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.

A Very Short History of Pain Theory

A theoretical understanding of a disease process and a definition of the problem is fundamental and essential if we want to help patients.  Having some idea of the disease process can suggests useful therapies and fruitful lines of investigation.  Without this, we have no basis for discussion, no way to measure either the problem or the efficacy of our intervention.

Reviewing pain theory history might not meet these needs, but it might help to illuminate why there is a problem in defining pain.  We might be able to see if there is any trends or trajectories to pain theory that might suggest the future of pain theory.  We might also find the roots to erroneous assumptions - the origination of cultural biases that color our thinking but have gone unchallenged.

According to my very brief research, in very early times, pain was thought to be the effects of evil entering the body.  These ill effects entered the body, caused pain, and when they left pain resolved.

It does not seem that there was a consensus among the ancient Greeks: some thought pain was an emotion, others an imbalance of vital fluids.  The central pain center was thought to be located in the heart.

The next model suggested that pain is the result of God testing our beliefs or putting us on trial. The therapeutic intervention that was recommended was prayer to confirm our beliefs.

The next big revolution came with René Descartes who conceived of the body as a machine.  He created a division between body and mind.  He moved the pain center from the heart to the brain.  He suggested that pain was damage to the periphery that traveled via some sort of pathway to the brain where something like a bell would ring. The stronger the stimuli the louder the ring.

Throughout the 1800s there was debate about receptors.  It was first thought that there were dedicated pain receptors and transmitters.  The Intensive Theory suggested that any sensation could cause pain as long as it was adequately intense.  In 1943 the summation theory proposed that stimulation of peripheral fibers would have to exceed some threshold for the sensation to spill over and send a signal to the brain.  Another theory proposed that only certain patterns of stimulation are able to create pain.

 In 1953, it was observed that a signal carried from injury traveled on two types of nerves: one with a large diameter, one that was small.  The large diameter fibers carried touch, pressure and vibration and these were found to inhibit the signal carried by the thinner pain sensation carrying fibers.

The final theory is the Gate control presented in 1965 by Ronald Melzack and Patrick Wall, and I'm quoting heavily from wikipedia.  They proposed that both thin (pain) and large diameter (touch, pressure, vibration) nerve fibers carry information from the site of injury to two destinations in the dorsal horn of the spinal cord.  From there, transmission cells carry the pain signal up to the brain, but inhibitory interneurons impede transmission cell activity. Activity in both thin and large diameter fibers excites transmission cells. Thin fiber activity impedes the inhibitory cells (tending to allow the transmission cell to fire) and large diameter fiber activity excites the inhibitory cells (tending to inhibit transmission cell activity). So, if there is more large fiber (touch, pressure, vibration) activity relative to thin fiber activity at the inhibitory cell, the less pain is felt. This is why we rub an injury.
    They pictured not only a signal traveling from the site of injury to the inhibitory and transmission cells and up the spinal cord to the brain, but also a signal traveling from the site of injury directly up the cord to the brain (bypassing the inhibitory and transmission cells) where, depending on the state of the brain, it may trigger a signal back down the spinal cord to modulate inhibitory cell activity (and so pain intensity).   For the first time, the brain itself is an active participant in the transmission of pain.

There are several points that I wish to make about pain theory:
- In reviewing the evolution of pain theory there is a trend to locate the processing of pain from outside the the human, to their periphery, to the spinal column and to the brain.

- There is a trend from ancient times to view the sufferer as a simple receptor for pain to more modern theories that suggest the sufferer to be an active participant in it's creation and modulation.  The sufferer was a passive victim, but is becoming more responsible for their own pain.

- New theories do not necessarily negate established theories.  Reality is actually a vast fog that is beyond our comprehension.  A theory describes a small part of it.  Most of us live quite content in the well described center, but a few will go to the edges.  Here they find unexplained phenomena and then develop a theory to explain the observation.  The function of a theory then is not so much to finally describe reality, but to widen our edges of knowledge and give others the opportunity to explore further.

And here are some lessons that we have learned from the study of pain so far:

- No pain center has yet been found.  Functional MRI imaging has found that the perception of pain is widespread throughout the brain.
- Destruction of pain pathways frequently do not yield long term pain relief.
- We have discovered "phantom pain".  This is pain in a body part that has been surgically removed and no longer exists.  Further, people can have pain and sensation in their bodies even after a verified sectioning of the spinal cord.  People can even have sensation and pain in a limb that was non existent at birth.

