The relevance of AT to rehabilitation following spinal injury: Technical, practical and ethical considerations of the teacher

I spent most of 2005 recovering from a severe spinal injury.  The experience raised several issues for me around how the Alexander Technique teacher can positively or negatively affect their student.

In December 2004, I was mountain biking. I crashed and severely twisting my body.  The bruising and bleeding was quite impressive, but I’d always bounced back from such injuries before!  As a result of the muscular and fibrous damage, bruising and surface wounds, I was forced to move in a different way in the following weeks. I was in discomfort, limping and having trouble breathing properly. 

My compromised pattern of use increased strain, in particular, on the intervertebral disc between L5 and S1, which was already damaged from the impact. (It has also been suggested to me that other prior injuries and a habitual pattern of use may have influenced a predisposition to weakness in this area.)  The annulus fibres were torn, the nucleus extruded and a fragment (about 2cm) broke off, lodging itself in the nerve root canal and severely compressing the nerve.  I had complete foot drop, could barely move my right leg, or take any weight in it and was in acute, constant pain by the first week on February 2005. 

I was taking 8 panadine forte a day - about equivalent to 32 Panadol.  A neurosurgeon classified me as: “in need of urgent surgery” and said there was “no chance of improvement without surgical intervention”.  I got a second opinion from someone who agreed the improvement I had over 10 days was significant enough to not undergo surgery.  His suggested the extruded disc fragment would tend to dehydrate and eventually decompress the nerve because it was cut off from receiving nutrient.  I continued directing my own rehabilitation using AT and Cranio Sacral osteopathy.  (I also tried Physio Therapy, Hydro Therapy, Pilates, Chinese Medicine and Acupuncture, but didn’t find these effective enough to pursue.)  

I have been training as an AT teacher and attended 3 to 4 days a week at my school receiving work from a diverse range of local and visiting teachers as well as trainees.  In addition, I took weekly private sessions (with the teacher whom I’ve referred to in this essay as “my teacher”) and some occasional extra sessions.  This is the experience of AT teaching I relate to in the text that follows.

Working with pain – the use of talking in an AT lesson

Without any verbal input from the teacher, it is very easy for the student to be preoccupied with their pain.  It may be the actual pain, the fear of pain, a search for the pain, or a search for a way out of discomfort.  The attention draws inwards and excludes the external environment, indeed, may exclude everything except the painful area.   Signs of this are the glazed eye look, blank expression or look of intense concentration and pulling down towards the injury.  

The teacher can engage the student in more constructive thinking.  The physical input of their hands can be enhanced by corresponding verbal directions, or descriptions, making the experience truly psychophysical.  Talking about what’s going on in the moment gives the student confidence you know what is going on, that you are listening to them (aurally and with your hands). It gives opportunity for the student to feed back to the teacher and clarifies his own subjective experience.  The student can support what the teacher is doing with his thinking and learns to be clearer about using constructive thinking himself.

Some examples of useful verbal instruction include; talking about what is releasing (generally or specifically), why it is, how this relates to other parts, what patterns exist, how certain patterns came to be, clarifying anatomical accuracy, what thinking interferes with the healing process and what is the more constructive thinking.  I have found this more useful than attempts to draw the focus away from pain by distraction (talking about the weather, or the weekend, for example).  Simplicity and clarity of instruction are of the essence when dealing with pain.

(16/6) My teacher was talking about the arms and shoulders feeding back in, rather than directing width and expansion.  She was saying how the injury has upset the torso and created a condition which wasn’t there before:  the ribs not moving freely, the arms dragging the shoulders along and getting stuck in the upper back, the upper back disintegrating itself from the lower back.  She described it as a symptom of the upper back trying to cope with having no support from below.  Much of what we discuss isn't new, but it verifies my own experience.  Makes it more tangible and therefore easier to work with.

There is, however, some relevant talk about things not happening “in the moment”.  The teacher and student need to discuss what has transpired during the week in regard to the injury, to give the teacher an idea of progress and what particular issues are relevant to today’s session. We need to know what thinking from the previous session has been productive for that week and what issues arise from dealing with the injury in daily life.  Forming a plan for the week, or talking about how the student will manage; this is productive talk which will help take the work beyond the teaching studio.

