Alexander Technique and pain

Mari Hodges, pain management therapist and Alexander Technique teacher, wrote recently that ‘many people living with persistent pain have felt unvalidated, unheard and stigmatized in their encounters with western medicine’. She continued:

the complexities of pain have long been misunderstood and ignored in western society, largely due to a division of mind and body that only recently western medicine is beginning to realize is artificial. Our health systems have developed based on this separation of physical and psychological.

Mari has co-authored with Dr Tim Cacciatore a comprehensive article entitled, ‘Modern Pain Science and Alexander Technique: How Might Alexander Technique Reduce Pain?’.

I want to bring this excellent in-depth work to a wider audience, and so this blog post is a summary of that article. It’s roughly half the length of the original (where the full list of research citations can also be found).

Introduction

Scientific studies show that the Alexander Technique (AT) helps with various kinds of pain, in particular long-term back and neck pain. But how? This article aims to answer this question in the light of pain science research. 

In recent years there has been a shift in the understanding of pain. The previous mainstream approach – known as the biomedical model –  assumed a direct link between tissue (physical) damage and pain. This view has been superseded by the biopsychosocial model which instead understands that biological, psychological and social factors interact with lived experience to create a unique pain experience for every individual and every incident.

The Biomedical Model

Though outdated as a model for understanding and addressing pain, the biomedical model is deeply ingrained and makes several assumptions as follows:

• pain indicates tissue damage, and so treatment should focus on an underlying physical cause;
• more pain means there must be more tissue damage;
• when there’s no evidence of tissue damage, pain is not ‘real’ but rather imagined or caused by psychological problems.

In contrast, there is now overwhelming evidence that:

• pain can occur without tissue damage (examples include persistent back pain, fibromyalgia and chronic regional pain syndrome);
• the degree of tissue damage does not predict the degree of pain (for example, people are often pain-free despite living with disc degeneration, disc hernias or rotator cuff tears);
• the brain is involved in the experience of pain.

A Modern Understanding of Pain: ‘Pain as Protection’

Many researchers agree that pain can be best understood as one of the body’s protective systems. While pain promotes a variety of protective behaviours (such as withdrawing a limb, resting or seeking help), protective responses themselves can influence the experience of pain.

These protective responses include sensitisation, motor (movement) changes and psychosocial behaviour.

Sensitization

Sensitization is characterized by magnified responses to stimuli and heightened perception of pain. A sensitized nervous system can perpetuate pain, even when there’s no (longer) evidence of tissue damage. For example, sunburn can increase sensitivity such that a light brushing of the skin causes pain despite lack of bodily harm. 

Evidence shows that sensitization can contribute to diverse conditions such as osteoarthritis, back pain, headaches and ‘phantom limb pain’ (following amputation).

Sensitization is a type of plasticity, i.e. a prolonged change to the nervous system. There is some evidence that plasticity itself can maintain or contribute to chronic pain; for example, in the case of changes that occur to attention, inhibitory neural mechanisms and the body schema (the brain’s map of body parts in space).

Motor (movement) disturbances

Pain is also associated with substantial changes to postural muscle activity and movement coordination. For example, in people with chronic neck and back pain there tends to be overactivation of superficial muscles and deactivation of deeper muscles.

Psychosocial factors

Psychological and social factors are closely linked to the experience of pain. For example, there is substantial evidence that:

• PTSD and adverse childhood experiences increase the risk of developing chronic pain;
• distress, fear, expectations, and beliefs about back pain strongly influence pain intensity;
• a hostile work environment, poor sleep, or concurrent health issues can increase sensitivity to pain;
• sociodemographic factors such as education level and minority status influence pain; 
• other people’s responses to pain can influence it.

In short, anything that influences the brain’s evaluation of threat can influence pain.

Novel interventions

Due to the link between psychological experience and pain, the mind is increasingly considered a central tool to address pain. Several approaches to pain now engage individuals’ thinking, in contrast to the passivity of the biomedical model and simple stretching or strength-based approaches.

One novel intervention called ‘cognitive functional therapy’ has led to striking reductions in low back pain. This approach begins by identifying the factors contributing to an individual’s pain (e.g. posture, cognition, emotion, behaviour and lifestyle) and then introduces a tailored education programme. It includes relaxation techniques and other active strategies for change.

