Hypermobility Living with an HMS Posture and movement Dr Bull developed an interest in the Alexander technique when in training as a rheumatologist in the 1980s. He has taken lessons, and has personally found it helpful, as have his patients and members of his family. In general terms, the Alexander technique helps you discover how the body is designed to function so that you can work with the design rather than against it. To set the scene, think for a moment about our evolution. In the process of evolution we have adapted to a bipedal, upright stance. Our ancestors were fit hunter-gatherers and probably managed well, but for the modern westernized population one of the health problems we face is our more sedentary life-style. As individuals, we are partly responsible for the problem as we tend to abuse our bodies, due to lack of exercise and poor posture. We often react with muscular tension when under stress. Developing unhelpful postural habits over the years may lead to muscle tension, as our body is making an effort to make the bad habit work for us. If hypermobility and de-conditioning come into play as well, you have got a recipe for painful symptoms. This, however, potentially may be avoided or reduced if we take the time to observe ourselves and understand what we are doing wrong. If you are symptomatic the Alexander technique may help you. When Dr Bull became an NHS consultant at the William Harvey Hospital in Ashford, Kent, he was lucky enough to work with various specialist physiotherapists who were very advanced in their thinking when employing physiotherapy techniques. Two were hypermobile themselves and had a way of treating patients that got results where others failed. This led to his personal interest in the condition because he was able to help. Whilst physiotherapy remains an essential element of treatment, it is not always right for everyone (especially if you have a sensitized nervous system) and unfortunately not all physiotherapists have expertise in the management of hypermobility conditions. Working with a local Alexander technique teacher Dr Bull was able to help more people and found that patients with hypermobility found it particularly helpful; some even life changing. In Dr Bull' experience an individual programme combining specialist physiotherapy followed by Alexander technique lessons often works well, allowing patients to self-manage their symptoms more easily. Physiotherapists and the Alexander technique teachers are quite different in their approach. Dr Bull' analogy is that a patient could think of themselves as a car: the physiotherapist could be seen as the mechanic, i.e. the person who optimizes the joints and builds up core stability, whereas the Alexander technique teacher can be likened to the driving instructor, i.e. teaching them how to drive their body with more skill. What is the Alexander Technique? The Alexander technique is an educational process for improving natural poise and movement skills, and reducing problems caused by unwanted habitual tension patterns. During lessons the teacher uses gentle hands-on guidance and verbal instruction to help pupils learn how to be more aware of their bodies and their habitual patterns of movement and thought. By learning to recognize these habitual patterns, pupils are gradually able to improve their posture and move with less effort, thus reducing the pressure on joints and muscles. Alexander showed that coordination and poise rely on the natural dynamic alignment between the head, the neck and the back. Interfering with this co-ordination is like operating a car with the handbrake on! Rather than concentrate on individual joints and muscles, the technique works on the total pattern of mental and physical response, promoting efficient and healthy functioning of the whole person. Teaching is usually one to one and you may notice a change as early as your first lesson. Nevertheless, as with all educational processes, it may take a course of lessons to learn the basic principles of the technique and how to apply it to your daily life. You will be taught to avoid ways of reacting and moving that may cause or aggravate any musculo-skeletal symptoms. Practicing the Alexander technique gives you the tools to make the best use of yourself when moving, resting, breathing and learning. It also helps to organize awareness and focus of attention, allowing better choices in reacting to demanding situations and return to a balanced state of body and mind. And it is not just about upright posture. Benefits of the Alexander Technique The Alexander technique can be helpful in the following ways: Back, neck and joint pain Muscle tension and stiffness Poor posture Breathing and vocal functioning problems Anxiety and stress related conditions Certain neurological conditions such as Parkinson’s disease Self care in pregnancy and childbirth We tend to waste energy with too much tension and effort. With the Alexander technique you learn to let go of unnecessary tension, take pressure off yourself and rediscover equilibrium of the mind and body. With this increased awareness you can be better balanced and coordinated, move lightly and effortlessly, be more alert and focused, become calmer, and more confident. Performers and sports people of all kinds recognize the value of learning the Alexander technique as part of developing and improving their skills. Are there any Side Effects? As the Alexander technique is an educational process and not a treatment there are none of the usual side effects that can be associated with drugs or some therapies. Alexander technique lessons are generally suitable for most people. It can also be helpful for longer term rehabilitation for those with acute issues such as spinal injuries, ruptured discs or acute joint pain once the immediate acute pain has been medically addressed. Who was Alexander? Frederick Matthias Alexander was born in Tasmania, Australia, in 