Back Pain Solutions How To Help Yourself With Posture-Movement Therapy and Education (Alexander Technique Based) by Bruce I. Kodish

BACK PAIN
SOLUTIONS
How To Help Yourself With
Posture-Movement
Therapy and Education
Bruce I. Kodish, Ph.D., P.T.
Extensional Publishing
Pasadena, CA
Back Pain Solutions
by Bruce I. Kodish
Copyright  2001 by Bruce I. Kodish
All rights reserved. No part of this book may be reproduced or transmit-
ted in any form or by any means, electronic or mechanical including
photocopying, recording or any information storage or retrieval system
without prior permission from the publisher except for brief quotations
in an article or review.
Published by Extensional Publishing
Post Office Box 50490
Pasadena, CA 91115-0490
Fax: 626-441-2339
Telephone: 626-441-4627
Email: [email protected]
Publisher’s Catalogue in Publication Data
Kodish, Bruce I.
Back Pain Solutions / by Bruce I. Kodish
Pasadena, CA:Extensional Publishing,  2001
320 pp. includes index
ISBN 0-9700664-5-7 (paperback: alk. paper)
Library of Congress Card Number: 00–191164
1. Backache. 2. Physical Therapy. 3. Physical Education and Training.
4. Posture. 5. Pain. 6. Alexander Technique. 7. Mechanical Diagnosis
and Therapy.
I. Title. II. Kodish, Bruce I.
LC Classification # RD771.B17
Dewey Decimal Classification # 617.564
Cover Design by Edward Dawson
Illustrations/Drawings by Max Sandor and Bruce I. Kodish
Disclaimer:
Every effort has been made to make the information in this book as complete
and as accurate as possible. However, new information may become available
after the printing date. In addition, mistakes, both typographical and substantive
may have occurred. Therefore this text should be used only as a general guide.You
are urged to read other available material. The publisher and author expressly
disclaim any and all liability or responsibility to any person or entity for any in-
jury, loss or harm of any kind, directly or indirectly caused or alleged to be caused
from the use of the ideas and information contained in this book. If you have or
develop any adverse symptoms you need to consult an appropriate healthcare
professional for diagnosis and possible contraindications. See Chapter 8 for
guidelines to determine when to see a physician. If you do not wish to be bound
by this disclaimer, you may return this book to the publisher for a full refund.
For more information go to www.backpainsolutions.net
You may contact the author at [email protected]
Contents
Dedication
Acknowledgements
Preface - Who Is This Book For?
Usage Note
Introduction
Chapter 1 – Is It Possible To Feel Better?.......................10
Part I - Problems and Solutions
Chapter 2 – Back Pain Problems.....................................20
Chapter 3 – Back Pain Solutions I:
Posture-Movement Therapy........................ 33
Chapter 4 – Back Pain Solutions II:
Posture-Movement Education..................... 39
Part II - Necessary Background
Chapter 5 – How Your Back Works................................58
Chapter 6 – The Pain in Sprain .......................................79
Chapter 7 – You Control Your Pain and Posture.............88
Part III - Therapy Solutions
Chapter 8 – Diagnosing Back Pain...............................104
Chapter 9 – The Circles of Pain and Recovery.............119
Chapter 10 – Now What Do You Do?...........................143
Part IV - Education Solutions
Chapter 11 – Essentials of Body Mechanics................176
Chapter 12 – Practice Body Awareness.........................188
Chapter 13 – Experience Your Full Stature...................205
Chapter 14 – Design Your Environment.......................234
Chapter 15 – Increase Your Postural Variety.................244
Conclusion
Chapter 16 – Preventing Back Pain .............................260
Notes.....................................................................270
Bibliography............................................................294
Index....................................................................308
About the Author
When you’re hungry, sing; when you’re hurt, laugh.
– Jewish Proverb1
Dedication
I dedicate this book to my parents. My mother of beloved
memory, Dorothy Berson Kodish, often reminded me to “act like
a mensh!”1 I’m happy that some of her directness, spontaneous hu-
mor and creativity rubbed off on me—at least I think it did. She
consistently encouraged me by letting me know that I could stand
up for myself and do what I set out to do. My father, Morris ‘Mashe’
Kodish, has demonstrated throughout his life a quiet competence—
with some swearing—that has shown me what it means to do what
needs doing. I admire his toughness and independence and am
grateful for his humor and love. Both my parents helped me de-
velop a Grade-A ‘crap detector’, gave me my love of books and
showed me that self-reliance and the love of learning depend on
your attitude and not on your title or on what degrees you have.
I am also grateful to my uncle, Sam Berson, who encouraged
me with his quiet humor to think for and challenge myself. I miss
him. My deep gratitude also goes to my in-laws, Beatrice and
George Samuelson, who supported me throughout the development
of my career. I miss their wit and courage.
I also feel gratitude to all of my physical therapy teachers (in-
cluding fellow students) at the University of Pittsburgh and else-
where. I feel a debt as well to my Alexander Technique teachers,
in particular Troup Mathews—who showed me what “growing
young” means—and Ann Mathews and Christine Batten, for their
patient teaching of a sometimes unruly student.
I feel indebted to my many students, patients and clients over
the years for helping me to learn what I could not get from books
or teachers.
Finally, I owe a debt to the work of Alfred Korzybski, perhaps
best known for his statement, “A map is not the territory.” This book
may be seen as my application of General Semantics, the discipline
which Korzybski founded, to the problem of back pain. My deep
gratitude goes to all of my teachers and colleagues at the Institute
of General Semantics. In particular, Charlotte Schuchardt Read and
Robert P. Pula have helped me to apply a scientific attitude (exten-
sional orientation) to my own life. I’m still working at it.
Acknowledgements
I wish to thank all those who read one or more versions

of the manuscript and contributed with critiques, comments
and discussion. These include Ron Dennis, Ed.D.; Barrett
Dorko, P.T.; Gary Jacob, D.C.; Marilyn Kodish Sutherland;
Rick Marken, Ph.D.; Max Sandor, Ph.D.; and Kristi Pallino.
My wife Susan Presby Kodish, Ph.D., served as chief editor.
Without her critical eye, love and untiring support I could not
have produced this book.
Preface:
Who Is This Book For?
Welcome to Back Pain Solutions! If you are currently ex-

periencing back pain, you have taken an important step to
learning how to reduce and abolish your symptoms.
If you’ve had one or more episodes of back pain, this book
is also for you. Time may not heal all wounds. If you’ve been
left with some residual pain, disability and fear of recurrence,
techniques in this book can help you find the confidence you
need to move through life with greater ease.
Even if you are not concerned about back pain, you will
find something of value here if you want to improve your
posture and efficiency of body use. You can also share this
book with someone you care about who is dealing with back
pain. The self-care principles I discuss apply to neck pain, re-
petitive strain and other joint and muscle pains, as well.
The opportunity to feel better is there for those who un-
derstand the possibilities of self-care for back and related pain
problems. These possibilities have been understood and avail-
able for many years but have been mostly unknown to the gen-
eral public and much of the medical community.
This book can also help medical doctors, physical thera-
pists, chiropractors, massage therapists, body workers and
movement educators to learn some new and different ways
of helping themselves and the people with whom they work.
I have attempted to be reasonably comprehensive. None-
theless, this book offers some back pain solutions, not ‘the’
solution or ‘all’ solutions. When possible, I point out where
to go for more help and further information. In the Notes sec-
tion at the end of the book, I provide references and technical
comments. For ease of reference, I have numbered those
places in the text that have a note.
I will be very surprised if you cannot find at least one thing
in this book to help your condition to some degree. Look for
small improvements. Small changes can lead to big differences
in some unexpected ways.
Bruce Kodish
Pasadena, CA
January, 2001
Usage Note:
To avoid confusion, I here explain my varying uses of double
and single quotes throughout the book. I apply double quotes according
to standard usage to indicate both direct quotes and terms/phrases used
by someone but not necessarily indicating a direct quote. I use single
quotes in the standard way to indicate a quotation within a quotation. I
also use single quotes to mark off terms and phrases which seem in vary-
ing degrees misleading (see Drive Yourself Sane for further explanation).
The single quotes here serve as a safety device to alert the reader to take
care when using such terms. For example, using terms such as ‘mind’,
‘body’, etc., may mislead one into assuming that what corresponds to each
term exists in the non-verbal world as an isolated, separate entity. I also
use single quotes to mark off terms used metaphorically or playfully.
My use of such language as “some,” “to me,” “as I see it,”
“seem(s),” “to some degree,” etc., may seem too indefinite or “wishy-
washy” for some readers. I do not apologize. Rather, this represents my
conscious effort to use an approach to language called EMA, English Mi-
nus Absolutism, which was formulated by General Semantics writer Allen
Walker Read. As Read has said, “ It is clear to many of us that we live in
a process world, in which our judgements can only be probabilistic. There-
fore we would do well to avoid finalistic, absolutistic terms. Can we ever
find ‘perfection’ or ‘certainty’ or ‘truth’? No! Then let us stop using such
words in our formulations.”1
Introduction
Thought is born of failure.
- L. L. Whyte1
Chapter 1
Is It Possible To Feel Better?
You wake up one morning feeling stiff in your back. “What

did I do?” you wonder. You drag yourself out of
bed…carefully. No, this isn’t just a stiff back; it hurts. You
feel a twang of pain which catches you if you move too
quickly. It goes across your back and into your butt on one
side. Bending over the sink to wash is a mistake. Ouch!
Despite being as careful as you think you can be, the pain
persists for the next few days. You try to figure out what caused
it but can’t be very sure. Was it that gardening the other day?
Your back did feel kind of stiff after you were bending over
for an hour pulling weeds. Hmm.What is wrong? You begin
to worry, “Should I go to the doctor?” Or maybe you already
have gone to the doctor, who has reassured you that nothing
serious is wrong, that this too shall pass. And it does—mostly
it does—but perhaps not as much as you’d like. And perhaps
you wonder when another episode will strike and whether
there isn’t something more that you can do to prevent it.
If your back hurts, you may have already tried various
types of treatment with varying effects. However, if you felt
entirely satisfied, you probably wouldn’t be reading this,
would you?
The field of back pain treatment is filled with multiple pro-
fessions making conflicting diagnoses, presenting confusing
claims and offering contradictory-seeming care with some-
times questionable results.
When practitioners offering treatments continue to debate
and fail to agree upon “Where is the pain coming from?” and
“What can be done about it?” how do you, someone with back
pain, decide what to believe and to whom to go to for help?
IS IT POSSIBLE TO FEEL BETTER? 11
Back pain can have multiple causes. Some of the appar-

ent confusion may have to do with the fact that effectively
treating this common complaint provides greater problem-
solving challenges than many people realize.
For example, one source of confusion comes about be-
cause any particular episode of back pain tends to run its
course, with the sufferer feeling better, if not completely pain-
free, with the passage of time alone. How then can you judge
whether a treatment offers real benefits or simply allows you
to fool yourself into thinking that it does?
Another reason for the continuing and confusing diversity
of viewpoints about back pain comes from the explosive
growth of medical information. This has made it easier for
genuinely useful knowledge to get buried and forgotten.
In this book I present some ways to help you cut through
the confusion. While further research is needed, some sound
and practical methods already exist for helping you to reduce,
eliminate and prevent your back pain symptoms.
Posture-Movement Therapy and Education

Back Pain Solutions is based on the simple, far-reaching
and widely-agreed-upon insight stated by Dr. Gordon Waddell
in his book, The Back Pain Revolution: “ Back pain is a me-
chanical problem in the sense that symptoms arise from the
musculoskeletal system and vary with physical activity.”1 In
this book, I will use the terms “mechanical” and “activity-re-
lated” interchangably to refer to this type of pain.
Back pain researchers have long understood common, ev-
eryday back pain as mechanical.2 Dr. Richard Deyo, a noted
researcher on the subject, has written that as much as 98% of
back problems comes under the category of activity-related
pain .3 However, the practical implications of this understand-
ing have yet to become common knowledge to many people
with back pain.
12 BACK PAIN SOLUTIONS
Activity-related (mechanical) back pain varies with activ-

ity. Such activity includes changes in posture and movement.
Back Pain Solutions is based upon my study of a number of
therapeutic and educational approaches that explore the rela-
tions of posture and movement to human functioning. I have
integrated these approaches into a two-tiered framework that
I call Posture-Movement Therapy and Education.
Posture-Movement Therapy
The first tier of activity-related solutions for back pain is
posture-movement therapy. Posture-movement therapy in-
cludes the relatively short-term use of static postures (posi-
tions) and movements to ameliorate pain, other symptoms and
loss of movement. If you have mechanical (activity-related)
pain, you may be able to influence it through the application
of specific positions and movements applied as exercises. You
may be able to do this on your own or with coaching as needed.
This insight has been especially developed in detail by physi-
cal therapist Robin McKenzie and his colleagues.4
Positions and movements can also be guided, facilitated
or passively applied in the form of manipulative or manual
therapy by an experienced practitioner. Manipulative tech-
niques exist on a continuum with the previously noted exer-
cises. My own bias is to first see what individuals can do for
themselves with the necessary coaching. However, positions
and movements applied by a hands-on practitioner may have
great usefulness as well.
Health professionals who offer one or more kinds of such
activity-related treatment include physical therapists, chiro-
practors, osteopaths and medical doctors specializing in
manual medicine. Many different schools of thought within
each of these specialties exist. Different practitioners may have
different theories and use different approaches and techniques.
Interestingly enough, despite these differences there also ex-
ists a great deal of overlap and similarity. This also holds true
for different educational methods which I’ll discuss in the next
section.
Nonetheless, different terms for similar things or the same
terms for differing things can lead to confusion and unneces-
sary opposition. The profusion of theories, terminology and
techniques can seem daunting. I offer the term “posture-move-
ment” as a neutral, descriptive label for the many varying
approaches to therapy and education.
The term “mechanical therapy and education,” which
could label such approaches, has lost its neutrality because it
has become too closely identified with one particular school
of thought, the “Mechanical Diagnosis and Therapy” of Robin
McKenzie. Although I value it enough to have studied and be-
come certified in it, I recognize that this approach does not
include the full range of activity-related methods available.
Also, the term ‘mechanical’ can have a machine-like conno-
tation that some people may find off-putting.
“Activity-related treatment and education,” which I use
at times, provides a more neutral term but lacks a certain de-
scriptiveness.
The term “posture-movement” labels in a descriptive and
easily understandable way the kinds of problems dealt with
and the types of solutions provided. It indicates the relations
between posture and movement. (See The Problem with Pos-
ture in the next chapter.) It does not refer to any particular or
‘patented’ approach. I offer it, rather, as a unifying term that
different practitioners can use to talk about the commonali-
ties of what they do.
It can refer to both therapy and education approaches.
What distinguishes posture-movement therapy from posture-
movement education? Posture-movement therapy, as I define
it, is practiced by a properly trained and duly licensed
healthcare professional. Someone offering posture-movement
therapy should have the ability to diagnose or screen for non-

mechanical problems that may require referral for appropri-
ate medical or surgical care.The practitioner should also be
trained to offer activity-related (posture-movement) treatment
that directly deals with specific pain and other symptoms
through the use of activity-related assessment, the use of spe-
cific exercises and/or manipulative treatments, and the ongo-
ing assessment of the effects of treatment.
Posture-Movement Education
Many have noted the effects of posture on human perfor-
mance and functioning. In relation to pain, your everyday pos-
tural habits—how you typically sit, stand, bend, lift, walk,
move, etc.—may influence activity-related symptoms.
Posture-movement education is the second tier of activ-
ity-related solutions for back pain. It focuses on the improve-
ment of your everyday posture-movement habits—your
learned, mostly automatic postural behavior. Posture-move-
ment education in itself is not a therapy. It does not in itself
involve the diagnosis, screening or treatment of specific pain
problems. Posture-movement education involves more long-
term and indirect preventive instruction.
In understanding the role of posture, I particularly draw
upon the principles and methods of the Alexander Technique
of Psycho-Physical (Cognitive-Kinesthetic) Education.5 The
Alexander Technique (AT) focuses on the application of con-
scious thought (Cognition) and sensory perception of the body
(Kinesthetic awareness) to improve posture and performance.
Ronald J. Dennis, Ed.D., a researcher and teacher of the Al-
exander Technique, defines it simply as “a nonexercise ap-
proach to the improvement of body mechanics.”6
Besides the Alexander Technique,which I was trained in,
there are many other educational approaches that can address
your habits of posture and movement. These include Body
Harmony, the Feldenkrais method, Ideokinesis, Rolfing, Sen-

sory Awareness, Simple Contact, and the Trager Approach,
among others.7 Studies in these approaches as well as in ap-
plied anatomy, body mechanics and ergonomics, have en-
riched my thinking and practice.
A point of clarification: Both posture-movement therapy
and posture movement education exist along a continuum.
Many healthcare practitioners who offer therapy also place a
major emphasis on education for back pain and other prob-
lems. Educational methods such as the Alexander Technique
(practiced by qualified teachers), though not therapies them-
selves, may lead to therapeutic effects for those who study
them.
This book will provide basic information that you need
in order to recognize whether you have a mechanical (activ-
ity-related) problem. The combination of posture-movement
therapy and posture-movement education reveals principles
that work together in a unique and synergistic way. You can
then begin to explore how to use both exercises and posture
as self-help tools to find your own back pain solutions.
A Scientific Attitude
In order to make the best use of the self-help tools dis-
cussed in this book, I suggest that you consider yourself as a
personal scientist.8 As a personal scientist you can apply a sci-
entific attitude, not only in those subject areas that you think
of as ‘science’, but also in your everyday life and problem-
solving. A scientific attitude involves an open-minded exami-
nation of your assumptions, with a willingness to test and re-
vise them on the basis of available evidence.
You can follow these steps as you apply the self-help
methods for activity-related pain that I discuss in this book:
• Clarify your problem. This can include uncovering your

assumptions about the problem and about possible solu-
tions.
• Ask answerable questions based on these assumptions.
• Make observations in a calm, unprejudiced manner to an-
swer these questions.
• Report your observations to yourself, and perhaps oth-
ers, as accurately as possible and in such a way as to an-
swer the questions that you asked to begin with.
• Revise your assumptions as necessary in light of the ob-
servations made and the answers obtained.
• Cycle through the process again and again.
As a scientific explorer in your daily life, you can actu-
ally begin with any one of these steps.9
The Method of Possibilities

To take such a broad scientific approach to your back prob-
lem you don’t necessarily need to do formal scientific research
with large groups of people, complicated statistics and elabo-
rate analysis. In studying your possibilties for feeling and
moving better, you are studying a single case—yourself.
Many researchers pooh-pooh the usefulness of studying
single cases, which they call “anecdotal evidence.” It is true
that if you are trying to generalize about what proportion of a
large group of people will respond to a form of treatment,
studying one individual will not get you very far. If that is what
you are trying to do, recognize that, as an old Jewish proverb
says, “ ‘For example’ is no proof.”10
However, there is another equally accurate Jewish prov-
erb, “We cannot learn everything from general principles;
there may be exceptions.”11 One individual, a single case, can
indicate that something is possible for that individual and per-
haps for other individuals as well.
Social science researcher Philip J. Runkel has proposed a

name for scientific methods that study the behavior of indi-
viduals. He calls such methods “specimen testing.” One par-
ticular method of specimen testing has special relevance to
you. Runkel calls it “the method of possibilities.”
The method of possibilities seeks to answer the question,
“What can be done?” As Runkel puts it, the method of possi-
bilities involves “a trial of a course of action to find out
whether it might be possible to bring it off.”12
It seems likely that you have not exhausted the possibili-
ties of dealing with your back pain. You can learn to use a sci-
entific approach to explore your back problem and reduce and/
or eliminate your pain. We will start this exploration in the
next chapter with a look at the personal and social costs of
back pain.
Part I
Problems and Solutions
Almost anything is easier to get into than out of.
- Agnes Allen1
Chapter 2
Back Pain Problems
“She killed herself,” a friend of mine told me of a co-

worker. “After years of chronic back pain, multiple surgeries
and heavy pain medication, she had had enough.”
This kind of tragedy fortunately doesn’t happen very of-
ten. Much more likely, a person with chronic or recurrent back
pain just learns to “live with it.” When her back ‘goes out’,
she restricts her activities, may take time off from work and,
with medication, a certain amount of grit, and whatever other
form of therapy she chooses, waits it out. Does this sound fa-
miliar?
Karen
The frustration experienced by those with persistent back
pain is apparent in what happened to one person I worked
with.1
Karen, a young woman in her early thirties, had over a
decade of activity-related back troubles. Over these years, she
saw many different kinds of health professionals. She had x-
rays, MRI (Magnetic Resonance Imagery) and other tests and
received many different diagnostic labels for her recurring
problems. Treatments she received included pain medication,
hot packs, electrical stimulation, spinal manipulation and
exercises. During these years she had four particularly bad epi-
sodes during which time she was briefly hospitalized and then
placed on extended bed rest.
After one such recurrence she went to an orthopedic sur-
geon who neither looked at her back nor examined her. Af-
ter hearing some of her history, he said, “Why haven’t you
had your disc removed?”
“What’s the alternative?” she asked.
“Whining for the Rest of your Life,” he replied.
BACK PAIN PROBLEMS 21
She did not return to his office.

