Posts in Alexander & Science
New Study: Alexander Technique Lessons Reduce Knee Pain and Co-Contraction in Subjects with Knee Osteoarthritis

A new study on the Alexander Technique and knee pain was published last month in the journal BMC Musculoskeletal Disorders. 21 subjects with knee osteoarthritis were each given 20 Alexander Technique (AT) lessons. After their lessons, they not only reported a 50% reduction in pain, but showed significantly less co-contraction in their leg muscles during walking. The entire study is available online to read here.

When I first read the study, I was struck by its size. 21 subjects (the study also used 20 healthy individuals as a control) didn’t seem to be that many. I’ve grown used to reading the larger randomized control trials, like the ATEAM back pain study published in the British Journal of Medicine in 2008. The ATEAM study involved 579 subjects. My assumption was that the larger the study, the more robust the findings. What could a study of 21 people really tell us?

The design of a study, however, depends on its purpose. The ATEAM back pain study—or last year’s ATLAS Annals of Internal Medicine study of whether AT or acupuncture are effective in treating chronic neck pain—is an example of a clinical trial, and such trials need to be large for a number of reasons. Subjects are divided into multiple groups. For example, the ATEAM back pain study randomly assigned subjects to groups that took 6 AT lessons, 24 AT lessons, 6 massages, or a control. Such large trials also deal with conditions that tend to have nebulous causes. The idiopathic back pain diagnosis studied in the ATEAM trial is just the technical way of saying, “your back hurts and we don’t know why.” The measurements in clinical trials—like self-report—are often subjective, and the clinical effects of an intervention are usually small. So a clinical trial needs to be large to show statistical significance.

Such large studies, though, can shift clinical practice—what doctors’ prescribe when they’ve diagnosed a patient with idiopathic back pain or chronic neck pain. As such, they also tend to generate headlines in the popular press. Last year’s ATLAS neck pain study was reported on by Time, NPR, Fox News Health, and Harvard Health, among others.

The current study of subjects with knee osteoarthritis is not a clinical randomized control trial. It is basic research, in a laboratory environment that is more controlled than usually possible in large clinical trials. It also uses more concrete measurement. As such, it can establish robust findings with many fewer subjects. And the purpose of such basic research is not only to establish whether the Alexander Technique might be an effective way to treat knee pain, but why. It’s an exciting window into researchers at work. Let’s unpack the study.

Why do we hurt?

Chronic pain is a surprisingly mysterious thing.

Take knee osteoarthritis. Knee osteoarthritis is a condition where the cartilage that cushions the bones of the knee joint starts the wear down. In this study, the 21 participants all had received an x-ray diagnosis of knee osteoarthritis. An x-ray doesn’t show cartilage: but it will show that the space between bones has narrowed, indicating osteoarthritis. Blood work can further confirm that the condition isn’t systematic (as in rheumatoid arthritis).

It sounds obvious, but if you have knee osteoarthritis, your knees usually hurt. But why? It has long been assumed that the pain that accompanies knee osteoarthritis is the result of the breakdown of cartilage in the joint. Less cushioning equals more pain. But researchers have been unable to show a relationship between the severity of pain and the degree of cartilage loss. Some people with minor cartilage loss in the joint suffer a great deal of pain. Others with major cartilage loss experience little discomfort—they may not even know they have the condition. The same is true in some forms of chronic back pain: there are individuals with significant damage to their vertebrae or intervertebral discs, yet experience little pain, and vice versa.

This new study explores two possible explanations for the pain that accompanies knee osteoarthritis.

1. Is pain a self-fulfilling prophecy?

One possibility is that the patients with knee osteoarthritis become more sensitive to pain. You might call this the “self-fulfilling prophecy” explanation of pain. The idea is that people with chronic pain begin to anticipate that pain, and therefore experience more pain. Previous research has found that Cognitive Behavioral Therapy or mindfulness meditation can reduce a heightened sensitivity to pain in subjects with osteoarthritis or fibromyalgia.

