Integration of the Body-self Neuromatirics

Ronald Melzac theory of the body-self neuromatrix is a theory that attempts to explains how the sensation of pain is created.   The core of the theory is the matrix whose task is to summarize diverse inputs, decide if homeostasis is lost, and generate a host of outputs.  One of the outputs is the sensation of ‘pain’.  The theory is revolutionary and a huge step forward in learning how to help those who are suffering.  However, as I have stated in previously, it has limits.  Although is has great negative predictive power (when homeostasis is preserved there will be no ‘pain’), the theory has poor positive predictive power (when homeostasis is lost there may, or may not be, 'pain').

What are we missing here?  Why is the BSN model limited in predicting ‘pain’?    

Consider these three independent phenomena:

1.  Loss of homeostasis of the BSN.

2.  The perception of a bright stimulus attributed to a body part (PBSABP).

3.  Tissue damage or inflammation.

Allow me to explain these phenomena:

    1. The 'Loss of homeostasis' is what Melzac suggests in the BSN model.  I've summarized the preservation of homeostasis of the BSN as "I'm OK".  It's loss is "I'm not OK" is a discrete, quantum, binary change.

    2.  There is not an easy English word for "perception of stimulus attributed to a body part" or “PBSABP”.  I fully admit the phrase is very awkward.  It is a concept in need of a word.  But it is as precise as I can make it.  By "perception" I want to include not only what is coming from up from the spinal cord but a higher order creation of the mind that may, or may not, correspond with anything that is going on in the periphery.  For example, this will include “phantom pain”.  Next, this perception is a "bright stimulus" - something of note.  A "bright stimulus" is more than the feeling of normal respiration or the clothing on one's back.  Something strong enough to trigger, or stimulate, a habitual response.  Next, "attributed to a body part", is a higher order judgement that does not necessarily correspond with any independently verifiable ascending input.    The PBSABP is prior to our  response, prior to most the judgments or thoughts about it.  It might trigger a habitual response, but that has not yet taken place.

   3. "Tissue damage or inflammation" is change to the body that threatens our intact, continued survival.

At first glance these phenomena completely overlap.  If you are walking barefoot and step on a nail then clearly all three of these phenomena instantly coexisting.  However, in closer inspection of these phenomena can exist with or without the other two.

In my last plast post I argued that the loss of homeostasis of the BSN is independent of the other two phenomena.  There are many inputs into the BSN that can contribute to "I'm NOT OK!".   The loss of homeostasis does not depend on a PBSABP.

This post asks if the PBSABP is always the result of damage or inflammation?  Will damage and inflammation always result in PBSABP?  If we have the strong sense of something going on in our body, does that mean that there is actually something going on in the body?  Is the meaning we ascribe to what we think we are sensing accurate and reliable?

It may be useful to consider the other senses.

Is what we see a reliable indication of what is really out there?

Is the blind spot created by the fovia obvious with monocular vision?  Are we susceptible to a wide range of optical illusions?  Consider that half of us fail the “gorilla perception test'?  If you see a recently deceased family member out of the corner of your eye, will your physician suggest you see an optometrist?  Obviously, we do not see what is 'out there'.  We see what affords action, what we expect, what makes us feel comfortable, what will help us live long enough to reproduce.  Our sense of our vision is not an accurate rendering of what is out there.  In short, we see, not with our eyes, but with our visual cortex, and our visual cortex is richly innervated by inputs other than the eyes.

And our sense of hearing?  Does a person who suffers from tinnitus need earplugs?  Does the stillness of the high desert nights really roar?

Even our sense of smell is vulnerable to corruption.  

Given that we have little basis to believe our other senses, why do we always believe our opinions about our what we think we feel?  There are endless examples of misperception.  The fields of embodied consciousness and the finding related to neuroplasticity provide rich examples demonstrating the unreliability of our interpretations of our somatic sense.  

We should be highly skeptical that what we think we feel is a reflection of reality.  The entire field of science since Descart is based on skepticism; based on the belief that our impression of our senses are not reliable.  Instead, science relies on reproducibility, objective quantification, independent peer review, etc.  Even in clinical medicine we rely increasingly on objective data such as radiography and labs and less on history.  Even in history taking we are far more interested in chronology and associations than on the pt's interpretations and speculation.

In terms of back pain, why do we abandon skepticism - the foundation of science and medicine - when pt’s ascribe their problem to their back?  Why do we believe our patients "back pain" is related to the back when:

- medicine and science are based on doubt?

- when there are no reliable history or physical finding associated with chronic back pain?

- when there are no reliable radiographic finding in chronic back pain?

- when despite hundreds of years we do not have any local interventions that have been found to be effective in the long term?

- when severing ascending nerves and ablating what we think are pain centers have not been shown to provide long term relief

- when all the senses of our patients, especially our interpretation of the somatic sense have been shown to be deeply flawed and unreliable?

- when modern pain theory states that back pain is not created in the back?

In conclusion, PBSABP is not the same as damage or inflammation.  They are independent phenomena.

Why is this important?  One of the main reasons we have not found local long term therapies for chronic pain is that we have not clearly identified the problem.  Is not a clear understanding of the problem the basis of medical research?  We are successful in treating and preventing diabetes and vascular disease because we have precisely defined the problem.  We have not done this with pain.    

   What hope do we have for effective treatment and prevention without an understanding of the mechanism behind the problem?  Because we a very good understanding about CAD we can talk about primary, secondary and primordial prevention of cardiac events.  The field of pain is unique in medicine because we pay so little attention to our words and thinking.  

Beyond arm chair speculation, there is important clinical utility in seeing these three phenomena as independent.  It is important to understand these phenomena as independent because:

• It explains and gives justification to recommending ‘mindfulness’ meditation
• It explains and gives justification for recommending cognitive based therapies.
• It predicts that ‘back schools’ are at best not helpful.
• It suggests that asking patients about their pain will impede healing.
• It suggest that our medical model is counterproductive.
• It provides a more robust basis for discussing how the Alexander Technique helps, in the long term, with chronic back and neck pain.  

I hope to amplify on these clinical points soon.  But I do want to be clear that all this does not subtract from the critical need to study and verifying the theory of the BSN.  

Body-self Neuromatics: A Shortcoming

The Ronald Melzacs theory of the body-self neuromatix is a big step towards understanding the nature of pain and suggesting avenues to helping patients.  Scientific theories can be evolutionary in the sense of using and extending existing paradigms, or revolutionary in that it challenges existing paradigms.  Melzacs theory of the body-self neuromatix is revolutionary in at least two ways.  But it has an obvious shortcoming.

To summarize the theory in one sentence: the BSN is a complex widespread neural matrix with a wide range of inputs that can lose homeostasis and produce many negative changes throughout the organism.  One of the negative outputs is the sensation of pain.
    How do we know if homeostasis is lost?  Just consider this rule-of-thumb question "Is my integrity as a healthy organism threatened?"  More simply: "Am I OK?"

Here is the problem: although the theory has great negative predictive power it has very poor positive predictive power.