At various times Karen also saw a number of chiroprac-
tors. While adjustments (the chiropractic term for spinal ma-
nipulation) sometimes seemed to help for brief periods,there
were times when they didn’t help or seemed to make her
worse. Chiropractic adjustments, she found, could be applied
in the same rote way as some of the other treatments she had
gotten from physicians and therapists. Some chiropractors she
met also emphasized returning for frequent and periodic ad-
justments, even when she didn’t experience a problem.
Following each episode, Karen often got advice to stay
active, do exercises and work on her posture. However, typi-
cally she would be handed a few stapled sheets of paper with
generic instructions. Occasionally, she was given more per-
sonalized attention, not all of it helpful.
During one episode when she experienced pain in both her
back and leg, a physician showed her an exercise he wanted
her to do. As she lay flat on her back, she was instructed to
pull one knee to her chest. After several repetitions, the pain
in her leg increased and shot down into her foot. “Try not to
pay any attention to it,” he told her as the pain in her foot in-
creased. She finally stopped the exercise, in tears.
She recalls a more positive experience when a physical
therapist patiently answered her questions and worked with
her on the exercises he gave her. The therapist got into trouble
for the extra time he spent with her. On her next visit, she was
treated by someone else.
She became resolved to “live with my problem” until, by
a set of chance circumstances, she came to see me.
Back Pain Problems

Back pain is common. It ranks as the fifth most likely rea-
son for visiting a medical doctor.2 As many as 80% of adults
can expect to experience back pain at some time in their lives.3
In any one year, 56% of adults will probably experience some
back pain while 18% will have frequent episodes within that
year’s time and 15% will experience back pain lasting more
than 30 days.4 Although Karen belongs to the smaller category
of people with frequent or chronic pain, her story illustrates
some of the difficulties confronted by anyone with a signifi-
cant back problem.
The Diagnostic Daze

The majority of back problems are, like Karen’s, activity-
related, involving some transient injury to the moving parts
of the spine (muscles, joints, ligaments and discs). Yet it ap-
pears that the actual parts of the back responsible for such me-
chanical pain are often difficult, if not impossible, to deter-
mine with any accuracy.5
In their efforts to come up with a diagnosis, some practi-
tioners may give too much credence to x-rays and other kinds
of diagnostic imagery that do not always correlate neatly with
the symptoms that people experience. By now, many studies
have been done that show a significant lack of correlation
between symptoms experienced and what one sees on diag-
nostic imaging.6,7 Among a group of people who reported
never having had back pain, about 20% had herniated discs
according to MRI studies. Of this same group, about 50% of
those under 60 and almost 80% of those over 60 had bulging
discs.8
This does not mean that arthritic changes or a bulging or
herniated disc can never cause back pain. It does mean that
having these visible problems on your x-ray or MRI does not
necessarily mean that you will have pain.
In addition, many of the other potentially problematic parts
of the back cannot be seen on x-rays or MRI images, or de-
tected with laboratory tests. Diagnosis and treatment should
not be based solely on imaging results. People like Karen may
become unduly frightened by practitioners who conclude more
than they ought to from such tests.
For physicians and other health-professionals, who want

to know what specific part of the spine is affected, these di-
agnostic difficulties can seem particularly frustrating. Once
serious disease or surgical emergencies (often much easier to
detect) are eliminated, we are left with what has come to be
called “non-specific back pain,” which accounts for the ma-
jority of all episodes.
Despite these diagnostic problems, many different groups
of practitioners have made an effort to explain as well as they
can what happens when someone’s back hurts. Different ex-
planations may imply different treatments. There are a vari-
ety of approaches, not all of which seem compatible. As Karen
discovered, the diagnosis that a person with back pain ends
up with may depend more upon whom she has seen than on
anything else.9
Chiropractors may diagnose “subluxations.”
Rheumatologists may diagnose “arthritis,” internists “low
back muscle strains,” orthopedists “herniated discs.” Might
all of these diagnoses be equally correct? Or might all of them
be more or less wrong? If there is some ‘truth’ to at least some
of them some of the time, how much and in what way?
Even though, or perhaps because, any one practitioner or
group of practitioners may show a great deal of assurance in
their particular viewpoint, the area of back care as a whole
teems with diagnostic and explanatory confusion. As a result,
people like Karen often feel confused as well.
Questioning Traditional Treatments

At the worst of her most serious bouts of pain, Karen was
hospitalized and then placed on lengthy bed rest, with a fo-
cus on receiving passive therapy with treatments like heat
packs, cold packs and electrical stimulation. This represented
the traditional conventional ‘wisdom’ which highlighted rest-
ing to promote recovery.
For years, a few lonely voices challenged this emphasis

on rest in treating back pain. For example, in a 1947 article in
the British Medical Journal entitled “The Dangers of Going
to Bed,” R. A. J. Asher wrote, “It is my intention to justify
placing beds and graves in the same category and to increase
the amount of dread with which beds are usually
regarded...There is hardly any part of the body which is im-
mune to its dangers.”10
More recently, the number of questioning voices has
grown. By now, numerous studies have challenged the im-
portance of bed rest as a significant treatment for back pain
and sciatica (back pain which radiates into the leg).11 It is now
more widely understood that unduly restricting activities with
enforced bed rest can lead to further problems of immobility
and disuse.12 These days, Karen would not be advised to stay
in bed so long!
The other widely applied passive treatments that Karen
received, such as heat, ultrasound and electrical stimulation,
although they may temporarily ease symptoms, have also been
de-emphasized. As the Agency for Health Care Policy and
Research (AHCPR) guidelines panel noted in their 1994 re-
port , “The use of physical agents and modalities in the treat-
ment of acute low back problems is of insufficiently proven
benefit to justify their cost. As an option, patients may be
taught self-application of heat or cold to the back at home.”13
Someone like Karen probably benefits now from another
growing trend: reduced willingness to do surgery. Back sur-
gery rates in the United States have been among the highest
in the industrialized world. When “failed back surgery” be-
came a diagnosis in its own right, some people began to won-
der if these higher surgical rates did equal better healthcare.
Despite the attitudes of a few surgeons like the one that Karen
met, surgery now has a much smaller role in treatment than
previously thought. This leads to more options for the person
with back pain, as well as better results when surgery does
seem necessary.
Karen’s experiences with chiropractic treatment represents

the experience of many as well. 40% of those getting care for
back pain see a chiropactor.14 As Karen discovered, spinal
manipulation (movements applied to the joints by a practi-
tioner) can sometimes provide relief. Some research evidence
indicates that such treatment can provide short-term benefits.
However, as Karen discovered, the long term benefit of
such care is not clear. Her confidence was not encouraged by
practitioners she met who used this approach as the major
part of their treatment and encouraged her to return again and
again for adjustments.
When Time Doesn’t Heal All Wounds

It has become widely accepted that activity-related back
pain has a self-limiting nature. In other words, a person will
likely recover from a particular episode simply with the pas-
sage of time. According to one widely referenced research
study, 44% of those with low back pain were better in a week,
86% were better in a month and 92% in two months.15
Therefore, pain medication as necessary, combined with
“watchful waiting,” appears to some practitioners as the best
overall approach for treating this common condition. Watch-
ful waiting involves the person with back pain remaining as
active as possible while letting nature take its course.16
The expense of dealing with back pain is staggering.
By the end of the twentieth century, lost productivity cost
U.S. industry more than $28 billion dollars per year. The
added costs of disability payments and medical costs may
have brought the total loss to more than $50 billion dollars
in the U.S. alone.17 For the sufferer, the expense of continu-
ing or recurring pain involves, in addition to monetary loss,
discomfort and emotional distress.
Is watchful waiting and encouraging general activity
enough to deal with this epidemic of disability? Is passage
of time sufficient?
As Karen learned, she was indeed likely to improve some-

what from any particular episode. However, afterwards she
still experienced some pain, restriction and weakness. Hav-
ing had a series of episodes over many years, she expected
future disabling recurrences as well. What then did “getting
better” mean?
Although some authorities still seem to believe that most
patients recover quickly and spontaneously from an episode
of back pain, evidence belies this. Researchers in Great Brit-
ain found that a much larger percentage of patients than ex-
pected had continuing severe symptoms a year after onset.18
Israeli researchers found that although the back patients they
studied did improve over time, most of them continued hav-
ing some pain and functional limitations at a two-month fol-
low-up.19
Recurrence of back pain also remains a persistent and
widely recognized problem.20 It may be true that for some
people each episode will be similar with similar periods of
recovery. Unfortunately there is little evidence that everyone
can expect full recovery with typical present-day treatment.
For a significant minority of people, ongoing symptoms
remain. Some of those who have gotten at least some relief,
may have continuing and worsening recurrences. Some de-
velop sciatica, which can include lower limb pain, tingling,
numbness and weakness in the muscles of the leg. This syn-
drome is commonly preceded by recurring episodes of back
pain.
Back pain is not necessarily as transient or as self-limit-
ing as it is often presented to be. As Karen learned, passage
of time is not always sufficient.
Activity and Exercise

Karen was told to stay as active as possible and encour-
aged to engage in moderate exercise after her acute episodes.
This advice follows the change in conventional wisdom I
discussed earlier. Rest is out. Activity is in. Most practitio-

ners presently agree that enforced and prolonged inactivity
does little good for back pain. Statistical evidence does indi-
cate that, in general, returning to normal activity as quickly
as possible seems beneficial to most people with an acute epi-
sode of back pain. Meanwhile, studies of people with chronic
back pain indicate that many seem generally to benefit from
fitness exercises even if they experience some pain while
doing them.21
But what activity and exercises are best for an individual?
Some practitioners seemed to have a theoretical rationale for
telling her to do one thing or another. Some doctors told Karen
that, as long as she kept active, no particular exercise seemed
best.22 When it came down to actually doing exercises, Karen
was often given generic exercises with only vague guidelines
about when to continue in spite of pain or when to stop be-
cause of it.
Karen’s confusion about exercise reflects the state of re-
search on exercise and back pain. Different theories may ex-
plain why an exercise should work or why an activity is use-
ful or harmful to the back. These theories may or may not be
sound. How can anyone know?
Based on their survey of various statistical studies, the
British Royal College of Physicians stated this in its Clinical
Guidelines for the Management of Acute Low Back Pain: “On
the evidence available at present, it is doubtful that specific
back exercises produce clinically significant improvements
in acute low back pain or that it is possible to select which
patients will respond to which exercises.”23
This vagueness and skepticism regarding exercise as well
as other forms of back treatment results in part because much
of modern healthcare has become overly dependent on a
particular, narrow, view of research.
A growing number of healthcare practitioners advocate
what they call ‘evidence’-based practice. It seems ironic that
some advocates of this approach emphasize the usefulness

of only one form of evidence: information gained from the
statistical study of large groups of people.
This kind of information can be useful for making cor-
relations between types of treatment and general outcomes
for groups of people. If you want to know whether a par-
ticular treatment works on the average, you need this kind
of study.
However, there is information that can never be gotten
from doing this kind of research. Statistical studies will
never tell you how a treatment works or how an individual
functions, although it may suggest ideas. Neither can any
statistical analysis tell anyone exactly how a particular
individual, like Karen or you, will respond to a particular
treatment. At best it can only provide probabilities. De-
pending too much on group statistical methods thus pro-
motes a generic approach to activity and exercise.
Such an approach seems well-suited to the mechanized
practice of medicine and healthcare that some insurance com-
panies and HMOs have come to encourage. The individual-
ity of each patient can easily get ignored and forgotten in the
push to compile statistics and cut costs.
Fortunately, other methods of research are available. If
you take the attitude of a personal scientist in regard to your
own problem, you don’t need to remain completely in the
dark about what and what not to do. You can apply the
method of possibilities, as discussed in the last chapter, to
discover what works for you.
Every person is a unique and different individual. Al-
though similar to others, you are not exactly the same in
all respects as anyone else. Therefore, it follows that par-
ticular activities and exercises will have their own specific ef-
fects on you. By closely observing these effects, it is possible
to determine what works best for you. A practitioner who fol-
lows such a scientific approach can help you in applying it to

your problem and you can learn to do it for yourself (see
Chapter 10).
The Problem with ‘Posture’

Every type of healthcare practitioner that Karen saw
talked with her about her posture. She was consistently told
by orthopedists, physical therapists and chiropractors that
good posture could help her to restore the proper functioning
of her back. She was given written postural instructions as well
as stretching and strengthening exercises to improve her pos-
ture.
Her experience reflects a significant consensus regarding
posture among these different groups.
For example, a brochure on Low Back Pain issued by the
American Academy of Orthopedic Surgeons states, “The best
long-term treatment [for lower back pain] is an active preven-
tion program of maintaining proper lifting and postural activi-
ties to prevent further injuries.”24
The American Physical Therapy Association Book of Body
Maintenance and Repair states, “Posture has significant im-
plications for the general health and well-being of much of
the body…The back, and the lower back in particular, is es-
pecially sensitive to proper or poor posture…For your body’s
sake…it is essential to practice proper posture as much as
possible in all activities of daily life.”25
The American Chiropractic Association issued a
policy statement that “…advises and recommends to the public
that good posture in all age groups has a direct and significant
impact on not only spinal biomechanics but on all bodily func-
tions. Recognition of the interrelationship and interdepen-
dence of good posture to good health requires that an increased
awareness be developed by the public regarding the necessity
of developing good postural habits in order to assist the body
in achieving and maintaining good health.”26
Posture is defined as the relative arrangement of the parts of

the body to each other and to the environment. Typically, it is
measured, as a person stands, by dropping a plumbline sideways
from the tip of the ear to the ankle joint and looking at the align-
ment of body parts along this vertical line. Alignment is also ob-
served from front and back views of the body.
Good posture (also called “body mechanics” or “use”) can
be defined as that posture which produces the least strain and
maximum efficiency during everyday activities.
This all seems fine and good. But there are hidden quanda-
ries. When people think about ‘good posture’ they often tend to
think of something static and fixed. This is reinforced by how
‘posture’ is measured, putting a person in a relatively static posi-
tion or taking a photograph and measuring the alignment of the
parts.
It is not that this type of measurement is not useful. It can be.
However, the static measurement of posture has been combined
with the view of posture as a static and fixed ‘thing’and a view
of the human organism as a collection of parts to be dealt with
separately.
People may then try to impose this static, piecemeal picture
on themselves or others by holding themselves in a way that can-
not be maintained for long. Or they may try to improve their
posture with exercises designed to improve parts of them-
selves, i.e., range of movement and strength of the back and
abdominal muscles, which achieve only partial effects.
This has gone along with a failure to recognize both the
general and individual requirements for learning new postural
habits. As Karen discovered, the end result has been an em-
phasis on specific exercises to improve everyday posture. Such
exercises are not sufficient for changing the moment-to-mo-
ment posture that you use in your daily activities. Thus the frus-
tration that many of us have when trying to ‘improve’ our pos-
ture.
“Posture” and “movement” are not necessarily opposites.

Even when you seem to be sitting or standing still, there
are always some movements going on. The movements of
breathing continue, as do the slight swaying or balancing
movements that occur when you are standing quietly. Posture
always involves movement or activity. Movement or activity
always involves some posture.
To acknowledge this relation between posture and move-
ment, some people refer to static posture as your posture at
rest. This roughly corresponds to sustained positions that we
get into. Dynamic posture refers to your posture when you
move.
I coined the term “posture-movement” to make the in-
terrelatedness of posture and movement explicit. Remember-
ing this relation may lead to better posture-movement solu-
tions.
Half-Mast and Full-Sail Self-Care

Most back pain involves activity-related (posture-move-
ment) problems. With less emphasis on bed rest, passive treat-
ments and surgery, we have advanced towards better ways of
dealing with these problems. More people understand the
general benefits of activity. This has led to more people see-
ing the importance of self-care and prevention, what the per-
son experiencing back pain can do for herself.
However, just being told to stay active or being given a
sheet of generic instructions on exercise and posture is often
not enough to take full advantage of the possibilities for self-
care. I call this generic approach the ‘half-mast’ way. A sail-
boat cannot take advantage of the wind if its sail is not up com-
pletely. An approach to prevention cannot work well with cur-
sory, surface efforts.
By contrast, in this book I present a ‘full-sail’ way of pos-
ture-movement self-care. I provide you with the background
you need for understanding your back problem and specific

principles and methods you can apply to make full use of your
potential for self-care.
With my help in applying such methods, Karen no longer
feels plagued by chronic pain. Although she has had recur-
rences, they are less frequent and less severe. Her back moves
more easily and she no longer feels the fear that “it is made
of glass and will shatter.” She is working out at a gym and
has begun playing tennis and basketball again for the first time
in eight years.
“I was very skeptical when I met you,” she wrote to me.
“I recall that my first few visits were filtered through my nega-
tive thought at the time, ‘What is this guy going to do for me?’
I’ve come to realize, it wasn’t what you did for me. It’s what
you taught me to do for myself.”
Possibilities
Is it possible that the tremendous costs of back pain dis-
ability are not inevitable?
Is it possible that the full potential for activity-related
methods might be realized by providing a means for compar-
ing theories of what should work against the experience of
what actually does work for individuals?
This book can help you to answer these questions for yourself.
Chapter 3
Back Pain Solutions I:

The year was 1981, the place a busy hospital in Pittsburgh.

