The first mechanism of action is relatively straightforward. Please read my first posting regarding a mechanism of action. Very briefly, students are taught to leverage their big cortex and neuroplaciticity. They are taught two concrete tools to employ and given several principles to consider. They are taught to stop doing the wrong thing - to stop their unconscious habitual patterns of doing things and responding to stimuli. Students are also taught to direct themselves - to set their intention - not to pull down and contract themselves - to oppose the characteristic pattern in the startle reflex.
The effect of this is to allow basic reflexes to re-establish themselves and replace habit with a conscious direction. Students gradually acquire more accurate interpretations from their senses. It also allows the student to employ greater efficiency in all activities, less tension and improved musculature tone. I will present studies that support these claims later, but here is an example.
Does all this influence the body-self neuromatrix (BSN)? Apparently it does. Again, I have reviewed the BMJ back pain study and will review other studies later. How does it influence the BSN?
Obviously, greater poise, ease of movement, improved tone changes the tonic somatic inputs. As the sensory interpretation improves we are able to accurately sense the degree of muscular effort. Typically when we lift, bend and stretch we brace much of our body and over use the remaining parts. With better use the effort is more widely, and appropriately distributed lessening the risk of injury. Of course, this new way of moving is contrary to our habitual use and initially might feel unusual and even wrong. But if one persists in the using the AT tools one can begin to respond to the stimuli to act, if one chooses, in a new and different way. An easier way.Another way to approach this is to question the cause of chronic, idiopathic back pain. One might say that the cause is a vertebra out of place, a muscle spasm, a pinched nerve or a damaged disc. Patients go to a chiropractor to realign the spine, a masseuse to address the muscle spasm, have a the pinched nerve ablated and allow the disc to repair it self. One commonly finds relief, but it is short lived, and the pain reoccurs. One might point to imaging as proof of the cause of pain, but abnormalities seen on imaging are poorly correlated with symptomatology. Indeed, asymptotic people will have, on average, over 2 abnormalities on MRI. Clearly, these problems are only the proximate cause of chronic back pain.
Since the back pain seems to be associated with some activities, one might assume that how we lift, sit, or bend is the ultimate cause of back pain. Indeed, physical and occupational therapy can be helpful. However, again they do not seem to reliably prevent recurrences. Although this may be the ultimate cause, our lack of curative therapy suggests that there is a primordial cause.
The primordial cause of chronic back pain is a 'use pattern' that underlies all our activities. It results in poor tone, chronic shortening and narrowing of the body, and excessive and inappropriate use of muscles when doing all activities. The AT addresses 'use' at this level. It does not teach how to walk, stand or do any particular activities. But the employment of the tools offered by the AT leads to improved muscle tone, a full and upright bearing and more appropriate muscular use in all activities. This leads to a more healthy reassuring sensory-descriminative input into the body-self neuromatrix. The final result is a 84% reduction in days in pain in those suffering from chronic back pain.
An AT student can also be expected to have improved visceral input. At the 2012 Northwest Pain Society general meeting it was recommended that chronic pain sufferers be trained to do deep breathing. Of course, the abnormality in breathing has no bearing on the tonic or phasic somatic inputs that are commonly assumed to be the sole contributor to pain. Yet it is very astute to notice that consciously directed changes to the breathing can effect the perception of pain. The body-self neuromatrix gives us a theoretical understanding why this is so. However, "deep breathing" is only likely produce small and temporary benefit.
With regards to breathing, when we have any stress, pain or anxiety, we naturally create thoracic rigidity. With rigidity comes only minimal shallow breathing. If, as recommended by some, we take a deep breath we only create a larger, but still rigid thoracic cavity.
AT teachers make no recommendation to do deep breathing, or any particular changes to the breathing. One of the basic recommendations in the AT is that the student set aside the rush to achieve an outcome and instead attend to what one is doing presently to get to the outcome. With regards to breathing, the problems is that the sufferer does not exhale very well. Fear, pain and anxiety all prompt us to breath in promptly and strongly. During each exhalation the sufferer cuts the exhalation off a bit sooner and then grabs onto an inhalation. The result is a hyper-inflated rigid thoracic cavity. This is irritating to the body-self neuromatrix. The AT student is asked to say "no" to gaining the desired outcome for a quick full lung of air. Instead the student might ask, is this really the end of my exhalation? If it is, then by all means please breath in. If not, then do not grasp some desired end prematurely. The result is a much healthier breathing process and one that is much more likely to be reassuring to the body-self neuromatrix. Admittedly, this is not easy to do continually in the face of noxious peripheral stimuli. However, it is much easier if one has attending first to the one's head-neck-back relationship. Indeed, the AT has been shown to improve respiratory function.
The above mechanisms can be grouped into "physical" inputs. The sensory-descriminative all seem to have related to body based inputs. Melzack, in the creation of this theory, adhered to the traditional division between body and mind. Personally, I feel to divide the tonic inputs from the brain from the tonic inputs from the body is an unfortunate error.
Traditionally, in the AT, this division is not thought to be helpful. It is frequently stated that the AT is 'body based'. It is emphatically not. If one were to summarize the teaching into two words it might be "Think Up!" This "Think" is the same "THINK" that IBM used as a slogan. The "Up" however is a geographic term anchored in the physical. The AT teaching is at the intersection of the body and the mind. Teachers tend not to think of the benefits of practicing the AT tools as mental or physical or emotional. In contrast, the AT improves the use of entire person, the unified self. That being said, I will continue to adhere, the best I can, to the BSN as presented by Melzack. But it is not easy. As one moves from the superficial cause of back pain, to the proximal, and then to the ultimate one finds the distinction between the body and one's beliefs increasingly tenuous. When one reaches the primordial cause of chronic pain this mind/body distinction only impedes progress.