And how is pain presently defined?  In 1994 The International Pain Society defined pain as "An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. "    Perhaps it is simply a reflection of my lack of intelligence, I frankly do not understand this.  The Society also includes a paragraph to help explain their definition.  I won't quote the whole paragraph but two sentence stand out "This definition avoids tying pain to the stimulus. Activity induced in the nociceptor and nociceptive pathways by a noxious stimulus is not pain, which is always a psychological state, even though we may well appreciate that pain most often has a proximate physical cause."

All the above is a preface to a discussion of the most current theory, The Body-self Neuromatrix.

The Importance of Pain Theory

In my 14 years as a medical care provider, I have gone to more than my share of medical conferences.  I have attended conferences in primary care, emergency care, internal medicine, cardiology, urology and other specialties.  Uniformly, they are a blend of theory and practice.  One must have some grasp of the theory behind a disease process to make sense of the promises and pitfalls of the interventions.
 
So it was quite a surprise to me that at the annual conference of the Western Pain Society, very little was said about the definition of pain, and even less about the theories regarding it's pathophysiology.  It was as if I had gone to a conference on the common cold and the presenters simple talked about the need for hydration, the merits of antihistamines, the role of antipyretics, etc without any interest in talking about the cold as a viral infection.

If we are going to talk about how to alleviate pain, we must present our definition and explicitly state the theory of we are using in our discussion.  How else are we going to evaluate relative efficacy?  How else are we going to discuss the mechanism of action?

The primary care provider might not recognize the need to examine a definition and theoretical explanation.   Typically, we simply accept what the experts give us.   For example, with type 2 diabetes we uniformly assume these needs are met with the A1c and the idea of insulin resistance.  But chronic pain has no clear definition, no way to measure it, and no universally accepted pathophysiology.

The conference of the Western Pain Society left me with the feeling that the pain specialty is in confused disarray.  The realization that the medical profession is actively seeking the participation of non medical providers initially gave me some hope.  But then I realized that the reason we welcome others is that we have so little to offer that is safe and effective   The medical providers, and the patients, are desperate.

To understand the present state of pain theory, I'll briefly review a history of pain theory.

The Head Neck Back Relationship

I have mentioned that one explanation of the mechanism by which the AT helps with back pain is simply that it improves posture, balance and coordination.  This is done by teaching the student to stop interfering with their inherent reflexes.  But this explanation does not explain the full effect of the AT and does not adhere to modern pain theory.

To begin to have a more robust understanding of the AT, we need to look more closely at reflexs. Again, the reflexes of most importance are the righting reflex and the startle reflex.  The righting reflex begins after an activity has been performed and, if working correctly, brings us back to a neutral,  upright, poised, relaxed but ready position.  This reflex works by comparing the desired ideal upright position with the current sensory information.  These inputs include the somatosensory inputs from the neck which are rich with stretch receptors.
   These and other reflexes were investigated by Rudolph Magnus.  He now has one of them named after him.   Magnus was very clear about the pivotable role the head-neck-back (HNB) relationship plays in our reflexes.  So much so that his work is frequently summarized as "the head leads and the body follows."  The HNB relationship is central to guiding the cascade of movements seen in reflex behavior   This might suggest that the HNB relationship is some kind of control center.  Of course, it is not.  The HNB relationship is part of the peripheral, not central, nervous system and as such it controls nothing.  But it is enormously influential.
    Significant problems arrise should the brainstem be conditioned to replace a default upright and neutral reference posture with some other default state.  This happens as habits influence our reflexes.  We can even see this happening over time by viewing the old frontal and sagital photos of disrobed children as the progress through grade school.  It is very sad to see this.

FM Alexander, independently of Magnus but at about the same time, also concluded that the HNB relationship was of primary importance.  The work in the first few classes of the AT focuses on improving the use of the HNB relationship, replacing the unconscious use patterns with a new consciously directed ones.  Alexander found that once the HNB relationship is improved, other habits of use of the self (such a stuttering, taking the eye off the ball durring a golf swing, etc.) are easily delt with.
But the process of improving the use of the HNB pattern is not trivial.  The skilled hands of the AT teacher can bring the student into an improved relationship, and this typically produces a sense of lightness, ease and uprightness.  But at the same time it can also feel unfamiliar and even wrong.  Student will invariable fall into their old accustomed patterns quickly.  So students are taught to rely, not on what is felt to be right, but on the tools provided by the AT teacher.

