Alan G. How does TMS cause tightness?

This question was submitted via our Ask a TMS Therapist program. To submit your question, click here.

Question

What is the relationship between chronic muscle tightness and muscular pain within the TMS framework?

My pain is confined to the back, hip and leg muscles on the right side of my body. I've noticed unsurprisingly that the muscles throughout my right side are permanently tense. However, when I move or stretch or even just adjust my sitting position, the pain will disappear for.a moment. As soon as I stop moving, the muscles tense up and the pain returns.

Is this chronic tightness likely a consequence of constant TMS pain transmission? Or is it possible that the tightness is actually a direct manifestation of TMS, which then in turn causes pain?

 

Answer

This is an interesting question, and one I've thought a lot about. I recently spoke with Dr. Schechter and Dr. Schubiner about this, and I have a theory which is by no means conclusive.

There's a lot of evidence that TMS pain is a function of learned neural pathways in the brain. This is not new, TMS physicians have been talking about this for years.

So the pain is in the brain, we get that. But how does that account for the physical tension that some TMSers have - physical tension that can be so profound, other people, such as massage therapists, can even feel it? This physical tension seems to indicate that in some cases the pain is more than just an interpretation of neurons in the brain.

I believe that neural pathways in the brain can flip a switch, generating physical tension in the body. The way one responds at the onset of the pain determines whether the tension perpetuates, or whether the switch flips off.

This is where the idea of outcome independence comes in.

If you buy in to the pain and generate fear, it sends signals to the brain and the switch stays flipped. You're in a fight or flight state, the tension and pain remain, as their psychological purpose is being fulfilled.

If on the other hand, you don't buy in to the fear, the switch eventually flips off. The pain and tension subside, as their psychological purpose (fear, preoccupation) is not being served.

An example: One of the many manifestations of TMS I had was heel pain. It came on one day out of nowhere. I don't remember banging it or anything, but even the slightest pressure was enormously painful. It felt like what it feels like when you have a bruise. There was clearly a lot of physical tension in that area.

For two days I limped, trying to figure out whether it was TMS or an actual injury. Then, I got a magical piece of evidence that changed everything. I woke up at 4 AM and had to go to the bathroom. Groggily, (is that a word?) I walked to the bathroom and back to bed. I was so out of it that I forgot to limp. But I didn't have any pain!

That was all I needed to know that for sure, definitively, it was TMS. The next day I forced myself to walk without a limp, reaffirming my evidence, standing up to the fear, and not caring whether or not it hurt. My goal was not to get rid of the pain, rather it was to hone a level of authentic indifference about whether or not I had pain.

It was hard. All those websites that I looked up days before saying you can develop long-term heel pain if you don't rest a bruise flashed through my mind. But I kept on repeating the evidence:

"It didn't hurt at all when I mindlessly walked on it barefoot at 4 AM."

Of course my fear brain would counter:

"What if it hurt but you were just too groggy to realize it?"

Me: That doesn't make any sense.

Fear brain: What if it didn't hurt because you'd been sleeping beforehand and it was rested a little?

Me: No, Schubiner said if it was a real bruise, it'd hurt even more after inactivity, not less...

I knew it was TMS.

By the end of the day, the pain and the physical tension were gone. I'm sure that if I had bought in to the fear and continued treating it like a structural injury, the pain and tension would have persisted. I believe that by interrupting the fear cycle, the neural pathways that were sending signals to generate tension in my heel were effectively switched off.

The muscular tension is real, but the source of the tension is the brain, and the way to ultimately relieve it is not through a physical intervention, but a psychological one.

---

Any advice or information provided here does not and is not intended to be and should not be taken to constitute specific professional or psychological advice given to any group or individual. This general advice is provided with the guidance that any person who believes that they may be suffering from any medical, psychological, or mindbody condition should seek professional advice from a qualified, registered/licensed physician and/or psychotherapist who has the opportunity to meet with the patient, take a history, possibly examine the patient, review medical and/or mental health records, and provide specific advice and/or treatment based on their experience diagnosing and treating that condition or range of conditions. No general advice provided here should be taken to replace or in any way contradict advice provided by a qualified, registered/licensed physician and/or psychotherapist who has the opportunity to meet with the patient, take a history, possibly examine the patient, review medical and/or mental health records, and provide specific advice and/or treatment based on their experience diagnosing and treating that condition or range of conditions.