The negative predictive power is to ask, if the BSN has not been destabilized then can there be 'pain'? Does the existence of homeostasis preclude 'pain'?   I believe time will show that pain is not possible without the loss of homeostasis.  Looking to the distant past, 'pain' has been happily endured if there was a belief that it brought the sufferer closer to god.  Or consider the meditator who can sit crossed legged for an hour without moving.  Clearly there is bright sensory input while sitting but because there is equanimity of the BSN the perception of pain is not produced.  You can not suffer if you are "OK".

  Perhaps some meditators can "go to their happy place" where the woes of the world can not reach them.  But most don't 'go anywhere' but instead are deeply engaged in the present moment without judgement.  What distinguishes them is their maturity, perspective and patience.  This helps to stabilize their BSN.  There is bright sensory input, but because they are 'OK' there is no 'pain'.  For them, there is no loss of homeostasis and no perception of pain.

If we had a word for 'bright intense somatic sensory input that is not associated with loss of homeostasis' my argument would be more persuasive, but we struggle to have a concept of this because we do not have a word for it.  But that does not mean the phenomena does not exist.

Or consider this experiment.  Put a cast iron skillet on the stove, turn the heat to low to medium and put your hand on the pan.  Set your intention to keeping it there for as long as possible.  You will feel the temperature change, but it will not hurt.  You may get a bit anxious thinking about where this is going, but keep at it.  I am sure you will find there to be a very precise, clearly defined moment when this is "too much!", when discomfort changes to 'pain'.  It is not a physical issue, you could have kept it there for a bit more without significant tissue damage.
     The loss of homeostasis is a central phenomena.  Notice, for example, the thoughts you were having just prior to pulling your hand away.  The cognitive inputs you were giving yourself was something like "This is OK!  I'm doing OK!  Just a little bit longer!"  You instinctively were using your thoughts to stabilize your BSN.  Maybe you said this out loud for further reinforcement.
     Then recall your thoughts just after you took you hand away: "OW!!!  THAT REALLY HURT! That was TERRIBLE!  What a stupid thing to do!".    These are the cognitive outputs Melzac predicts.
If you observe the physical changes you will note the avoidance Melzac predicts: rubbing the hand and running it under cold water, etc.  As an Alexander Technique teacher I can assure you that you will also see shortening and compressing of the spine.  Stress hormones have gone way up.  Immune function altered, vascular tone changes.  I doubt there is any area of the self that is not affected by the loss of homeostasis.  All this is what Melzacs theory predicts.
  As long as one is "OK" then there is no 'pain'.

So the negative predictive power is the BSN is very good.  That is, if homeostasis is not lost, then 'pain' will not be produced.  What is the positive predictive power of the BSN?  If the BSN is destabilized will pain always be produced?   It is clear to me that there are plenty of situations where the BSN's homeostasis is lost - where the organism is "Not OK!" - that are not accompanied by 'pain'.
Imagine a roller coaster ride that is more than you bargained for: "Not OK!" but no 'pain'.
Imagine a seeing a loved one being hurt and you are powerless to help: "Not OK!" but no 'pain'.
Imagine a the loss of a loved one: heart broken, but no 'pain'.
     The most extreme example is a full blown panic attack.   The victim will say "OH GOD!! I'm dying!!"  You may ask them: are are you in pain?  "I CAN'T BREATH!".  Yes, yes, but are you in pain?  "HELP ME!"  Does it hurt anywhere?   No?   In this case, it does not matter if there is 'pain'.  The obvious problem is loss of homeostasis and the profoundly negative outputs.  But the output of 'pain' is null.  The BSN is not creating pain.  Why?

What place does the BSN theory play if it can not predict pain?  What is the broader picture that makes sense of this?

My question is how to we put all this to work to help those who are suffering?  Better yet, can we follow other medical fields and start thinking about the prevention of suffering?

This is not merely an intellectual problem for the amateur pain theorist.  Chronic pain - and the subset of narcotic prescriptions - are arguably the greatest problems in medicine within the US today.  Answers to these questions are extremely pressing and important.

I have a dream.

I have a dream where patients can come and receive effective medical care, which is by definition, the use of science in healing.

I have a dream that pain will be viewed, not a problem, but as one of the symptoms of a more fundamental problem.

I have a dream where we can answer our patient when the ask "Why do I have pain?"  "What is wrong with me?"

I have a dream where we can offer sufferers interventions that are proven to be effective in the long term.

I have a dream where our interventions are safe.

I have a dream where we can not only help with chronic pain, but with the anxiety and PTSD that typically accompanies pain.

I have a dream where patients feel that the medical care provider never questions the unity of their experience of the sense of themselves.  Where they are never regarded as just "their back" or "all in their head".

I have a dream where we use our understanding of the underlying mechanism which predispose us to chronic pain, anxiety and PTSD, to intervene and stabilize this mechanism to prevent pain, PTSD and anxiety in ourselves and our patients.

In my dream we can help people with their suffering.

In my dream we can help people avoid suffering.

To the Alexander Technique Community

This blog is to help the medical community understand the Alexander Technique.

I do not think it is the responsibility of the AT community to help raise the awareness of the AT in the medical community.  It is the the responsibility of the medical community to practice evidence based medicine and to choose interventions which are effective and safe.  That they have ignored the AT since the BMJ study is one of the greatest medical errors of modern time.

That being said, as an emerging Alexander Technique professional I want to help the AT community to relate more effectively with the medical community.  I've written them this entry:

In my nearly three years of training to become a teacher I have been very impressed with the wide ranging benefits that students in the AT can expect.   One of the most perplexing questions surrounding the Alexander Technique is “Why is it not more popular?”

All AT professionals come to the AT from particular groups and backgrounds.  We naturally see the benefits and potentials of the AT in terms of our history.  Having spent the past 15 years in the medical field, I tend to focus of the benefits that the AT could provide for the patients.  If the medical profession recommended the AT, their patients would benefit, but it is also important to note that medicine is influential in the broader culture as well.  So why doesn’t the medical profession recommend the AT?

I think much of the blame can be placed at the feet of the medical care establishment.  It is their job to diagnose a condition and then recommend interventions that are safe, effective and within the patients means.  That they have not been recommending the AT is rather damning.

But is the entire blame to be placed on the medical community for their lack of appreciation of the benefits of the AT?  Could the AT community be approaching the medical community in a more effective manner?

At the last ACGM, I was bemoaning to one my betters the fact that so few medical professionals recommended the AT.  He replied that if we could only get our hands on more doctors they would be very happy to support us.  Indeed, this was the practice of Alexander himself and he was very effective.   But this approach no longer seems to work.  The AT is stuck in an obscure corner of “alternative therapies” with few sign of expanding to it’s potential.  Are we just not trying hard enough?  After 100 years is it time to try something different?

This article discusses some possible reasons why we have been ineffective, and suggests a change in course.

To be honest, I’m being unfair.  Just the continued existence of the technique says quite a bit about it’s efficacy.  Scores of Great Ideas have caught the publics attention over the past 100 years.  Sooner or later they’ve all faded into the background.  But the AT has persisted.  This says quite a bit about it’s benefits and about the quality of it’s teacher training programs.