While the subjects in this new study reported a significant reduction in pain after their Alexander Technique lessons, the researchers didn’t find evidence that their Alexander Technique lessons had reduced their sensitivity to pain. The research didn’t disprove the idea that subjects with osteoarthritis might have a heightened sensitivity to pain, just that the benefits of AT didn’t seem to function along those lines. (The authors caution that the study might be too small to know for sure.)

2. Is pain the result of how you move?

The other possible explanation for knee pain that this study explores is that the patients with knee osteoarthritis use excessive co-contraction of their leg muscles during walking and other everyday activities. To understand co-contraction, it helps to know a bit about how muscles work.

Muscles often work in pairs. The muscle that’s doing the work is called the agonist. The muscle that is allowing the work is called the antagonist. Take a simple action like the biceps curl. When your biceps works to close the elbow joint, its antagonist, the triceps, releases. When the triceps works to open the arm at the elbow, the biceps releases. The biceps and triceps are an antagonistic pair.

Your hamstrings and quads muscles in your legs are an antagonistic pair as well. Check out this animation of the muscles that are active during walking. While walking is a much more complicated movement than a biceps curl (this animation also includes the iliopsoas, the glutes, and muscles of the lower leg called the tibialis anterior and calf) you can see the quads and hamstrings taking turns during the gait cycle. If you find the action of the muscles hard to follow, watch the bars of activity on either side of the walking figure.

[This animation was done for Aberystwyth University in Wales. It is not associated with the AT and Knee Osteoarthritis study that is the subject of this blog post.]

Co-contraction is when muscles that are usually antagonistic activate simultaneously. In everyday activity, co-contraction functions to brace a joint and isn’t necessarily unhealthy. But previous research has found that individuals with knee osteoarthritis often use excessive co-contraction in their leg muscles during walking and other everyday activities. In this study, the subjects with knee osteoarthritis showed significantly higher levels of co-contraction in their leg muscles than the healthy control group as measured by EMG at the start of the study.

After Alexander

In the study, the 21 participants with knee osteoarthritis had 20 Alexander Technique lessons. The lessons were spaced out over 12 weeks: they had lessons twice a week for 8 weeks and then once a week for the final four weeks.

After their Alexander lessons, the participants showed a dramatic reduction in pain: 56% less pain than at the start of the study. 15 of the study participants regularly took pain killers (analgesia) at the start of the study. 10 stopped taking medication after their Alexander lessons ended. 11 of the participants also reported experiencing less pain in other areas, including neck, shoulder and back.

The subjects also exhibited significantly less co-contraction during walking than at the start of the study. Interestingly enough, the patients did not show an increase in strength over the course of the study—the measurements of leg strength were the same before and after their Alexander lessons.

None of the subjects used any other therapy during their Alexander Technique study. When the researchers followed up 15 months after the start of the study, the subjects had retained the reductions in pain, reporting 51% less pain than before their Alexander lessons.

Evidence & Measurement

We are living in an increasingly “evidence-based” world. Evidence depends on valid and reliable measurement. Alexander teachers have learned that their experience and the experience of their students isn’t considered very robust evidence for scientists studying health and movement. However compelling the anecdote—of pain diminished, increased ease, health restored—saying, “I saw it happen” or “It happened to me,” doesn’t really count.

Most studies of the effectiveness of a particular health intervention use some kind of self-report. For the current study, the subjects filled out the WOMAC questionnaire—a common tool used to evaluate knee and hip pain, stiffness and functioning—before and after their Alexander lessons. It’s on the basis of that self-report that we can say that pain was reduced 56% by Alexander Technique lessons. This kind of self-report is quite a bit more reliable than anecdotal data, but researchers are always looking for other sources to corroborate self-report. Bias too easily creeps in.

The advantage of basic research is the chance to experiment with different types of measurement. With only 21 subjects, the researchers can hook them up to EEG to try to measure the anticipation of pain. They can measure muscle activity with EMG and put the subjects on a force platform to assess joint loading. This kind of laboratory research is much more time intensive and expensive than having someone fill out a questionnaire.