The general advice and information provided in this format is for informational purposes only and cannot serve as a way to screen for, identify, or diagnose depression, anxiety, or other psychological conditions. If you feel you may be suffering from any of these conditions please contact a licensed mental health practitioner for an in-person consultation.

Questions may be edited for brevity and/or readability.

 

I personally correlate tightness with the need to pop my spine and neck . I got into a serious habit of doing it and that further added to my shopping list of anxiety surrounding the condition of my spine. it became something of a party trick I would perform and get people to give me reverse bear hugs. feels really good but the relief only lasts momentarily hence the creation of habit.
Given the TMS discovery, I wonder do many others pop their spines like a crisp bag (potato chips packet in US speak).
Just back today from the Doctor and finally got MRI results that indicate minor degenerative changes and he said ''nothing to worry about'' and actually mentioned how many studies show little correlation between pain and degeneration.

interestingly my foot is playing up again, right in the ball of it. my back is feeling OK so Im onto its game!

 

Hi, Irishskeptic. This should be good news to everyone... "Just back today from the Doctor and finally got MRI results that indicate minor degenerative changes and he said ''nothing to worry about'' and actually mentioned how many studies show little correlation between pain and degeneration. "

Dr. Sarno says the same in his book Healing Back Pain.

Incidentally, my next-door neighbors are from Ireland, and they're great people.
This weekend the Chicago area had its 4th heaviest snowfall in its history and they cleared my front walk and long side driveway THREE times!

 

haha Walt. My dad welcomed home an old friend from Chicago he hadn't seen since the 80s. he works as a bricklayer and still refers to it as ''Chi-cargo'' like some people in North of Ireland do.

Yes, Irish people tend to be nice, the British didn't invade, we welcomed them in!

Indeed though my Doctor is pretty good in recognising stress as a factor in pain but I never broached TMS theory with him yet.

 

I had a similar experience with heel pain this past summer. I went to a podiatrist who said "plantar fasciitis". He xray'd and said it wasn't serious and gave me guidelines to follow. He said if it didn't clear up by next visit he would give me a shot in my foot. I did NOT want a shot in my foot. I went home and told myself that it was going to stop hurting because I was not getting a shot in my foot! Guess what...it stopped hurting. No shot needed because it was TMS. I didn't realize at the time, but I know it now. If I can just get my back muscles to do that, I'll be all set! The explanation of switch flip makes a lot of sense to me. I'm doing the evidence dialog too .. when I wake up in the middle of the night and get up, it doesn't hurt as much as 2 hours later when I get up from the alarm. There ya go.

 

Alan:
Thank you for this really clear explanation. This post interested me. Makes a lot of sense. I assume the brain can also cause inflammation (ie: in that spot you learned was "abnormal" on the xray or MRI), which does also cause pain - but the root being the brain, not some aggravating exercise or something like that. Another question - it is possible that the location of the abnormality may actually have been caused by a minor physical trauma and then the brain just associates fear and emotion with that "spot" and even makes it tight, inflamed etc? I am getting how this works?
In my case, many years ago i was rear ended, bounced pretty hard and felt a ton of pain in my tailbone area. Was definitely shaken up but the pain went away by the next morning. So more recently, a few years later, that "spot" (and things seemingly connected to it) has been in bad shape. And then I remembered the same pain from the car. What are your thoughts on this?
Finally, what exactly does it mean to "stop all physical treatments" - In connection with all this recent stuff, of my own accord, I chose to start personal training to get stronger (Im not very strong) and until a recent flare up (which i associated with "stretching wrong and pulling something") it was going well. I would like to be stronger, why stop this? Same with massage - it helps. How can being in good strong shape NOT be relevant? What is wrong with saying strong abs are good for you, and might help your back too. Is there a way to do all this keeping TMS in mind?
Actually, one more question - am I misunderstanding: while I understand say, continuing going for a walk even when it hurts, if my body just wont bend over, for example, without excruciating pain, am i just supposed to ignore that and bend over anyway? It seems physically impossible, and perhaps actually dangerous, the pain it just too bad (as in close to passing out!)
Thanks!