The second reflex of concern is the startle reflex.  This is both a unique and central reflex.  It is also of great interest clinically.
     The Veterans Administration is very interested in post traumatic stress dissorder.  The DSM-IV definition of PTSD is a blend of historical, psychological and behavioural factors.  But also central to the diagnosis is one neurological finding: an elevated startle response.
    Wikipedia defines the startle reflex as a reflective response.  That is, the stimulation goes directly into the brainstem and the brainstem in turn stimulates the cranial nerves: blink and the shortening of the sterncleidomastoid and trapesius muscles.  The shortening of the HNB relationship is first postural change one sees on highspeed photos of the startle reflex.  One would not think such a reflectory reflex could by influenced, but indeed it seems to be.  On one extreem PTSD heightens the response, and on the other, meditation seems to inhibit the response.
    The link between PTSD and pain is well established, and multiple theories on the relationship exist.  These theories lack an understanding of the primacy of the startle response (and modern pain theory that I will discuss later).
    Repeated and/or extreem triggering of the startle reflex creates a chronic shortening of the HNB relationship.  This chronic tension produced by the effort to shorten the HNB relationship is the cause of the neck and back pain that is very commonly seen in PTSD sufferers.
   The effects of the startle reflex do not stop with the HNB relationship but extend in a characteristic fashion throughout the body.

Durring lessons in the Alexander Technique students are taught, in part, to direct the use of themselves against the characteristic pattern seen in the startle response.

It is to Alexanders credit that he found that improvement in the use of the HNB relationship will lead to a less reactive nervious system and a lessening of the "fear response".  This is quite remarkable since he knew nothing of theories regarding reflexes or PTSD.

In sum, the HNB relationship is important for the following reasons:
- It is the first region of the body to respond to the startle reflex
- The sensory apparatus gives the HNB relationship primary importance in deciding how to orienting the rest of the body and thus is very influential.
- the HNB relationship is the gateway through which the not only the startle reflex must pass to influence the entire organism, but also fear and anxiety.
- Our use of the HNB relationship can either amplify the startle response (and the emotions of fear and anxiety) or suppress the response.

The above is an introduction to the importance of the HNB relationship.  The argument will be fleshed out once modern pain theory is reviewed.

A Mechanism of Action

There are several mechanisms of action by which the AT helps with back pain.

To explore these mechanisms, I'd like to start again with the cause of back pain.  As I have said in previous posts, the cause of ideopathic back pain is our poor "use".  Use is the accumulations of habits we've aquired durring a lifetime that lend a characteristic pattern which colors how we do everything.

I want to distinguish these habits, which are aquired, from reflexes which are not aquired.  I'm particularly interested in the righting reflex and the startle reflex.  These reflexes are brain stem mediated, hardwired into the reptilian brain.  Based on research by Rudolf Magnus, who studied the decerebrate model, we know that these reflexes operate quite independently of the cerebral cortex.  They are enduring and hardwired.  In fact, wikipedia refers to the startle reflex as a "brainstem reflectory reaction".

This matter is simple in insects and reptiles.  A spider or a frog react reflexively to a fly.  But animals with larger cortexes can alter the expression of their reflexes.  Dogs and cats can be trained.  Human are an extreem example of an organisms ability to influence their reflexes.  We have a large cortex that can exert great influence.  In addition, we have greater neuroplasticity.  Thus we have been able to adapt to a broad range of social and physical environments.

Lets consider a very basic relex, the startle reflex.  Although wikipedia refers to it as "reflectory" humans have found ways to interfere with it.  People who meditate have suppressed startle reflexes and the degree of suppression varies with the type of meditation.  On the other end of the spectrum are those with PTSD.  Part of the very definition of PTSD is the increased startle response.  Meditators and trauma victims have aquired a habit of intefering with their startle response.

Students of the Alexander Technique are given the tools to stop the missuse, or the missaplication, of these basic reflexes.  Some believe that students are given the tools to stop the interference in their reflexes.  I would go a bit further: the AT gives the tools to help bring the students response to stimuli under conscious control.