That the AT continues to exist does not dilute my central thesis: the AT has not grown to it’s potential in the healthcare setting.  Pain is the most common complaint in the medical setting and chronic back pain is the most common type of chronic pain.  Yet the medical community has little that is safe and effective for chronic back pain.  For this reason, there is an acupuncturist, a chiropractor and a massage therapist are on every corner.   Why is the AT nearly invisible?






CAN WE TALK TO DOCTORS?

My bosses boss was the first doctor I spoke with about training to be an AT teacher.  I opened my pitch saying that I wanted our organization to help pay for my AT teaching program.  I had not gotten past this first sentence when he stopped me and spoke for about 2 minutes without stopping.  Of course, he had never heard of the AT.  But in those two minutes he told me three times that he was ”openminded”.   I knew I had my work cut out for me!

Physicians have several barrier to understanding the AT.  They have a very strong tendency to try to fit anything new into their existing paradigm.  The medical view is quite different from the AT world view.  For example, they help others by recommend therapies and prescribe treatments.  That the AT is an educational technique is confusing to them.   Next, the therapies prescribed by physicians have very narrow indications.  They will assume any intervention will only help a narrow population with a very specific illness.  Finally, the notion that it is always useful to fragmented the self into not only the body and mind but into specific organ systems is utterly unchallenged.

In addition to the fundamental differences we have with the medical profession, we can expect that the medical professional will immediately lump the AT in with all the other new age, alternative, Next Big Things which are constantly being thrown at the physicians.    Physicians grow fatigued responding to these “Great Ideas” which generally have unproven benefits and are both expensive and dangerous.  Further, they are promoted without reference to the life sciences or the scientific method which form the bedrock of medicine.    It is not surprising that medical professionals are impatient and reflexively sceptical of anything new.

WHAT IS THE ALEXANDER TECHNIQUE?

It’s a sure bet it will be among the first questions the physician might ask.  Like any other encounter, the first moves are crucial.  Very soon the conversation will turn to the specifics and studies.  I take the opportunity to start dissolving the assumptions physicians are sure to have.

Well, I think it’s very important to understand the the Alexander Technique is an educational technique, not a therapy.  

As an educational technique, a variety of benefits can be expected.  Also, I’m not claiming cures and miracles.  If a medical provider can not imagine anything other than a therapy might possibly be helpful, I might make the analogy to nutrition.

The Alexander Technique helps students make changes at a pretty fundamental level.  Some people use the analogy of nutrition.  If you send an patient who eats fast food and has high cholesterol to a nutritionist, and they make the changes that the nutritionist suggest, then you can expect fundamental changes to a lot of ailments.  But nutrition is not a specific therapy for high cholesterol.  Good nutrition is fundamental to living well.  Of course, the AT has nothing whatever to do with eating, but both are educational interventions.

 “OK, the Alexander Technique is some kind of educational technique, but what is it exactly?”

“Oh, I can tell you.  But is that what you really want to know?”

WHAT DOES A MEDICAL CARE PROVIDER REALLY WANT TO KNOW?

Physicians want to provide the best possible care.  How do they decide what to recommend?  In ancient times doctors relied on tradition or religious beliefs.

In FM Alexander's time medical professionals placed emphasis on expert opinion and the consensus among elders.   Alexander realized this and was very successful by seeking out the most influential medical professionals of his time.

But in modern times we have moved well beyond relying on ‘tradition’ or the ‘consensus of experts’.  Currently, physicians are taught to be suspicious of tradition, expert opinion and community standards.  Moreover, physicians are taught to discount their own experiences and those of their colleagues.

So how does the contemporary medical community decide what care is best?  How do they decide what to recommend?

     “Oh, I can tell you what the Alexander Technique is, but is that what you really want to know?  Do you know the story of penicillin?  Prior to the discovery of penicillin blood poisoning (sepsis) was nearly always fatal.  But then it was found that the mold from bread, when refined, was safe and effective in curing sepsis!  But for 40 years no one knew exactly why this was so.  No one knew the mechanism by which it worked.  Those physicians who started to use penicillin when it was found to be safe and effective saved their patients.  Those physicians who waited till they figured out how penicillin worked lost many patients during those years.
    Sure, I can explain how the AT works, but is that what you really want to know?  Don’t you want to know what evidence is there to suggest that the AT is safe and effective?”

BUT SAFE AND EFFECTIVE FOR WHAT?

The fact is, of course, we have no idea what the boundaries of the benefits are with the AT.  All the studies are encouraging but there are whole fields of human endeavor where the AT has not been studies.  The best study to date has to do with chronic back pain.

The primary care physician will be very interested in this.  Back pain is among the most difficult problems physician face.  Although back pain is a leading cause of chronic pain, disability, and medical visits, physicians have not identified any cause.  Only fifteen percent of back pain has an identified cause.   Because physicians have not found a specific cause to the remaining 85% they call it “non specific”.

Until recently modern day physicians were taught to aggressively treat pain.  Since narcotic were shown to be helpful in the short term, they became very popular as a treatment for long term “nonspecific” back pain.  Recently they have been found to be neither safe nor effective for chronic pain.  So physicians are desperate for anything that is safe and effective for back pain.

HOW DO MEDICAL CARE PROVIDERS DECIDE WHAT RECOMMENDATIONS TO MAKE?

This is a highly controversial topic and there is heated debate with medical, legal, ethical and economic considerations.  But there is evolving consensus within the medical community to rely on population based evidence when caring for the individual.  This means that the medical provider is encouraged to look to scientific studies of large numbers of people who are similar to their patient for guidance when prescribing care.

The stratification of the quality of evidence that a treatment is effective is important.  There are  two bodies have have been created to give grades to the quality of evidence - or level of certainty - that an intervention is effective.  These two bodies are the US Preventative Service Task Force, and the UK National Health Service.  The US Preventative Task Force defines the lowest level (Level III) of evidence to the opinions of respected authorities.  So much has changed since FM’s days when this was the best available evidence!  The highest level (Level I) is given to “Evidence obtained from at least one properly designed randomized controlled trial.”

Again, more than any other criteria, physicians want to know that an intervention is safe and effective.  We now have a definition about what is thought to be effective, but how does safety come into equation?  Again, the US Preventative Task Force has tried to lend guidance.  They have summarized both the quality of the evidence - and dangers - of an intervention in their “Categories of Recommendation”.  The top level is Level A: “Good scientific evidence suggests that the benefits of the clinical service substantially outweigh the potential risks. Clinicians should discuss the service with eligible patients.”

“After lessons in the Alexander Technique one can expect a variety of benefits.  The BMJ study suggests that it is highly effective in the long term relief from back pain.  In fact, it is the highest quality evidence: Level I.  And because there was no unwanted effect from the Alexander Technique it should have your top recommendation. Right?”