The results of the study suggest that this kind of EMG measurement is worth it in studying the effects of AT on knee pain and osteoarthritis. The researchers found that the self-reported reduction in pain was correlated with a measurable change in the subjects movement coordination—a physiological change in the activity of their musculature. It points in a promising direction, both for scientists who study human motor control and the causes of musculoskeletal pain, as well as doctors who treat knee osteoarthritis. And it might even inspire one of those large randomized control trials to see if the findings hold up in the messy world of clinical medicine.

Many thanks to Tim Cacciatore, one of the authors of the current study, for his feedback on an earlier draft of this post.

 

New Study: Alexander Technique Lessons Alleviate Chronic Neck Pain

A new study published in the Annals of Internal Medicine shows a significant reduction in chronic neck pain after lessons in the Alexander Technique.

517 patient with chronic neck pain were assigned to one of three groups. The control group received the usual care: physical therapy and prescription drugs. A second group was assigned 20 one-on-one, 30-minute Alexander Technique lessons (600 minutes total) with a certified teacher. The third group was assigned to 12 acupuncture sessions (also 600 minutes total).  On average, patients made it to 14 of their 20 Alexander lessons and 10 of their 12 acupuncture sessions. 

Patients taking Alexander Technique lessons and those receiving acupuncture both experienced more than a 30% reduction in their chronic neck pain. A 25% reduction in pain is considered clinically significant. As Time points out in their coverage of the study, physical therapy and exercise lead to only about a 9% reduction in pain.

The most important result from the study is that the benefits of Alexander lessons persisted after lessons had ended. Patients completed their Alexander lessons in about 4 to 5 months after the start of the study. A year after the beginning of the study the patients were still experiencing a reduction in pain. 

Stuart McClean at the University of the West of England in Bristol discussed the study with Reuters Health and suggested that the Alexander Technique helps “patients change past behaviors and habits and lead towards improved coping strategies and self-care.”

The lead author of the study, Hugh McPherson, explained that the results of the study were too robust to be the result of the placebo effect. And none of the participants in either Alexander Technique lessons or acupuncture sessions experienced adverse effects of any kind. “No other single treatment is known to provide long-term benefits,” Hugh McPherson told Reuters.

These kind of large, randomized studies of the Alexander Technique are rare. This is the first study of its kind to be published since the ATEAM study of back pain published in the British Medical Journal in 2008. That study found that back pain sufferers experienced significant relief from as few as 6 Alexander Technique lessons.

Such studies are confirming what Alexander Technique teachers have been teaching for 100 years: learning to improve your posture and movement habits can have a significant impact on your health.

See also: "Lighten Up" or "Pull Up"? A New Study about the Alexander Technique and Parkinson's Disease. And: That's Right: Nothing is the Solution to "Text Neck"

"Lighten Up" or "Pull Up?"; A new study about the Alexander Technique and Parkinson's Disease.

Word came last week about a new study published in the journal Neurorehabilitation and Neural Repair about the Alexander Technique and patients with Parkinson’s Disease.

Parkinson’s Disease is a progressive neurological condition affecting movement. Progressive in this sense means that symptoms worsens over time. The condition often begins with slight tremors and reduced facial expressions and may eventually lead to a stiffening and slowing of all movement. Parkinson’s is largely treated with medication, though Parkinson’s patients and their doctors often explore methods that can improve a patient’s quality of life while coping with the disease.

The Alexander Technique and Parkinson’s has been studied before. In 2002, a randomized control trial published in Clinical Rehabilitation assigned 98 Parkinson’s patients either to 24 individual Alexander Technique lessons, 24 individual massage sessions, or no intervention beyond their normal drug treatment. The study showed that Alexander lessons significantly increased the ability of patients to carry out everyday activities (there was no significant change in the massage group). The benefits remained when patients followed up 6 months after their lessons ended. The Parkinson’s patients who took Alexander Technique lessons also had less change in their Parkinson’s medication than either of the other groups (this is notable since medication dose usually increases with time as the disease worsens). The patients themselves reported improvements in balance, posture, walking, and increased coping with the disease and reduced stress.