Consistency.    

Regular lessons with one teacher make the technique even more valuable.  The teacher follows progress thru, knows history and is able to deal with what has come up each week in perspective.  My experience has been that without regular contact, it can take all lesson for the teacher to begin to understand what I am capable of. A regular teacher can also point out landmarks as the student progress – which the student won’t necessarily notice himself, and other people won’t realise the significance of. The speed of change in rehabilitation is so slow that a progression of movement will be most useful when spread over a series of lessons.

The building over time of a working relationship between teacher and student enhances the effect of the work.  The student can gain so much more from a session if he has complete trust in the teacher’s understanding of the injury.  An anatomical understanding may help but a practical understanding of the psychophysical effects on the student’s use is more important.

(6/05)  I can question my teacher about what she is doing.  She will stop straight away if I ask, and I know she will not be offended.  When we talk about what is going on, she listens to my input, so it becomes a discussion.  That way I feel I am being respected and treated very much personally.  She talks in a language that is very clear to me.  It always is consistent with her hand’s input.

Assumptions

One of the most frustrating things I had to deal with was people (including some teachers) making assumptions about what I was, or was not able to do within the restrictions of the injury.  Alongside listening in the moment, the regular contact with my teacher meant that she became familiar with the boundaries of pain or range of movement.   There needs to be a degree of patience on behalf of the teacher – not to anticipate what the pian needs, but to wait for the need to be revealed from the student.

In addition to the practical application this knowledge lends to “hands on” teaching, my teacher recognised the more psychological impact of being asked to do something the injury doesn’t allow, or assuming you are incapable of doing things the injury does allow.  Because so many people don’t understand what these limits are, or how to relate to someone restricted by injury, a kind social breakdown develops (in the student’s life, not in the lesson). The environment for normal social interaction is also not conducive to people with spinal injury.  It is advantageous for the teacher to be aware of this, to remember the student is an individual who has a life, and is currently in a particularly vulnerable condition.

Everything is amplified in the student with intense pain: they become hypersensitive so the quality of input is very important.  Non-doing hands are essential to allow the student to release in whatever pattern the body suggests.  Such is the nature of AT.  The teacher works with constructive thinking, on all levels, as the need arises within the student - not as is expected by the teacher.   The student and teacher are in a process of continual learning and change.  With each lesson is an increasing potential for subtle refinement of direction and use.

(26/8) Talking about the condition and how I’m handling it is essential for me.  I get much clarity in my thinking from being able to talk with someone who has a thorough knowledge of what’s going on physiologically as well as in an Alexander framework and someone who sees me regularly.  That’s why I look to my teacher for advice on every aspect of the injury - coping with the depression, work situation, study and social situation as well as recovery and various treatments.

The more emotional or psychological effects of having someone listen, non-judgmentally, when you are in pain, are well documented.  When the teacher listens without judgment, I find my pain is validated, and I feel the teacher better understands what I am experiencing.  Their hands reflect how well they have listened, and assessed the conditions of use present.  

Discussion and Experiment

Some practitioners I saw gave me their diagnosis without ever really “hearing” my subjective viewpoint.  Their diagnosis was then incomplete as it neglected the aspect of what beliefs or thinking I was using regarding the rehab.  This made it hard for me to trust their perspective. The more helpful sessions were when the diagnosis and prognosis were a discussion between practitioner and me.

These discussions seemed most productive when there was space for me to reflect back if my experience supported the diagnosis.  Options for the prognosis made a huge difference, as I then had choices.  I don’t believe there is much value in using “absolute” language in this situation.  My reaction was to reject advice, or AT work that didn’t allow for negotiation or other possibilities.

(7/05)  My teacher calls it her “experimental“ method, “if it works do it, if it doesn't work, chuck it.”  Thus she’s able to stay with the means whereby, because she’s not attached to one method - if it doesn't work, she’ll just try something else. There are no assumptions, she openly admits she doesn’t know what will work, but has a knack of coming up with useful ideas of things to try, which usually work out anyway.

Approaching emotional issues relating to the injury: 

Constructively counselling or advising a pupil and the appropriateness of the AT teacher’s role in this.