There only remains one problem, and that is that we only have this one top quality study.  Physicians feel much more confident when they have several top quality studies with similar conclusions.   After admitting this, one can feel free to add:

“- The number of participants in the BMJ study were huge - bigger than some meta studies of other interventions.
- It was sponsored by the British NHS who had a genuine interest in an unbiased outcome.
- It was consistent with other AT studies that show the AT is very effective.
- The benefits did not wear off as time went on like everything else that has been studied.  In fact, the benefit from the AT was actually better at 12 month follow up than it was 6 months.
- The reduction in days in pain, one of the two primary outcomes, was huge: an 86% reduction compared to the control group.  The other primary outcome, disability, showed a 42% reduction.  The secondary outcomes also showed very impressive benefits.
-Sure, subsequent studies may show less benefit, but what is the chance, given the size, quality, and magnitude of benifit that subsequent studies with prove that there is no benefit?  
-  Oh, and did I mention that this is 100% safe?

HOW DOES THE ALEXANDER TECHNIQUE HELP WITH BACK PAIN?

Ultimately, medical providers are human and curious, and want to understand the underlying mechanisms.  Although I’ve argued that physicians should not predicate their recommendation based on an understanding of how the technique works, it’s not unreasonable for them to ask how it works.  An easy response would be to simply quote the BMJ study it self:
“Lessons in the Alexander technique offer an individualised approach designed to develop lifelong skills for self care that help people recognise, understand, and avoid poor habits affecting postural tone and neuromuscular coordination. Lessons involve continuous personalised assessment of the individual patterns of habitual musculoskeletal use when stationary and in movement; paying particular attention to release of unwanted head, neck, and spinal muscle tension, guided by verbal instruction and hand contact, allowing decompression of the spine; help and feedback from hand contact and verbal instruction to improve musculoskeletal use when stationary and in movement; and spending time between lessons practising and applying the technique (also see appendix on bmj.com).”

This is a convenient and easy-to-understand definition.  And the claim that the AT improves postural tone and neuromuscular coordination is supported by other studies.     But as a definition of the AT I do not think it is very complete.
One of the overarching themes in FM writing is that that is not useful to divide the mind and the body.   This is not some abstract theory.  It is the reason some teachers, like Becca Furguson, have been using the AT to help students with anxiety, trauma and PTSD.  Lessons in the AT lead to more than just changes in muscular tone.  But how do we explain all this to medical care provider whose paradigm is so different than our own?

WHAT IS PAIN?

When physicians gather to talk about medical problems, they first define the problem.  The definition of pain, and the theory about how it is created, has changed quite a bit over the years.  In ancient time, pain was thought to be evil spirits entering the victim.  With the advent of religion, pain was thought to be a test of ones faith, and treatment involved prayer and devotion.  Our culture is heavily influenced by Descartes who gave us a mechanistic, dualistic perspective.  Descartes suggested that pain was trauma or inflammation in the periphery, triggering pain receptors, traveling through pain pathways to a pain center in the brain.  But we now know there is no pain center in the brain: pain is a widespread phenomenon.  Also, years of cutting nerves thought to carry of pain rarely result in long term pain control.

 Ronald Melzac, a Canadian researcher, developed the “gate control” theory of pain.  He hypothesized that a ‘gate’ in the spinal cord inhibits, allows or amplifies the transmission of pain from the periphery.  In the model, inputs to the gate from the brain can descend the spinal cord and effect this spinal gating mechanism.  This model is now generally accepted.

The progression in pain theory from early times to modern time is marked by increasing participation of the sufferer: from victim to active participant.  And the cause of pain has moved from outside the body, to the periphery and now more centrally.

However, the gate control theory does not account for a common finding called phantom limb pain.  This is when people feel pain in a non-existent limb:  It is common for people to feel pain in a limb that was amputated.  Even more puzzling is the perception of pain in a limb in a person that was not born with the limb.  

To explain this, Ronald Melzac has proposed another revision to pain theory.  This one is called the “body-self neuromatrix” (BSN).  This theory is bit complicated but well worth the effort to study it.  The BSN theory states that there is a widespread scaffolding or lattice of neurons that extend throughout the brain.  One is born with this matrix, but it can be modified during one's life.  This matrix has a variety of inputs and outputs and the specifics of it’s workings are very complicated.  However, it has two functions.  First, it decides if the ‘self’ is OK or Not OK - it decides if equilibrium, or homeostasis, is preserved or lost.  The second function is that the BSN generates a constant neural stream that goes to the “sentient neural hub” where it is converted to a continually changing stream of awareness.

 Melzac, a psychiatrist by training, divides the inputs to the BSN into three categories: the mind (thoughts, beliefs, history, culture, anxiety, etc), body (somatic sensation such as trauma, trigger points, tonic state, sight, sounds, etc) and from the endocrine system (stress hormones, immune system, etc).  All these inputs can contribute to the loss of homeostasis, and can destabilize the body-self neuromatrix.

Melzac groups the outputs from the body-self neuromatrix into three categories.  These three outputs include the creation of the perception of pain and stress, changes to one’s actions (coping activities such as voluntary and involuntary actions, social interactions, etc) and body (stress hormones, changes to the immune system, etc).




Again, I believe this theory can be very helpful to anyone cares for those with chronic pain, or anyone at risk of having pain.  Here are some points I’d like to emphasize:
-Pain is created in the mind.  Pain is a psychological phenomena.  Somatic stimuli can contribute to the perception of pain, but these stimuli are not the pain, and are not necessary for the creation of pain.  So, one’s chronic back pain may, or may not, have anything to do with one’s back.
-Pain is not an isolated phenomena.  It is only one of the outputs from the BSN that affects the entire self.  The other outputs are very important and can lead to a wide array of serious psychological and interpersonal problems, as well as endocrine, inflammatory and immunologic diseases.
-This theory appears to be a fragmentation of the self, something we view as not very helpful.  But the medical professional that adopts this model will be forced to recognize the contribution of the entire self in the creation of pain.  Also, the medical professional will be forced to acknowledge that loss of homeostasis results in widespread harm to the entire self and not simply the creation of pain.  In fact, some believe that the notion of “pain” unduly narrows the attention of both patient and medical provider, and diverts attention away from other very serious disruptions.  Some believe the the notion of pain is obsolete and should be replaced with a more inclusive term.
-Melzac proposes this is a linear process: input, processing in the BSN, and then output.  But clearly, it is not this simple.  The outputs from the BSN will effect the next cycle.  For example, the startle reflex (like other reflexes) is a brainstem reflectory process and does not have cortical (thought, memory, beliefs, etc) participation - this is what Magnus found.  But within a few milliseconds the repercussions of the startle reflex itself will influence the BSN.  What we observes, then, in the startle response is the sum of the startle reflex plus the stability, or lack of stability, of the BSN.
-This theory does more than explain how pain is created.  It also explains how PTSD and anxiety are created.  Researchers have long noted the connection between post-traumatic stress disorder and chronic pain.  With this theory, we no longer have to wonder about the relationship of pain and PTSD: PTSD/anxiety are created by the BSN along with pain.
-Finally, this theory extends the progression of pain theory.  Originally pain was thought to be external and victimizing the sufferer.  This theory places the creation of pain, not outside or inside the body but in the mind.  Hence, the sufferer is not a helpless victim but actually an active participant in the creation of their suffering.

HOW DOES THE AT HELP WITH PAIN?
Now we have a usable theory of what pain is, how it is created and what contributes to pain.  This theory can used to discuss the AT and some of it’s mechanisms with the medical community.