Does the AT effect the cognitive-evaluate input? One might find evidence in the BMJ study discussed earlier. Again it states there was a "42% reduction in Roland disability score and an 86% reduction in days in pain compared with the control group" after one year. Although a 42% reduction is still impressive, why the discrepancy in the two outcomes? Why was such a dramatic reduction in days in pain not reflected in a reduction in disability? I suppose there are many possible explanations, but one is that the disability score reflects the influence of the AT on only the body, while the days in pain reflect the sum of the influence of the AT on the body and the mind. While disability score reflects the bodies ability to perform activities, pain, according to Melzac, depends on the state of the body and the mind.
The AT influences the phasic inputs cognitive-evaluative from the brain in two ways. AT teaching does not place much emphasis on the ideas and opinions that are based on their sensations. The technical term is 'unreliable sensory appreciation'. Instead of relying on 'feeling' to guide our response to stimulus, the AT instead suggests using the two tool I have discussed previously. The AT lesson, then, is a time when the student is allowed to set aside fixating on sensation. In a life that is consumed with finding relief from pain, and trips to doctors and therapist (who all might appear like solicitous spouses) the student is offered an opportunity for a reprieve during a lesson.
To discuss the second way phasic inputs from the brain influence the BSN I must bring up two criticisms of this theory. First, the time arrow at the bottom of the graphic suggests the process is linear. It is not. Clearly, if homeostasis is lost then all the outputs from the BSN will, in turn, become irritating to the BSN. Loss of homeostasis promotes continued instability. My second criticism is that Melzac does not stratify the importance of inputs into the BSN. Are all these inputs into the BSN equally influential? They are not. Inputs from the body are most influential and the head neck back relationship is the foremost of these. This is not to trivialize other inputs, indeed we can have pain in a non-existent body part. But the shortening and narrowing of the head neck back relationship is invariably present in times of stress, fear, anxiety or pain. If these characteristic changes in the head-neck-back relationship are not present during times of noxious input from the body or mind then the BSN will not be overwhelmed. This is an aggressive statement to be true. But the head-neck-back relationship is so influential that stimuli which used to create pain and anxiety will be transformed into a unique experience that is not suffering.
This new experience will still not be pleasurable, to be sure but it will not trigger the catastrophic changes.
I do not want to repeat myself, but I want to be clear. The key for the AT student is to be able to apply the tools in difficult situations and prevent interference in the head neck back relationship. If they are trained in the AT, they have some space between this stimulus and their reaction. Instead of reacting in their habitual fashion they use the directions taught to them. The result is that the the length and width of the head neck back relationship is maintained. In subsequent cycles of the BSN the fearful ideation and the noxious stimulus from the body compete for attention in BSN with the uncharacteristic length and width. The input now is dramatically different from what the BSN typically experiences and since the dominant input is the head neck back, homeostasis is not lost.
Fitting this into the BSN schema of mind body duality is a bit tricky. I am suggesting that the AT student use their conscious mind to delay a reaction to a stimulus that may be either physical or mental, and instead use the conscious mind to interfere with the habitual misuse of the head neck back relationship, with a final outcome of reassuring the BSN which is part of the mind. The heart of the AT is a continual conscious intention to not interfere with the head/neck/back relationship. But this intention can be brought into the foreground quickly and energetically should a noxious stress threaten the BSN.
When the student applies these tools continuously the effect is to quiet the BSN, to interrupt the positive feedback loop that would otherwise be generated and thus raise the threshold of stimuli that must be present for homeostasis to be lost. The resulting tonic changes from the mind will, as FM Alexander claimed, calm the overexcited fear response. The AT is not only an intervention for existing pain, fear, PTSD and anxiety but an immunization against these problems.
This concludes the main thrust of this blog. I have presented a list of the considerations a medical care provider should use when recommending interventions. I have presented a brief explanation of the AT. I have given an overview of the history of pain theory and described a modern theory of pain. I have applied the AT to this model to describe the mechanisms by which the AT is effective in relieving pain.
I believe this presents a reasonable argument to recommend the AT to those with chronic back pain. In addition, I think the evidence supports more large scale studies of the AT and chronic pain. Because of the close link between chronic pain and PTSD, and the theoretical argument that the AT should be effective for PTSD, I propose that studies should be done to examine the effect of AT on PTSD and anxiety. It seems to me that the intersection of the AT, chronic pain, mindfulness meditation and PTSD is the startle reflex. If my proposals are correct, those with PTSD and chronic pain should have a heightened startle reflex and the mental, physical and endocrine sequel from the startle will be prolonged relative to a control. Meanwhile, those with experience with AT and experienced meditators should respond more appropriately with a dampened response and faster return to baseline than both the control and those with pain/PTSD.
It is time to abandon the notion that chronic pain can be effectively treated by focusing only on tonic somatic input and output. We need to acknowledge and intervene in the global disastrous outputs when homeostasis is lost. We need to identify which of the inputs is most destabilizing to the BSN and focus therapeutic interventions there. Finally, we must find which input is most influential in stabilizing the BSN and find an intervention that we can use in our daily lives to increase the ability of the BSN to withstand noxious stimuli without leading to destabilization.
I believe we are at the brink of discovering the cause of low back pain and an effective treatment for PTSD. It is time to start dreaming about an effective immunization for chronic pain and PTSD.
David Garlick, The Lost Sixth Sense, a medical scientist looks at the alexander technique.
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