Whether teachers like it or not, student will look to them for guidance in many spheres.  They recognise AT teachers as people who have devoted a lot of time to their health and well-being and may transfer this into viewing them as experts in all things medical.  When they realise AT can affect every aspect of our lives, they might view the AT teacher as a role model for many things beyond use.  So pupils may directly ask for advice, or indirectly want the teacher to give them guidance as to what to do about their problems.  

Much of what they ask for, teachers are not qualified to give opinions on, however they can offer a unique perspective as the AT teacher will be the only practitioner any patient is likely to see who will factor use, misuse, primary control, end-gaining, the effect of thinking and faulty sensory perception into a diagnosis or prognosis.  Ideally the student will come to viewing their injury as psychophysical change through their own study, but pain, trauma and fear can challenge their clear thinking.

(24/7/05) Injury affects conditions and manner of use.  Causes different thinking - requires different thinking.

It behoves the AT teacher to acknowledge when they know that treatment other than AT will benefit the student.  In my case, taking painkillers was an essential part of dealing with the injury.  The snowballing of pain itself was escalating the problem and whilst directing was useful for pain relief, it wasn’t sustainable enough to be effective.  I found that by identifying what caused what part of the injury package gave me a deeper understanding of how to constructively approach it.  Some symptoms were use related; others the results of things like sleep deprivation or drug usage.  The AT teacher can identify these more effectively because they view the student as a psych-physical entity.  In addition, the AT teacher may be the only practitioner who can integrate the effect on the students use that arise from emotional stresses resulting from trauma.

(26/8/05) Part of the healing comes from being able to talk to someone about stuff which comes up (emotionally and psycho-phys.

Anyone facing trauma is likely to be getting conflicting advice from numerous people.  The recommendations I felt most comfortable receiving, were those that were obligation free - backed by support unconditional to following the person’s advice.

(7/05)  My teacher offers advice when I ask for it.  She does this with conviction:  she has belief in what she says, but always leaves her opinions open to modification.  So I feel confident in following advice, if I choose to, instead of ambiguous about the course of action. I also feel I can choose not to follow advice without upsetting or insulting anyone.  She is great to talk about options with because sees the pros and cons quickly, from an objective space, with a holistic and qualified perspective.

Teaching and Advising

Especially if the pupil isn’t seeing any other practitioner, but even if they are, the AT teacher can help the student identify what activity is enhancing and that which is hindering recovery.  During the rehabilitation period, AT can provide the optimal conditions for the body to heal itself.  It follows then to be appropriate for the AT teacher to ask the student to stop, find alternatives or modify their Use during activity if it is counter productive.  In these situations, I appreciated decisive advice.  The teacher sees things objectively, and from a qualified viewpoint.  I needed lots of advice on what was potentially going to cause distress to the injury as nothing in my previous experience of back pian had prepared me for the extent of limitation disc injury can cause.  

(6/05)  My teacher will see what needs doing, and do it without messing round – whether this is a “hands-on” procedure, or delivering advice. 

This “advising” fits into the context of an AT lesson because you are teaching the student a means-whereby to deal with the pain or injury.  The chance to talk through what activities, or manner of use in activity was leading to pain was a great benefit to me.  Because the feedback of pain is sometimes delayed, and often the pain is referred, identifying “what caused what” is not always easy.  The AT lessons taught me to recognise, undo and change patterns of use from the injury, and others which had been unresolved over time, but became pertinent because of the injury.

The AT teacher is able to address the multitude of these issues by finding the appropriate support for the demand of the current situation. The most useful support comes from the student’s own primary control (taking support in it’s broadest psycho physical definition). One of the distinctive advantages of the AT is the one on one time the student has with the teacher, which allows for the discovery and integration of this kind of support.

Another unique thing the AT teacher offers is permission for the student to be in whatever state they are in, and just sit with that.  Because we always work with an indirect procedure, the work allows space for the student to acknowledge, give permission to and listen to their pain.  The teacher gives a non-judgemental impression, as they are not attached to results.  This helps the student view their pain in a more detached and productive manner.  The student learns he has choice over how he will respond to the stimulus of pain and trauma.

Part of the work involves making me direct, empowering me by getting me to prove to myself I know what needs to be done and can do it.