 In terms of the body self neuromatrix, I suggest that the AT works in the following ways:

1.  The AT affects the phasic (ie., rapid, transient) state of the mind.  The tool of inhibition can be used to stop the perseveration and catastrophizing that are common responses to somatic sensations.  This is not distraction.  This is consciously attending to the wide variety of inputs - our entire sensory environment - rather than attending solely to the habits of mind.
2.  The AT affects the phasic somatic inputs.   Acute injury and emotional trauma are strong stimuli to the BSN and strong stimuli to pull down and shorten in the characteristic pattern seen in the startle response.   The tools of the AT have the potential to prevent this response.  If we can prevent this characteristic response, then the BSN will be confronted with a discordance: in the moments following significant trauma, there will not be the characteristic phasic somatic input (ie. no  shortening and contracture) input to the BSN.  It does not change the trauma, but it does change our response to it.  The quality of the experience will be different and less likely to cause suffering.
    One curious finding in the BMJ study is difference in the magnitude of the effect in the two primary outcomes: days in pain and disability.  The percent reduction in days in pain (86%) was over twice the reduction in disability (42%).  There may be any number of reasons for this disparity.  One reason might be that many participants may well have continued to have problems with their back a year after the intervention.  The somatic sensations that accompany such activities as chores around the house, may prevent them from doing the chores.  This would lead to less reduction in the disability score.  But if these same somatic sensations were not accompanied by the characteristic changes that always accompany pain (shortening and narrowing), the BSN will be stabilized and not prompted to create the sensation of pain.  This would lead to a greater reduction in days with pain.
3.  The AT affects the tonic state of the mind.  Some have noted the similarities between the AT and mindfulness meditation.  Becca Furguson goes so far as to refer to the AT as “movement based mindfulness”.    This is important because meditation is known to make the mind less reactive.  As such, meditation holds great promise in helping those with PTSD and pain, and “mindfulness based therapies” are very popular.
   Meditation is gathering the mind.  But if we look closer it’s really a two step process.  The first is to recognize and stop the distracted mind.  This then allows the meditator to come back into the present.  The second step to focus on the object of meditation.  This second step, “focusing”, is optional but generally recommended.
    FM used only slightly different language.  His “inhibition of end gaining” is to continually say no  to caring more about getting to an end than about how one gets there.  This ‘end gaining’ seems the same as getting ahead of oneself and is similar to ‘not being present’.  This ‘inhibition of end gaining’ is the same activity as the meditators first step: coming back to the present.  The main difference is not the activity, but the context: the meditator aims to ‘be present’ on the meditation cushion while the AT student intends to ‘inhibit end gaining’ in all activity.
   Mediation is known to help those suffering from pain, anxiety and PTSD.  The BSN theory predicts that it should be helpful.  We can argue that the AT will have even more benefit than meditation:  inhibition is taught as the response to all stimuli to act throughout the day, and not practiced only once or twice a day.

4.   The AT affects the tonic somatic inputs.  The AT improves postural tone and spinal coordination.  This was used as a definition of the AT in the back pain study cited above, with evidence provided by Dr. Tim Caccitore.  This improved tone is relayed to the BSN and will decrease tonic inputs.   This improved tone is not consistent with loss of homeostatis - it is consistent with stability.
In addition, it’s reasonable to assume the improved tone and spinal coordination - a “healthy back” - should help prevent future injuries.

CONCLUSION

For the past 100 years, little progress in communication has occurred between the AT community and medicine.  Meanwhile back pain sufferers have little hope and the AT remains in the shadows.   Waiting for the medical community to come to us is obviously not working.  It is time to try something else.

There are risks in engaging the medical community, as FM clearly perceived.   The medical establishment can be expected to relate to the AT in procrustean terms, ignoring or trivializing central points that do not fit the medical paradigm.  Any equivocation or simplification on the part of the AT community will result in the AT being defined as a therapy with narrow indications.  I believe it is important to have a robust platform from which to discuss the AT in be broadest possible terms.

Although there is a great divide between the medical care paradigm and the AT community, it does not mean that we can not find common ground.  We both have inter-relating unmet needs and solutions.  For example, medical care providers are desperate to find anything that will help with chronic back pain but they require scientific proof of safety and efficacy.  The AT community has excellent, but not complete, science to support it, and a stellar safety record.  We all can also discuss how the AT works using modern pain theory.  

We must understand the medical mind and appeal to it in it’s terms.  This means understanding  and speaking clearly about science and logic.  This is not a small task for the AT  community whose roots tend to be in the performing arts - a group not known for it’s firm grasp on logic, biological science and statistics.    But if we understand how medical decisions should be made, our task is much easier.  We do not have to explain how, exactly, the AT works.  “How” is not a logical consideration when recommending the AT.

The AT community needs be clear only on two points.  First, nothing other than the AT has been shown to be significantly effective in non-specific back pain in the long term.  Of course, the studies on the AT are not conclusive.  But there is almost no medical problem where the evidence to recommend an intervention is unequivocal.  Almost nothing in medicine is black and white.  In this grey zone, medical recommendations should be heavily influenced by safety: first, do no harm.  This is the second of the two points at which the AT community must be clear when talking with the medical community: There has never been an unwanted outcome - there has never been any harm - in any study involving the AT.

And yet, the medical community is curious and will want to know how the AT works.  By what mechanism does the AT help with pain?  We can not use old theories of pain.  Most medical care providers have simplistic, unexamined assumptions about the nature of pain based on ancient, incorrect assumptions regarding the nature of the Self.  It is not surprising then that their efforts, based on these false assumptions, have not yield an effective therapy for chronic back pain.  Also, these older theories do not give us the possibility to have a full discussion regarding the mechanisms by which the AT works.

The good news is that advances in pain theory are starting to re-integrate the fractured self.   Modern pain theory provides the opportunities to discuss not only the effects of improved postural tone and spinal coordination, but improved phasic response to otherwise disruptive somatic stimuli, interrupting the undue fear response, the psychic perseveration and the catastrophization.  And in the same discussion about the mechanism by which the AT helps with pain, we can discussed how the AT will help with other problems, such as PTSD and anxiety.

Conclusion

We have a theoretical model for back pain.  And we have evidence the AT is effective in back pain.  How do we apply the model to understand a mechanism of action by which the AT works to lessen back pain and disability?

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.

Scientific Research in the AT, Part 1

Before we apply the theory of the body-self neuromatirx to the Alexander Technique, I think it is important to review the scientific evidence for efficacy.

This is of course, of prime importance to the medical provider.  As stated in the introduction, a theoretical understanding for the mechanism of action may be interesting to the provider, but it should have little, if any, role in deciding to recommend an intervention to a chronic back pain sufferer.  Again, the decision should be based on:

-the need VS safety (interventions with even small risk should not be considered in the treatment of male pattern baldness.  Alternatively, high risks may be acceptable for life threatening problems)
-cost
-availability
-scientific evidence to support it's efficacy.