My first glimpse of Paul was of his being wheeled down the
hallway of the physical therapy department towards the cur-
tained booth where I would see him. Lying on his back on a
gurney, a patient transport table on wheels, he looked nervous.
I felt a little nervous myself, as I often did just before
meeting a new patient. I didn’t need to feel worried. As a
young physical therapist working with people with back pain,
I had begun to have a fair amount of success applying the
activity-related approaches I had studied.
An New Old Approach to Back Pain

The ancient Chinese and Hindu civilizations both used
therapeutic exercise (positions and movements) in their sys-
tems of medicine.1 Posture and movement as therapy also has
a long history in the West. More than 2000 years ago, the
Greek physician Hippocrates used manipulation and traction
to treat people with back pain.2 Massage and exercise also
played important parts in his general practice.3 In his book On
Articulations he emphasized the importance of balancing rest
with active movement. He wrote:
...all parts of the body which have a function, if used in
moderation, and exercised in labors to which each is ac-
customed, become thereby healthy and well-developed,
and age slowly; but if unused and left idle, they become
liable to disease, defective in growth, and age quickly. This
is especially the case with joints and ligaments, if one does
not use them. In those who are neglected and never use the
leg to walk with but keep it up in the air, the bones are more
atrophied than in those who use the leg.4
As Erwin H. Ackerknecht noted in his Short History of

Medicine, Hippocrates also “put great emphasis on the value
of observation of the disease process, on the practical rather
than the theoretical. This...relegates speculative theories to
minor importance.”5
In later centuries, this activity-related and observation-
based approach began to get neglected in relation to back pain.
By about 200 years ago,Waddell notes, “restriction of activ-
ity, rest and even bed rest [had become] the traditional medi-
cal treatment.”6
Nonetheless, a small number of medical doctors and sur-
geons, osteopaths, chiropractors and physical therapists,
among others, carried on the practice of various forms of ac-
tivity-related (posture-movement) therapy for back pain with
varying degrees of success.
In the twentieth century, James Cyriax, M.D., had a ma-
jor influence on physical therapists interested in using activ-
ity-related therapy for back pain and other musculoskeletal
problems. Cyriax promoted a precise method of testing and
diagnosing mechanical disorders by observing the effects of
postures and movements on symptoms. As he noted, “a change
in symptoms corresponding to the stresses acting on the le-
sion is common to all disorders of the moving parts.”7 He
taught simple, precise methods of treatment, particularly ma-
nipulation (passive movement), and promoted the use of these
methods by physical therapists.
Physical therapists such as Freddy Kaltenborn, Geoffrey
Maitland, Stanley Paris and others have carried forward this
tradition of activity-related treatment, especially the use of
passive movement (manipulative therapy). Maitland, for ex-
ample, has greatly elaborated on the art of closely observing
the relation of the “pain response (its quality and its behav-
ior) to movements and positions.”8 He has taught therapists
how to use this pain response as a guide to treatment by means
of passive movement.
POSTURE–MOVEMENT THERAPY 35
Physical therapist Robin McKenzie has also advanced

activity-related treatment. He and his colleagues emphasize
using exercises (movements and static postures carried out by
the individual) as a form of self-treatment. As Jacob and
McKenzie note, “ As with the rehabilitation tradition, the pref-
erence is for patient self-generated movements.”9
In this approach, self-treatment with posture and move-
ment, guided as needed by a therapist, does not preclude the
use of passive movements when necessary. However, as self-
treatment often works successfully on its own, it seems bet-
ter to apply it first before going on to manipulative treatment
by the therapist. This provides the person with back pain more
opportunity to learn how to manage his own symptoms.10
Paul’s story illustrates the usefulness of this approach.
Paul
Paul was a mechanic in his mid-thirties. While he was
guiding a heavy engine being put into place with a hoisting
device, the chain slipped. Before he had time to think, Paul
tried to catch the engine to keep it from falling. He felt some-
thing give way in his back. Over a number of weeks the im-
mediate low back pain had gradually spread into his right
buttock and down the back of his leg into his calf.
After about two months and despite some physical therapy
and chiropractic treatments, the pain was now constant and
disturbing his sleep. Sitting and bending were agony, as were
standing and walking any distance. He was unable to work.
He had been admitted to the hospital for a workup, including
a myelogram, prior to anticipated surgery for a herniated disc.
A myelogram is a special x-ray test wherein fluid is first
injected into the spinal canal. This fluid makes it possible to
see dents in the lower spinal cord and nerves which can indi-
cate if and in what location a herniated disc may be pressing
on nerve tissue. Paul’s myelogram was scheduled for the next
day.
Paul was in the clinic this day for some ‘palliative’ treat-
ment: heat, ultrasound, massage and flexion exercise. I got a
history of his problem from him and carefully (he was in con-
stant, severe pain) tested the reflexes, sensation and muscle
strength in his legs. Although he had pain and tingling in his
right calf, the results seemed normal.
To comply with the orthopedist’s orders to do flexion
exercises, I asked Paul to pull his knees to his chest. Paul was
willing to try. However, the pain in his calf increased and
spread into his foot after only a few movements. I decided that
flexion exercises were not for him right now. I asked him to
stop and roll over onto his stomach (a static prone-lying pos-
ture). He moved slowly and carefully, in evident pain, and I
went to get the heat pack.
Knowing how positions and movements can affect symp-
toms, when I returned I asked him how far the pain in his right
leg extended. His foot had stopped hurting and tingling—
however, he felt intense discomfort going down to his mid-
calf.
I helped him to lift himself up while I placed a pillow un-
der his belly to see if this might make a difference. He felt no
worse. I helped him lift up again to place another pillow. This
time the pain retreated up to the back of his knee. I was en-
couraged because the site of his pain had changed by chang-
ing his position. I placed the hotpack on his back and left the
room for a few minutes.
When I returned, Paul reported that his knee felt better.
He felt pain from his back and buttock down to his mid-thigh,
a good sign. The pain was “centralizing,” a term McKenzie
uses to describe symptoms moving out of the limb and towards
the spine (see the section on Soft Tissue Changes in Chapter
9). So I left Paul with both pillows and the hot pack, which
was basically there to distract him and keep him still.
POSTURE–MOVEMENT THERAPY 37
After five minutes his symptoms had not significantly

changed. I decided to see what would happen if I removed first
one pillow and then the second. After he settled back down
on the table, with his spine in a basically neutral position, he
reported no pain in his thigh, only in his back and buttock.
An hour later, my supervisor was wondering why I was
keeping my patient so long and Paul was doing press-ups, an
exercise during which he repeatedly extended his spine —bent
it backwards—by pushing up with his arms while lying on his
stomach (Exercise #3 in Chapter 10). He had some difficulty
doing this. The movement was limited. However, the pain in
his leg and butt had vanished. Although the right-sided back
pain was still present, it had shifted closer to the center of his
back. It had taken more than an hour, with many gradual ad-
justments of pillows and body position on the table, but both
Paul and I felt elated.
Paul’s orthopedic surgeon had his office next to the physi-
cal therapy clinic. I ran over to talk with him. I described what
I had done with Paul and how he had responded. I requested
that the order be changed to extension exercises and explained
my rationale for doing so. At the time, flexion exercises were
prescribed almost universally in the U.S. and this approach,
using extension when appropriate, was not well known or ac-
cepted. He looked skeptical but agreed and I beat a hasty re-
treat.
Back in the clinic, Paul’s arms felt sore. He had done 40
press-ups while waiting for me to return. But although he felt
moderate pain across his lower back, he felt much better over-
all, with no buttock or leg pain. I suggested he do the exer-
cises every couple of hours, and sent him back to his room.
Paul returned to the clinic the next morning. He had a small
amount of constant back pain which, with exercise and a brief
use of passive movement (spinal manipulation) applied by me,
he was able to get rid of by the afternoon’s session. His my-
elogram had been cancelled. He was discharged the follow-

ing day and continued coming for about 3 weeks as an outpa-
tient, until he had returned to full duty at work and was en-
tirely pain-free. On his last visit he thanked me for helping
him to avoid surgery.
As Paul discovered, the effectiveness for an individual of
activity-related treatment does not depend on abstract theo-
ries or statistics. Neither a theory nor a statistic will indicate
exactly how you as an individual will respond to a treatment.
Rather, treating you as an individual requires an empirical, ob-
servational approach.
Taking the attitude of a personal scientist, you can deter-
mine what works for you. Applying some of the insights of
Hippocrates, Cyriax, Maitland and others, you can become a
better observer as you explore the possibilities of posture and
movement to reduce your pain and improve your functioning.
In this way, you can become a better consumer of the
healthcare services that you receive. Using the insights of
McKenzie, you especially can explore the role of self-treat-
ment in posture-movement therapy. (Chapter 10 details a set
of positions and movements that you may find useful.)
What positions and movements reduce your symptoms
and improve your ability to move?
This chapter has introduced you to some of the background
and application of posture-movement therapy. This approach
to therapy solutions for back pain works together with edu-
cational solutions which I explore in the next chapter.
Chapter 4
Back Pain Solutions II:

Posture-Movement Education
The Problem of Habit

As I saw more and more people with back and neck prob-
lems, I continued to have many successes. I found that people
often were able to control their symptoms through exercises
using different positions and movements, with manipulative
treatment (passive movements) supplementing this when
needed. As part of this work, I also emphasized the importance
of dynamic posture in daily life. However, as the following
story shows, I discovered difficulties in helping people adopt
new, healthier habits.
One day, while visiting a friend’s house, I noticed some-
thing different about his 15-year-old son. I had gotten used to
seeing Jeremy slumping, his spine in the shape of a big letter
C and his head protruding in front of the rest of his body. This
day, although this usual posture hadn’t changed, Jeremy
moved carefully and stiffly. What was the problem?
Jeremy had woken up with a pain in his neck and upper
back on one side. He had difficulty turning his head. He had
no idea what had caused this to happen all of a sudden. I asked
him and his father if I could help. Knowing that I worked as
a physical therapist who specialized in this kind of problem,
they both agreed.
I first asked Jeremy to tell me a little bit about the pain.
(See Index Your Symptoms, in Chapter 10, for more on the
skill of accurately describing symptoms.) Jeremy’s pain felt
constant. That is, he noticed some discomfort even when rest-
ing. I asked him to show me on his body exactly where he felt
the pain. It spread from the right side of his neck and upper
back to several inches along the top of his right shoulder blade.
His head and neck movements appeared restricted and
painful, especially towards the right. He also couldn’t extend
his head and neck very far back to look up towards the ceiling.
I asked him to rate his symptoms on a scale from 0 to 10,
with 0 meaning no pain and 10 meaning the worst that he could
imagine. Using a simple scale like this provides a way to be-
come a better observer of your symptoms and thus to prac-
tice being a personal scientist. Jeremy said it felt like a 6.
I explained to him that these kinds of symptoms are often
related to positions and movements of the body. Seeing his
greatly distorted protruded-head position, I thought that work-
ing on his posture would be a good place to start.
I asked him if he would allow me to help him to experi-
ence a different position of his head and neck in order to see
what effect it would have on his symptoms. He agreed to this
and I invited him to sit on a chair. I proceeded very gently to
guide him into a position where his back was no longer
rounded and his neck and head were brought back closer to
the top of his spine. This took several minutes, during which
time I talked with him, asking him to let go of tensions or
holding here and there and encouraging him to let me know
how he was feeling.
After getting repositioned, he sat erect, an unusual posi-
tion to see him in. He himself felt quite odd, almost crooked.
I asked him what he felt in his neck. There was now only a
small amount of discomfort, about a 3, along his spine in the
mid to lower neck. Just changing his sitting posture had
changed his symptoms for the better. Interestingly enough, his
ability to move had also improved.With my hands gently
guiding his head and neck movements, he could now turn his
neck more fully to both sides with little increase in pain.
POSTURE-MOVEMENT EDUCATION 41
Since I had to leave soon, I reviewed the importance of

everyday posture in the best way that I could under the cir-
cumstances. I demonstrated good and bad postures and ex-
plained how maintaining good posture would help. He ac-
knowledged that he already had experienced evidence of this.
Then I instructed him in the “chin-tuck” exercise (de-
scribed in Chapter 15), a movement that emphasizes the op-
posite direction of his habitual protruded-head position. He
had some difficulty doing it on his own and I guided him
through the movement with my hands. The small amount of
pain decreased and, after about twenty repetitions, had alto-
gether vanished.
While I talked with his father, Jeremy walked around for
a few minutes. After awhile I could see that he had begun to
return to his habitual slump. When I asked he said that some
of the neck pain, not as severe, had also returned. I urged him
to do the exercise I showed him, even if he had a bit of trouble
with doing it correctly.
I didn’t see him again until several weeks later. He was
slumping as much as ever. When I asked him how he was
doing, he thanked me. He had done the exercises and corrected
his posture as best he could and he reported that he had no
pain. Given his slumping, how long-lasting would this be, I
wondered.
Working with people with back, neck and other activity-
related pain, I had many similar experiences. A few people,
who it clearly seemed could benefit from improving their
posture, didn’t see the point. “I’ve slumped all my life,” they
might say, “but I just started having pain in my back so how
can you tell me that my posture is a problem?”
Many others did see the point but despite their best efforts
to comply often were unable to maintain the good postures
that I showed them for sitting, bending and moving. And more
often than not, people thought they were doing the exercises
correctly and moving with better posture and body mechan-
ics when they weren’t.
It seemed clear here that so-called ‘subjective’ or ‘men-
tal’ factors—people’s desire to change, their body awareness,
their willingness to experience themselves in new and unfa-
miliar ways and their persistence and willingness to work,
among other factors—had as much importance as the ‘objec-
tive’ exercises and instructions I gave them.
Fortunately, what people could do often seemed good
enough temporarily. But I felt frustrated about not being able
to make further inroads in helping people change their habits
—habits that might prolong their symptoms and make them
more vulnerable to future episodes of pain. I wondered about
the bent-over elderly people I saw in the hospitals and nurs-
ing facilities where I had worked, as well as on the street. To
what extent was this condition due to years of postural neglect?
My study of therapy approaches had brought me to the
edge of what appeared to be an educational problem. It is easy
to treat your body as an object and let your attention go some-
where else while doing exercises. This can reinforce the illu-
sion that there is a separate ‘mind’ and separate ‘body’. Then
you can neglect the so-called ‘mental’ aspect. However, for
posture-movement education to have any chance of success,
‘subjective’, or ‘mental’ factors, cannot be left out.
Education and ‘Body’–‘Mind’ Unity

By the time I went to physical therapy school in the late
70s and early 80s, lip service—perhaps more commonly given
nowadays—was already being paid to the unity of the ‘mind
and the ‘body’ (ironically, by talking in terms of two separate
things—the ‘mind’ and the ‘body’).
In practice the split of ‘body’ and ‘mind’ pervaded physi-
cal therapy and medicine, as it does today. The approaches I
learned in physical therapy school emphasized the ‘body’ as

a machine made of isolated parts and downplayed or neglected
the role of the inner life (consciousness) of the individual.
Understanding the mechanisms (how they work) of
nerves, muscles, joints, exercise, etc., was and still is consid-
ered ‘objective’ and ‘scientific’. Understanding the role of
consciousness—the mechanisms (how they work) of my own
inner life and that of the individuals I sought to help—was
considered ‘subjective’ and less ‘scientific’, or at least not a
part of ‘real science’.
As a physical therapy student, I observed that the best cli-
nicians and teachers were able to unify the so-called ‘objec-
tive’ and ‘subjective’ elements in their work. Nonetheless, my
interest in dealing with both the outer and inner person seemed
odd and peripheral to the main business of exercise science
that I studied.
As a student of the practical philosophy of General Se-
mantics, I had already rejected the divisions of ‘objective’ and
‘subjective’, ‘body’ and ‘mind’, as unsound.
With biologist C.H. Waddington, I agreed that:
An attempt to make a clean cut break between the subjec-
tive mental observer and the objective material observed
[what philosopher Alfred North Whitehead called the ‘Bi-
furcation of Nature’], is a basic error. They are initially
parts of a whole, and if one wants for some purposes to
separate them, that can only be a matter of convenience
that should be indulged in with great caution.1
I began to put this understanding into practice by becom-
ing more aware of my language and that of others. I worked
to remember what general semanticist Alfred Korzybski
wrote:
Linguistic and grammatical structure also have prevented
our study of human reactions. For instance, we used and
still use a terminology of ‘objective’ and ‘subjective’, both
extremely confusing, as the so-called ‘objective’ must be
considered a construct made by our nervous system, and

what we call ‘subjective’ may also be considered ‘objec-
tive’ for the same reasons.2
I began to think, talk and write about myself and others in
terms of Korzybski’s phrase “organisms-as-wholes-in-envi-
ronments.” 3 I worked at remembering that successfully deal-
ing with the living reactions of individuals (myself included)
must involve the so-called ‘subjective’ factors as nervous sys-
tem functions of the organism. I began exploring practical
methods of working with people that did not divide a fictional
‘mind’ from a fictional ‘body’. These studies included Sen-
sory Awareness (discussed in Chapter 12) and F.M.
Alexander’s work. Eventually I became a teacher of the Al-
exander Technique.
A New Old Approach to Posture-Movement Education
Posture-movement education almost undoubtedly goes
back to the first efforts of early humans to help their young
learn the motor skills related to hunting, gathering and other
aspects of daily life. Written records of posture-movement
education can be found in accounts of the several-thousand-
year-old practices of Chinese Kung-Fu (Qigong), Indian Yoga
and Greek and Roman gymnastics, which paralleled the work
in therapy that I discussed in the last chapter.4
In Europe in recent centuries, singing teachers and voice
coaches focused on their students’ posture habits in relation
to breathing and movement.5
During this same period, posture-movement education
also continued in the work of a number of physicians and as-
sociated workers in physical education. These people realized
the importance of engaging the body-mind (organism-as-a-
whole-in-an-environment) when working to help people with
posture, movement and breathing difficulties.6
Probably influenced by translations of Chinese Qigong
texts,7 the Swedish Gymnastics movement founded by Pehr
Ling, had particular importance in both the medical and non-

medical areas.8,9
Dr. Mathias Roth wrote this about Ling’s system of Medi-
cal Gymnastics in his 1856 Handbook of the Movement Cure:
The oneness of the human organism, and the harmony
between mind and body, and between the various parts of
the same body, constitute the great principle of Ling’s gym-
nastics.
The development and preservation of the harmony between
mind and body, as well as among the various organs of the
body, is the object of Ling’s system with regard to healthy
persons, and this is the educational or prophylactic part of
the system, while the restoration of the disturbed harmony
of the different organs produced by diseases, forms the
object of the medical part.10
It is against this background that Australian-English ac-
tor F. Matthias Alexander (1869–1955) sought a solution to
the vocal problems that he developed in the last decade of the
nineteenth century.
According to Alexander’s account in his 1932 book, The
Use of the Self,11 he worked over a period of time observing
himself in the act of speaking. Although obscure about his
sources, it seems likely that in order to work out his own prob-
lems he supplemented his self-observations with study of
some of the available literature and consultation with profes-
sionals in the field.12
“Synthesizing parts from voice pedagogy and physical
therapy,” as Ed Bouchard and Ben Wright state in their book
Kinesthetic Ventures, Alexander “...developed a ‘technique’
employing gentle touch to teach natural posture and breath-
ing essential to effective vocal use.” 13 This work has also been
found effective in working with people with back pain and
other posture-movement related problems.
Alexander’s synthesis follows a number of basic prin-
ciples. Patrick Macdonald, a student of Alexander’s who be-
came a well-known teacher of his technique, listed these as

follows (modified by me and in a different order):
Recognition of the Force of Habit
Head-Neck-Back Relations
Importance of Sensation/Perception
Inhibition
Sending Directions 14
I will briefly discuss each of these notions in turn, as to-
gether they cover some of the main issues of posture-move-
ment education.
Recognition of the Force of Habit
Alexander emphasized the role habit plays in our posture
and movement. William James, in his 1890 classic Principles
of Psychology, had already written a great deal about habits.
In a lecture based on this work he said:
All our life, so far as it has definite form, is but a mass of
habits, — practical, emotional, and intellectual, — system-
atically organized for our weal or woe, and bearing us ir-
resistibly toward our destiny, whatever the latter may be.15
James wrote directly about posture-movement habits
(what Alexander called “the use of the self”) in his essay, “The
Gospel of Relaxation”:
The general over-contraction may be small when estimated
in foot-pounds, but its importance is immense on account
of its effects on the over-contracted person’s spiritual life.
...For by the sensations that so incessantly pour in from the
over-tense excited body the over-tense and excited habit
of mind is kept up.... [O]ver-tension and jerkiness are pri-
marily social, and only secondarily physiological, phenom-
ena. They are bad habits, nothing more or less, bred of the
imitation of bad models and the cultivation of false per-
sonal ideals.16
As Alexander found, those who seek to help themselves
or others move towards better posture will need to deal in one
way or another with the force of habit.
Head-Neck-Back Relations
In his later writings, Alexander emphasized the importance
of the relations among the head and neck, the back and the
rest of the body. Years after his initial explorations, he noted
that these relations constituted “the primary control” for body
use (posture-movement habits).17
Talking about “the primary control” can imply that some-
thing exists as a more-or-less separate and all important en-
tity. Some have attempted to locate “the primary control” in a
single part of the anatomy or as an isolated physiological func-
tion. However, the mutual, dynamic postural relations among
the head, neck, back (spine), torso and limbs exist in a larger
context of the external environment, a person’s internal physi-
ology and his/her conscious state. These complex interrela-
tions make it inadvisable to label any one part or factor ‘the
primary control’.
Nonetheless, in posture-movement education, the head,
neck and back (spine) relations do have importance. Many rec-
ognized this prior to Alexander.
Japanese, Chinese and Indian practitioners in various
meditative and movement practices recognized long ago the
importance of the head, neck and back in “right posture.”18
The singing teachers and teachers of medical gymnastics
mentioned before taught this as well. Scanes Spicer, M.D., a
physician who studied these approaches and with whom Al-
exander was acquainted, wrote early in this century about the
importance of the head, neck and spine in posture education
for respiratory and other problems.19
These students of posture and movement understood the
mutual relations among the limbs, the lower torso (the belly
and lower back), the rest of the torso (chest and upper back)
and the neck and head. They knew that inadequate support
from below can encourage poor posture of the head and neck.
In turn, habitually tightening the neck and pulling the head
backwards, or letting it slump into this position, can encour-