The profoundness of giving the student that confidence that they can do something about their own pain cannot be underestimated.  I experienced many times when direction seemed to be the only way to control pain.  It means that the student can accept where he is, and also feel he is doing something, indirectly, to improve the condition in between sessions with the teacher, or whatever other practitioner he is seeing.

Explanations

Whilst some positive things arise from experiencing severe injury, I never found it productive to have people offer “explanations” of why this happened to me.  Being told things like “you must have needed to slow down your lifestyle” or “everything happens for a reason” didn’t do anything to aid the emotional turmoil.  More useful was to hear, “This is what is, now lets see how we can live with it, and not discount the possibility of finding something useful you can take from the experience”.  I felt most comfortable receiving practical advice – specific to what was happening at that point in time.

Fear

Initially, almost all activity pushed the boundaries of the injury.  Teaching or advice that promotes this, holds the potential to cultivate a fear of moving or exploring boundaries.

I feel fear in a new way.  I think it’s partly now I have something very tangible to fear.  Firstly the pain.  When I do something that aggravates the injury, I think I overreact a bit in fear of the pain escalating to what it did before.  Perhaps this protective reflex is nearing its useful expiry date.  I have the same sort of fear in going into a twist or something like that; “this might cause pain,” I think, or “this might prolong healing”.   This fear is based in the past, fear of what was.  The other sort of fear is in the future: that things might not get better than they are, that I might never swim again.  I hope that if I stay in the moment, all I get is feedback as to what is useful or not.  But sometimes the effect is delayed, so it’s difficult to learn from this experience.

Fear can become a major obstacle in healing.  It disrupts the psycho physical being and challenges clear thinking.  It gets in the way of the requisite trust that sending directions will be effective.  Especially with chronic or intense pain, clear thinking is tiering – it is very tempting to fall back into a fear-based way of approaching pain.  Again we are challenged with confronting habit.  By dealing with changing thinking, AT offers a uniquely valuable treatment.

Working with the whole body in an AT context gets support from the whole for the injury. This is a very practical way to approach the fear around the inured area.  There is a place for putting hands directly on the injured area, or dealing asymmetrically on a person’s pattern of pain because these things are disco-ordinating the student, and working with pain by addressing misconceptions, reintegrating or stimulating these areas may not necessarily resemble traditional AT lesson format.  The work is still indirect; so long the teacher is adhering to the means whereby and maintaining their own direction.  On one side the whole body has to support the injury, but on the other side, the injury has to integrate into the whole body.  Learning to allow pain to be received by the whole body rather than disconnecting the areas was a major step in my rehab.

Because of the time frame of rehab, certain compensatory patterns for the injury need to be kept into perspective as they become habitual.  Knowing when a certain pattern is past it’s usefulness as protective is one of the most challenging things to the student, as this very pattern is what, to the, feels like is holding them together.  Letting go of these compensations evokes a fear of falling apart – of regressing into pain.

Conclusions

All methodologies have strengths and weaknesses.  AT appeals to me because it allows for the student to direct his own recovery.  It is effective in pain relief and helps to deal with what you need to, to get through the injury.  It ensures the disturbed postural patterns don’t become the habitual basis for movement. Conventional support isn’t adequate, the one on one time and holistic support the AT teacher offers is unique.  The slow change of AT integrates fast change work from other practitioners and supports a multi disciplinary approach to healing.

When thoughts are negative or deconstructive, AT teaches us to replace this thinking with constructive thoughts.  There will always be physical tension associated with negative thinking, if we recognise this, and release it, then we are breaking a downward snowball.  Working with AT thinking is something we can do when it appears there is nothing that can be done.

Few of us get through life without facing pain or trauma.  It is such a strong stimulus that we form some self-preservative response to. AT thinking can challenge the value of the habitual way we deal with pain.  An injury of magnitude dredges up issues of how successfully pain has been dealt with in the past.  The habit t is a psychophysical reaction established by past experience.  This being the case, it is bound to vary greatly between individuals.  The teacher is faced with a compound problem, but rather than structuring some great unravelling, the most profound healing and learning experience comes from the teacher creating a safe place of exploration.  From there she can facilitate a process for the student to discover (or create) a means whereby they can finds the support of their primary control and can look after themselves through constructive thinking.

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