In FM Alexanders time, medical care providers made decisions primarily based on the expert opinions.  Today, however, we have scientific research.  In todays evidence based world we like to see:
- reports published in respected journals by editors who have reviewed the findings.
- peer reviewed so that experts who know the field have reviewed the methodology.
- controlled trials, with the intervention compared with either placebo or standard care.
- Large numbers of participants to insure a statistical significance.
- Clearly stated primary and secondary outcomes.
- A patient cohort that reflects our patient population.
- Researchers should not be biased or have any stake in the outcome.
- We would also like to see several of these trials, hopefully with a meta-study to compile them.

The AT claims to improve the 'use of the self', with the 'self' defined somewhat broadly.  It does not claim that it will provide any narrow, particular benefit.  As such we there is currently no way to discover if the AT is effective.
      We can investigate if the AT helps with a narrow concern such as back pain.  But the outcome of AT/back pain investigations will have little bearing on the central claim made by the AT.  Metaphorically, nutritionists claim that eating well helps to improve health.  What does it mean if studies of those who have seen nutritionist fail to find improvement in visual acuity?

The flagship study of the AT and back pain can be found here.
   Very briefly, it was funded by the UK health care system.  It had 579 patients enrolled.  It measured the effects of several interventions inc normal care (which served as the control group), exercise, massage (to control for the hands on, one on one interaction), six lessons in the AT and 24 lessons.  Primary outcomes were Roland Morris disability score (number of activities impaired by pain) and number of days in pain.  The study was done in the UK and was done with 152 AT teachers and massage therapist.
    There were several very notable things about this study.
-The number of participant was quite large.
-This was a fairly impaired population.   For example, the control group at the end of the study reported 21 out of 28 days with back pain.
-The follow up was a full year after the intervention.
-  The study concluded "One to one lessons in the Alexander technique from registered teachers have long term benefits for patients with chronic back pain. Six lessons followed by exercise prescription were nearly as effective as 24 lessons."

This statement really does not capture the magnitude of the results.

The number of subjects exceed that to some metastudies of other interventions.

The one year follow up is also noteworthy.  There have been studies of a variety of non medical interventions that have suggested benefit in the short term.  But back pain is commonly recurrent and chronic back pain is one of the major problems in medicine today.   Why shouldn't we set our expectations high and ask for long term - even permanent - results?  

The authors are conservative in their conclusions:  to say that there was 'benefit' belies the magnitude of the result.  At one year follow up, the control group had 3 weeks in the past month in pain.  The 24 AT lesson group had 3 days in pain.  This is a 86% reduction.    This must be close to the background occurrence of back pain.    Also of note, the effect at 12 months was actually greater than the effect at 3 months.  When medical providers consider interventions we usually think about therapies, and therapies typically decline in efficacy over the years.  But the AT is an educational technique and the effects of it's use, apparently, improves over time.

In those people who do not carry a diagnosis of low back pain, how many days in pain would they confess to having if they were polled?  Does this study suggest that the AT has the potential to cure back pain?

The second outcome was disability, and here there was a 42% reduction based on the Roland Disability Score.  Again, to says this is "benefit" is rather an understatement.  I will present in future posts some thought on why the effects is not as robust as the days-in-pain result.

Again, the body of scientific evidence should be the primary consideration in the decision to recommend and intervention.  How far does this study go in meeting the need?
- It is not a meta study, but does include a great number of clinically relevant patients.
- It's researchers have no interests to disclose.
- Outcomes measure long term results.
- It was published in a major peer reviewed medical journal
- The results were unequivocal and dramatic.

Should the AT be recommended?  Again, based on our criteria above:
- Risk/reward: Chronic back pain has very significant global negative implication for the sufferer.  As such, we should accept a moderate amount of risk for an intervention that has shown efficacy.  However, for the AT, we do not need to accept any risk because there has never been an unwanted outcome from any study, including this one.
- The cost?  In my community, a lesson might cost $40.  24 lessons would cost $960.  However, a compelling argument can be made for recommending 6 lessons plus an exercise prescription.
-  AT teachers are available in most communities in the US.  Healthcare Saving accounts can be used to cover lessons in the AT with "back pain" as a diagnosis and "Alexander Technique/neurophysical re-education" as the recommended treatment.

This is a brief review of the scientific evidence regarding the AT and back pain, and it certainly does not negate the need for the caregiver to review the BMJ study.
I should be very clear that this is not the only study that has been done with the AT.  In subsequent posts I'll review other studies of the AT.    But for now, we should go back to the body-self neuromatrix to again consider it's efficacy in part to discuss the discrepancy between the days in pain result and the effects on disability.

The Body-Self Neuromatrix

I am very happy to finally get to a discussion of the Body-Self Neuromatrix.  There is no doubt in my mind this will become an extremely important and influential theory.  I'll explain why in my summery.

This theory deserves our attention because it was developed by Ronald Melzac PhD.  Dr. Melzac established his credibility in the pain field as the developer of the Gate Control Theory.  The Gain Control Theory is now widely accepted and serves as the basis for most current research into pain.  That he has revolutionized such an important field not once but twice is very impressive.

To understand this theory I strongly suggest that the reader read a presentation by the author.

It is too important, and too complex, for me to adequately summarize, but I'll say the following:
It hypothesizes a widespread network of neurons that provide a scaffolding, or matrix.  One is born with the matrix, but it can be altered during ones life.  It involves parallel cyclical but communicating pathways.  It has several classes of inputs and outputs, but the function of the matrix is relatively simple.  It decides is homeostasis is lost.

As conceived by Melzac, there are three classes of inputs.  The first comes from the brain, and includes both tonic (slowly changing) and phasic inputs (more reactive).  Please see the chart below for examples.  The second group of inputs comes from the body.  The sub divisions are phasic cutaneous, tonic somatic, visceral inputs and visual, vestibular and other sensory inputs.  His third group of inputs is labeled "motivational-affective" and includes our endocrine milieu.
 Outputs include pain perception, action programs and stress-regulation programs.

One of the outputs discussed in the article I linked to above, but not listed in the diagram, is the suggestion that one of the outputs from the BSN goes to an area called the sentient neural hub.  Here, a continuous stream from the body-self neuromatrix is converted to continually changing stream of awareness.   Further, he suggests that the output from the BSN bifurcates, one goes to the sentient neural hub and another eventually activates spinal cord neurons for activity.

Among the wonderful attributes to this theory is that:

-it finally conceives of pain as a psychological phenomena that may or may not have a basis in the body: finally a theory describing the creation of pain that is congruent with the International Pain Societies definition of pain.

-the theory is not only a pain theory, but a theory of PTSD and anxiety as well.  We no longer have to wonder about the relationship of PTSD and pain: they are generated by the same mechanism.

-This theory continues the progression of pain theory from outside the body to now squarely in the central nervous system.

-We have, for the first time, a complete accounting for the factors that can increase our chances of having pain.  The BSN provides a basis upon which various medical and non medical interventions can be evaluated.  It provides a common ground for pain discussion between medical, surgical, psychological and non-medical interventions.  For the administrator, who much decide how to spend limited research funds, we now have a complete list of factors that cause chronic pain, PTSD and anxiety.  

