Prevention and Health:
New Diagnostic Criteria
The last several decades have witnessed remarkable changes in approaches to health and disease. Recognizing that many modern complaints are not medical in the strict sense of the word, increasing numbers of people are exploring new ways of addressing health problems through relaxation, meditation, and other "alternative” methods designed to reduce stress. But what causes stress, and why do we need to relax in the first place?
The notion that when we suffer from an ailment we must do something to cure it is so ingrained that we hardly question it. Yet many problems we think are the result of stress are caused by our own misdirected actions, and we can rise above stress by learning to gain command over the unconscious behaviors and actions that create this internal imbalance. By learning to identify the unconscious actions that interfere with the natural working of our bodily systems and learning to do things more consciously, we can restore natural functioning, lower stress, and achieve a higher level of awareness and control in living.
To illustrate these concepts, here we present a case study of a violinist with an unexplained shoulder problem.
"The study of proprioception and motor control is not only worthy of our attention
but essential to a complete model of health and assessment."
1. The Relation of Specific Parts to the Whole
I want to turn now to the problem of applying this subject matter to the practical challenge of helping someone with a specific complaint. Anyone who has suffered from a specific muscular problem of the shoulder, back, or arm is very likely aware of methods seeking to strengthen and stretch muscles, mobilize joints, increase range of movement, and relax specific muscles. These methods often differ in approach, but they possess one element in common: they seek to restore the function in a particular region of the body by acting on the muscles, joints, and related structures in that region. Often several methods are combined in the effort to produce greater strength in some muscles while relaxing or increasing flexibility in others, but the basic aim is the same: to restore function in specific parts.
It must be kept in mind, however, that the use of a specific part of the body never takes place in isolation from the use of the entire body, so that a harmful condition of, say, the lower back, is invariably accompanied by a pattern of tension throughout the entire length of the back and legs. Furthermore, this entire pattern of tension is organized, not in reference to the specific area where the tension may seem to focus, but by the relation of the major components of the body in its functioning as a total system. To be properly dealt with, then, a specific problem must always be looked at in its relation to the entire system of which it is a part, and in relation to the larger organizing principle governing the muscular system.
To illustrate this principle in its practical application to a physical difficulty, let me describe the case of Sarah, a professional violinist who suffered from a painful right shoulder. Sarah had been to several doctors, who diagnosed her problem as a form of strain injury caused by too much playing. She tried the exercises which they prescribed for her but they did not help, and she sought alternative means of addressing her problem.
Observing Sarah’s condition, it was clear that the muscles around her shoulder were in spasm. The shoulder was not only somewhat tender and sore; it was also held visibly higher than the left shoulder, with the result that there was decreased mobility in the joint. But this shoulder tension was only part of the problem. The musculature that supports the body against gravity is organized by the relation of the head to the torso. When this system is working properly, the neck and back muscles are lengthened, the back is full and supportive, and the entire torso has length without unnecessary stiffness. In Sarah’s case, however, this relationship was completely interfered with. Her neck was tightened on the right side, causing her to twist her torso to the left, and her shoulders were compressed and tightened across her chest. Perhaps most significantly, her lower back was arched and tightened, so that the entire chest and rib cage were held in a kind of rigid pose that prevented the upper body from relaxing in the way it is designed to do. In short, the harmful condition of the shoulder was part of a larger pattern of tension which constituted a total interference in the way Sarah’s body was designed to work.
This pattern of tension was also connected with a harmful way of using her arm in activity. When I asked her to play for me, the tension in her shoulder and neck intensified as she raised her arms, and her back muscles also became more tightened along the spine. When I asked her to do nothing at all, and to allow me to raise her arm, she was unable to leave the arm relaxed: the moment I raised it, she tensed the shoulder as though she had deliberately decided to move the arm herself, and again tightened her neck and back muscles.
During the first few lessons with Sarah, it was pointless to try to make any changes or improvement in her shoulder per se. The condition of the shoulder was in fact so dependent on the overall state of tension that, until this overall condition was improved, the shoulder itself was not capable of improvement and could only remain in spasm. By making various adjustments in the head and torso, however, it was possible to release the tension in the neck and back and restore the elasticity of the muscles in these regions. After several more lessons, the overall condition of tension began to lessen and her entire muscular system as a whole began to work with an increased fluidity and ease. Her body regained some of its lengthened quality, and her back became fuller and more supportive.
With this general improvement, however, came an even more dramatic change. As the condition of her back and neck changed, her right shoulder, which had until now remained raised and tightened, softened in the region of the shoulder joint and began to drop into place. Until this point, the shoulder had been overworked and the overall condition of tension had made it impossible for it to function normally. With the reduction of tension in the areas surrounding her shoulder, however, the raised shoulder could resume a normal and relaxed position and function in a more coordinated way with the shoulder girdle and back.