 

It's most likely that in your accident example, your brain learned and remembered the pain. The specific mechanism, whether it's simply learned nerve pathways, etc., isn't important. Sometimes overly focusing on the physiology of what's going on can be counterproductive.

Physical exercise is fine, as long as you're not doing it because deep down you think that's going to affect your chronic pain. That just reinforces the belief that there's something that needs to physically be addressed to get better. Personal training for the sake of getting stronger, getting a massage because it's relaxing and it feels good- totally fine.

If your body can't bend, don't bend. It's not always necessary to confront your symptoms so dramatically to get better. I happened to challenge my heal pain in the example I gave, but if I would have just gone about my life establishing a stance of authentic indifference about whether or not I had symptoms, the pain would have faded in a few days anyway.

I've found that people usually have more success just working toward ignoring the symptoms (and the corresponding fear) than directly challenging them. Challenging the pain can be a double-edged sword. Remember, the purpose of the pain is to serve as a vessel of preoccupation. When you're aggressively challenging the pain, you're definitely giving it a lot of attention, and if it doesn't recede, often people feel hopelessness or despair. This feeds into the pain cycle, as it undermines the goal of outcome independence.

Alan

 

I've been struggling with this dilemma as well. The subtlety between pain and muscle tightness, and which are TMS symptoms vs physical symptoms. In my case, I had a back spasm that kept me in bed for 4 days. I fully acknowledge the spasm to be induced by TMS. As the spasm released I began to get sciatic pains down my left leg - another clear manifestation of TMS. In addition to that though, I've had lingering tightness in my back and buttocks from the spasm that continue to hamper my mobility and flexibility. What I cannot determine, or come to terms with, is if the lingering tightness is a direct result of current TMS symptoms or just a consequence of a TMS induced spasm, as walllc643 put it in the original post here.

This dynamic really comes into play when deciding if I should be stretching out the tight muscles. Of course, if the tightness is a direct manifestation of TMS then I should avoid any stretching, PT, or other treatments to relieve it. But what if it was considered a consequence of the original spasm? In that case would it be okay to treat the tightness?

The same dilemma exists about whether or not to resume physical activity and how. On one hand we are directed to resume physical activity, but does that make sense if there are remaining physical symptoms (tightness, lack of mobility) that would hamper my ability in those activities? To me it's one thing to exercise through sciatic pain, but another to try to push forward with what seems like remnants of a muscle spasm. Part of me wants to just push through it all (sciatica and tightness) and go be active, but another part still gets caught in the fear cycle of it all.

I need to figure out how to flip that switch, as Alan explained in his initial post above.

 

good point Easy.....I think once I figure out how to flip the switch my life will get much better, and fast. My symptoms are most noticeable when at rest, most physical activity is no problem.

 

And on that note... I'm gonna go play some basketball tonight.

 

Hi Rabbit,
I received your pm, but I don't think your account is set up to receive private messages so I'll respond on this thread.

These two articles will help give you some techniques to try and break the pain cycle:
http://www.tmswiki.org/ppd/Breaking_the_Pain_Cycle,_by_Alan_Gordon,_LCSW
http://www.tmswiki.org/ppd/A_Word_About_Outcome_Independence,_by_Alan_Gordon,_LCSW

Additionally, you may want to consider working with a therapist who specializes in TMS treatment. They have a lot of experience guiding pain patients through the cognitive-behavioral process of altering their neural pathways. I have several TMS therapist colleagues who specialize in Skype treatment.

Alan

 

I have a lot of muscle tension and some pain. I used to have less muscle tension and more pain. It kind of gradually swapped. Obviously the tension can lead to pain eventually but it's funny how when I have loads of tension I don't really have that much pain, then if I manage to get the tension to subside temporarily, then the pain is brought to the forefront.

I live with a constant choice of either chronic tension or pain. One or the other. I clench my teeth at night, so my tightness is in my shoulders, neck, head and face.

Does this sound like a tms situation to anyone? Any informed replies would be greatly appreciated. I have had chronic tension/pain for over 5 years and basically have no life. Thank you, thank you, thank you, in advance.