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.
Thursday, June 27, 2013
Wednesday, June 19, 2013
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.
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.
Monday, June 3, 2013
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.
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.
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