1869 and developed the technique in the 1890’s. Alexander’s promising career as a young actor was threatened by recurring vocal problems. He sought the help of doctors but with no lasting result. Since there was no clear medical cause of his problem Alexander thought he would explore what he was doing when reciting. He observed himself in mirrors and after years of self-experimentation he developed a technique which enabled him to take up his career again. He noticed that not only had his vocal problems disappeared, his overall health and functioning had improved as well. Gradually others came to him for help, a number of doctors referred patients to him, and he gave up reciting in order to teach his technique on a professional basis. He realized that if someone is badly coordinated then their sense of body awareness (proprioception) may not be reliable enough to help them make useful improvements in how they move. He further realized that ‘nature does not work in parts but treats everything as a whole’. In order to make effective change it is important to work with the whole person including their thought patterns. In 1904 Alexander brought his technique to London. He published four books, established a training course for Alexander technique teachers, and taught right up to his death in London in 1955. Recognition from Scientists and the Medical Profession A number of scientists endorsed his method, recognizing that Alexander’s practical observations were consistent with scientific discoveries in neurology and physiology. Most eminent of these was the Nobel prize-winner Sir Charles Sherrington, today considered the father of modern neurophysiology. The Sherrington School of Physiology still exists at St Thomas’ Hospital. Another Nobel Laureate, Nikolaas Tinbergen, who won the prize for “physiology or medicine” in 1973, dedicated a significant part of his Nobel acceptance lecture to the work of Alexander. You can watch his speech on www.nobelprize.org/mediaplayer/index.php?id=1584. Many doctors were advocates of his work and sent patients to him. In 1937 a large group of physicians wrote to the British Medical Journal urging that Alexander’s principles should be included in medical training. Recent Scientific Research into the Alexander Technique The Society of Teachers of the Alexander Technique (STAT) has its own research group that monitors and supports current and upcoming research. The effectiveness of the Alexander technique has been explored through research ranging from case studies, to carefully designed trials with measurable outcomes. One randomised control trial of Alexander technique lessons compared with exercise and massage (ATEAM) for patients with chronic low back pain was published in the British Medical Journal in 2008 and serves as an example of evidence-based medicine. The results are summarised as follows: One to one lessons in the Alexander technique (AT) from STAT registered teachers have long term benefits for patients with chronic low back pain Twenty-four Alexander lessons proved most beneficial After one year those who had AT lessons had an average 3 days of pain per month compared with 21 days per month with usual care On going research includes the ATLAS randomized clinical trial involving more than 500 people with chronic neck pain, and funded by Arthritis Research UK. This study is evaluating the effectiveness of one to one Alexander technique lessons compared with usual care, and acupuncture compared with the usual care. Other areas of past or current scientific research are summarized on the STAT website which can be found by clicking HERE. The Alexander Technique and Joint Hypermobility There have been no studies of the effectiveness of the Alexander technique in people with joint hypermobility. Dr Bull' personal experience of the technique is that it does work for many patients. A view from Alexander technique teacher Julie Barber (MSTAT) is that in her practice ‘at least half of people have some degree of hypermobility, ranging from general hypermobility to Ehlers-Danlos syndrome.’ ‘In general terms, the Alexander technique helps you discover how the body is designed to function so you can work with the design rather than against it. With hypermobile joints, sitting and standing often involves ‘locking’ joints at one end of their range of movement as a way of stabilizing them... The Alexander technique teaches how to avoid the locking and yet be able to sit or stand comfortably - and in balance - without having to make an effort. No more ‘Sit up straight!’ because one is sitting in a slumped and collapsed way. Instead, we’re talking easy, upright sitting, that can be maintained for long periods. Simply not locking knees backwards can lead to a significant decrease in pain levels. Bending over, working in the kitchen, walking, carrying shopping and many other everyday activities can become a lot easier. Pain levels are likely to diminish as tension reduces. Breathing is also likely to improve. Sometimes hypermobility leads to reduced proprioception (our body awareness sense). Through Alexander work people become more in touch with their bodies in a useful way, they can learn the difference between tense and free muscles so that they can look after themselves better. It helps prevent misuse and overuse, such as overstretching when doing exercises or chronically tightening muscles around joints in an attempt to produce stability (the classic paradox of being both ‘too loose’ and ‘too tight’ at the same time). As tension reduces, balance and co-ordination improve. Confidence grows in one’s ability to move well and efficiently, with less risk of injury. Alexander technique takes time to learn, just as bodies take time to change. People generally notice improvements after only one or two sessions, but to reap the full benefits takes a full course of lessons. The pupil/teacher relationship is a collaborative one. Anyone