age a downward direction and shortening of the rest of the
body. This is the protruded head position that Jeremy habitu-
ally assumed.
By contrast, adequate support from below allows freedom
in the neck so that the head can move from the backwards-
pulled position to a more forward and upright one. This means,
in Spicer’s words, a “passive, loose balance of head on spine;
no active muscular tension or rigidity.”20 In turn, this encour-
ages a continuing upward direction and lengthening of the rest
of the body with “fullest spinal extension...straightening out
not only dorsal spine (to enlarge chest), but also cervical spine
(to enlarge throat) and lumbar spine (to make room for vis-
cera backwards).”21 This is the more neutral, erect position
that Jeremy assumed with my help. Figure 4.1 illustrates the
head and neck portion of these two contrasting postures.
Figure 4.1 – Head Back and Down vs. Forward and Up
A phrase used by Alexander summarizes this second, more

beneficial posture: “Let the neck be free, to let the head go
forward and up, to let the back lengthen and widen.”
Importance of Sensation/Perception
Our sensations/perceptions play a major role in our
posture-movement habits. Observing himself and others, Al-
exander noted what his student Macdonald called “faulty sen-
sory awareness.” We may not have an adequate sense of what
we are doing with ourselves. Someone who mistakenly per-
ceives himself as already having good static and dynamic pos-
ture will not see the need to correct it.
Before and since the time that Alexander presented his sys-
tem, others working in the field of posture-movement educa-
tion have been aware of the fallibility of our senses and the
importance of improving awareness in relation to our posture
and movement.
Dr. Mathias Roth, whose work influenced Spicer (and
quite likely Alexander as well), published An Essay on the Pre-
vention and Rational Treatment of Lateral Spinal Curvature
in 1885. Roth noted:
The majority of patients suffering from various forms of
spinal curvatures are not aware of their abnormal position;
they feel straight while in a crooked position, and while
the spine is curved; the spinal curvature is usually accom-
panied by compensating abnormal position of the head.22
Roth advises that with training, sensation can become a
more reliable guide to posture and movement:
The majority of patients being unconscious of their abnor-
mal position, the first object to be obtained is to change
the false mental impression they have in believing them-
selves straight when they are crooked, and feeling crooked
when placed in a normal position. The second object is to
enable the patients to retain the normal position, which at
first causes the sensation of being crooked.23
In keeping with this, Alexander worked at developing
hands-on teaching methods to help students gain more trustwor-
thy sensations/perceptions related to better body use. As he said:
Surely...if it is possible for feeling to become untrustwor-

thy as a means of direction, it should also be possible to
make it trustworthy again. 24
Inhibition
In The Use of the Self, Alexander described how he gradu-
ally became more conscious of the abnormal positions and
movements ruining his voice. He also gradually began to
change the false impression he had of his posture and move-
ment and to experience better, more normal positions.
However, once he had begun to realize a better way of us-
ing himself while speaking, he found that he couldn’t retain
it. He still often continued with his old, bad posture-move-
ment habits.
These included pulling his head back and downwards on
his neck. At the same time he would compress and tighten his
throat, puff out his chest and ribs, arch his back and tighten
his legs and grip his feet on the floor, among other things. He
could see and feel that this excessive effort interfered with his
breathing even as it involved greater and greater pushing to
get his voice out.
Observing the effects of faulty sensory awareness in him-
self, he also saw that his problem was not simply ‘physical’.
It started with his intention to speak. As soon as he formu-
lated the idea of speaking he could observe himself tighten-
ing his neck, pulling his head back and down, and initiating
the rest of his pattern of excessive tension.
Alexander experimented with pausing before he actually
spoke. While he did this, he consciously focused on not go-
ing into the old pattern. This idea of pausing, or stopping and
not doing some intended action, had been applied by others25
and became an important aspect of what Alexander taught. He
called it “inhibition,” a term used in various works of psychol-
ogy available at the time. Alexander combined inhibition, or
delaying the immediate response to a situation, with what he
called the process of “sending directions.”
Sending Directions
While Alexander observed himself with mirrors—as rec-
ommended in the physical therapy of the time26—he practiced
sending “directions” or “orders.” These were subvocal instruc-
tions that he gave to himself, which included negative direc-
tions. He thus reminded himself to delay his response to speak
and to not pull his head back, etc.
Alexander’s negative directions qualified as, in William
James’ words,“inhibition by repression or negation.” James
had pointed out the danger of focusing too much on what not
to do where “both the inhibited ideal and the inhibiting
ideal...remain along with each other in consciousness, produc-
ing a certain inward strain or tension there.” 27
Alexander wisely sought to reduce this strain by also send-
ing positive directions—positive subvocal verbal instructions
for proper use that he gave himself. The words served as aids
for him to direct his attention to himself: “Let the neck be free,
to let the head go forward and up, to let the back lengthen and
widen.”
This second, positive use of directions allowed him to
practice what James called “inhibition by substitution,”
wherein “the inhibiting idea supersedes altogether the idea
which it inhibits, and the latter quickly vanishes from the
field.” 28 The positive instructions for good use helped him sub-
stitute for, and supersede, the poor use. This positive use of
directions may have greater usefulness than the negative.
James noted:
It is clear that in general we ought, whenever we can, to
employ the method of inhibition by substitution....Spinoza
long ago wrote in his Ethics that anything a man can avoid
under the notion that it is bad he may also avoid under the
notion that something else is good.29
Continuing to observe himself in the mirror, Alexander
could confirm that he was not doing what he didn’t want to
do. He could also see that he was doing what he wanted to

do. His sensory awareness became more reliable. With prac-
tice he found that he could continue his good body use while
speaking and with other activities of daily living as well. He
could thus avoid the habitual strain to which he previously had
been accustomed.
James had written “To think...is the secret of will....”30
Whether Alexander read William James’ work directly is un-
known. But the ideas of the new psychology, research in hyp-
nosis, as well as popular watered-down versions of this work
involving so-called mind cures, etc., were in the air. Earlier
medical practitioners like Roth had emphasized the impor-
tance of sensory awareness and the conscious direction of will
to deal with posture-movement problems. Again, more an-
cient practitioners had gotten there first. The Chinese Qigong
classics advised: “Use intent, not force.” 31
Did Alexander re-discover this completely on his own?
Who knows? Nonetheless, it is a powerful notion which he
used and taught to others. Posture-movement habits can best
be improved not with stretching or strengthening exercises
(force) but with the ‘exercise’ of thought and awareness (di-
rected intent) in daily life.
Alexander’s Contribution
In seeking to solve his own vocal problems, Alexander
brought together the notions of direction, inhibition and the
other elements discussed previously into a unique system of
posture-movement education.
A strong sense of ethical concern permeates his approach
—characterized by the realization that ends and means exist
inseparably from one another. In connection with your every-
day posture-movement habits, if you use stress-inducing body
mechanics as your means, the ends you actually achieve will
more likely include pain and inefficiency. Aldous Huxley, who
took lessons from Alexander, pointed out that this can serve
as a exemplar for the larger area of human ethical action.32
Alexander’s contribution to posture-movement education
has been well-summarized by posture-movement researcher
and Alexander Technique teacher Ron Dennis:
In what must now appear as a variously-sourced synthe-
sis, Alexander's creative contribution needs clear acknowl-
edgment. If he did not, on the one hand, singlehandedly
reveal an entire new field of endeavor, he did, on the other,
succeed in fashioning, from heretofore disparate elements,
a distinctively harmonious system, one praised by contem-
porary physicians as 'a very advanced craft and a very
subtle philosophy',* and one moreover imbued with an
ethos of self-help not merely for symptomatic relief but
for the very rightness of it all. This ethical aspect of 'the
Work' may well have been what drew such eminent think-
ers as John Dewey, Aldous Huxley and George Bernard
Shaw, as well as numerous others, to it. 33
[*The reference is from The Use of the Self, Appendix, Letter
of May 8, 1930, from Drs. Cameron, Douglas, et al.]
The Skill of Everyday Living
A. N. Whitehead wrote that “Familiar things happen, and
mankind does not bother about them. It requires a very un-
usual mind to undertake the analysis of the obvious.”34 We
easily recognize the skill involved in the feats of Olympic and
professional athletes. Yet most of us do not recognize the com-
plexity of skill involved in the the most obvious activities of
everyday living.
C.S. Sherrington, an ‘unusual mind’ who helped found
modern neuroscience, once observed:
[Standing] requires among other things the right degree of action
of a great many muscles and nerves, some thousands of nerve-
fibres and of perhaps a hundred times as many muscle-fibres.
In doing so my brain’s rightness of action rests on receiving
and adjusting pressures, tensions etc. in various parts of me.35
Our everyday skilled acts may involve unnecessary effort

that can have cumulative harmful effects on how we
function.This can contribute to back pain, among other prob-
lems. Sherrington also observed:
Breathing, standing, walking, sitting, although innate,
along with our growth, are apt as movements, to suffer from
defects in our ways of doing them. A chair unsuited to a
child can quickly induce special and bad habits of sitting,
and of breathing. In urbanized and industrialized commu-
nities bad habits in our motor acts are especially common.36
Perhaps because we do not usually think of our basic acts
as skills, we do not take advantage of the possibilities for im-
proving them. Dennis has emphasized that posture-movement
education, as exemplified by the Alexander Technique, fo-
cuses on helping you acquire greater skill in your mostly un-
consciously acquired activities of daily living.37 In develop-
ing your posture-movement skills, you can reduce the stress
on your back and other parts and improve your level of effi-
ciency and comfort.
Posture-movement therapy, discussed in the previous
chapter, focuses on using particular postures and movements
to alleviate specific symptoms. It provides an “exercise” ap-
proach for dealing with your back problems.
Posture-movement education, because it focuses on
awareness and intent in your everyday activities, provides an
“un-exercise” approach—as Dennis has called it—to enhance
your posture-movement skills.38
In Part II (the next three chapters) you will learn how your
back is constructed. You will find out what happens when you
experience pain. You will read about principles of learning ap-
plicable to controlling your pain and your body use. These
chapters may seem a bit theoretical and you may be tempted
to skip them to get to “the good parts.” Of course, you can do
so if you wish and still benefit from what you read. However,
I suggest that, if you read these chapters first, you will have
more of the necessary background for understanding the “ex-
ercise” approach of Part III and the “un-exercise” approach
of Part IV, which follow.
Part II
Necessary Background
Knowledge: A little light expels much darkness.
- Bahya Ibn Paquda1
Chapter 5
How Your Back Works
Your beliefs play a large part in helping or not helping you

to get what you want. How do you evaluate your back pain?
Do you think that your pain represents punishment for your
‘sins’? Or perhaps you think that it’s a mysterious thing that
just happens and that you have no control over it? These be-
liefs will surely lead to different results than if you think you
have an activity-related problem possibly correctable through
posture and movement.
I want to help you to evaluate your back problem more
effectively. In order to do this, I will use the next three chap-
ters to present certain background information that you can
use to understand your problem. In this chapter, I provide basic
information on the anatomy and physiology of your back.
Chapter 6 discusses pain, how it works and how your system
is built to deal with it. Then Chapter 7 presents a basic out-
line of Perceptual Control Theory (PCT), a theory of human
behavior based on feedback principles, that provides a con-
ceptual framework for learning how to control your pain and
your posture-movement habits.
Them Bones,Them Joints,Them Muscles,Them Nerves

It’s been said that your spine is a column. You sit on one
end and your head sits on the other.1 Be that as it may, in or-
der to take care of your back, you may find it useful to know
more than “the back bone’s connected to the head bone.” If
you find yourself becoming intimidated by unfamiliar medi-
cal terms, just read on. You don’t need to understand every-
thing in order to begin to feel a bit more comfortable and fa-
miliar with the parts and functions of your body.
HOW YOUR BACK WORKS 59
Before discussing the specific parts of the back, I’ll briefly

review the different types of structures involved in our sens-
ing-moving system, that is, the Neuro-Musculo-Skeletal
(NMS) system. Neuro here refers to the nervous system: the
brain, spinal cord and nerves that go to and from every part
of the body. Musculo refers to the muscles that create move-
ment and that make up approximately 40% of the weight of
the human body. Skeletal refers to the bones and joints.
Let’s look at the Skeletal aspect first. The bones provide
the framework of the body and the actual segments that move.
We may think of them as solid and unchanging but the bones
are anything but inert, since they can change shape according
to the mechanical forces, like muscle pulls, that work on them.
A joint is a place where bones meet (see Figure 5.1).
Movement occurs (for the most part) where joints are located.
The majority of joints are synovial joints and consist of the
adjoining ends of the respective bones and a surrounding en-
velope of connective tissue called the joint capsule. The shapes
at the ends of the bones determine the direction of movement
that occurs at the joint. The ends of the bones are covered by
cartilage, which is the firm but spongy white covering that
you see at the ends of chicken bones sometimes.
The cartilage secretes a fluid that fills the joint capsule and
lubricates between the cartilage surfaces of the bones, allow-
ing for smooth movements. The outside of the capsule is re-
inforced with ligaments, which are tough connective tissue
structures attached to the adjoining bones. Ligaments limit ex-
cessive or abnormal movement.
Now let’s look at the Musculo part of the NMS system.
Muscles typically are attached across a joint from one bone
to another. They are attached to the bones by means of ten-
dons, which are also formed from connective tissue. The
bones, cartilage, joint capsules, ligaments and tendons can all
be considered passive tissues because they do not move by
themselves. Muscles can be considered the active tissues of

the NMS system because, when signaled by nerve impulses,
they can actively create tension, contract, and change their
length.
Figure 5.1 – Joint-Muscle Complex
This leaves us with the last, Neuro, aspect of the NMS

system to consider. Spinal nerves exit from the spinal cord and
bind into “cables” called peripheral nerves. These course
through the torso and limbs. Since the individual nerve fibers
are bound together by connective tissue sheaths, they are ca-
pable of getting stretched, compressed and sometimes injured
by mechanical forces. Impulses carried in the nerves signal
the muscles to contract. The nerves also provide the sensory
connections from muscles, tendons, joints, skin, etc., which
provide input to the Central Nervous System (CNS).
The CNS consists of the brain, encased in the skull, and
the spinal cord, which is housed within the central opening
of the spine, called the spinal canal. The CNS provides the
main control system for the organism. The brain and spinal
cord are surrounded by connective tissue sheaths, which are
continuous with those surrounding the peripheral nerves. The
nervous system is illustrated in Figure 5.2.
Figure 5.2 – Nervous System
The nerves to the muscles (efferent fibers) are the final

common pathways of signals from the CNS. Messages from
sensors in the muscles as well as the tendons, ligaments and
joints also travel back into the CNS control areas (afferent
fibers). This feedback, some of which we can become con-
scious of, is important. To the extent that we can perceive
various aspects of our posture and movement, we have the
potential to control them.
The Movement Chain

Like the rest of the organism, the NMS system works
as a whole. Whether you write your name in the sand with your
finger or your toe or turn off the light switch with your elbow
or your nose, it’s not just the toe or the nose that’s involved.
No part of the moving system works in isolation.
Rather, the movement of finger or elbow is the end point

of a movement (kinematic) chain2—a linkage of body seg-
ments connected through the joints that goes from the tips of
the toes to the neck and head. A seemingly insignificant move-
ment of one part of the body requires muscular and joint ad-
justments, however slight, in other parts. What happens at one
end of this movement chain can impact what happens at the
other end.
You can experience this kind of ‘chain reaction’ by sitting
slumped, with your back in a collapsed C curve. Stay in this
position while you try to raise your arms over your head.
Notice how far your arms go. Now consciously sit erect. (For
the purposes of this demonstration, it doesn’t matter if this is
a little forced). Again raise your arms and notice how far you
can bring them over your head. Did you find that you could
raise your arms further when sitting erect? This illustrates how
the configuration of one part of the chain can affect movement
of another part.
Professional athletes are sometimes more aware than the
rest of us of these chainlike connections. Picture a baseball
pitcher winding up at the mound. A pitcher throws not just with
his arm but with his whole body (functions as an organism-as
a-whole-in-an-environment).
Martial arts experts also emphasize this kind of whole
body relationship. Tai Chi Grand Master William C. C. Chen
has talked about how “If you are loose and the body is coor-
dinated you will have power using the whole body. The whole
body moving as a unit. That is my whole concept.” 3
Just keeping awareness that your whole body can be
involved in a movement can keep you from unduly isolating
a part like your back. It’s important to realize that your back
has ‘friends’ and ‘neighbors’ within the movement chain. The
different parts can function together so that less stress is taken
by any part. Looking at a skeleton can help you to see some
of these bodily connections. If you don’t have access to an

actual skeleton (other than your own) or a plastic model, a pic-
ture will do for now. See Figure 5.3.
Figure 5.3 — Human Skeleton

A Personal Anatomy Tour

The head, spine, rib cage and pelvis represent the central
framework of your body. Together they form the core, or axis,
of your body’s framework.
The upper and lower limbs make up the appendages to this
central framework.
Let’s locate the different parts of your skeleton in order
to define them more clearly (not just with other words but with
experiences).
Feel your head with your hands. Your head, as I said, sits
at one end of your spine. Do you know where that sitting place
is actually located? If you place each index finger in the hol-
low just behind your earlobes, your fingers will be pointing
approximately at the level at which your head sits on top of
your first cervical (neck) bone or vertebra (medical-speak for
spinal bone). The first cervical is also called the “atlas,” in
honor of the Titan of Greek mythology who held up the world.
With your fingers still in place, delicately nod your head
in a “yes” motion. Two rounded knobs at the bottom of the
skull sit on top of two concave hollows on the atlas and allow
that slight rocking motion to take place.
The atlas, in turn, sits like a ring positioned over the pro-
truding posterior ‘finger’ of the second cervical vertebra, the
axis. This arrangement facilitates your head rotating on your
neck.
Seven neck bones are stacked one on top of the other. Feel
around the back of your neck and move your fingers down
the midline until you come to a bump. That bump is probably
the palpable back portion of the seventh and last cervical bone.
So the cervical or neck portion of your spine extends from
the base of your skull (level with where you previously placed
your fingers) to the level of that bump, the seventh cervical
vertebra.
The neck region as a whole includes all of the structures

