By Mari Hodges and Tim Cacciatore
Studies show that the Alexander Technique (AT) helps with various kinds of pain,1-5 and many people come to the AT to resolve a pain condition. Two major clinical trials have shown reductions in long term back and neck pain after a course of lessons, and one smaller trial has shown reductions in knee pain. These positive results occur even though the AT does not typically target pain directly.
But how and why does the AT reduce pain? This article aims to explore these questions. Pain is complex, and modern pain science has begun to shed light on various mechanisms behind pain and its alleviation. Recent advances in pain science may help us to understand ways that AT can help to reduce pain.
Over the past few decades, there has been a substantial shift in the field of pain science that addresses many of the limitations of past understanding. To clarify the significance of this shift for the AT, we will first review what has previously been the mainstream model of pain – referred to as the biomedical model – along with its shortcomings. We will then describe a contemporary model of pain that includes previously unrecognized factors and mechanisms of both acute and chronic pain.*
Pain is incredibly diverse, arising from a wide range of conditions, from a paper cut to a broken bone to fibromyalgia to cancer, and there are multiple aspects of the pain experience, including sensation, emotion and cognition. While there is a broad range of contributing factors and conditions, and each pain experience is highly individual, pain emerges from a common protective system. This system includes peripheral nerves, the spinal cord and the brain–all within a person within an environment–and all of which participate in the perception of pain.
*Chronic pain is usually defined as longer than three months.
The Biomedical Model
The biomedical model posits that pain is a direct indication of tissue damage and that the underlying pathology must be treated to reduce pain. This idea appeals to our common sense – pain feels like something is damaged. In fact, mainstream Western medicine for centuries has presumed that there is an underlying anatomical cause to pain, and that this relationship is proportional: more pain means more damage. This presumption also implies that pain without evidence of an anatomical source is not “real,” but rather imagined or caused by psychological problems. Additionally, it ignores evidence of the involvement of the brain in the experience of pain. This perspective, while deeply ingrained in today’s approaches to pain, is limited in its utility for understanding and addressing pain.6
To understand these limitations, let us consider some familiar examples. Many of us may have experienced a minor–yet incredibly painful–injury such as a stubbed toe or tension headache. In these cases, the degree of damage, if present, is out of proportion with the severity of the pain. In other conditions such as chronic back pain,7 fibromyalgia8 or chronic regional pain syndrome,9 severe pain may occur without any identifiable structural pathology. On the other hand, athletes injured on the field may only notice the injury after the game is over. Also, people with significant spinal abnormalities such as disc degeneration or disc hernia are often pain-free or show only weak pain correlation with the degree of abnormality.10 Likewise with rotator cuff tears: a large percentage of people with tears have no pain.11 In fact, recent research has found that tissue damage is not predictive of pain severity. Pain is such a poor indicator of the state of tissues that leading medical bodies such as the American College of Radiology12,13 and National Institute for Health and Care Excellence14 now recommend against early scans for people with back pain.
A Modern Understanding of Pain
Research in recent decades has revealed previously unrecognized factors besides tissue damage that influence pain.15 It is now understood that pain is not an unambiguous consequence of tissue damage, but is multifactorial and multidimensional. Biological, psychological and social factors interact with lived experience to create a unique pain experience for every individual and every incident.16 While information from the body is of course important, the brain uses all the information it has available to determine whether the person or body part is in danger and in need of protection.
Pain as Protection
Many researchers concur that pain can be better understood when viewed as one of the body’s protective systems.17,18 Pain promotes a variety of protective behaviors to address threats to bodily integrity and increase chance of survival, like withdrawing of a limb, guarding, resting and seeking help. Protective responses include varying degrees of sensitisation, motor changes, and psychosocial behavior, which themselves influence the experience of pain. The evolutionary advantage of pain is lost, however, when pain endures for long periods of time. When this happens, there is much more at play than tissue damage, and the relationship between tissue damage and pain becomes more tenuous.18
Sensitization refers to a reduced pain threshold or a magnified response to stimuli and heightened perception of pain. Sensitization adds extra protection by changing the way signals are processed in the nervous system. For example, a sunburn increases the sensitivity of the nervous system such that a light brushing of the skin or a shower can be painful despite lack of harm. The heightened sensitivity contributes to preventing future potentially damaging behavior. While the increased tenderness from a sunburn resolves in a matter of days, sustained changes throughout the nervous system can occur and become an important contributor to persistent pain.