can learn it with the help of a qualified teacher (registered with an Alexander Technique professional association such as STAT, see details below) but obviously it is great to learn as a young adult to help lay the foundations for a full, productive life. It is a skill that will last a lifetime. One word of caution: In my experience, people who are very weak and have a hypermobility syndrome may also need a structured exercise programme to gently build strength and stamina before they fully benefit from Alexander technique. The two work very well together. Julie Barber, 2016. To read more about the Alexander technique, visit STAT’s website by clicking HERE. Dr Philip Bull FRCP, Consultant Rheumatologist, SPIRE St Saviour’s Hospital, Hythe, Kent. Edited by Dr A. Hakim, First published HMSA Journal April 2015. Website published 30/10/16 - version 1 Comments From an Alexander student: about 6 months ago I was sitting in the theatre and suddenly thought, I haven’t noticed my back! I was sitting free of pain and discomfort, still and upright. For the first time in 40 years I wasn’t constantly shifting position to try and get more comfortable. I put this down to a combination of undertaking physiotherapy exercises and Alexander technique (AT) at the same time. It has been a very slow process as, by the time I was diagnosed with hEDS, my muscles had become very weak and de-conditioned. It was a real challenge to connect with them at all, but thinking in the AT way helped a lot. Even doing gentle exercise and slowly building up the repetitions would leave my muscles feeling stiff and tight (whilst looking very flexible). Most people would be advised to stretch at this point but if you are hypermobile it is so easy to overstretch. I now find releasing muscles using the Alexander Technique avoids this, and also makes my rehab exercises easier and more beneficial as I am using the appropriate ones for the exercise. Alexander has been a really useful and integral part of my continuing recovery. I feel more balanced, grounded and connected. My proprioception is more present and reliable, my neck feels more comfortable, I can breathe more easily and overall my pain has eased. I feel better than I have in years! Working with hypermobile young musicians: in the past few years we have seen a definite increase in the number of students with hypermobility, particularly young women, at the Royal College of Music and Junior Royal Academy of Music. It is very hard for these very flexible young people to be able to work for sustained periods, holding instruments that can be heavy and awkward. Another challenge is being able to work for long periods with the sort of concentration needed for practicing and performing. To us it seems vital to help these young students find easy stability in standing and sitting while playing music. This stability often leads to reduced or eliminated pain. It is also useful for musicians to develop some awareness of basic anatomy. The principles of the Alexander technique, which are covered in lessons, give them useful strategies while playing music as well as for their daily life. Our work's emphasis on effortless thinking and inclusive awareness gives young musicians choices to find an easy attitude and it helps their learning process. By Peter Buckoke, Professor of Double Bass and Alexander technique, Royal College of Music, and Judith Kleinman, Alexander teacher, Royal College of Music and the Junior Royal Academy of Music. Being a hypermobile Alexander technique teacher: I was always a bendy child, my sister even more so. We showed off by performing gymnastic contortions, and generally took full advantage of it. I was also very clumsy and often ‘turned my ankle’, finding myself all of a sudden on my hands and knees. As a teenager I simply wasn’t able to sit up straight, and after a big growth spurt in my mid-teens I looked like a droopy flower. During a routine medical at university I was told I had a scoliosis but not given any advice about it; I often used to stand with my left leg turned under at the ankle, in order to feel ‘straight’. In my thirties, while teaching the piano, I developed terrible pains in my wrists, which led me via a circuitous route to having Alexander Technique lessons. I found them very helpful but things started to really change for me when I had more intensive lessons. I learned not to lock my knees back – this led to confusion for a long time as my knees simply had no idea where to ‘be’. For a while I walked around with them slightly bent, but this just led to different problems. I also seemed to have exchanged fixing my knees for fixing in the hips – in order to stand up securely I obviously felt I had to tighten something! I’m still struggling somewhat with this dilemma, but at least I know when I’m doing it. I have never officially been diagnosed as hypermobile, although my legs, arms, hips and lower back clearly fit the bill. Since becoming aware of it in myself, I have realised how many of my pupils have issues with hypermobility in one or more areas of the body, some quite severe. It’s often the people who seem at first to be the most stiff and unaware of sensation in their joints who turn out to be gripping tightly in order not to collapse. The Alexander Technique can help to return proprioceptive awareness to these areas and undo inappropriate muscle tension, and also to exercise safely in order to build strength in the joints. Three years ago I started doing yoga classes, and initially managed to injure myself frequently, despite a very sensitive and non-pushy teacher. It’s taken a while for me to learn how to do the movements without over-stretching – it’s often the things that feel ‘easy’ that lead to problems. I always think that without the Alexander technique I’d probably be in a real mess by now, but fortunately I have this marvellous tool to keep myself in a good state as I age. By Maddy Paxman (MSTAT).