(muscles, nerves, glands, throat, etc.) within the length that
the bones define. The joints of your neck allow a great deal
of flexibility for flexing, extending, side-bending and rotation
movements.
The twelve thoracic vertebrae link up the next portion of
your spine. These bones link with the ribs, which are con-
nected in front to the sternum or breastbone. The area encircled
within the ribs, thoracic vertebrae and sternum contains the
lungs and other vital organs. Your ribs are able to move, which
allows for the expansion and contraction of your lungs.
Gently press the palms of your hands along the front of
your rib cage just above the navel. Can you feel the move-
ment there as you breathe? The thoracic vertebrae themselves
have less movement than that of the neck, due to the rib at-
tachments and the shape of the bones. They have some flex-
ion (forward bending) and rotation ability as well as
sidebending, with a very limited amount of extension (back-
ward bending).
The five lower back or lumbar vertebrae are thicker than
the ones above. They are approximately at belt level. These
bones can sometimes be felt, especially when lying flat or
bending forwards. The lumbar vertebrae have significant
amounts of flexion and extension, with lesser amounts of side
bending and rotation.
The lowest portions of the spine, the sacrum and coccyx
(tailbone), consist of fused spinal bones that are wedged like
an inverted triangle at the rear of the pelvis between the bones
of the pelvis. The fibrous, immovable joint between the sacrum
and pelvic bone (the ilium) on either side is called the sacro-
iliac joint and is reinforced by a number of strong ligament
connections between the bones.
As you look at a standing side view of the whole length
of the spine in Figure 5.4, you can see its characteristic four
curves. In the normal adult spine, the cervical spine usually

appears concave (hollowed) towards the back. The thoracic
part of the spine curves convexly (bump outwards) towards
the back. The lumbar spine again has a concavity or hollow
called the lumbar lordosis. Finally, the fused sacrum and coc-
cyx are curved convexly (bump outwards) towards the back.
These curves are gradually formed from infancy as we
develop our upright posture. Our tendency to form them re-
sults from the evolutionary adaptation to standing erect, which
was made 4 or 5 million years ago by our smaller-brained, but
upright and walking predecessors.
This adaptation can be explained by the engineering dis-
covery that the resistance to compression of a column in-
creases if it is curved. Consider just the three curves above
the sacrum: the cervical, thoracic and lumbar portion of the
spinal column has 10 times more resistance to compression
than it would if it were entirely straight.4
Some people claim that the prevalence of back pain has
something to do with an imperfect human adaptation to the
vertical position. However, the presence of these curves shows
that some evolutionary adaptation has occurred. Reversing
evolution by returning to walking on all four limbs (except
occasionally) does not seem practical.
Your habits and life style can lead you to spend too much
time with one or more of your spinal curves either reduced or
exaggerated. In this way, you can lessen your spine’s resis-
tance to mechanical stress. You can benefit by looking at how
you can change these habits.
Continuing your anatomy tour to your pelvis, feel the bony
shelves on either side of your ‘waist’. These are often called
the ‘hip bones’ and confused with the hip joints, which I will
discuss below. What you feel are the top edges or ‘wings’ of
the pelvis. They are at about the level of the fourth and fifth
lumbar vertebrae.
Figure 5.4 — The Spinal Curves
The pelvis itself consists of a combination of three paired

bones. The two large bony knobs on each side that make con-
tact with the chair when you’re sitting are the sit bones (is-
chial tuberosities) of the pelvis.
On either side, the pelvis forms the the socket portion of
the ball-and-socket hip joint. The ball part is at the top of the
thighbone (femur). The hip joint is too deep to be felt directly
but is located inside the crease of the groin which bends when
you flex your upper leg or when you bend forwards when sit-
ting or standing.
Together, the pelvis, spine and ribs, with all that they con-
tain, comprise the torso. The upper and lower back region is
simply the back part of the torso. This completes our tour of
the central framework of your body—your torso, neck and
head.
If you haven’t done so, I suggest that you find these dif-
ferent parts on yourself. Knowing where the different regions,
parts and joints are located can help you begin to perceive and
control your posture and movement better.
Here I am emphasizing the skeletal or bony aspects. Re-
member, though, that all the other kinds of tissues of the NMS
system are also included. In addition, the major organ systems
of the body are contained within this framework.
The Lower Back

We have gradually narrowed our focus from the organ-
ism-as-a-whole to the neuro-musculo-skeletal system, from
the entire movement chain to the central axis of the body
framework. We now have some context for looking at the
structure and function of the lower back (lumbar area), while
staying aware of these larger aspects.
The lower back is the most common trouble site for ac-
tivity-related problems of the spine. A bit less than two-thirds
of such problems are localized here, especially in the lowest
segments. A bit more than a third of problems occur in the
neck. Only a small percentage of problems occur in the up-
per back, the thoracic spine area.5
In Figure 5.5, you can see a simplified diagram of the lum-
bar vertebrae (back bones) and associated parts of the spine.
As I mentioned before, the lower back consists of five
lumbar vertebrae and their related tissues. A good way to look
at the spine is to see that it is made up of functional units
known as motion segments. A motion segment consists of two
adjacent vertebral bones and their related nerves, joints, liga-
ments, discs and muscles.
Figure 5.5 — Lumbar Vertebrae
Bones
The vertebral body, which makes up the main bony mass
of a single lumbar vertebra, sits in front (anteriorly). This
merges into a ring of bone called the vertebral arch (see Fig-
ure 5.6). The vertebral arch extends to the rear (posteriorly).
Bony extensions also jut out along either side of the arch.
The vertebral body and arch together form a hole. When
the vertebrae are ‘stacked’ on top of each other, the holes form
a tube-like space called the spinal canal. The spinal canal con-
tains the spinal cord.
Bony asymmetries—static deviations from a geometri-
cally ‘normal’ alignment of the vertebrae—appear normal and
do not necessarily mean that someone will have painful symp-
toms.
Nerves
The spinal cord provides the machinery for the lower lev-
els of nervous system control related to basic motor output
and sensation. It starts at the base of the brain and ends at about
the level of the first lumbar bone (L1). When the spinal cord
gets injured during serious trauma or in the case of serious
medical problems, paralysis and loss of sensation can occur.
At each level from neck to lower back, spinal nerves come out of
the cord, carrying motor and sensory fibers to the trunk and limbs.
The spinal nerves also carry autonomic fibers that regulate glands and
the smooth muscles of the organs , including the heart and blood ves-
sels. Each nerve exits through a hole formed at each side of adjoining
vertebrae. Since the spinal cord actually ends at the level of the L1
vertebra, spinal nerves below this level hang down within the spinal
canal in a bundle called the cauda equina (Latin for horse’s tail) be-
fore exiting along the sides between the vertebrae.
Joints
Two adjacent vertebrae have synovial joints located along
each side (see Figure 5.1). In the lumbar spine, the bony sur-
faces of these joints allow mostly flexion (forward bending)
and extension (backward bending). Practitioners of spinal ma-
nipulation may feel for increased or decreased movements in
these joints. While this kind of testing can provide useful in-
formation at times, it cannot in itself determine the site or
nature of a back problem.
Ligaments
Various ligaments not only reinforce the front and back
outer portions of the disc but also connect the other bony parts
of the motion segment (see Figure 5.5). These include the an-
terior longitudinal ligament, a broad fibrous band that runs
along the anterior (front) part of the motion segment. The pos-
terior longitudinal ligament supports the posterior (back) part
of the vertebral body and disc. In the lumbar spine, it is not as
broad as the anterior ligament. Especially along its sides (lat-
erally) it does not cover either the vertebral body or the disc
completely. This may explain why the posterior part of the disc
is more vulnerable to mechanical stresses.
Discs
Intervertebral discs sit between each vertebral body start-
ing in the upper to mid-neck and ending at the lower lumbar
spine. Discs allow movement and serve as weight-bearing and
shock-absorbing cushions for the spine.
The whole spine normally has twenty-one discs, which
make up about a quarter of its length in adults.6 The first disc
is located between the second and third cervical vertebrae, the
last between the fifth lumbar and first sacral vertebrae. Be-
cause each disc is located between adjacent vertebral bodies
it can be classified as a separate joint composed of a special
kind of cartilage. The disc is reinforced by ligaments in front and
back and is separated from the vertebrae above and below it by car-
tilage endplates. Figure 5.6 shows a top-down view of a lumbar disc.
Figure 5.6 - Disc Structure
Internally, the disc is composed of a concentric outer layer

of strong, stretchable connective tissue, called the annulus.
Near its center the disc has a semi-fluid gel-like structure
called the nucleus pulposus which contains large molecules
that attract water. The enclosed fluid disc acts like a pressur-
ized container that can accommodate movement and absorb
shocks. After the first years of life, especially once we develop
upright posture, the blood supply to the disc disappears. By
the time we reach adulthood, the disc is the largest structure
in our bodies that lacks a direct blood supply. Since it con-
tains cells that require nutrients and give off waste products,
the disc must exchange fluids with the surrounding tissues.
The weight of the body compresses the discs so that much
of their fluid content moves into surrounding tissues. Depend-
ing on our age, we can lose as much as 18 millimeters of
height in the course of a day. This equals about 1% of body
height.7 This loss of height can be accentuated or reduced by
the amount of weight that we carry or whether we spend some
time lying down.
When we are non-weight bearing, especially during the
length of a night’s sleep, fluids are reabsorbed. As a result, by
the time we get up in the morning, we are usually taller than
we were before we went to bed.
In the erect standing position, with the normal spinal
curves, forces on the disc tend to be the most symmetrical, or
evenly balanced. Different positions and movements, wherein
the spinal curves either increase or decrease and reverse, tend
to create asymmetrical pressures on the disc. Depending on
the direction of this force, the shape of the disc and the posi-
tion of the fluid nucleus inside of it will change as shown in
Figure 5.7.8
During flexion (forward bending), the anterior part of the
disc gets compressed, the posterior ligament gets tensed and
the nucleus shifts to the back. During extension (backward
bending), the opposite occurs with compression of the poste-
rior part of the disc and shifting of the nucleus to the front.
Bending towards the side tends to move the nucleus towards
the opposite direction.
Figure 5.7 - Movements Within Disc
As we get older, we dry out. The water content of the disc

tends to decrease. The nucleus becomes less distinct from its
outer covering, which develops cracks and fissures. Since the
disc material has no direct circulation, it does not regenerate.
Cracks, fissures and other minor damage are repaired, not with
new disc material, but with fibrous connective tissue. As a
result of these changes, the disc space may shrink. This pro-
cess, called “disc degeneration,” continues into old age.
Since bone is a living changing tissue, changes to the sur-
rounding bone also tend to occur. Nuclear material may push
into the surrounding vertebral bodies. Movements within the
disc that create persistent tensions on spinal ligaments may
cause tensions on the attached bone as well. As a result, bony
ridges called osteophytes may form that can be seen on x-rays.
Interestingly enough, spine researchers consider these
changes part of the normal biological process of aging. Al-
though they may be associated with reduced range of move-
ment, they are not necessarily pathological or painful. If they
were, we would expect the oldest among us to have the most
back pain. This is not the case. Though elderly people may
have posture and movement-related problems of their own,
most acute lower back problems occur in those around 30 to
55 years of age. What could account for this?
During this prime time for back pain, the drying up and
cracking of the disc continues to occur. However, movement
within the disc is still possible. What may occur is that after
being compressed, the discs of people in this age group tend
to expand more rapidly and with greater pressure than those
of either younger or older people. This may not be a problem
unless our usual posture-movement pattern keeps us in a con-
dition of asymmetrical pressure for too long, for example sit-
ting for long periods of time.
After a continuous period of this kind, which combines
compression with assymetrical positioning, the gel-like
nuclear material will have shifted out of its neutral position.
Pieces of this stuff may even get pushed into one or more
cracks inside the disc. This substance may then expand and
remain in the place where it has gotten pushed, similar to the
way that a piece of material can get stuck or displaced inside
of a hinge.
Movements which require the disc material to shift again
may not allow this displaced material to change position
quickly enough. Instead, the joint and surrounding tissues will
experience abnormal stress, with pain and loss of movement
resulting. This process has been called “intradiscal displace-
ment.” 9
Muscles
When someone with lower back pain presents himself bent
forwards in pain, unable to bring himself erect, a physician
or other practitioner may feel the back muscles hardened in
contraction. The patient may also find them tender to the
touch. It is easy to conclude that the muscles are “in spasm”
and are the source of pain. However, attributing pain to the
back muscles may at times be mistaken.
First of all, when pain does get attributed to mucle spasm,
the back muscles are often not in spasm. If they were, the per-
son bent over in pain would not be bending forwards. In
spasm, the back muscles would pull the person into an ex-
tended (backward bent) position, which is seldom seen in acute
low back conditions.
In this kind of situation, what seems more likely to be hap-
pening is the following: If a displacement, say within the disc,
obstructs joint movement, the person may feel forced to bend
forwards as a way of holding or guarding the area in order to
reduce pain. The back muscles will then automatically kick
in to hold the person up, as they do with anyone bending for-
wards.10
Displacements can sometimes be resolved quickly, in a
matter of minutes, by specific positions and movements or by
joint manipulation. When this happens, not only can the per-
son stand erect but also the muscles no longer feel hardened
in contraction. Touching the muscles no longer hurts, either.
There is no way that a muscle strain, which would involve at
least some microscopic tearing of muscle fibers with subse-
quent bleeding, inflammation, etc., could resolve so quickly.
In this case, it seems unlikely that the back muscles them-
selves generate pain. However, the back muscles still have im-
portance in the cause and prevention of lower back pain. This
is because of the way they affect the movements of the spine
and so affect other tissues.
There are many muscles that affect movements in the lum-
bar spine. I won’t list them individually. In general, they in-
clude various anterior (front) abdominal muscles and poste-
rior back muscles. The muscles in the back connect one or
more motion segments of the spine. There are also muscles
connecting the torso to both the upper and lower limbs. These
also have an effect on the movement and posture of the spine.
Muscles tend to work in pairs that oppose one another.
When one set of muscles is shortening, another set on the
opposite side of the joint will lengthen. Muscles may work
most efficiently when they first lengthen before they contract
and shorten. In part this explains the windup of a baseball

pitcher. If a muscle is chronically held in either too shortened
or too lengthened a state, it will not function at its best.
Muscles work best at their resting length, which can be slightly
more stretched than ordinary. 11
In general, we can classify muscles into physiological flex-
ors and extensors. The flexors lie to the front of the spinal
column from the neck down and the extensors lie along the
back of the spinal column and along the backs of the thighs
and legs. The extensors are sometime called antigravity
muscles because they typically support the upright standing
position against the pull of gravity.
In addition, these same muscles also seem to be laid out
in diagonal patterns. In the torso, the muscles that affect the
movements of the back form what anatomist Raymond Dart
called a “double-spiral.” Starting with the deep abdominal
muscles along one side, a diagonal or spiral can be traced into
the more superficial muscles on the opposite side. This in turn
spirals around into a diagonal arrangement of the extensor
muscles of the back. Diagonals can be traced on both sides,
thus forming the “double spiral” described by Dart, that fol-
lows a path that he traced from the pelvis to the skull.
These spiral connections account for the abilities we have
not only to flex and extend but also to rotate, bend sideways,
etc. According to Dart, this non-typical way of looking at mus-
cular arrangements may explain some of the curious postural
distortions and fixations that can occur involving multiple
areas of the body.12
Summary—Your Lengthening Spine

Your neuro-musculo-skeletal system functions as a whole
even as you focus on one part. Your lower back takes part in
a movement chain that includes the other segments of the spine
as well as the limbs. As an important link in the movement
chain, what happens in your lower back affects the rest of your
spine and limbs. What happens in these other areas can, in turn,
affect how your lower back functions.
Dynamic posture remains a matter of coordination of the
system as a whole. This depends more on awareness than on
the length and strength of your muscles. Therefore, awareness
of the connections among the various parts of the movement
chain will provide you with a more effective coordination of
effort and a greater efficiency of movement than stretching
and strengthening exercises for a particular area or part.
Your spine as a whole functions as part of your ‘anti-grav-
ity’ system. The resistance of your spine to compression and
other forces is assisted by the presence of its normal curves,
the optimal length of postural muscles (especially the exten-
sors) and the cushioning effects of the discs, among other
factors. Spending more of your time functioning at full stat-
ure helps your antigravity system.
As noted, the disc does not have its own blood supply. As
we age, its ability to move and its resistance to mechanical
stresses tend to lessen. Reduced movement and postural mo-
notony (which reduce circulation) can accelerate these
changes. Maintaining asymmetrical positions can also distort
the motion segments of the spine. To promote the optimal
functioning of your spine, getting out of distorted asymmetri-
cal positions as often as possible seems necessary. Postural
variety, by balancing periods of activity and rest, compres-
sion and decompression, will help you to accomplish this.
The anatomy and physiology discussed in this chapter
provide the beginnings of a basis for some standards for the
proper use and functioning of your back; I can perhaps sum-
marize this in one phrase: “a lengthening spine.”
Ron Dennis writes:
The attainment of poise is ...a matter of learning the art of
lengthening. Lengthening means pre-eminently that in
standing, sitting, walking, bending, or in any activity what-

ever, one must prevent both unnecessary muscular effort
and the very common distortions of the natural curves of
the spine.13
You’ll benefit by keeping your lengthening spine in your
awareness, as we go on in the next chapter to examine injury
and pain in relation to the back.
Chapter 6
The Pain in Sprain…
Why does it hurt? That’s probably a question many people

ask themselves when they suffer from back, neck or other pain.
In some ways it’s not a very useful question to consider for
very long since the ‘why’ often implies a kind of awfulizing
and catastrophizing attitude that can get in the way of finding
solutions and getting on with your life.
On another broader level, however, that question may
bring us to consider why anyone has pain. What possible bio-
logical purpose could there be for experiencing pain?
The answer to why we feel pain seems obvious at first.
The ability to experience pain warns us and protects us from
damage. It leads us to reduce or eliminate our discomfort. But
although pain can be useful in this way, the pain warning sys-
tem works far from perfectly.
Some people with serious illnesses like cancer may not
feel any pain as their problems develop. Although not inevi-
table, pain often occurs in such cases at the end stage of the
illness when it would no longer seem to serve as a useful
warning.1
Other people like soldiers in combat, accident survivors
and disaster victims may not feel immediate pain despite
serious injuries. In the heat of the moment of dealing with the
battle or the accident, attention may not focus on personal
damage as much as on escaping with one’s life or helping
fellow soldiers or accident victims.2
Experiments with hypnosis and placebos like sugar pills
also indicate that the amount of pain does not necessarily
correspond with the extent of injury. The use of these ap-
proaches indicates that physiological states and tissue reac-
tions may sometimes relate, in part, to suggestion, expecta-
tion and psychological state.3
In other cases, some people are believed to have psy-

chogenic pain. Such pain may be considered by some to have
a psychological origin without tissue injury. The person is
believed to be expressing internal conflicts and personal prob-
lems in the language of bodily distress.4
People may also experience pain long after an injury has
healed, when damage is no longer impending or occurring.
The phantom limb pains often experienced by people who
have lost a limb are a good example of this type of process.
Some chronic back and neck problems may also involve this
kind of condition. This may have something to do with dam-
age to nerves which can then become hyperexcitable, or to
other nervous system mechanisms.
The phantom limb phenomenon also brings out the point
that we often inaccurately locate the source of pain. You need
not have had an amputation to experience referred pain, where
pain is projected to—experienced in—an area of the body
other than the site of injury.5
As we grow up we learn to associate the site of an injury
with a specific area of the skin that we can see or touch. We
do this because we do not have visual and tactile experience
with areas deep within our bodies or even deep in our muscles
and joints. We may thus project or interpret input from such
areas as coming from another part of the body (the skin) that
shares a common nerve pathway, but with which we are more
familiar.6
For example, pains felt in the muscles of the buttocks or
down the thigh may have their actual source deep in the joints
of the lower back. This can be confusing but, fortunately, re-
ferred pain patterns have been mapped out. This can help
health professionals pinpoint the pain source.
In various ways, then, the pain warning system appears
less than perfect. Nonetheless, there does remain some cause-
effect relation between pain and injury. Pain can warn us that
THE PAIN IN SPRAIN... 81
damage is impending or occurring. The changes that we ob-

serve in relation to the pain we feel can give us some indica-
tors about what to do and what not to do. We can learn how to
heed the messages of pain more carefully.
What ‘Is’ Pain?