Sensitivity can become problematic when it becomes overly protective,19 as in the case of osteoarthritis or chronic back pain. In chronic pain conditions in particular, increased sensitivity can act to perpetuate pain independent of the state of the tissues. Osteoarthritis is an example of a condition in which a sensitized nervous system contributes to joint pain. Evidence for this sensitization includes greater sensitivity to pain in areas remote from the painful joint as well as the weak correlation between structural damage and pain.20-22 Sensitization may also contribute to other pain conditions such as back pain, temporomandibular joint disorder, headaches, and phantom limb pain even without corresponding damage in the tissues.23,24
Sensitization is a type of plasticity, i.e., prolonged change to the nervous system. Other forms of plasticity include a wide range of sensorimotor disruptions associated with chronic pain, such as changes in the brain’s representations of body parts and other widespread changes in the brain.25 Changes occur, for example, in relation to heightened attention,26 inhibition,27 and body schema.28 While much remains to be learned about the relationship between brain changes and pain, there is now some evidence that sensorimotor disruptions actually maintain or even contribute to chronic pain.29 There is also some evidence that pain related plasticity can be reversed. For example, cognitive behavioral therapy for chronic pain30,31 and osteoarthritic hip replacement surgery32 have both been shown to reverse brain changes. Moreover, these changes were correlated with improvement in people’s pain. This supports the idea that plasticity plays a role in perpetuating pain.
It is also clear that pain is associated with substantial and diverse changes in the distribution of postural muscle activity and movement coordination.33,34 One such tendency is an overactivation of superficial muscles with concurrent deactivation of deeper muscles in people with chronic neck35,36 and back pain.37 However, in general, the relationship between pain and motor control has been tricky to study because of the highly individual nature of motor changes to pain.34,37
There is substantial evidence that psychological and social factors are closely linked to pain.38,39 For example, PTSD and significant adverse experiences in childhood tend to increase pain sensitivity and the risk of developing chronic pain.40 Distress, fear, expectations, and beliefs about back pain strongly influence pain intensity and the likelihood of developing disabling back pain.7 In fact, emotions influence processing of noxious stimuli (such as injury or temperature extremes), reflex withdrawal from a noxious stimulus, and pain perception.41 Also, the contextual factors around an injury such as a hostile work environment, poor sleep, or concurrent health issues may heighten a sense of threat and increase sensitivity to pain.42,43 Contextual factors surrounding a treatment, including practitioners’ negative beliefs, can induce a nocebo effect (i.e. physiological changes brought about by expectations of negative outcomes).44 The social context within which an injury occurs and sociodemographic factors such as education level and minority status have also been shown to influence pain and the transition to chronic pain.45,46 Even other people’s responses to the pain can influence it.47 Often, these threatening contextual factors are broad and outside of conscious awareness. Essentially, anything that can influence the brain’s evaluation of threat can influence pain.25
Overwhelming evidence of nervous system changes and psychosocial influences on pain, as well a reconceptualization of pain as protective rather than indicative of damage, has led to a shift in the understanding of pain. This new understanding has resulted in novel treatment strategies to address pain and related disability. These new interventions for pain seem more aligned with the AT than previous biomedical approaches and are showing positive results.
One such intervention is “cognitive functional therapy” for chronic disabling low back pain, which consists of first identifying the many factors contributing to each individual’s pain and disability, including movement patterns, posture, cognition, emotion, behavior, social and lifestyle related aspects.48 Identification of individual factors is followed by tailored education about pain. Finally, individuals learn relaxation techniques and active strategies for gradually changing thoughts, posture, movement, and lifestyle habits. This approach is designed to engage the individual actively in management and recovery rather than promoting a passive attitude toward treatment, as is typical of a biomedical approach. A recent large trial showed that cognitive functional therapy led to strikingly large and sustained reductions in pain and disability, in contrast with older, more conventional interventions for chronic musculoskeletal pain, which typically show short-term, but not long-term, reductions in pain. These results are similar to those found by the single large study on AT for chronic back pain,1 which also found a substantial sustained reduction in pain and disability.