-We also are forced by this model to acknowledge that pain does not exist in isolation.  The consequence of a loss of homeostasis are wide ranging.  With this model the clinician is forced to see that a chronic pain suffer is in danger in many different areas of his or her life.  We can see that every corner of a suffers life is at risk including his mental health, bone health, immune system, etc.  Now, more than ever, we can see the importance in aggressively helping those suffering with pain, PTSD, anxiety.

-The BSN theory also continues the historic trend from 'the sufferer as victim' to 'the sufferer as an active participant'.

Any good theory should raise questions and opportunities for further research.  This theory certainly does:

-Is it valid to conceive of the BSN as a machine which does not trigger an alarm till a certain threshold is met?
-The BSN is drawn fairly simply with inputs and outputs.  Can we add a concept of a positive feedback to the process?  That is, can the outputs from the BSN itself create conditions that irritate the BSN the next moment?
- Is it possible to calm, reassure or stabilize the BSN?  Can we make it more resistant to triggering the alarm?
- We have a list of inputs into the BSN.  These inputs can irritate, or promote the BSN to action.   Can these same inputs also stabilize the BSN?  It would seem to me that if we were interested in finding ways for humans to suffer less, research into this question should be a high priority.
- What input to the BSN is most influential?  Does the BSN preferentially look to one of these inputs to decide if homeostasis is lost?
-  Which of these inputs are most easily changed?
-  The BSN outputs vary in relative intensity.  But with chronic pain all outputs are stimulated.  Thus, chronic pain never occurs as an independent, isolated entity within the sufferer.  Is, then the concept of chronic pain too limiting?  Should it be obsolete?  What term shall we use for the sum the BSN outputs?

One of the great mistakes in modern medicine was to create and perpetuate the idea that the physician alone is responsible for providing health.   Chronic pain is the most dramatic example of this paternalism.  The result, all too often, is a patient addicted to our prescribed narcotics but still in pain.  The sufferers sole object in life is to constantly badger the physician for more pain medication, while in utter denial that they have any role in their pain.  If we have any chance to shift the responsibility to more balanced position, we must be able to give the patient the tools to help themselves.

The creation of pain is now in the brain.  The sufferer is now no longer a victim but an active participant.  We have a definition and a model of how pain (and PTSD) are created.  We have a list of opportunities to stabilize the BSN.  What tools can we give the patients to help themselves?

We have a huge cortex, a vast ability to think and a high degree of neuroplasticity.  We can leverage these tools to guide sufferers to relief.

PTSD, Meditation and the Alexander Technique

Again, this blog seeks to introduce Alexander Technique to the medical provider, and explore if the AT should be recommended.  The blog makes most sense reading from start to finish.  The last entry, "Conclusion" wraps it all up.

But I have more thoughts to share.  This essay was inspired by a talk given by Steven Dobscha, MD from Portland Oregon, an expert on PTSD.  He spoke recently on the connection between pain and PTSD.  He suggested that mindfulness meditation seems to hold the most promise for treating PTSD.  This essay is about the intersections of pain, the AT, meditation, the Body Self Neuromatrix and PTSD.

I will try to present in this essay why the AT might be effective in alleviating PTSD.  This is very important.  If there is no clear theoretical reason suggesting that the AT is effective in PTSD, then only a small pilot study is indicated.  It makes sense to be prudent in these days of limited funding.  However, if there is a firm theoretical basis explaining why the AT would be effective in the prevention and alleviation of PTSD then more serious, definitive research is indicated.

Pain, PTSD, meditation and the AT all intersect at the startle reflex.

The startle reflex is among the most deeply entrenched and ancient reflexes.  Wikipedia refers to it a brainstem reflectory reaction.  It does not involve higher brain participation.  And yet, the reflex can seem to be influenced.  A heightened startle reflex is part of the very definition of PTSD.  So significant past trauma has the potential to interfere with the startle reflex.  On the opposite side of the spectrum is the meditator.  There was an intriguing study that showed that a meditator with 40 yrs experience can alter the startle reflex.

Perhaps if we examine meditation we can gain some insight on how it influences the startle reflex.

In the study above, the meditator was an expert in two forms of meditation: "open presence" and "focused" meditation.  Open presence is when the meditator tries to prevent the mind from getting stuck on anything.  The goal is not to dwell on any concerns or thought, not get wrapped up in emotions, not to get too curious about sights or smells to the exclusion of other sensory input.  In open presence the meditator does not exclude or neglect anything in the realm of awareness.  In distinction, focused mediation brings the mind back to an object and, over time, it becomes more and more fixed on it.  Of course, one can choose any number of things to bring the mind to: a question or thought, the sensation of breathing, a candle flame, etc.  All of which might have different effects on the meditator.

One might think that these meditators are special people with superhuman abilities.  Maybe after 40 year of experience they are (I doubt it), but I'm sure they didn't start out like that.  We all start out the same: with plenty of doubts, fears, obsessive preoccupations, nagging pains: a huge variety of distractions from either an "open presence" or a "focused" meditation.
   In the "focused meditation" what do you do when you've been distracted?  It is a three step process.
1.  The first is to wake up and realize that, for example, you just spent the last 10 minutes thinking about chocolate chip cookies instead of your object.
2.  The next step is to stop the distraction.
3.  The third step is redirect the mind to the object.
Those who practice the "open presence" do without the third step, and just rely on the first and second step.

There are countless ancient and modern lectures, books and teachings to navigate these three steps.  The huge variety of teachings exist to support and encourage any person in any situation.  But all the teaching support the notion that these two forms of meditation are “mind only”.  There is no role for the body.   Here is the process in a nutshell:  The mind wanders off.  The mind realizes that the mind has wandered off.  The mind stops focusing on the distraction.  And, in the “focused meditation” the mind drags itself back to the object.

For the beginner, a long period of time will go by without any 'stopping'.  But as time goes on ones skills improve.  A good meditator will recognize and stop distractions hundreds of times in an hour.  The mind will not wander very far, nor be away for very long.  One begins to be extremely good about stopping and shepherding the mind.

How might meditation effect the startle reflex?  It would seem reasonable to divide the reflex into two parts.  The first is the immediate reflective response to the jarring stimulus.  Again, this is by definition reflexive and does not have any higher cortical participation.  I believe that is is similar to the reflexes studied by Rudolf Magnus, and would expect this reflex to work quite well in the deceribrate model.
   The second part is not the reflex per say, but the fallout.  It's the longer term response.  It a combination of the lingering response from the reflex plus our cortical participation.
    What kind of time frame are we talking about?
      According to the scholarly review paper reviewing the startle eye movement "The psychological significance of human startle eye-blink modification: a review by Diane L. Filion, Michael E. Dawson, and Anne M. Schell:
"Based on these observations, we have proposed that within this paradigm startle inhibition at
the 60 ms lead interval represents automatic, pre-attentive processes, whereas startle inhibition at 120 ms represents a combination of automatic and controlled attentional processes."
      So the startle reflex is quick, about 60ms.  What I am calling the startle response begins to come into play at roughly 120 ms.