Pain is not something in a bone, muscle, joint, etc. “The
pain in sprain is mainly in the brain!”7 In other words, your
nervous system constructs the complex psycho-physical ex-
perience of pain. The International Association for the Study
of Pain defines it as “an unpleasant sensory and emotional
experience associated with actual or potential tissue damage,
or described in terms of such damage.” 8
A useful framework for understanding some of the more
specific mechanisms of pain perception is the Gate Theory of
Melzack and Wall, first formulated in the 1960s.9
According to the Gate Theory, messages from receptors
sensitive to noxious input travel along certain nerve fibers into
various transmitting cells in the spinal cord. These transmit-
ting cells then send their own signals to higher levels of the
nervous system/brain and to other cells that signal muscles to
contract.
Transmitting cells are influenced not only by ‘pain’ input
but also by the input of other sensory receptors from skin,
muscles and joints. These other receptors are called mechani-
cal receptors and convey signals related to touch, movement
and other non-noxious stimulation.
Transmitting cells also get input from cells located in another part
of the spinal cord that serve as the ‘gates’ of the theory. These gates
can shut down or open up the transmission of potential pain messages.
Both the ‘pain’ and touch/movement messages branch into these
gates, as well as to the transmitting cells. ‘Pain’ messages inhibit
(‘close’) the gates and touch/movement messages facilitate (‘open’)
the gates.
If a gate gets opened sufficiently by touch/movement sig-

nals, it will inhibit a transmitting cell from sending potential
pain messages to higher levels, in spite of input indicating
damage. In this way, a sufficient amount of peripheral touch
and movement stimulation can reduce or prevent the experi-
ence of pain. This explains in part the effects of massage and
movement (manipulation or exercise) as well as heat and cold
in reducing pain.
The entire system of gating and transmission cells also
receives inhibitory and facilitating input from the cerebral
cortex and inhibitory input from the brainstem. The existence
of these higher-level inputs provides a way to begin to explain
how beliefs, attitudes, anxiety, hypnosis, etc., can influence
the experience of pain.
The Chemistry of Pain

The nervous system reactions discussed above are medi-
ated by a complex chemistry. This bio-chemical aspect relates
not only to how we deal with pain but also to how we think,
feel and act in general.
Chemical messengers called neuropeptides are necessary
for the transmission of signals from one nerve cell to another.
These neuropeptides are related to hormones. They affect and
are affected by other organ systems of the body, including the
immune system. The neuropeptides and the hormones can be
considered the communication molecules of the organism.
Around 1970, scientists gradually became aware of the
possible existence of receptors on nerves and other organs for
these kinds of chemicals. Receptors for morphine, a power-
ful plant-derived pain killer, were discovered in various sites
in the brain and in other organs.
Scientist reasoned that, if such receptors existed, they did
not evolve in order to fit the morphine molecule. There must
be some naturally occurring substance in our brains similar
in structure to morphine. Eventually, several such substances,
which work not only for the pain control but also for the car-
diovascular and other systems, were discovered and given the
name endorphins for endogenous (inner) morphine.
Endorphin receptors exist in the ‘gate’ areas of the spinal
cord. In the brain, endorphin receptors are wide-spread, al-
though they are particularly concentrated in the limbic sys-
tem (especially involved with emotions) and in an area in the
midbrain. This last area sends powerful inhibitory signals to
the spinal cord. It has many connections with other areas of
the brain and may account for some of the effects of placebos
and hypnosis since electrical stimulation of this area results
in wide-spread pain reduction.10
This undoubtedly is part of a larger complex system that
affects pain perception. It can be affected, in turn, by disease
and injury, drugs, sensory-motor stimulation, anxiety, expec-
tations, learning and personality, among other factors.
The neurological circuits and neurochemical connections
discussed here are related to what you do and how you think
and feel. They likely evolved because they enhanced our an-
cestors’ ability to survive—to mobilize themselves to fight or
flee from danger and further damage. Each one of us has in-
herited what Melzack and Wall call these “natural resources
in the brain.”11
The Experience of Pain

You don’t need to understand these neurological and neu-
rochemical connections in great detail. It is sufficient to know
that they exist and that your experience of pain is intimately
related to them. Let us look more closely at your nervous sys-
tem experience of pain (what you do and feel) illustrated in
Figure 6.1.
Let’s start at Level I. Something happens in your lower back. Let’s
say that you bend forwards unexpectedly and a bone, disc, joint, liga-
ment, muscle or nerve suddenly gets stretched, compressed or even
injured to some degree (there may or may not be injury).
At Level II, the immediate sensory impact, nerve fibers

in your back can be stimulated in response to the sudden me-
chanical pressure or pull. If injury has occurred, chemicals re-
sulting from inflammation may stimulate nerve receptors.
However, at this point, you do not yet have an experience of
pain. The arrow from II to III stands for the nervous system
processes in the spinal cord and brain involving the gate cells,
transmitting cells, etc.
Figure 6.1 — Nervous System Processing of Pain12
Level III represents the even more complex nervous sys-

tem processes of your non-verbal experience (what you later
call “pain”). If you feel some discomfort in your back or in
some other part of your body right now, just notice it. If not,
for the purpose of experiment (you are a personal scientist after
all!), pinch your finger. What do you feel? Whatever words
you then say about it, such as “ouch!” or “it’s painful!” etc.,
are not the experience itself.
Distinguishing your non-verbal pain experience from the

way that you talk about it, and learning to observe your pain
and other symptoms better, can help you deal more effectively
with your symptoms.
With Level IV, we arrive at the verbal level. At this level
you describe your experience in words, i.e., “flickering, sharp,
dull,” etc. Your words may involve judgements and conclu-
sions about your experience, i.e., “dreadful, unbearable, vi-
cious,” etc., or “Hmm, perhaps that’s a warning, better change
how I’m sitting.”
What you describe and talk about at Level IV partly de-
pends upon the stress or injury at Level I and your Levels II
and III processing of it. How you talk about the pain also re-
flects how you evaluate your previous experience. For ex-
ample, you might say things like “How stupid to injure my
back again” or “Another onset, too bad! What’s the best way
to deal with it now?” Which general attitude may be more
constructive in the long run?
According to general semanticists, Level IV is not some-
thing ‘mental’ apart from the physical. Rather, your interpre-
tation or evaluation involving language qualifies as a nervous
system event as much as what happens on Levels II and III.
Your Level IV interpretation is also not the linear end point
of some pain-causing stimulus. Rather, the entire experience
of pain, like most other human experiences, is very much part
of an ongoing process of circular causation.
This circular or cyclic process of causation is shown in
the looping arrows on top of the diagram that go from the
‘higher’ to ‘lower’ levels of reacting. In practical terms, this
means that your evaluation of your back pain (the meaning
you give to it), which includes how you talk about it to your-
self, can shape your ongoing behavior and your experience
of pain. This means, among other things, that anticipating pain
may make you more sensitive to it.
I do not say here that your back pain is just a matter of

what you believe and how you behave. I do say that your ex-
perience of pain does not simply depend upon some immedi-
ate ‘noxious’ input. Your experience of pain, as indicated in
Figure 6.1, depends upon many levels of nervous system func-
tioning. These levels can involve beliefs, attitudes, moods, at-
tention, etc., as well as various drugs and other chemicals, and
different types of sensory stimulation and movement, among
other factors.
Many Paths to Feeling Better

In this chapter I have touched on the fact that pain is not
simply a function of injury. Many factors enter into whether
and to what extent you will experience pain. Many influences
bear on whether the ‘gates’ of the spinal cord will open or close
to let nerve signals become painful experiences. Therefore, it
is likely that many different kinds of treatment, working on
different levels in different ways, can help you to feel less pain.
It is useful to know that there are many ways of dealing
with your pain. The advantage of using activity-related (pos-
ture-movement) approaches to deal with activity-related pain
is that you deal directly with a significant source of your back
pain problem.
As I discuss in greater detail later, non-damaging move-
ment can often usefully reduce the chemical irritants that ac-
cumulate after a musculoskeletal injury to the back (or neck,
etc.).
Properly guided movements (exercises) may also help
resolve activity-related pain caused by shortened muscles and
stiff joints, as well as pain resulting from the kind of interver-
tebral joint displacements discussed in the previous chapter.
Non-damaging movement also provides peripheral stimu-
lation that can help open the spinal cord gates that turn off the
further transmission of potential pain signals.
Improved posture-movement habits provide a non-irritat-

ing environment for the muscles and joints to heal without
further damage.
In addition, doing something to take control of your pain-
ful symptoms in itself has positive benefits. Taking action for
your own well-being provides a sense of efficacy and self-
confidence. For one thing, it gets your attention away from
simply dwelling upon your symptoms. As neurologist Barry
Wyke has pointed out, you should not overlook the power of
“ensuring cerebral disregard” (distraction).13
In the next chapter, we take a deeper look at the psychol-
ogy of control and its relation to pain and posture.
Chapter 7
You Control Your Pain and Posture
You are not a victim of circumstance, at the mercy of your

painful symptoms. Rather, you can control your back pain. As
already shown, you often can control your pain by changing
your posture and movement.
Such control is not perfect. Nonetheless, you have prob-
ably not come close to exhausting the possibilities for gain-
ing control of your symptoms. In this chapter, I explain what
some behavioral scientists have learned about the process of
controlling your experience.
Consistent Results, Variable Actions

Although they are not immune to the laws of physics, liv-
ing creatures, including you, are not like inanimate objects that
simply respond to a push or a kick by moving a predictable
amount. Unlike a rock, you move under your own power.
Neither are you a stimulus-response machine, destined to
react in a set, reflexive way. Rather, you have purposes,
choices, options. When pushed you may resist, push back or
decide to yield.
In order to survive as a dynamic system functioning as
an organism-as-a-whole-in-an-environment, you transact with
a changing and turbulent world. You take action and evaluate
the results in order to maintain a certain set of relatively con-
stant conditions inside and outside yourself. You attempt to
get what you want to satisfy your needs.
Imagine a world that always gives you what you want and
need. Would you have to act or to perceive the results of your
actions? Probably not!
YOU CONTROL YOUR PAIN AND POSTURE 89
However, as you know, we do not live in such a world.

Instead, the changing, turbulent world in which we live is full
of disturbances. It not only doesn’t give you what you want
but often gives you what you don’t want — things like back
pain! Life, it has been said, is what happens while you were
making other plans.
To get what you want, despite whatever disturbances oc-
cur, you need to know what result you desire. You also need
to perceive current reality, what presently is going on inside
and outside your skin.1 Psychologist William T. Powers writes:
The general rule is that if you want to control something
[achieve a particular result you desire], you have to per-
ceive it. This doesn’t mean just perceiving that something
exists,…It means perceiving exactly the aspect of the world
that is supposed to be under control.2
In this way you can adjust your actions to give you the par-
ticular experiences you want.
This ability to adjust your actions has importance.You
pursue particular consistent perceivable results through vari-
able actions. Powers considers this a central defining feature
of behavior. For example, picture that you’re driving and man-
aging to keep your car inside your intended lane.3 You are
probably not conscious of what particular muscle contractions
you make. Instead you are controlling for a particular perceiv-
able result, staying inside the lane. There may be cross winds,
bumps on the road, pressure changes in your tires, among other
things. To achieve your desired perceivable result, you must
counter these moment to moment disturbances with your vary-
ing actions.
You sometimes may move the wheel or sometimes hold
it steady in one position. In either case, your moment to mo-
ment motor output, which cannot be programmed in advance,
serves the ongoing purpose of continuing to give you the con-
sistent experience of staying between the lines of the lane (if
that’s what you want to experience). Though your visible ac-

tions may appear similar from one time to the next, the exact
particular actions you make at any one time must vary to take
varying environmental conditions into account.
There are some regularities in the world and over time we
tend to develop more or less stable systems of behavior, or
habits, for getting what we want. So our visible actions, al-
though variable, do have a certain consistency as well (hands
on steering wheel, etc.). These habit systems develop pretty
much unconsciously from trial and error.
Feedback Control
What I have been describing above is the operation of
a negative feedback control system. In everything you do, you
seek to control for the perceivable results you want to experi-
ence (for example, you may be reading this book in order to
learn how to control your back pain and your related posture-
movement habits).
The notion of feedback has been applied throughout physi-
ology to understand how our body systems function to main-
tain a more-or-less steady internal state (the concept of ho-
meostasis). Surprisingly, though, only a small group of sci-
entists have comprehensively applied this notion to our ex-
ternal behavior. Many of them work in the field of Percep-
tual Control Theory (PCT) formulated by Powers and his as-
sociates.4 As Richard J. Robertson, Ph.D., notes:
Control theory is the most recent in a succession of names
for the developing body of theory based on a feedback
system paradigm. Other names are “cybernetic-psychology,”
“general feedback theory of human behavior,” or simply,
“systems theory psychology.”5
Despite the complexities involved, the bare basics of a simple
one-level negative feedback control system can be seen in Fig-
ure 7.1. This schematic model, along with the description which
follows, explains the organization of a simple control system such
as one that you are probably familiar with—a thermostat.6
○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○
Figure 7.1 — A Negative Feedback Control System
Key to Negative Feedback Loop

1. The action or output (A) of the furnace (0) [output
device],
2. The environment in which it acts, including distur-
bances (D) [The downward pointing arrow from O repre-
sents A’s unintended consquences on the environment],
3. The temperature, the controlled variable (CV) influ-
enced by both A and D, sensed or measured by the sensor
(S) [The effect of A on CV constitutes the actual feedback.],
4. The perceptual signal (P) created by the sensor,
5. The internal standard or reference level of the ‘desired’
temperature (R),
6. The comparison (C) and difference/error (E) between
perception and reference which signals the furnace to pro-
duce an output, and so back to 1, etc.
The activity of the thermostat-furnace system gets the con-

trolled variable of temperature to the desired reference level.
The system involves a circular or cyclic loop of causation from
system to environment to system involving feedback, since
the results of the system’s actions affect the ongoing activity
of the system. It is a negative feedback loop because the ac-
tions of the system exactly negate or counter whatever dis-
turbances occur to move the controlled variable away from
the ‘desired’ temperature.
The parts of this loop of causation happen all at once so
that the ongoing output affects the sensed input at the same
time that the sensed input affects the ongoing output. The in-
ternal standards of the thermostat have primary importance
in determining what happens in the system.
A thermostat system is designed to control a variable in
its environment, the temperature of the room. I label the tem-
perature CV for controlled variable. The thermostat has a sen-
sor (S) or input device that changes in a predictable and pre-
cise way in relation to the temperature. This sensor creates an
ongoing perceptual signal inside the thermostat labeled P.
In an area inside the thermostat, labeled C for compara-
tor, this perceptual signal gets compared with a reference, an
internal standard, that has been set for the temperature. This
reference level, labeled R, represents a goal state, an intended
level for perceivable temperature. In the case of the thermostat,
you create this reference level when you put the setting of your
thermostat at 72 degrees (or whatever temperature pleases
you) in order to create a toasty winter environment.
The difference between R and P, labeled E, is called the
error of the system (a technical term for a normal part of a
feedback systems operation). When the temperature is at 72
degrees or above, E = 0. In this case, there is no E signal and
the furnace remains off. However, when the temperature
measured by S goes below 72 degrees, E becomes a positive
value and provides a signal to an output device (O), the furnace.
The furnace, in turn, acts on the environment of the house,

including the room where the thermostat is located. Let’s say
it blows warm air through air ducts which feed into the rooms
of the house. I label the action, which includes whatever op-
erations occur inside the furnace, A. The activities of the fur-
nace may, of course have other effects on the environment
besides the intended one on the controlled variable.
In addition to the action of the furnace, there are many
different external factors that affect the CV, the temperature
of the room. The outside weather, drafts created when doors
and windows open and close, people walking by, the number
of people in the room, some other heat source near the ther-
mostat, etc., all serve as disturbances, labeled D. These dis-
turbances move CV away from the desired reference value
R. The actions of the furnace must counter these influences.
Depending upon the reliability of the sensor and the sen-
sitivity with which the system responds to error, the control
system of thermostat and furnace may keep the room tempera-
ture at a steady 72 degrees despite any disturbances that oc-
cur.
Behavior: The Control of Perception
According to Control Theory, the thermostat–furnace–
temperature control system has been designed by engineers
to do what you and other living things do all the time (though
often imperfectly): control your perceptions. As Robertson
notes:
...a profound consequence of this theory for psychology
is the implication that living organisms do not control their
environments by controlling their outputs. They control
their inputs—their ‘perceptions’—as Powers states in the
title of his book, Behavior: The Control of Perception.7
The system shown in Figure 7.1 controls its input. In other
words, it keeps the perception (P) of temperature matching
the reference (R) for desired temperature. P is kept equal to

R even when there are disturbances (D) like drafts and people
that would tend to push P away from R (the desired value for P).
You function as a perceptual control system. Like the ther-
mostat I’ve described, you act to control what you perceive—
your perceptual input. However, humans (unlike thermostats)
set their own R values. This is autonomy. People decide what
they want to perceive (they set the R in their brains) and act
to make their perceptions continuously match R.
When you change R (change what you want), the percep-
tion P changes right along with the wanted R. So control of
perception means that you are continuously deciding what you
want to perceive and are acting to perceive it. If you are not
perceiving what you want to perceive, then there is a failure
of control.
You obviously are a lot more complicated than a simple
thermostat. According to the PCT model, your nervous sys-
tem is made up of a huge number of control systems arranged
in a hierarchy of at least 11 levels of nerve networks that in-
tercommunicate.8 Each level involves different and increas-
ingly complex kinds of perception. The names of these 11
perceptual levels, moving from the most basic to the most
complex, are intensity, sensation, configuration, transition,
event, relationship, category, sequence, program, principle
and system. To get a sense of what intercommunication among
these levels might look like, imagine a network of tiny Christ-
mas lights linked together and glittering off and on in intri-
cate patterns.
The PCT model proposes that each successive level of
perception gets constructed from the previous lower levels.
We control our perceptions at each of these levels in the way
that the thermostat controls the temperature of the room.
At the lowest level of control, the output of the system directly
results in muscle contractions that, when combined with environmen-
tal disturbances, result in your visible movements and activities.
Your actions are significantly determined by the higher

level perceptions/references (beliefs, principles,values, etc.)
that operate in you. The direct output of any of these higher
levels of control is not to the muscles directly. Rather, higher
levels provide the reference signals to lower levels of control.
As a consequence, your yearning for chocolate ice cream may
eventually result in any number of different actions, such as
driving, bicycling or walking to an ice cream shop.
Reorganization and Learning
So far I’ve described the organization of a hierarchical
control system already present and operating. Except for some
basic ‘reflexes’, you are not born with control loops at any of
these levels. How do they develop? How do you learn to con-
trol the important variables of your life?
PCT theorists propose the existence of an innate, geneti-
cally determined system called the Intrinsic Reorganizing
System. The Intrinsic Reorganizing System underlies the op-
eration of all of the 11 levels noted above and also works on
negative feedback principles.
The Intrinsic Reorganizing System includes the system of
basic needs that you have at birth. These needs involve preset
reference levels for such physiological and biochemical quan-
tities as blood sugar, oxygen, carbon dioxide, etc.
Various sensors in your nervous system/brain, especially
in the hypothalamus, monitor these levels, thus providing
feedback to your Reorganizing System. This system may also
monitor internal conflicts among the various levels of the be-
havioral control hierarchy as well as continued errors beyond
a certain amount at any particular level.
According to the Reorganization model, feedback regarding your
intrinsically controlled states such as blood sugar or oxygen gets com-
pared to the reference levels for those states. Any difference between
the two generates an intrinsic error signal that directs a message to
your 11-level behavioral control hierarchy to reorganize.
Reorganization basically functions by trial and error. As