One of the challenges in a randomized control trial like the 2002 study is to explain why a particular intervention is effective. In the 2002 study, massage was used to control for the effects of touch. Though massage and the Alexander Technique use touch quite differently, they use an equivalent amount of touch in a session. Since the Alexander Technique had a beneficial effect but massage did not, the researchers could conclude that touch alone wasn’t enough to benefit the Parkinson’s patients. The patients who took Alexander Technique lessons clearly learned something, but what?

Enter the most recent study: “Lighten Up: Specific Postural Instructions Affect Axial Rigidity and Step Initiation in Patients with Parkinson’s Disease,” by lead author, Dr Rajal Cohen. (You can read it in full here)

This was a smaller study and deceptively simple: 20 patients with mild to moderate Parkinson’s Disease practiced two contrasting postural instructions for all of ten minutes each. One set of instructions, called “Pull Up,” was based on effortful conceptions of posture. The other set of instructions, “Lighten Up,” were based on the Alexander Technique of releasing into length.

The research team then measured axial rigidity (increased axial rigidity interferes with movement), postural sway (sway can increase the risk of falling in Parkinson’s patients), and the smoothness and efficiency of initiating movement.

The study is fascinating to anyone who is interested in movement and posture because it shows that how we think about posture can make a measurable difference in the quality of our posture and movement.

During the study, the Parkinson’s patients read contrasting explanations for the two separate set of instructions. The “Pull Up” instructions were based on familiar conceptions of posture:

Parkinson’s makes you weaker, so it is important to activate your core muscles to pull yourself up to your full height. For the next few minutes I would like you to focus on feeling your neck and trunk muscles work strongly to pull you up.

The patients then practiced these specific “Pull Up” instructions (which might be familiar to anyone who has worked with either a personal trainer or a drill sergeant):

Use your core muscles to pull yourself up to your fullest height; engage the muscles in your abdomen and lower back; feel your neck and trunk muscles working to pull you up; pull your stomach in, your head and chest up, and your shoulders back.

“Lighten Up” instructions were based on the Alexander Technique. The researchers had the subjects read this explanation:

Whatever our condition, we make matters worse by pulling ourselves down, and especially by tightening the neck and pulling the head down. For the next few minutes I would like you to focus on allowing an upward direction.

Then the patients practiced the following instruction:

Notice that you are pulling yourself down and give yourself permission to stop doing it; let your head balance easily at the top of your spine; allow your spine to be uncompressed and your torso to open effortlessly; let your shoulders and chest be open and light.

As a control, the researchers had the patients practice a “relaxed” condition:

Imagine that it is the end of a long day and you feel tired and lazy; allow your head to feel heavy and sink slightly forward and down; relax your shoulders and allow them to hang heavily.

The researchers varied the order in which the patients practiced “Pull Up,” “Lighten Up,” and “Relaxed,” to control for possible carryover effects from the different instructions. What did they find? When patients practiced “Lighten Up,” they showed less axial rigidity, less postural sway, and increased smoothness of initiating movement than when they practiced “Pull Up” or “Relaxed.”

There are a couple of surprising things about these results. The authors note that since Parkinson’s Disease has such a detrimental effect on motor control, they did not expect the patients to show a measurable difference when practicing something so subtle as differing postural intentions. Most remarkable to me is that such brief instructions, given without the hands-on guidance found in a traditional Alexander lesson, would have a beneficial result. The study gives some inkling of why a course of lessons—like the 24 lessons in the 2002 study of Parkinson’s patients—might be so positive.

One of the things that excites me about this study is the way in which it clearly articulates the difference between how Alexander Technique teachers approach posture—lightening up to make things easier—versus more familiar approaches to posture—pulling up to make you stronger. We Alexander teachers often feel like we are in danger of getting swept away in the great wave of “core conditioning,” struggling to prove the benefits of a gentler approach to movement than “power through” and “no pain no gain.” If this study can help convince people that lightening into length has proven benefits, it might help not only Parkinson’s patients, but anyone who wants to move more easily and effectively.