This might sound confusing or impossible, but the medical care provider does just this - albeit in a crude simplistic way- on a daily basis.  As part of my medical training I was frustrated in eliciting a reliable patellar reflex (knee jerk) response in more experienced patients.  To those nieve to the exam, it was easy to elicit a response.  The more experienced patients get very slightly nervious when they see the rubber mallet moving twards their knee.  They subconsiously (habitually) tense their quadriceps   This tension intefers with my ability to stimulate the patients stretch reseptors.  I suppose it also intefers with the sudden contraction of the muscle that extends the knee in a characteristic fashion.  I tried to instruct the patient to "relax" but I found that the habitual tension in the leg was not under their conscious control.  It was a subconscious habitual response to a stimuli  ie., the presence of a rubber mallet in my hand.  When I mentioned this to my wise preceptor, she recommended that just prior to striking the patellar tendon I instruct the patient to interlock their hand and pull their arms away from each other.  If my timing is good, this works quite well and I was able to elicite a more authentic reflex.  By giving this instruction it confuses the patient, and distracts them from the rubber mallet.  This is a very crude example - only distracting and confusing the patient, but it shows that the cortex can be used to interfere with the habit of interfering with a reflex.

In the AT students are given the tools to use their cortex - their thinking and intention - to stop interfering with the attitudinal and righting reflexes.  Once these basic reflexes are allowed to express themselves without the influence of habit, people have less chronic tension, and move with greater ease and efficiency   With regards to back pain, lessons in the AT have been shown to result in dramatically less disability and pain, even a year after the lessons.

But this is by no means the end of the story.  The AT has other mechanisms of action that need to be explored.  In addition, his formulation of back pain - that it is simply a musculoskeletal problem - relies on a theory of pain has been challenged.

To explore the full scope of how the AT works, we must go deeper into these reflexes, present some missing pieces of the AT, and discuss modern pain theory.

What is the Alexander Technique?

The most definitive definition of the Alexander Technique (AT) can be found in the writings of F. M. Alexander.  His most popular book is The Use of the Self.

Or can go to Wikipedia, but this is written by a consensus of people with unclear knowledge.  On can go to may of the online definitions written by Alexander Technique teachers.  The pitfall here is that contemporary teachers might be defining the technique in simplistic terms that makes the AT sound appealing to a prospective student.

A traditional way of explaining the AT is to describe it's origins.  F.M. Alexander lived between 1869 and 1955.  He was a professional actor and reciter.  As he became successful he began to lose his voice.  He consulted with medical professionals and no significant underlying pathology was noted. He was told to rest, and this seemed to help initially.  But when he resumed performing his problems reoccurred.  Along with this physicians, he deduced that he must be doing something wrong while performing.  He set up mirrors so that he could observe himself.  He made observations regarding his actions, his "use", while performing and found correlations between what he was doing and the manifestations of his problems.  He observed that his patterns of poor use were nearly universal among others he observed.  He distilled his insights and developed a teaching technique to help others.  Towards the end of his life he started a teacher training program.



But where is a medical professional, who cares for patients with back pain, to turn for an accurate definition?  Where is the sufferer of back pain to turn if they want a complete definition based more on science than metaphor?   By no means am I the first to take a stab at this, but most of the definitions that I've read are inadequate.   I've tried to define the Technique in my sister blog, but that was written for those interested in the intersection of Zen practice and the AT.  In subsequent blogs I'll reference the studies and theories that I'm using to make my claims.

To precisely define the AT, with acknowledgement to modern science, I think it is best to first consider the cause of back pain.  Most people believe their back pain is caused by a defect in the condition of the body.  That is, there is a lack of strength in some areas of our body, or lack of flexibility or balance, or we are too active, or not active enough.  This is the generally held belief despite the fact that no intervention that improves our condition has been found to help in the long term.   Another consideration is that there is something wrong with our "use".   "Use" is our underlying tendencies to do everything we do in a characteristic fashion.  We use our bodies in a variety of tasks but with consistent and observable underlying tendencies.  These tendencies tend to shorten and narrow the body.