This change illustrates a central principle governing the working of the limbs, back, and other specific parts of the body. Problems may develop in the limbs or lower back, but this doesn’t mean that only those parts are involved. In fact, such problems always involve the entire system, and in order to address the specific problem it is necessary to understand how the system works as a whole. Specific anatomical diagnosis might explain the immediate cause of the problem, but by far the most crucial element in the solution of such problems is an understanding of the general working of the organism, and of the normal use and function of the limb based on this general knowledge.
The Fallacy of Specific Medical Diagnoses
Understanding the relation of specific parts to the whole reveals a fallacy underlying medical diagnoses in such cases. When a problem develops with the shoulder, the average person goes to a doctor to seek its cause and the doctor, responding to the complaint, examines the shoulder to find out if something is wrong. Even if related structures are visibly tense or in spasm, the doctor is unlikely to consider this as a factor or even to notice, since he is trained to look at joints and tissues, not at general function. But the functioning of the shoulder is intimately connected to the working of the muscular system as a whole, and abnormal conditions of the shoulder are associated with an interference in this general system. By understanding how the shoulder works under normal circumstances and how it is being mis-used, it becomes possible to understand the symptom, not in terms of specific malfunction of the shoulder, but as a further development of this wrong overall use. This requires a general knowledge of the use and function of the arm and shoulder and of the total workings of the muscular system on which they depend. This general knowledge would then make it possible to understand how the problem developed and what to do about it.
But instead of gaining this general knowledge of how the body works, most of us, when faced with a similar problem, look instead for a specific "cause” for our seemingly inexplicable problem. When once we are given a medical diagnosis that locates the injured or defective part, we are more or less satisfied with the diagnosis, even when we can do little about it, because at least we now know what is wrong and are under the care of someone who may be able to treat the symptom. But these types of problems are not really medical in nature. If we reflect on the history of the problem, we will likely be able to remember a number of signals that something was wrong—pain, discomfort, muscular strain or inflammation—that indicated, not a medical problem, but something harmful in how we were using the arm and shoulder. Instead of addressing the problem at this earlier stage, however, we let it get to the point that we now require medical care.
Underlying this approach is a basic unquestioned assumption: when it comes to problems we regard as physical, we accept specific anatomical explanations as the main facts of the case. One might even say we have a bias for these kinds of facts. In reality, a problem has a number of contributing factors, which correspond to a number of ways of explaining what causes the problem. The pain may be caused by an impingement of a nerve. The long-term cause of the problem may be constant mis-use of the parts concerned. Injury may have been a precipitating cause. The point is that identifying the immediate cause—in most cases, some sort of injury or inflammation of the part—does not provide the basis for a valid diagnosis if such knowledge is not adequate to provide a solution to the problem. In fact, from a practical standpoint, such knowledge is not only useless, but positively misleading, since focus on the shoulder can only direct attention away from the true issue: the relation of the specific symptom to the working of the body as a whole. Understanding this relationship requires knowledge, not of detailed anatomical structures, but of the coordinated working of the muscular system, and in particular the role of the head and torso in organizing muscular action and support.
2. Faulty Action and the Need for Prevention in Activity
So far, we have looked at the shoulder problem specifically in relation to bodily coordination, but there is another crucial aspect that must be dealt with if we are to fully solve the problem. We observed a moment ago that the harmful pattern of tension occurs as part of the total act of standing or performing a particular action, and therefore must be perceived and prevented in activity in order to be adequately addressed. Even when a skilled teacher is able to make dramatic physical changes which bring about an improved condition of the back or other affected part, the harmful condition of the affected part will recur in activity, requiring an educational phase of the process which demands that the student learn to prevent the harmful pattern of tension while performing daily tasks.
To continue with the example, when I was able to make changes in Sarah’s general coordination so that the condition of her shoulder was restored to normal, I then told her I wanted to teach her how to play violin in a way that would not interfere with the balance of her muscular system. To this end, I would place the violin on her shoulder so that she would be ready to play, but I would support the neck of the violin so that she would not have to tighten her back or shoulder muscles in her customary way. The point of this whole procedure, I explained, was to help her play without invoking the pattern of tension that would cause her to mis-use her shoulder. But the moment I asked her to raise her left arm to support the violin, her old condition returned. At a subconscious level, she had tightened her neck and back and raised her chest, bringing about the harmful condition of tension associated with the raised shoulder. I had wanted her to use a minimal amount of effort, but the act of raising her arm to support the violin caused the harmful pattern of muscular activity to come into play at a level of which she was entirely unaware.