Another recent intervention involves graded sensorimotor retraining that addresses the altered pain processing that disrupts sensorimotor ability.49 This psychophysical intervention was designed to alter how people think about their body in pain, how they process sensory information, and how they move. After learning about pain, participants engaged in various activities involving proprioception and active movement. These included tactile acuity tasks, observing and mentally rehearsing different body configurations, with a gradual progression to physical movement intended to reestablish non-protective patterns of neural activity and movement.17 A recent large trial found that graded sensorimotor training led to modest and sustained improvements in low back pain.49
As a result of the new understanding of how closely linked psychological experience is to pain, the mind is now considered a central tool to address pain. This is in stark contrast to the biomedical model and to simple stretching and strengthening based approaches. It also paves the way for interventions that incorporate a mental component, like the Alexander Technique.
How Might Alexander Technique Reduce Pain?
Advances in pain science may shed light on how the AT acts to reduce pain. AT mechanisms may overlap with newer interventions that are supported by modern pain science. In addition, there may also be unique mechanisms specific to the AT that reduce pain. A description of things that occur in an AT lesson can be illustrative of these mechanisms.
The AT is taught by a highly trained teacher. This in itself creates expectations of improvement, which can improve pain outcomes.50,51 It is taught in an individualized manner with importance placed on an empathetic, caring relationship between teacher and student. This kind of individualized care has been shown to be important when addressing persistent pain,52,53 and a therapeutic relationship characterized by empathy and positive communication enhances outcomes.54,55 While approach and content vary widely, a teacher generally provides education on the principles of AT, including awareness of habitual physical and mental patterns, whole-body organization, and the psychomotor processes involved in changing these. Education in and of itself can be therapeutic,56 particularly when combined with movement.57
One of the central features of this individualized interaction is the specific use of touch by the teacher. Touch in and of itself has many non-specific effects that are beneficial for pain. For example, it can suppress pain-related sensory input58 while promoting reorganization of body representations in the brain,59 feelings of safety and relaxation, and a positive therapeutic relationship.60,61 Touch in the AT lesson is used both to sense and to invite change in the postural state of the student. For example, AT touch also draws attention to a region, thereby providing feedback that promotes changes in tension. A teacher might touch a student’s neck and back, helping to redistribute postural tone in a way that encourages lengthening of the student’s spine. A teacher might also gently move a student’s head to promote an adaptive state of tone.
Such changes in postural state are likely to include changes in the excitability of neural circuits that regulate tone.62,63 These circuits have been hypothesized to underlie pain-related motor disruption.33 This may have various specific effects including: 1) changing the loading on painful regions; 2) normalizing sensorimotor function; and 3) reducing protection from pain.33
A teacher will also use verbal and other means to engage the student’s mind in relation to their body and space. The concept of mind-body unity behind this guidance is similar to the unified person perspective advocated by leading pain researchers.64 The teacher may ask the student to notice specific parts of their body, for example their neck or feet, without judgement or attempt to change. This kind of accepting attitude has been shown to be associated with movement improvements and other pain-related outcomes.65-67 The teacher may then cue the student to embody certain qualities of fluidity, support, freedom of a joint, or the relationship between body segments, such as the length and width of their back. Such embodied cues are referred to by practitioners as “directing.” There is evidence that promoting embodiment of particular physical characteristics is beneficial for pain.68,69 A related possibility is that AT directing may engage and normalize body schema.70 For example, a cue such as “let the back lengthen and widen” may encourage a student to reimagine the configuration of the back, promoting changes in muscle tone and overall postural state. The student is specifically asked to “think” the cue and not to “do” it, consistent with the idea that AT promotes remapping rather than repositioning. This may be similar to interventions involving tactile acuity training and mental judgements of observed body positions, which are also thought to address body schema. Such tasks could act to re-engage and recruit disengaged body regions that have “dropped out” with the presence of pain.25 The AT may also affect body schema in ways that are not well understood.