Robertson points out:
An ‘organizing-reorganizing’ system activated by rising
error signals within the intrinsic system, functions simi-
larly to the random signal generator used by cybernetic
engineers to inject miscellaneous neural impulses into the
control hierarchy, thereby arbitrarily resetting reference
signals and disrupting homeostasis.9
Neural connections get altered. Reference levels, percep-
tual signals, relations within the hierarchy, etc., all have the
potential to get changed. The rate of reorganization depends
on the amount of intrinsic error present. The visible results of
all of this will be seen in changes in what you do. Presum-
ably, reorganization will continue until the error of your in-
trinsic system equals zero. New perceptual control circuits
(habits) will get created in such a trial and error process by
their ability to reduce intrinsic error. Powers writes:
Reorganization theory relies on a model of the internal
workings of the organism. It says that we learn in order to
satisfy internal needs, and that we stop varying the way we
behave in a given environment (although we don’t stop be-
having) when those needs are met.10
Some interesting implications follow from seeing learn-
ing as a reorganization process. For one thing, this viewpoint
implies that problems and obstacles constitute opportunities
for learning. Difficult people, frustrations, mistakes and prob-
lems, including the pains that you feel, may serve as ‘teach-
ers’. In his book Wholistic Healing, Dr. Elan Z. Neev writes:
One of the best ways to Wholistic health is total acceptance
of life as a series of lessons. This attitude will automati-
cally remove much of the strain and stress of everyday life
and of the painful experiences of the past or the dread of
tomorrow....every experience is an opportunity for learn-
ing and growth, every problem, mistake, failure, pain, and
obstacle is beneficial if we are willing to learn from it....Look
for the blessings in disguise, even if the disguise is excellent!11
Seeing learning as reorganization also means that no one

can teach anything to someone else in the sense of simply
‘pouring content’ into a waiting, empty ‘container’. What you
learn will result from your own reorganization process—what
you put together in your own somewhat unique way. This
cannot be entirely programmed by someone else. At best a
teacher or a book can only facilitate learning for you by cre-
ating the conditions for your reorganization process.
Attention may have an important role in this process.
Attention seems to function as a way of focusing reorganiza-
tion on the particular areas of experience that will most likely
have the greatest effect on reducing the intrinsic error present.
In this way, the reorganization process does not have to be to-
tally random. Your skill in directing your attention and calmly
observing what is going on (functioning as a personal scien-
tist) can help you direct your learning process more effectively.
Emotions or feelings can also be understood in relation
to the intrinsic system. Emotions seem to correspond to our
internal perceptions of our intrinsic state. When you are go-
ing through some sort of reorganization process, whether
minor or major, you may feel varying levels of confusion,
distress, anxiety, conflict, etc. It’s important to understand that
these kinds of feeling are normal. Accepting your feelings will
allow your Reorganization System to work more efficiently as
your “mind’s repair kit,” as social worker/educator Edward E.
Ford calls it.12 When you realize this, you can avoid additional
distress created by feeling anxious about your anxiety and con-
fused about your confusion when you are learning something new.
Controlling Pain
The experience of pain involves a continuous feedback
control loop. The loop includes perception, desire and action
at multiple levels of the nervous system. This has been im-
plicitly recognized by others besides Perceptual Control psy-
chologists. For example, pain scientist Patrick Wall writes:
Our understanding brains steadily combine all the avail-

able information from the outside world and within our
own bodies with our personal and genetic histories. The
outcomes are decisions or tactics and strategies that could
be appropriate to respond to the situation. We use the word
pain as shorthand for one of these groupings of relevant
response tactics and strategies. Pain is not just a sensation
but, like hunger and thirst, is an awareness of an action plan
to be rid of it.13
Initially, your back pain may have started as an unintended
consequence of controlling for some other variable, such as
lifting a package, sitting too long on a plane, etc. At some
point, your sensation of back pain became a variable you
sought to control in its own right. If you have an ongoing back
pain problem, it may now qualify as a poorly controlled vari-
able.
Pain involves not just one thing but rather many dimen-
sions of perception that vary (see Index Your Symptoms in
Chapter 10). It can feel strong or weak, sharp or thick, short
or long, etc. You can locate it in different parts of your body,
e.g., your lower or upper back, on either side, down your leg,
etc. When you control a perception, you pick the perception
that you want and try to act in a way that produces that per-
ception. So if you want less pain anywhere, you have to act
to bring the different dimensions of the perception to their de-
sired state.
As indicated in the previous chapter, there are many path-
ways that may be used to deal with pain. Your efforts to re-
duce your pain may have made use of some of them. How-
ever, you may not have taken full advantage of posture-move-
ment methods of pain control.
This book suggests kinds of actions that you can take to
influence your pain perceptions. If you have activity-related
pain, you can reduce, change the location of and eliminate your
symptoms by means of positions and movements. You can
begin to change your posture-movement habits to reduce the

stress on your back. Using these approaches, you can learn
to judge whether what you are doing is changing your per-
ception of pain in the way that you want.
Controlling Posture
Perceptual Control Theory (PCT) also relates to how you
use yourself, your posture-movement habits, which can affect
your back pain symptoms. PCT provides some possible ex-
planations for how your habits developed. It also suggests
guidelines for learning to improve these habits.
A major portion of your “self-sensing” (proprioceptive)
perception system monitors your body position and move-
ments. This system includes numerous sensory receptors in
the muscles, tendons and joints, as well as the inner ear.
As you developed from babyhood, one of the first areas
that you learned to perceive and control was your own body.
Your body use developed more or less by trial and error learn-
ing through a process of reorganization. This process of reor-
ganization did not necessarily lead to the optimal way of us-
ing yourself. Rather this trial and error process resulted in your
tending to act like a short-term opportunist. It led to whatever
behavior worked for the moment, e.g., catching the ball tossed
to you, keeping from falling down, or picking up a heavy box.
In this way you formed a more or less stable system of
unconscious posture-movement habits controlled by negative
feedback—a postural set point (homeostasis).14 This set point,
which became your standard of body use, may explain the
resistence that you experience when beginning to change bad
postural habits which have come to feel ‘right’. Your short-
term opportunism continued as you got older and focused ever
less attention on the lower levels of the hierarchy of behav-
ior, especially those perceptions involving body use. As a re-
sult, your body use got put on the ‘back burner’ of your awareness.
This is very much what happened to F.M. Alexander, who

I wrote about in Chapter 4. Alexander sought to achieve a
short-term perceivable result (his end), projecting his voice
to the farthest corner of the performance hall. He perceived
success in doing that. However, he did not at first notice the
fact that the tense and awkward way in which he did it (his
means) led to strain and hoarseness in the long run.
If you successfully pick up the package you want to lift
by means of bending awkwardly, you may not notice that the
tense and uncoordinated way you do it may lead to strain and
pain in the long run.
In other words, for any particular perceivable result you
seek to bring about (your end or goal), you, like most if not
all other humans, naturally tend to ignore the means (process)
that you use to achieve them. For example, if you carry a bag
with a shoulder strap are you aware of whether or not you
unecessarily raise your shoulder to do it? You (like most, if
not all, other humans) tend to tune out unintended conse-
quences—unless, for example, bodily pain and strain feels
severe and lasting enough to signal intrinsic error and ‘de-
mand’ reorganization.
Initially, F. M. Alexander was not aware of how his use
was creating his vocal problems. People with back and neck
pain and repetitive strain are often not initially aware of how
their body use affects these problems. Recognizing that your
problems may be affected by how you are using yourself is
an important first step towards doing something constructive
about it.
Perceiving this relation can narrow the amount of trial and
error required to develop more effective control of your pos-
ture and pain. For example, a student of mine, a massage thera-
pist, always had a pain in his back while doing dishes. The
pain vanished when he learned to fold his body rather than
bend it (see Chapter 13). He quickly was able to apply this to

other activities that had previously brought discomfort, e.g.
bending over his massage table.
The bottom line here is this: You have many ways to move
and you can relearn new ones. Although you tend not to fo-
cus on them, your own actions (though not usually the indi-
vidual muscle contractions) are perceivable aspects of your
environment that you can direct your attention to and control.
Once you see the particular relations among posture, move-
ment and pain that hold for you, it’s possible to begin to view
your bodily use as an area of interest to explore and change.
Part III
Therapy Solutions
...we need comfort, support, recognition and help
if we are to make the best of our days in pain.
– Patrick Wall1
Chapter 8
Diagnosing Back Pain
Most episodes of back pain represent activity-related (me-

chanical) problems that can improve with time, appropriate
pain control and posture-movement approaches. Such prob-
lems include what Waddell calls “simple backache,” as well
as many cases of “nerve root pain,” wherein leg pain is asso-
ciated with evidence of injury to a single nerve root. Leg pain,
sometimes called “sciatica,” may also get referred from a se-
vere backache without nerve root involvement.1
If this is the first time that you have had a significant back
problem or if your symptoms are different from previous epi-
sodes and you have not received a diagnosis, I suggest that
you go to a medical doctor (an internist or family practitioner
will often do). As I mentioned in Chapter 2, specific diagno-
sis of back pain is controversial. However, a general screen-
ing diagnosis which reasonably separates activity-related
problems from other less likely but more serious medical/sur-
gical conditions can be readily done.2 A physician who can
perform such a screening can provide reasonable assurance
that you do not have a serious medical or surgical disease. With
that knowledge you can proceed more confidently and safely
in pursuit of posture-movement solutions.
In order to diagnose your problem, your doctor will likely
get a history—your story of the problem, how it started, what
your pain is like, etc. He or she may also examine your back
by inspecting it visually, observing your posture and manner
of walking, as well as doing a more detailed spinal examina-
tion. Among other things, he or she may ask you to bend for-
wards, backwards and sideways, with one or two movements
each, to assess the amount of movement you have and whether
DIAGNOSING BACK PAIN 105
or not you have pain. He or she may test the muscles of your
legs as well as your sensation and reflexes to see if there is
any indication of a nerve root getting pinched. In some cases
he or she may decide to do x-rays or other tests as well.
Red Flags
Only a small percentage of back problems result from
serious disorders such as fractures, tumors, infections or in-
flammatory diseases.3 These uncommon sources of back pain
need to be detected before they can be treated effectively.
Therefore, you should see a medical doctor if you can answer
“yes” to one or more of the following questions. These are
considered “red flags” that may indicate possible serious con-
ditions that need to be looked into further.4
• Are you under the age of 20? Are you over the age of 55
and experiencing a first onset of back symptoms or differ-
ent ones than usual?
• Do you feel constant pain at rest or moving that does not
improve with any positions or movements?
• Do you have pain at night not relieved by medication?
• Have your symptoms continued to worsen since they be-
gan?
• Do you experience persistent restriction of spinal move-
ments?
• Do you have a major spinal deformity (are unable to
straighten up or are twisted to one side) or notice any sig-
nificant change in the appearance of your back?
• Have you been in an accident, had a fall or experienced
some other form of trauma?
• Do you have pain, pins and needles or numbness in your
leg or foot?
• Do you notice weakness in your leg or foot?
• Have you suddenly lost bowel or bladder control or do

you feel tingling or numbness around your groin and anus?
(If so, this requires immediate emergency medical atten-
tion!)
• Do you feel generally unwell, experience a fever, or have
unexplained weight loss?
• Do you have a past medical history of cancer, systemic
steroid use, drug abuse or HIV?
Below, I briefly discuss possible meanings of each of these
“red flags.”
Are you under the age of 20 ? Are you over the age of 55
and experiencing a first onset of back symptoms or different
ones than usual? For those under the age of 20 or over 55,
especially those who have never had a significant back prob-
lem before, x-rays and other tests may be needed to rule out
more serious structural problems or diseases.
Do you feel constant pain at rest or moving that does not
improve with any positions or movements? Do you have pain
at night not relieved by medication? If you feel constant pain
that does not seem to improve with changes in positioning or
movement or that disturbs your sleep, these indicate the need
for further investigation by your doctor. Your problems may
involve a significant non-mechanical condition such as an in-
flammatory disease.
Have your symptoms continued to worsen since they be-
gan? Persistent or worsening pain should also get you to the
doctor since this does not follow the expected pattern for the
natural history of back pain.
Do you experience persistent major restriction of spinal
movements? Do you have a severe spinal deformity (are un-
able to straighten up or are twisted to one side) or notice any
significant change in the appearance of your back? Severe
restrictions or deformities may indicate a problem beyond a
simple backache. It may involve a major mechanical problem
(like an extensive disc herniation) or some other medical or
surgical condition that requires further investigation and help.

Have you been in an accident, had a fall or experienced
some other form of trauma? Pain and difficulty moving after
an accident or other trauma may mean no more than a sprain
or strain. Although x-rays are no longer recommended for
every complaint of spinal pain, they have a use when the doc-
tor wants to rule out fractures and other more serious forms
of injury. Depending on the type, extent and severity of your
symptoms, your doctor may decide to do x-rays or some other
form of diagnostic imaging.
Do you have pain, pins and needles or numbness in your
leg or foot? Do you notice weakness in your leg or foot? Pain,
pins and needles, numbness and weakness in the lower ex-
tremities may indicate that a nerve root has gotten compressed,
most likely by a disc herniation. Impending or increasing
neurological damage may also indicate a need for further
study.
Have you suddenly lost bowel or bladder control or do you
feel tingling or numbness around your groin and anus? A loss
of bowel or bladder control can indicate a large disc hernia-
tion pressing against the bundle of nerves (the cauda equina)
that provide sensation and motor control to these vital func-
tions. A relatively rare occurrence, this indicates the need for
immediate surgery, which can prevent permanent loss of con-
trol of these functions.
Do you feel generally unwell, experience a fever, or have
unexplained weight loss? If you feel unwell or have a fever,
your doctor may want to do further tests to rule out the rare
possibilities of infection or an inflammatory illness.
Do you have a past medical history of cancer, systemic
steroid use, drug abuse or HIV? A medical history of cancer,
systemic steroid use, drug abuse or HIVdoes not mean that
your back pain is necessarily caused by these. However, your
doctor should know about such things, as they can be related
to serious, though rare, spinal diseases.
I will repeat: even if none of these situations is present, I

recommend that you see your medical doctor if you are ex-
periencing your first significant episode of back pain and/or
have not previously had your present symptoms diagnosed.
If the probability of having more serious and relatively rare
conditions has been reasonably ruled out, the doctor is likely
to give you a general diagnosis of mechanical (activity-re-
lated) lower back pain. He or she will likely be able to pre-
scribe medications that can help you to get through the epi-
sode with greater comfort. He or she may also provide you
with some general postural advice and advice on activities and
exercise. As I already noted in Chapter 2, such general advice
may not always help you sufficiently to deal with your par-
ticular activity-related, posture-movement problem.
Activity-Related Pain and the Diagnostic Impasse

Simple activity-related back pain remains, as I have noted,
one of the most common complaints that brings people to the
doctor’s office. Yet the attempt to get more specific about this
general diagnosis has gotten stuck at an impasse which I al-
ready described in Chapter 2. I will further discuss the nature
of that impasse here.
The word “diagnosis” comes from the Greek words
“gnosis” for “seeing or knowing” and “dia” for “through.”
Thus “diagnosis” implies a kind of “seeing through” a par-
ticular set of observations or facts in order to infer an under-
lying, though not directly visible, cause or causes for a par-
ticular problem in a particular individual.
A physician or other health professional does tests and makes
observations that allow her to make inferences about an under-
lying cause that she cannot directly observe. Biologist and medical
educator M. L. J. Abercrombie describes diagnosis as “a process
of judgement; that is, making a decision or conclusion on the basis
of indications and probabilities” when the information is incom-
plete (no one ever has all of the information about anything).5
For example, a man falls while skiing. His foot spasms

and twists and he can’t put weight on it. He may or may not
feel much pain. The emergency room doctor examines him
with her unaided senses. She suspects a fracture based on her
observations and her experience and knowledge of similar
cases. Her tentative diagnostic inference of a fracture allows
her to make predictions that can be tested, e.g., x-rays will
show a fracture. This and other tests can then be done that sup-
port or bring into question what the doctor infers. A firmer di-
agnosis can be made which succeeds if it leads to effective
treatment.
A basic set of assumptions for diagnosing musculoskel-
etal problems (a working theory) was formulated by James
Cyriax, M.D.:
1. All pain arises from a lesion. [Some pain does not arise
from a lesion, as I will show in Chapter 9.]
2. All treatment must reach the lesion.
3. All treatment must exert a beneficial effect on the le-
sion.6
A musculoskeletal lesion is defined as a pathological con-
dition in a particular tissue, a muscle, joint, disc, ligament,etc.
A fourth principle seems implicit here: the practitioner’s goal
should be to discover the tissue at fault so that a beneficial
treatment can be given. This becomes the point of diagnosis.
Laslett points out two elements desirable in making a mus-
culoskeletal diagnosis: First, where is it? This means identi-
fying the specific anatomical site or tissue involved, i.e.,
muscle, joint, disc, etc. Second, what is it? This involves iden-
tifying the nature of the condition affecting the tissue, i.e., frac-
ture, inflammation, activity-related problem, etc.7
Fractures and severe sprains, strains, dislocations, etc., are
examples of musculoskeletal problems that can be specifically
diagnosed very successfully as to anatomical site, tissue in-
volved and nature of condition. The diagnosis allows the con-
dition to be dealt with successfully, e.g., with surgery. Once

these kinds of diagnoses have been eliminated as possibili-
ties, however, we are left with non-surgical musculoskeletal
problems such as common back pain.
A clinical method of examination, which Cyriax and oth-
ers helped develop, can be applied for diagnosing such non-
surgical problems. This method involves applying controlled
physical stresses to the musculoskeletal system. Through
knowledge of applied anatomy, it is often possible to apply a
selective tension or stress to a specific muscle, joint or liga-
ment. Usually this is done with one or two applications of
tension or movement for each tissue being stressed. Based on
a person’s response to observed movement and to stress ap-
plied by the examiner, it may be possible to come to fairly re-
liable conclusions about the anatomical site and specific tis-
sue that is the source of a person’s symptoms. This approach
seems to work reasonably well with areas of the body such as
the shoulder or knee.
Except when neurological testing indicates that nerve
damage exists from a herniated disc, diagnosing the specific
tissue at fault in a case of back pain cannot be done very eas-
ily. In most cases of back pain, neurological damage is not
evident. It may be possible to localize the general anatomical
site of the problem, i.e., the moving parts of the spine. We may
feel fairly sure that an activity-related problem exists. None-
theless, the muscles, joints, ligaments, discs, etc., of the spine
cannot be isolated easily from one another to perform selec-
tive tension testing. So in the case of a seemingly-simple back
pain there exists an impasse for individual practitioners and
individual patients looking to treat a specific tissue at fault
This impasse results from the view that “a lesion,” a spe-
cific pathological tissue that is the source of pain, must always
be found with certainty before successful treatment can be
given for back pain. Although accepting this premise may
sometimes have led to useful results, an absolutistic quest for

“the lesion” may have blocked the path to more fruitful meth-
ods of therapy for many back pain patients.
Doctors and therapists and their patients can get hung up
trying to find a traditional tissue diagnosis. The diagnosis can
become more important than helping the patient. Some clini-
cians and researchers may latch onto a particular explanation
of “the lesion” with a degree of certainty that is not actually
warranted by the evidence. Others may throw up their hands
in regard to the possibility of effective treatment other than
watchful waiting. If they can’t identify a specific lesion, they
may call common everyday lower back pain “non-specific.”
Treatment of this ‘non-specific’ pain then often involves non-
specific advice on posture and exercise. If you have back pain,
you thereby are left in the dark, dependent upon passage of
time.
The Primacy of Clinical Evidence

A specific tissue diagnosis involves some kind of theory,
an inferred map or model that goes beyond what’s directly
observed. Such a diagnostic classification can give direction
to the attempted treatment. However, in order to provide ef-
fective treatment when a particular diagnostic label remains
in doubt, it may be desirable to deemphasize the label while
not entirely neglecting it.
Cyriax’s third principle was “All treatment must exert a ben-
eficial effect on the lesion.” How did he know that the treatment
he provided had a beneficial effect? He asked his patients!
Cyriax, who used spinal manipulation (passive movements
applied to the spine by doctor or therapist), advised systematic
questioning and observation of the patient before and after ev-
ery procedure. Despite his focus on diagnosis, clinical evidence—
symptoms and observable posture and movement—had major
importance for him.
Practitioners of a number of schools of posture-movement

therapy have followed this line of thought. In spite of not
clearly knowing the exact pathological source of many
people’s back problems, they often have been able to apply
successful treatment by assessing its effects on the clinical
evidence—how the patient feels and functions.
Australian physical therapist Geoffrey Maitland has pur-
sued the insight of what he calls “the primacy of clinical evi-
dence” 8 in a particularly detailed and systematic way:
Matching of the clinical findings to particular theories of
anatomic, biomechanical, and pathological knowledge, so
as to attach a particular “label” to the patient’s condition,
may not always be appropriate. Therapists must remain
open-minded so that as treatment progresses, the patient
is reassesssed in relation to the evolution of the condition
and the responses to treatment.9
While this may seem like ‘common sense’, this approach
to thinking, which Maitland has refined to an art, requires
subtlety and skill and is not necessarily common.
Some steps in Maitland’s concept of therapy can be use-
ful to anyone treating back pain (including you when you seek
to help yourself). These steps include:
1. Having assessed the effect of a patient’s disorder [de-
scription of symptoms and observation of movements], to
perform a single treatment technique
2. To take careful note of what happens during the perfor-
mance of the technique
3. Having completed the technique, to assess the effect of
the technique on the patient’s symptoms including move-
ments
4. Having assessed steps 2 and 3, and taken into account
the available theoretical knowledge, to plan the next treat-
ment approach and repeat the cycle from step 1 again10
Maitland has also emphasized that “the initial application of

a technique must be gentle.” These steps apply the scientific
approach to problem-solving discussed in Chapter 1.
Mechanical Diagnosis and Therapy

