.2-4, Neuropeptides and Immunopeptides, New York, NY. NewYork Academy of Sciences, 2 E. 53rd St., New York, NY LW27. (212)838.0230.Oct. ll-15, American Academy of Child and Adolescent Psychology,New York, l.lY. (202) 956-7300.Oct. 23-25, The Ecology of Work: Improving Productivity and theQuality of Work Life. Toronto, Ontario. Contact Tom Chase, R.R. #2,Box tKa, Northwood, NH 03251,Oct. 26-29, Academy of Psychosomatic Medicine, Las Vegas, NE.Academy o f Psychosomat ic Med ic ine , 5824 N. Magno l ia .

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