    As I have said in previous entries, I am a big fan of the body-self neuromatrix theory.   If the reader is not familiar with this one might read my blog post on this theory, but it is a much better idea to read this paper by Melzack.  One of the many fascinating aspects of this theory is that it illuminates not just the creation of pain, but of PTSD, and anxiety: any loss of homeostasis.  I have stated in the past that I believe the utility of the body-self neuromatrix would be enhanced by conceiving of the process not as simply linear, but as cyclical: the outputs from the BSN quickly become inputs in the next cycle of the BSN.

So, how fast is one cycle of the BSN?  It would seem somewhere in the range of 0.12 seconds or about 8 cycles/second.
 
Using the theory of the BSN how is the startle response is influenced?  First there is the loud, unexpected sound.  There is a reflective brainstem response called the startle reflex which can be seen in the startle eye movement and changes to the head-neck-back relationship.  This loud sound also sends a dramatic input to the BSN via the phasic sensory-discriminative pathway.  A loss of homeostasis occurs and various outputs are produced.    On the next pass of the BSN, there is the input of sensation via the tonic and phasic somatic inputs.  These are muscular changes that are the characteristic pattern of fear.  In addition, there is influence of the activation of the sympathetic nervous system.  There is input to the BSN from the brain: both tonic inputs (such as underlying PTSD) and phasic brain inputs (such as the pre-conditioning provided by researchers).  The thoughts and beliefs, the somatic inputs and the changes in the endocrine milieu are potent irritants to the BSN and lower the threshold for loss of homeostasis when presented with a sudden noxious stimulus.

Stimulating the startle reflex is then a sounding blast into the BSN.  Geologist sometime set off underground explosions and then observe the reflective seismic repercussion.  Thus they can find gas and oil deposits.  Just so, the response to a loud sound can be a measure of the stability of the BSN.  A robust startle response would suggest instability of the BSN and a predisposition towards PTSD, anxiety, and chronic pain.  This explains, in part, the findings of this study of Emotion, attention, and the startle reflex which finds that the "startle response (an aversive reflex) is enhanced during a fear state and is diminished in a pleasant emotional context."

The expected startle reflex will be seen in any neurologically intact person.  A healthy subject will have a minimal startle response.  That is, they will quickly realize that there is no real danger.  The tonic and phasic inputs from the brain will be reassuring on all subsequent cycles of the BSN.  In addition, the tonic inputs from the body will be reassuring.  The phasic inputs - the contraction characteristic of the startle reflex - will still be irritating to the BSN.  The overall response then is basically healthy: it is mostly appropriate to the non threatening environment.

In someone suffering from underlying anxiety, fear or PTSD the startle response triggered in a benign environment will be inappropriate to the surroundings: abnormal and unhealthy.  This secondary response is heightened by obsession, perseveration, distraction; and muscular tension, trigger points, deformity, etc.   The response is driven more by habit than by conscious reasoning.  It is undesirable if we hope to respond appropriately to our environment.

  Just the opposite is seen in the meditator.  As I have said above, meditators are very, very good at 'stopping'.  The meditators are experts in stopping the inappropriate, undesired responses to stimuli - both external stimuli such as loud sounds, and internal stimuli from the sympathetic nervous system.    The meditators underlying tonic state of their body/mind might be so non responsive that it would be very difficult for scientist to see after 60ms.  Should there be some spill over and the BSN becomes unstable in the next few passes, the meditators phasic abilities to "stop" distractions quickly will interfere with continued habit based responses.

Finally, we can take a look at how the AT student operates during a startle provocation.  Like the meditator the AT student is also an expert in 'stopping'.
        FM Alexander had no experience in meditation and was unfamiliar with it’s jargon.  But his language does capture the essence of contemporary mindfulness meditation.  He speaks about stopping the tendency to focus on the endpoint of our efforts.  He called focusing on achieving our goal as “end-gaining”.  Honestly, although the words he chooses might be a bit refreshing, this first tool does not add anything substantive to mindfulness meditation.  Realizing that we are well ahead of ourselves and stopping that distraction is nothing new, but it is vitally important.  Alexander called this first tool “inhibition” and the AT technical term is "inhibition of end-gaining" where end-gaining - the grasping after some goal - is more important than the means by which one achieves the goal.  This is similar to the meditator who is experienced at stopping the response to a stimulus that threatens to distracts from their object of meditation.  The AT student is an expert at stopping the distraction from how one responds to stimuli to achieve an end.  For example, if the phone rings during meditation, the meditator will be distracted, realized they are distracted, say no to the distraction and return to the object.  The AT student will hear the ring and inhibit the initial impulse to reach across the desk to answer it.  Both meditation and the AT are similar up to this point.   In modern pop psychological terms, both meditation and the AT radically anchor one's attention in the present.

But there is more.  This "inhibition" is only one of the two tools that the AT teaches.  This second tool is employed in the "space" created by stopping.  With meditation, one realizes that there is distraction, then stops it.  The meditator then passively waits until there is another distraction.  The AT makes use of this space between stopping and another distraction.  It is in this space that the second AT tool is used.

The second tool is unique to the AT.  Once we have applied the first tool we can apply the second tool.  This tool is to muster energy, or intention, to direct the use of the body in such a way as to oppose the characteristic pattern seen in the startle reflex.  As opposed to the first tool, this “direction” tool his highly nuanced and extremely experiential, hence the need for lessons with a skilled teacher.

The use of 'direction' will change the tonic somatic inputs to the BSN.  It's a rather bold statement, but the science suggests this is true.   This is a nice summary of some of the research that has measured the tone in AT experts and with those with back pain.  This improved tonic somatic input leads to greater resilience of the BSN.

So in addition to the influence of meditation on the BSN, the AT provides an improved tonic somatic influence that provides a highly stabilizing influence to the BSN.

Before moving on, there is one more important distinction between the AT and mediation. Meditation is done on a cushion in a quiet room by people who spend quite a bit away from an otherwise productive activities.  Apart from time spent in lessons, the AT is practiced while in every day activities.

So the Alexander Technique starts with the same tools used in "open focused" meditation, but then it adds a unique perspective that has a great deal to offer.  It should be far more effective than meditation in alleviating PTSD and anxiety.  It is ‘body-based mindfulness’ or ‘meditation in activity’.

So we can see how both meditation and the AT will effect the late expression of the startle response.  But so what?  What has this got to do with PTSD or anxiety or pain?  PTSD is at heart an abnormal, irrational, response to stimuli.  PTSD is a habit.  Both the AT and meditation help to replace unconscious, habitual, irrational, pathologic responses to stimuli with  conscious reasoned responses.  Both the meditator and the AT student are highly trained at quickly interrupting the response.  In addition, the AT student is experienced in directing the use of the self ways from the characteristic pattern seen in the startle reflex and thus with improvement in the tonic state of the body/mind will further stabilize the BSN.

The AT is effective for chronic pain.  There is strong scientific evidence for this.  If we subscribe to the theory of the BSN, we can also conclude that the AT is also helpful for PTSD and anxiety as well.    I have described here the theoretical basis why the AT is effective in chronic pain, and why the AT should be highly effective in PTSD and anxiety as well.  With this theoretical understanding we can suggest the AT to patients and justify spending significant resources on testing the hypothesis.