The Alexander Technique improves this use, but it does not teach one how to stand, sit, walk, bend, or type.  Instead it works at the level of our habitual, characteristic patterns that color all our activities.  The AT is a educational technique that gives the student the tool to be free from their habits.  I want to be quite clear that I am not refering to habits of body only.  I am refering to habitual ways of responding to stimuli in a very broad sense.  Since habit of body and mind influence every corner of our life, a student can expect global changes.  It is not that the technique itself is particularly profound.  But the AT produces a wide range of changes because it works with the habitual unconscious ways of responding and these habits govern quite a bit of how we respond to the world.  The AT does not claim that it's application will make any specific changes.  That specific changes happen are a positive side effect from mastering habits and better use of the self.  The AT also does not make any claim other than that it teaches students how to use themselves better.  The teacher is an expert in finding defects in use, and helping the student work through barrier to imporve their use.  But teacher are not taught to predict what changes improved use will bring.   As I'll discuss later, it is not unreasonable to expect much less back pain, anxiety and relief from PTSD.


To go a bit deeper into a definition of the technique, we can consider why people have defects in use.  This is a huge topic, but ultimately people use themselves poorly because of their beliefs.  The AT teacher is trained to help students let go of beliefs that are related to their poor use patterns.  This may sound like some kind of therapy, but typically in a lesson there is not much talking.   As opposed to approaching beliefs on a verbal, or intelectual plane, AT appears to be a physical technique because beliefs are approached by gentle touch.    Westerners are very "mind centric" and conceive of beliefs as being mental or psychological.  But it is a fundamental premise in the Alexander Technique that there is no useful distinction between the mental and physical.   Our beliefs are reflected, created, and supported by patterns of habitual shortening and narrowing of our bodies.  These patterns color how we do everything.  The AT calls the sum manifestation of these patterns our "use".  The AT gives students the tools to alter their habits, lossen the beliefs and change their habitual use patterns.

A classic definition of the AT is that it teaches how to bring reason to bear on our response to stimuli.   Habits are by definition not conscious - we are not aware of them.  The AT teacher provides two concrete tool for the student to employ in their daily life.  The AT teaches, first, how to stop a habitual response. Next, it teaches how to use the conscious, reasoning, thinking mind to direct ourselves to a new and improved way of responding.  To support and clarify these tools the student is also provided with several principles over a course of instruction.  The AT is a way to replace subconscious responses with conscious direction.  It teaches how to replacing habit with reason.  The AT improves the use of the self.

The AT is about change but the end result is not clear.  Habits are known to us, are predictable and if not comfortable then reassuring.   Habits are the 'known'.  But they are also restricting and by nature prevent change, growth and progress.  The AT shows how to move from the known to the unknown.

The AT improves the use of the self.  Those who practice the tools of the technique have less pain, less anxiety, etc as a byproduct of the improved use.  Imagine a nutrition referral, would taking the advice of a nutritionist treat obesity?  No, but it it not unreasonable to assume that taking the advice of a nutritionist will lead to global improvements including helping with obesity. Improved use is every bit as important as eating well.

It is absolutely essential to understand that the AT is an educational process - emphatically not a therapeutic modality.  It requires the active participation of the student (not "patient"), and it requires diligents, effort, interest and homework.   The AT model is not dissimilar to the music teacher who see students for individual lessons for 1/2 to one hour lesson.  Generally, student progress faster with more than one lesson per week initially.  How many lessons is needed is unclear but studies generally involve six to 24 lessons, but traditionally more than 24 are recommended.

This has been an attempt to define the AT from a variety of angles.  The next post will be to try to define the AT in a way more comfortable to the scientist or medical professional.

An Overview of Idiopathic Back Pain

How does the Alexander Technique help with back pain?

I'd like to begin by talking a bit about back pain.  First, the type of back pain that I'd like to discuss is the most common form.  This type is not caused by something that can be clearly identified.  Cancer of the spine, a stab wound: this is not what I'm discussing.  I'm talking about the back pain whose cause is unknown.

To be clear, there are at least two types of causes.  First, there is the proximate cause.  I lifted the casserole from the oven wrong.  I twisted my back last week.  I pulled my back weight lifting.  I blew out a disc sneezing.  These are all the causes that are temporally closely related to the experience of this round of back pain.  The second cause is not closely related in a time sense, but is the underlying cause.  The ultimate cause of back pain creates the conditions that predispose one to experiencing pain.  In cardiology, the proximate cause of a heart attack is a plugged coronary artery.  The ultimate cause is a lifetime of high blood pressure and high cholesterol.