Another intervention which has led to some success is ‘graded sensorimotor retraining’ which is designed to change how people think about their body in pain, how they process sensory information and how they move. After learning about pain, individuals engage in activities focusing on proprioception and active movement.

How Might Alexander Technique Reduce Pain?

The Alexander Technique bears similarities to novel interventions such as the above. Notwithstanding the specifics of AT, research would suggest that it is likely to improve pain outcomes by:

• being taught by a highly trained teacher;
• emphasizing an individualized, empathetic caring relationship;
• taking an educational approach combined with movement.

AT teachers educate students about their habitual physical and mental patterns, and the processes involved in changing these. The likely influence of specific aspects of AT on pain are explained below.

Touch

Touch in and of itself has effects which are beneficial for pain; for example, it can suppress pain-related sensory input while promoting reorganization of body representations in the brain, feelings of safety and relaxation, and a positive therapeutic relationship.

AT teachers use touch to sense and invite change in a student’s postural state. This provides sensory feedback which, for example, promotes changes in tension. Such changes in postural state are likely to include changes in the excitability of neural circuits that regulate postural muscle tone. This has been hypothesized to influence pain by: 

• changing the loading on painful regions; 
• normalizing sensorimotor function; 
• reducing protection from pain.

Body-Mind Engagement

AT teachers engage the student’s mind in relation to their body and space, and this is similar to the unified person perspective advocated by leading pain researchers. In particular,

• AT teachers may ask the student to notice specific parts of their body without judgment or attempt to change. This kind of accepting attitude has been shown to be associated with positive pain-related outcomes.
• AT teachers may cue the student to embody certain qualities of fluidity, support or freedom of a joint etc. There is evidence that promoting embodiment of particular physical characteristics is beneficial for pain.
• It is likely that AT teachers are helping the student to engage and normalize the body schema (the brain’s map of one’s body parts in space). This may be similar to interventions which re-engage body regions that have “dropped out” with the presence of pain.

Procedures and Activities

AT lessons often involve activities or procedures, and the way these are performed may be instrumental to the way AT affects pain. For example, AT has been found to reduce the ‘lurch’ forward from sitting to standing, and the smoothness of this movement may influence pain through changed excitability and tissue loading. 

Performing functional tasks while thinking about movement integrates multiple senses, and may improve sensorimotor disruptions, proprioception and spatial acuity which are all relevant to pain.

Self-Efficacy, Overcoming Fear Avoidance, and other Psychological Factors

Development of certain cognitive skills can reduce fear and anxiety and contribute to a greater sense of control over pain, all of which are strongly correlated with pain.

Firstly, an increase in self-efficacy (the belief in one’s ability to engage in activities) was found after AT lessons and was linked to reduced neck pain.

Secondly, significant reductions in fear avoidance were found as part of a large study of AT and back pain. Learning not to fear the movement, and disconfirmation of the expectation of pain or injury, have been shown to enhance learning that leads to long-term pain reduction.

Other studies of the AT have found that it increases psychological well-being, optimism and confidence, as well as empowerment and self-care skills. All of these psychological factors are known to positively influence pain.

Attention and Reactivity

AT often involves intentionally redirecting students’ attention and expanding their awareness beyond the site of their pain, and this is known to affect pain processing.

The AT may also be able to decrease overall reactivity, and this could reduce heightened pain sensitivity. There is some evidence that the AT improves executive inhibition, and this regulation of general reactivity may decrease pain sensitivity.

Conclusion

As discussed, it is now understood that there is not a direct relationship between tissue damage and pain (the biomechanical model) and that pain is instead the action of a protective system influenced by biological, psychological and social factors (the biopsychosocial model).

While there is evidence that the AT reduces pain, the mechanisms by which this occurs are currently not well understood. AT shares similarities with many newer interventions for pain, and may have common mechanisms such as:

• emphasis on learning;
• normalization of sensorimotor function;
• improvement of psychological factors.

Moreover, AT is also likely to have other unique mechanisms that affect pain including:

• sensorimotor changes related to normalizing muscle tone, neuronal excitability, and tissue loading;
• alterations to body schema.
• reductions in overall reactivity.