Procedures and Activities
Lessons often involve activities or procedures, some more “mental” and others more “physical.” These can be viewed as experiments to observe how the student’s mental and physical changes affect the activity. For instance, it is common for a teacher to guide a student from sitting to standing, a non-trivial task for people with chronic pain. This is often performed in a slow way that highlights the difficult-to-prevent tendency to use momentum and “lurch” forward at seatoff. The AT has been found to reduce this lurch,71 and performing this task slowly allows the student to get feedback about the smoothness of this transition. The specific way that this and other AT procedures are performed may also be instrumental to the way that AT affects pain. For instance, it has been hypothesized that the smoothness of the sit-to-stand transition relates to stiffness and the adaptability of postural tone,70 which may thus influence pain through changed excitability and tissue loading.72 These changes in postural tone and stiffness observed following AT lessons could also account for reported reductions in knee and neck pain,4,5 perhaps via changes in excitability. In particular, the lower stiffness and higher adaptivity of muscle tone from the AT63 could act to decrease prolonged static or inappropriate tissue loading.72
This way of performing a functional task while thinking about the movement integrates multiple senses, and thus may improve sensorimotor disruptions, proprioception and spatial acuity–all relevant to pain.17,25 The activity also provides the student with the opportunity to reappraise the degree of effort required.
Self Efficacy, Overcoming Fear Avoidance, and other Psychological Factors
Development of certain cognitive skills73,74 can reduce fear and anxiety75,76 and contribute to a greater sense of control over pain, all of which are strongly correlated with pain.77 The student learns not to fear the movement, and disconfirmation of the expectation of pain or injury enhances learning that leads to long-term pain reduction.78 A large, randomized, controlled trial on the AT for back pain (ATEAM) found significant reductions in disability and fear avoidance.1 Improved movement performance also leads to an increased sense of self-efficacy (the belief in one’s ability to engage in activities despite pain). Self-efficacy is strongly correlated with pain reduction and reduced risk of disability due to pain.79 Studies on the AT for neck pain found that increased self-efficacy after AT lessons was linked to reduced neck pain.4,80 Other studies of the AT have found that it increases psychological well-being, optimism and confidence, as well as empowerment and self-care skills.76,81 All of these psychological factors are known to positively influence pain.
Attention and Reactivity
There may be other ways in which the AT reduces pain related to attention and reactivity. For example, AT teachers often instruct a student to attend more broadly than to the site of their pain. Aside from distraction, this manner of intentionally redirecting attention and expanding awareness is relevant to pain processing.82 Movement coaching methods that direct attention toward non-provocative aspects of motion by prioritizing other senses have been shown to reduce pain.83 Brain imaging shows that diverting attention to cognitive tasks unrelated to pain activates pain inhibitory systems.82 In general, mindful awareness is associated with lower pain and reactivity.84,85 Finally, the AT could reduce heightened pain sensitivity by decreasing one’s overall reactivity. There is some evidence that the AT improves executive inhibition,86 and this regulation of general reactivity may act to decrease pain sensitivity.87
While there is evidence that the AT reduces pain, the mechanisms by which this occurs are currently not well understood. However, advances in pain science may shed light on how the AT reduces pain. We have seen that there is little direct correlation between tissue damage and pain, and that pain is the action of a protective system that includes neural, biological, and psychological mechanisms. Chronic pain is closely intertwined with the plasticity of these systems. Modern interventions stemming from the new understandings around pain show increased efficacy for improving pain and function compared to older interventions based on a simple biomechanical model. Many of these new interventions share similarities with the AT and may have common mechanisms, such as learning, normalization of sensorimotor function, and improvement of psychological factors. The AT likely has other unique mechanisms that relate to its pedagogy. These may include sensorimotor changes related to normalizing muscle tone, neuronal excitability, and tissue loading, as well as alterations to body schema and reducing overall reactivity.
We are grateful to Rajal Cohen and Patrick Johnson for their helpful comments on this article.
- Little, P., Lewith, G., Webley, F., Evans, M., Beattie, A., Middleton, K., . . . Sharp, D. (2008). Randomised controlled trial of Alexander technique lessons, exercise, and massage (ATEAM) for chronic and recurrent back pain. BMJ, 337, a884. doi:10.1136/bmj.a884
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