At a medical conference I recently attended, the presenter claimed that this very common form of back pain should be called "non-specific" back pain.  That is, the obvious causes have been excluded and the cause is not specific.  Patients will tell us the proximate cause, but it is not very helpful: It is not helpful to tell patients "Well don't sneeze!" or "Don't lift anything!".   Many patients will believe that the cause of their back pain is arthritis which was seen on a X-ray, or a blown disc that was seen on a MRI after their last bout of back pain.  But it is very important to note that 60% of people with no pain at all with have at least one bulging disc on MRI.  Also it has been shown that radiographically proven arthritic changes are poorly correlated with symptom severity.   The bottom line is that the vast majority of back pain has no known cause that is acknowledged by the medical community.

But that does not make this back pain "non specific".  There may well be specific cause of back pain - it is just that it has not been medically acknowledged.  More precisely this back pain is idiopathic.  Per Wikipedia:  "Idiopathic is an adjective used primarily in medicine meaning arising spontaneously or from an obscure or unknown cause."  This is more precise.

The other crucial understanding is that it is not useful to think of back pain as an isolated physical problem.  This is the medical approach and it has failed miserably.  It is based on a deep cultural presumption which has never been supported scientifically - indeed there is much evidence to the contrary.  But since patients are quite sure they have a purely physical problem and the physicians are trained to see problems as purely physical the assumption that back pain is simply a physical problem is never questioned.  Perhaps this is why the medical community has never found any scientific evidence that any of their interventions are provide long term benefit with idiopathic back pain.  Further, the science suggests that there are only two interventions that have been shown to help with back pain.  And these two, yoga and the Alexander Technique, are quite rigorous at resisting dividing body and mind.

To understand back pain, we have to become a student of modern theories of pain.  I will go into this in some detail in future posts, but for now I'll says that modern theories of pain acknowledge that a persons history, beliefs, levels of stress in the body and mind, the endocrine system all play a crucial role in the creating of pain.  Although the dominant determinant in the creation of a sensation of pain comes from the periphery, the creation of the sensation of pain is done in the mind which is strongly influenced by other factors.  In fact, so influential are these other factors, that one may have experienced pain in a part of the body which has been neurologically severed from rest of the body.  Indeed, one can have pain in a part of the body that does not exist!

Lastly, just as the inputs that prompt pain are legion we need to acknowledge the adverse consequences of pain is not limited to the creation of undesirable physical sensation.  Chronic pain can completely remodel the sufferer: physically, emotionally, socially.  It can destroy a person.

In conclusion, to help patients with back pain we have to be willing to set aside out deeply held beliefs in the duality of mind and body and instead become a student of modern pain theory.  We have to see our patients as a unified being that is suffering.  This is not to say we have to set aside reason and logic.  Just the opposite.  It is unreasonable and illogical to adhere to beliefs that have been disproven.

Introduction to This Blog

This blog is about the intersection of the Alexander Technique (AT) and pain/suffering.  The central question I will address is "Should medical care providers recommend the Alexander Technique?".  My argument is that the AT should be recommended not only for back pain, but for any problem whose origins are based in habit (such as PTSD and anxiety).  This is based on the science which supports underlying claim if the AT, and the science which supports its use for back pain.  My argument is also based on the cost and safety of the AT.  I will write that it is unfair and irrational to evaluate the AT on the basis of whether or not it "makes sense".  Never-the-less, since the medical community is heavily swayed by such concerns I will write about the underlying mechanism of the AT and explain how it is effective.

I will write briefly about the magnitude of the chronic back pain problem.   I will talk about the failure of the medical establishment to offer effective long term relief.  I write about the consequences of the treatments that are offered.  This is important not only because the commonly used treatment fail to provide long term relief.  They also have disastrous implications for the suffers themselves, lead to addiction and death of others in the community, and cost the health care system enormous amounts of money.

I will define the AT.  The definition I present is more broad and more accurate than the definition that is typically presented.  With this definition I will show that the AT actually has two different mechanism by which it helps with pain and suffering.

The AT is not a cure all.  For all its benefits it is limited.  Although I am obviously a supporter of the AT, I will try to present the limits of what is known.  It is also important to review the qualifications a medical care provider should make when recommending the Alexander Technique.

