Resolving Chronic Pain

Mags Clark Smith

I am a TMS/PPD practitioner and the process I teach is called Resolving Chronic Pain. In clinical terms TMS stands for Tension Myoneural Syndrome and PPD for Psychophysiological Disorder, both of which refer to unexplained pain. 

I am currently the only trained teacher, teacher trainer and university lecturer on the TMS/PPD clinical list, as all my colleagues are health professionals. Most are doctors, concerned primarily with either the mind or the body. My own perspective is different, and as an educator I naturally consider it’s an intriguing one to share with you with the aim of filling a gap in current understanding. This gap could be described as ‘they can’t find anything wrong’. I want you to be able to identify what’s actually happening when someone is experiencing chronic pain: someone who has had all the scans and seen all the relevant professionals, and has still not found a satisfactory answer.

My first love was dance, and I was delighted to be offered my first third level lecturer post in the Theatre Studies Department at Lancaster University, where I became the movement specialist. In that role I also worked with London Contemporary Dance and the Laban Centre, looking at movement and psychology. Inevitably, this drew me to the work of Joseph Pilates. As part of my research I trained as a Pilates teacher and set up my own Pilates studio. 

Out of this came a real curiosity about what was happening with respect to healing pain. Why was it that some people would come to me and their pain would dissipate, when they’d been to see lots of other health professionals to no avail? My referrals included a number of pregnant women with pelvic girdle pain (PGP). They had not had any successful pain reduction anywhere else, and yet these women were getting better. That led me to talk to obstetricians at the National Maternity hospital in Dublin and St Michael’s hospital in Blackrock. When I was invited to attend discussions with them regularly, midwives jokingly asked ‘Are you the miracle worker that can get rid of pelvic pain in pregnancy?’ This happened every time I visited. I’m not a miracle worker at all, but yes - the pain did seem to reduce in every case. 

My background in research was making me very curious about what was going on. I submitted an academic poster to an Irish Pain Society conference and met the head of the neuroscience department at University College Cork. This led me to working with UCC from 2016 to 2019, looking at the autonomic nervous system and its role in pain. I led two pilot studies in how Resolving Chronic Pain methodology supported pain reduction to nil in most cases of women experiencing pelvic girdle pain. I’ve also worked with Chronic Pain Ireland, the Irish Pain Society and collaborated with both doctors and psychologists in the US. After speaking at a conference in London I collaborated with three others to write and edit a PPD textbook. I’m pleased to say that this is now being used as part of medical training in some American states. It is helping to widen the brief beyond the conventional narrow medical outlook. 

The Resolving Chronic Pain process

Firstly, what is chronic pain? It’s normally used to describe pain that has been experienced for more than three months, whereas acute pain is in the moment. The latter is caused by an accident, perhaps, or when someone hurts themselves. With this kind of pain it’s appropriate to seek intervention such as surgery, physiotherapy or osteopathy. Acute pain interventions can be assisted by the body’s internal system supporting each intervention.

Chronic pain is more complicated. Often, in searching for an explanation for the source of their pain, people have MRI scans, ultrasounds and other tests or investigations, only to receive a verdict from their specialists that there is nothing wrong. It may be that a little bit of wear and tear is identified on the spine, but invariably this doesn’t explain the pain. If you are expecting a diagnosis and a clear path to recovery this can be quite frustrating - particularly if there is an implication that as there’s no reason for the pain, maybe it really isn’t very painful at all. 

The most recent research and current approach to chronic pain is to look at the part played by stress: the ‘brain/pain’ component. Hence it is sometimes called stress illness. The autonomic nervous system, which is a physical mechanism, controls the stress response. This means that the brain/pain relationship is unequivocally physical and not in the patient’s imagination. The term ‘psychosomatic’ is unhelpful, as it can suggest that the patient is somehow responsible for conjuring up their own pain. Indeed, such thoughts may be responsible for turning on the stress response. It is therefore crucial to establish from the outset that the pain is indeed physical. I think it’s very important for patients to hear this when they get referred to me, because it validates the pain they are experiencing. 

What, then, is responsible for the main symptom of pain if it is not structural? When I began to research chronic pain I read about the work of Dr John Sarno, the American physician who introduced the term Tension Myoneural Syndrome (TMS). He believed that many chronic pain conditions were caused by the brain’s response to psychological stress and repressed anger. I subsequently met Dr Sarno, who described how the energy that is required for someone to mentally push anger down can manifest itself in physical pain. Presumably to keep his message clear, he focused on anger rather than the whole range of unresolved emotional experiences now identified by PPD practitioners as having the ability to trigger the stress response and consequential imbalance in the autonomous nervous system. 

Chronic pain is when a neural pathway has been established and the brain has got into a habit of expressing pain at the site of the original acute pain. Neural pathways can not only impede healing, but they can actually stop the healing by initiating the stress response. Fear perpetuates the expression of pain, as we are programmed to seek a structural explanation. If the specialists can’t find anything wrong this can cause anxiety, and without a clear medical explanation other issues can arise. People often come to me with searing pain in their back or terrible pain down one leg or in one shoulder, but they also have depression. They may have a sense of fatigue or may not be sleeping well. This is all part and parcel of chronic pain. Rather than separating these symptoms out, I often suggest that we deal with, say, the pain in the back (if it is the main symptom) and consequently the other things will start to fall into place. Almost imperceptibly fatigue will begin to ease, energy will start to come back, and I notice that the patient’s mood will seem to lighten. The big one, sleep, is usually the stumbling block, although in my experience sleep problems also resolve themselves along the way. 

The characteristic that seems to be shared by everyone who is receptive to the new pain research is a willingness to consider innovative approaches; an openness to seeing how things might be different from the way we’ve always assumed them to be. Most people begin to consider the validity of stress illness only when they have explored all the conventional medical routes. This means that a willingness to try a different approach is often born of desperation. In my view this is because it takes tremendous courage to consider something new, to believe in their own reality rather than in the conclusion of experts that nothing can be done.

Resolving chronic pain is a process of education. Importantly, it begins by establishing a rapport with the patient based on trust. Listening skills and genuine respect for the individual are imperative. Many patients have never had the opportunity to explain in detail the discomfort they have been experiencing with dignity, and this can be healing in itself. Sometimes patients may describe themselves as not having left their bed for over 20 years because of the amount of pain they’ve been in. Once trust is established, together we investigate what has triggered their pain. We gradually and collaboratively select appropriate personalised tools to create a metaphorical toolkit of how to solve the issues that ignite their pain. The intention is to create autonomy so the patient knows what to do in each circumstance.

Creating an individual ‘life prescription’ was part of my ‘Whole Health Medicine’ training with Lissa Rankin MD in 2014, described in her book Mind over Medicine. The philosophy behind this involves the patient identifying what they require to feel at ease, enabling them to deal with a particular trigger when it comes up in the future. This way people can learn what resonates with them and what works for them. 

RCP education is practical and helpful. It will help you to develop a rich emotional vocabulary, which is a useful and important way of gaining more information about yourself. The goal is to resolve pain, and this often leads to identifying latent aspirations to fulfil your potential. The resolving chronic pain process helps you to understand yourself in a new and different way and to examine the possible roots of familiar or hitherto unknown issues. It can help to answer important questions about why you might have experienced unsatisfactory relationships or why you might be sabotaging yourself in certain situations, for example at work or with family members. For many, the way out of these perplexing problems lies in understanding feelings or fears that have been buried or unacknowledged because of (often unidentified) underlying shame. Understanding our feelings and being able to use that information is a strength, a key to growth and resilience, and an outcome of reducing pain.