Why this happen? The muscular system works at the service of our intention to act, and is in this sense part of a pathway which begins with the idea to do something and ends with a motor act, or the muscular performance of the action. When Sarah was not asked to perform an action, we were able to remove the activity of this system sufficiently to bring about the improved condition of the shoulder. But the act of playing the violin was a different matter. She had played violin nearly all her life. She had a particular conception about how to do it, and the habitual muscle tensions were part of that conception. The moment I made the slightest suggestion that she was to play violin, she was bound, by habit and by the force of instinct, to perform the act as she always had, with the result that the muscular system was invoked in the usual harmful manner.
I will not, at this stage, explain all the steps involved in solving this problem. Suffice it to say that, in such cases, this tendency is at first almost always impossible to prevent. When I asked Sarah to put the violin down and again made adjustments so that we could restore the improved condition, the moment we repeated the procedure the tension returned again with a recurrence of the harmful condition of the shoulder. It was necessary, over and over, to present her with the challenge of playing, reinforcing her ability to do nothing, and simply to maintain the head-torso relationship, thus reinforcing the new way of using her system in action.
Eventually, Sarah could begin to see that, at the moment she had the idea to act, the tension pattern interfered with this relationship. The moment she believed she was to play the violin or had the idea suggested to her, she could see that she interfered with the whole exercise by unconsciously performing the act, and that this act began with an interference in the head-torso pattern. Perceiving this pattern of interference made it possible, finally, for her to support the violin herself, but without invoking the usual pattern of tensions and without harmfully raising her shoulder.
This example illustrates a second and essential stage in addressing the problem of tension in activity. If we suffer from a harmful condition of tension, the process of reducing the tension is not sufficient to remove the cause of the problem. We have to identify what we are doing in action to cause that problem, and learn to prevent it. This preventive aspect of the problem is absolutely critical in addressing problems such as Sarah’s. Her tight shoulder may seem like a "condition” requiring treatment, but this condition is in fact the direct result of actions performed in a harmful manner. In this sense, the problem with the shoulder is most certainly not a purely physical problem nor even a problem of muscular tension, but a problem of activity. What appears to be a static condition is in fact intimately connected with faulty action. Once action is initiated in the form of speaking, walking, or even thinking, the wrong working of the muscular system comes into play and, along with it, the wrong use of the shoulder. Since this wrong manner of performing actions is habitual, any form of activity—including the attempt to correct the shoulder—will bring about the wrong overall conditions associated with the raised shoulder. It is therefore necessary, not simply to restore the improved physical coordination, but to prevent the faulty action that interferes with it.
The difficulty in doing this is to be able to kinesthetically perceive the harmful pattern as it actually happens. Until we can see what we are actually doing to cause a problem, we hold to the belief that the problem is in the body and continue to seek treatment even though the problem keeps returning. Virtually all the awareness techniques which seek to reduce tension or increase awareness in movement, in fact, make the same oversight, based on the same mistaken notion. Somatic conditions are attacked with the aim of releasing underlying "holdings,” or increasing bodily mobility and awareness, when in fact the underlying cause is not a harmful condition of the muscles, but faulty muscular activity, subconsciously performed. Techniques that appreciate the emotional aspects of somatic conditions do not fare any better. To say that muscular holdings are connected with emotional states is certainly psychophysical in approach, but this approach belongs, more properly, to the domain of psychotherapeutic treatment and, in thus treating the problem therapeutically, still fails to address the faulty subconscious activity. Only when the body is coordinated properly is it possible to observe the harmful actions that perpetuate the problem. This leads to an understanding of what the true cause of the problem is and how to prevent it.
The problem of physical tension, then, can’t be solved by methods that address only the physical condition or that treat the physical problem as an expression of emotional imbalance. When Sarah tightens her neck muscles by pulling back her head, or unnecessarily tightens her shoulder to play violin, we perceive such behaviors as predominantly physical, when in fact they are really part of a complex neuromuscular pattern of action. In such cases, the symptom is usually diagnosed as an isolated condition and attributed to strain injury, but it is in fact directly related to the working of the body in activity. In order to improve the condition it is necessary to affect the working of the system, both at rest and in activity.
In summary, there are two phases in addressing Sarah’s problem. The first is the re-educational phase in which the muscular system, which is organized primarily by the head-torso relationship, is restored to its general coordinated condition, bringing about an improved working of the specific parts concerned. The second is the preventive phase in which the harmful condition, which recurs as a pattern of faulty activity, must be recognized and stopped in order to prevent the harmful raising of the shoulder. In this sense, the problem isn’t physical at all but ultimately a matter of preventing misdirected activity which cannot be addressed simply by relaxing the body or training muscles.
These two phases are F.M. Alexander's work in a nutshell. The Alexander Technique was developed specifically as a means of addressing these issues.