The underlying cause of common back pain is poorly understood by the medical establishment.  They can not define it, measure it or objectively diagnose it.   This failure is due to the lack of recognition of advances in pain theory.  I will explain the mechanism behind chronic back pain using the most current theory of pain: the body-self neuro-matrix.  For the first time, this theory present the factors that contribute to pain and it goes a long way towards explaining the role of the mind in chronic pain.  This theory also explains that pain is not an isolated phenomena but has terrible implications for all aspects of the sufferer.  Finally, the body-self neuromatrix describes not only pain, but also other disturbances of homeostasis, such as anxiety and PTSD.

Those who are aquatinted with my other blog will know that I aim to make each entry an argument towards my central thesis.  However, each entry offers just a small slice of the complete argument.  Although not presented in a logical progression, taken as a whole I hope that this blog will ultimately present a compelling argument for the medical establishment to recommend the Alexander Technique to those patients who suffer from chronic back pain as well as PTSD and anxiety.

Finally, I want to present a challenge to the medical community.  Please consider that back pain might be like other health problems, with both a proximal cause and an ultimate cause.  Also consider that back pain might be cured.  Without even considering that such things might be possible, we will never take the first steps towards effective treatment and prevention of chronic back pain.

Prologue

Once a medical diagnosis is made, how does a medical care provider choose an intervention?

If it is based on science, the decision to recommend an intervention would consider:
-  the number and quality of the scientific studies supporting the intervention
-  the cost of the intervention
-  the safety of the intervention
-  the availability
-  and then compare this intervention with other alternatives.

But in my 14 years as a Physician Assistant, I have found that medical care providers typically have other considerations.  Such considerations might include:
-  is the intervention something I was taught in school?
-  is it the community standard?
-  is it what the patient is asking for?
-  is it recommended by professional organization?
-  have I read about it in journals?
-  will I receive financial compensation?
-  will it expose me to litigation?
-  is it already a part of my medical practice?  Is it my habit?
-  Do I have a family member that has benefited from this intervention?
-  Have other patients of mine benefited?
-  Have those whom I trust found benefit?

But the two most influential of all are:
- Have I benefited from direct experience of the intervention?
- Does the intervention make sense?   Do I feel comfortable with my understanding of the mechanism of action?

I want to be very clear that I believe that medical care providers should give tremendous weight to the first set of scientifically based considerations.  The medical profession has a very long history of doing tremendous harm when we stray from then.

But at the same time, I have to acknowledge that medical care providers are human and naturally swayed by other considerations.  In addition, we simply do not have the robust evidence to clearly recommend an intervention for all our patients ills.

This blog reviews the rational for recommending the AT in the medical setting.  I will review the first set of criteria that I hope will be used when considering a recommendation.  But I will also acknowledge that medical care providers are human.  I will resist recommending that medical care providers try the Alexander Technique for themselves.  A sample of one should never be considered.  I will, however, make every effort to describe how the Alexander Technique works using my limited knowledge of anatomy, physiology and science.

But why should the underlying mechanism be important?  Certainly, if we are considering a pilot study or a large scale study, we would only want to spend scarce research money to large studies where intervention in question is theoretically promising.  But this blog is written for the primary care provider who struggles every day to help suffering patients.

But truly  does it matter how the Alexander Technique works?  Lets consider the really crazy idea that the mold from bread inhibits bacterial growth and that a very good study shows that it is safe and effective in curing sepsis.  Well it's just nuts to consider it as an intervention because there is no scientific reason for it to work.
    The first medical providers who reviewed the efficacy, safety, alternatives and availability of penicillin and prescribed it are heros: they stepped up and did the right thing.  I suppose there were other medical care provider who waited 17 years till the correct chemical structure and mechanism of action was elucidated.  Perhaps these care providers had some pride because they did not harm anyone by providing an intervention that was not fully tested, reviewed and accepted.  But what of the very substantial harm they caused by waiting?  These are not scientist but arrogant people who put too much weight on the importance of their understanding.  They actually have two little faith in scientific principles.

This blog is an argument that to help patients with chronic pain we have to follow the best science and study modern theory.  We have to look at our fundamental assumptions and rely on skepticism.  If we do all this, there is a tremendous opportunity to make giant strides to solving one of the most pressing problems in medicine today.