The emphasis on clinical evidence has been taken a step
further by physical therapist Robin McKenzie. McKenzie has
created a unique system of mechanical (activity-related) di-
agnosis and therapy. Rather than focusing on discovering a
specific tissue lesion, McKenzie’s system focuses on the sec-
ond element of diagnosis that Laslett mentioned, the nature
of the condition.
Based on the effect of positions and movements on the
patient’s symptoms and movements, McKenzie has shown
some ways to distinguish mechanical (activity-related) from
non-mechanical back problems. He also has formulated sev-
eral different categories of activity-related problems based on
a person’s symptoms and posture-movement patterns.
The McKenzie approach is a system of assessment and
therapeutics based on the recognition of patterns of me-
chanical and symptomatic responses to the stimuli of load-
ing (applying forces to) the spine. This recognition is de-
rived from historical information related by the patient as
well as clinical findings that compare mechanical and
symptomatic responses before, during, and after (1) sin-
gular movements, (2) repetitive movements, and (3) sus-
tained positionings.11
What makes McKenzie’s approach to diagnosis unique is
its primary use of a person’s own movements and positions
rather than passive movements applied by a therapist. Treat-
ment flows clearly from this method of testing. Because it
starts with a person’s own self-generated positions and move-
ments, it encourages self-care.
McKenzie has promoted the use of repeated movement

and sustained position testing.12 These examination procedures
are getting used increasingly often by spinal care practitio-
ners of all types. What are they and how do they work?
During daily activities, your musculoskeletal system un-
dergoes forces (loads) that involve varying amounts and di-
rections of push or pull on the body. Mechanical (activity-
related) pain is pain that can be produced, change location,
increase, decrease or disappear as a result of these forces cre-
ated by different positions and movements.
Think of the mechanical forces that affect your spine in
the course of your normal daily activities. You may sit in front
of a computer for an hour or more, with your lower back in a
flexed position for most of that period of time. This involves
a sustained position of asymmetrical force on your spine.
You may work in your garden and repeatedly bend, reach
and lift. These repeated movements involve repetitive forces
in one or a few directions. If you have back pain, where in
your body you feel pain, when you feel it and how easily or
with what difficulty you can move in various directions may
very much depend on these kinds of ‘normal’ (though not nec-
essarily beneficial) daily sustained positions and repeated
movements.
The forces brought to bear on your spine from the one or
two movements of a standard spinal examination cannot be-
gin to simulate the forces that occur in your everyday activi-
ties. If the practitioner only observes one or two movements,
how can he provide you with the specific, detailed and indi-
vidualized advice you need to feel better as fast and completely
as possible? He can’t! Testing with repeated active movements
and sustained positions creates forces on the structures of your
spine in a way that comes closer to simulating the forces that
occur with everyday activities.13 By means of these forms of
testing, a skilled practitioner can discover the particular ef-
fects of various positions and movements on your condition.
Your symptoms may include pain, tingling, pins and

needles, and numbness that you can feel and report. Mechani-
cal effects may include normal movement, movements lim-
ited by a certain amount or in a particular pattern, excessive
movement, and/or distorted positions that you and the practi-
tioner can observe.
A Repeated Movement examination includes having you
actively move to end range (as far as your joints will go in
each direction tested). The movements are done to your tol-
erance and only as many times as necessary to gain informa-
tion about their effect on your symptoms and ability to move
(ten times will often suffice).They are never done to the point
of further injury. The basic movements for lower back test-
ing include flexing and extending the back in the standing and
lying positions, as well as other manuevers.
A practitioner using this method of examination will have
already taken a thorough history. He will assess your sitting
and standing posture. Then he will ask you to move once or
twice through each of the test movements, similar to what is
done in a standard back evaluation. This allows him to assess
your range of voluntary movement in each direction.
Then he will ask you to describe the exact location and
quality of your symptoms. You will repeat each movement and
report on the location and quality of your symptoms both
during and at the end range of a repeated series of movements.
At the end of this repeated series you will report on your symp-
toms, their location and whether they seem better or worse.
You may also be asked to assume one or more static positions
to determine their effects on you.
This kind of examination provides a safe and controlled
way to simulate the types of forces that you experience in your
everyday activities. Carefully monitoring your symptoms and
movement allows you and the practitioner to establish, with
greater assurance, whether you do or do not have an activity-
related (mechanical) problem.
If you do have a mechanical problem, it is possible to

determine the specific nature of that problem in terms of the
effects of positions and movements on your symptoms. As a
result, you can receive an individualized program of treatment
based on those movements and positions that ease your symp-
toms.
Using this approach does not require definitely knowing
the exact anatomical source of the problem in order to resolve
it. Even if the exact spinal tissue affected remains in doubt, a
detailed examination using repeated movements and sustained
positions can provide the information you need in order to
have a beneficial effect on your symptoms.
The examination is based on your own active movements.
In this way you have an opportunity from the start to find out
how you can ease your symptoms through your own efforts.
Your pain becomes a controlled variable. The practitioner
works with you by guiding and coaching you through this
process, which emphasizes self-care.
McKenzie’s system, which he calls “mechanical diagno-
sis and therapy,” starts with self-administered treatment. This
is often sufficient to deal with problems and guarantees that
patients have had the opportunity to learn how to deal with
their own symptoms independently.
Rather than viewing exercises (self-applied movements)
and manipulation (passively applied movements) as entirely
separate categories of treatment, they can be viewed together
on a continuum. Self-administered treatment may sometimes
prove inadequate, even when it helps somewhat. A person may
be moving in the right direction but not generating enough
force to remain improved. At this point, therapist-generated
forces (spinal manipulative therapy) can be used.
In this case, the results of repeated movement/sustained
position testing and of the client’s own efforts indicate in
which direction to move the spine. Starting with the least
amount of force, the therapist can apply pressure at the indi-

cated level in the indicated direction. The therapist continu-
ally monitors the person’s response. Using this approach, the
therapist can safely increase the amount of force as needed.
The purpose of this is to make self-treatment effective again.
Conclusion
In this chapter, I have indicated when you need to go to a
medical doctor for diagnosis. Getting assurance that you do
not have a serious medical problem is important. Once you
have been told that you have mechanical (activity-related)
back pain—what I call posture-movement-related pain—what
do you do about it? Further diagnosis seems essential. But
what kind of diagnosis?
When possible, finding “the lesion” can help. However,
beyond a certain point, it often appears fruitless to search for
a definitive diagnosis about the specific anatomical tissue at
fault. When that is not possible with any degree of certainty,
you still can get beneficial therapy.
Various therapy approaches use clinical evidence, changes
in your symptoms and posture-movement patterns, to guide
activity-related treatment. Because of the detailed attention
to observing and describing what happens, this is different than
just saying “it works.”
I have described McKenzie’s system of mechanical diag-
nosis and therapy as one example of this kind of approach.
This system uses a person’s own positions and movements to
distinguish activity-related (mechanical) problems from non-
activity-related ones. It also provides a way to distinguish dif-
ferent types of activity-related problems, allowing for a more
specific posture-movement-based diagnosis. Self-treatment
using a person’s own posture and movement follows from this.
Having been certified in this approach, I have found it useful
in developing my own way of practicing posture-movement
therapy—with due modesty, every practitioner develops his

or her own way of practicing.
McKenzie’s approach and the other approaches discussed
in this chapter provide examples of some specific and effec-
tive ‘maps’ (models) for dealing with “non-specific” back
pain. I have little doubt that other useful approaches exist or
can be developed. I accept what science philosopher John
Ziman wrote:
[t]here is no simple “scientific” map of reality—or if there
were, it would be much too complicated and unwieldy to
be grasped or used by anyone. But there are many differ-
ent maps of reality, from a variety of scientific viewpoints.14
In the following chapter, I present my own model of ac-
tivity-related back pain that makes use of McKenzie’s and
others’ approaches and which places them in a broader con-
text. This map will provide the basis for my recommendations
about what you can do now for your back pain.
Chapter 9
The Circles of Pain and Recovery
Previous chapters have explored the anatomy and physi-

ology of the spine, the processes involved in experiencing pain
and those by which we act to control our experience. The last
chapter looked at the general process of getting a diagnosis.
In this chapter, I will put together these factors into a posture-
movement model to explain how activity-related back pain
starts, gets perpetuated and then resolved.1
A Biopsychosocial Approach to Back Pain

Many researchers in the area of back pain show an increas-
ing interest in the role of psychosocial factors in the origin,
continuation of and treatment of back pain. In what has been
called the “biopsychosocial” approach by Gordon Waddell,
mechanical, psychological and social factors work together.2
The posture-movement model presented in this chapter rep-
resents such a biopsychosocial approach, with the various fac-
tors working together in interacting and ‘circular’ negative
feedback loops.
Because human behavior is purposeful, how you evalu-
ate your back problem (what you believe and feel about it)
can make a great difference in how you cope with it. This may
ongoingly affect and be affected by how much pain you feel,
how distressed you feel because of the pain, how disabled you
may become as a result, and what you do to get better. This
may all affect and be affected by the social environment of
your family, work, health care practitioners, and the larger so-
ciety.
The most accurate way to consider the biological (includ-
ing activity-related), psychological and social factors always
present in back pain is not to treat them as if they were en-
tirely separate and isolated. Indeed, adequate posture-move-

ment-related evaluation reveals part of the biological aspect
of the problem in a way that can also help build a positive psy-
chosocial climate for the person experiencing back pain and
disability.
The Circle of Injury and Pain

Figure 9.1 on the next page shows the first half of my pos-
ture-movement model. It shows important stages (italicized
in the text) in the process of initially responding to injury and
pain. The key below lists and briefly defines these stages. Un-
fortunately, the useful process of initial response to injury can
sometimes lead to a self-perpetuating vicious circle of disuse
and pain, which I will explain in the section following this one.
Key to Figure 9.1

Environment: As organisms-as-wholes-in-environments
we transact with objects and processes such as air, food,
gravity, etc.; other organisms (microbes, cats, dogs, etc.);
other people and the resulting social-cultural processes
(language, beliefs, etc.). The environment of each
individual’s nervous system also includes what goes on in-
side and on the skin. “The animal does not merely adapt
to the environment, but also constantly adapts the environ-
ment to itself.” 3
Initial Injury: Visible or microscopic disruption or dam-
age to soft tissues of body (muscle, joint, disc, ligaments,
etc.) through undue application of force.
Inflammation: Sequel to injury characterized by swelling,
redness, heat and pain. May also result from infection and
from certain inflammatory diseases.
Sensory Impact: Immediate information (feedback) about
internal and external environments.
THE CIRCLES OF PAIN AND RECOVERY 121
Non-Verbal Experience: Higher-level nervous system pro-

cesses of which organism has awareness. Shared by ani-
mals and humans. Involves ‘thinking’, ‘feeling’, perceiv-
ing without words.
Attitudes, Beliefs, Expectations: ‘Thinking’, ‘feeling’, per-
ceiving expressed and elaborated in words and other sym-
bols. Through complex, circular feedback mechanisms,
these are both influenced by and influence ongoing Sen-
sory Impacts and Non-Verbal Experiences.
Altered Mobility: Efforts affected by and further affecting
our experience of injury and/or pain. Includes withdrawal
from external source of damage (considered trivial) and
more important stage of guarding (protective holding) of
painful area.
General Posture-Movement Patterns: Global organism-as-
a-whole changes of posture and movement related to Al-
tered Mobility. Posture-movement patterns can develop
as a response to local changes in muscles and joints fol-
lowing injury, inflammation and healing. They may also
be based on imitation of others, on emotional factors, e.g.
slump of depression, and may become habitual.
Local Soft Tissue Changes: Local tissue changes in joints,
ligaments, discs, muscles, etc., related to Altered Mobility
following injury, inflammation and healing of these tissues.
May also occur as consequence of continuing guarding and
immobility and as a result of poor General Posture-Move-
ment Patterns.
An initial injury occurs. As the result of some visible
trauma, bone, muscle, joint capsules, ligaments, discs, nerves
and other tissues can suffer. Forces strong enough to bruise,
stretch, tear or compress one or more of these tissues of the
spine may cause immediate pain from the damaging stress.
Physiology texts traditionally have focused on the impor-
tance of a sudden reflex-like withdrawing from the source of
damage at the time of this sensory impact. This can be repre-
sented in the diagram by the arrows leading from sensory
impact to altered mobility and back to sensory impact, a rela-

tively simple lower-level feedback loop. However, pain re-
searcher Patrick Wall considers this kind of reaction trivial and
rather over-emphasized in people’s efforts to understand hu-
man responses to pain.4
Following the immediate damage, sensory nerves in the
area respond by releasing chemicals that dilate local blood ves-
sels. These can also stimulate pain. In addition, products from
the broken cells of damaged tissues and the enzymes that
break down these products both provide chemical irritants that
can trigger additional pain.5
Thus begins the process of inflammation and its familiar
signs of swelling, redness, heat and pain. In a peripheral in-
jury, such as a sprained wrist or ankle, we can observe this
more easily than in a back injury. The swelling walls off and
isolates the area of injury as fluids from the dilated blood ves-
sels move into the tissue spaces. White blood cells also move
into the area to clear up the damaged tissue.
Inflammation provides the basis for repair of damaged tis-
sues. Cells called fibroblasts begin the process of forming new
connective tissue. New blood vessels and nerve fibers may
also grow. This process of healing creates a scar which knits
together the broken elements. Both the swelling and the cel-
lular cleanup and healing operations may provide chemical
sources of inflammatory pain.6
This inflammatory response can occur not only with in-
jury but also in cases of inflammatory illnesses, such as rheu-
matoid arthritis. Such illnesses involve the inappropriate ac-
tivation of an inflammatory response due to some malfunc-
tioning of the immune system. The chemical by-products pro-
duced during such an episode can also result in tissue destruc-
tion. Posture-movement related problems may exist once such
an active epsode has passed.
The sensory impact of injury and inflammation continues
ongoingly. The upward-directed arrows from sensory impact
to non-verbal experience to attitudes, beliefs, expectations

represent various levels of the nervous system experience of
pain illustrated in Chapter 6, Figure 6.1. As you can perhaps
see more clearly now, the sensory impact and non-verbal ex-
perience steps also represent the input side of a complex nega-
tive feedback control hierarchy, as described in Chapter 7.
A downwardly-directed arrow moves from attitudes, be-
liefs, expectations towards altered mobility. This arrow has
breaks in it to indicate that the influence of the higher level of
beliefs, expectations, etc., is not direct. Rather, as indicated
in the chapter on control theory, the outputs of higher levels
exert their influence on lower levels by providing internal
standards (reference signals) which ultimately affect the ac-
tions of the organism.
The arrows pointing in towards and then out from lower
levels indicate that beliefs, etc., affect non-verbal experience;
beliefs and non-verbal experience in turn influence the level
of sensory impact. The full extent of these influences includes
internal changes in the nervous system (remember the gate
theory) and hormonal and immune system changes, as well
as observable efforts that you make. All of these occur within
an environment, both ‘physical’ and ‘social’, which influences
and in turn is influenced by what you do.
Your pain may tend to powerfully capture your attention;
yet your immediate environment, other concerns that you at-
tend to, the meanings you give to the situation, your beliefs
and expectations (both personal and culturally-derived) may
all have very real effects on your ongoing experience and on
your physiology. This provides the basis for understanding the
beneficial (placebo) or harmful (nocebo) effects of sugges-
tions and expectations.7
Psychiatrist and neurobiologist J. Allan Hobson writes:
...consciousness is causal, and in a very material
way....since subjectivity is itself a brain [nervous system]
function, it very naturally can redirect its own energy from
one neural region to another.8
Let’s return to what happens following an injury. You can

trace the arrows directed out and to the side from non-verbal
experience and from sensory impact and follow their path to
altered mobility. These arrows suggest the organism-as-a-
whole-in-an-environment process related to posture and
movement that takes place once damage has occurred and in-
flammation has set in.
The process of altered mobility following injury involves
guarding, reducing the amount of local movement in the dam-
aged area to allow the repair process to adequately take place.
As Wall describes it:
All of us have minor accidents several times a year, often
so minor that we may forget them, but, during the recov-
ery time, we guard the damaged area, protect it, and move
it as little as possible. That motor behavior, which is the
opposite of the sudden brief withdrawal, is crucial for re-
covery because the area of damage cannot complete the
inflammatory and recovery processes if it is moving and
under pressure.9
Guarding a damaged area after an injury constitutes a
healthy and necessary process. It completes a negative feed-
back loop by providing the means for controlling the ongo-
ing sensory impact and thus reducing the non-verbal experi-
ence of pain. It allows the process of recovery to proceed with-
out further aggravation. Wall points out the disastrous conse-
quences of minor injuries for those people who have a rare
condition called congenital analgesia. These people do not ex-
perience pain and subsequently do not guard their movements,
thus continuing to damage their joints, increase inflammation,
etc.10
Guarding actions involve the organism-as-a-whole. To
indicate this, an arrow points down and to the right from al-
tered movement towards general posture-movement patterns.
This outward-pointing arrow and the reverse arrow represent
global changes in posture and movement related to localized

altered mobility following injury. Wall notes:
Joints are splinted by the highly unusual, steady, simulta-
neous contractions of all of the muscles that can move the
joint...Dogs are a wonderful example of the widespread
readjustment of muscles produced by a small injury to one
foot. They switch effortlessly to a three-legged gait with
one foot steadily flexed. This requires an instant reorgani-
zation of all the leg and body muscles. And so it does with
us.11
Changes in general posture-movement patterns can occur by
means of feedback loops of conscious and unconscious be-
havior that control potentially painful perceptions.
These posture-movement patterns are associated with
other organism-as-a-whole changes involving the autonomic
nervous system, which regulates the hormone-secreting
glands, the heart muscle and the smooth muscles of the blood
vessels, gut and other internal organs. Under calm conditions,
there exists a balance between the parasympathetic and the
sympathetic parts of this system. The parasympathetic system
generally slows heart rate, increases circulation to the limbs
and surface of the body, and aids the digestion of food. The
sympathetic system, the “fright, fight, flight” component,
raises the heart rate, shifts circulation to the muscles and body
core, and reduces digestion and movements in the gut. When
you experience pain, your autonomic balance will tip towards
this sympathetic response of “fright and flight.”12
Another arrow from altered mobility points up and to the
right towards local soft tissue changes. Here we change the
scale of interest from general posture-movement patterns to
a much more narrow focus on particular muscle, joint, and
other tissue changes. As mentioned in the previous chapter,
various practitioners have found it difficult to agree on diag-
nosing the particular tissue (muscle, joint, disc, etc.) respon-
sible for common back pain. Nonetheless, injury and the pro-
cesses of inflammation and healing (via scar tissue formation)

undoubtedly can occur in any of these tissues. Through the
kind of testing discussed in the previous chapter, movement
patterns and pain responses can help to determine what tis-
sue might be affected. More importantly, such testing can help
determine the appropriateness of any particular posture-move-
ment strategy to help restore normal function.
The Vicious Circle of Disuse and Pain

Immediately after injury, inflammation may predominate.
and you may feel pain all of the time. With inflammation pain,
what McKenzie calls “chemical pain,”13 reducing your move-
ment has some usefulness. However, even here some ways
of reducing movement, i.e., staying as relaxed as possible
while maintaining neutral spinal postures, may be better than
“a body fixed in an overall pain posture.”14
Once an injury has occurred and healing has taken place,
pain and altered mobility may continue past the point where
they serve much useful purpose. Some pains may get incor-
rectly interpreted as meaning further damage. This leads to
continued guarding of posture and movement to avoid the
pains which get interpreted as more damage and lead to more
guarding, etc. You can trace the circle in Figure 9.1 that goes
around and around in this way.
Wall describes this circle of disuse, pain and more disuse
as follows:
Muscles are in steady contraction and, as time goes by,
some muscles grow while joints and tendons deteriorate
because [the] frozen posture sets off local changes....the
problem is to override a natural defence mechanism that
has a protective role in brief emergencies but becomes
maladaptive when prolonged....movement that produces
pain does not necessarily increase the injury...lack of move-
ment that seems at first to prevent pain eventually acts to
prolong pain.15
Many practitioners in the posture-movement field have

pointed out that hurt does not necessarily equal harm. The ex-
istence of pain does not necessarily mean the existence of dam-
age. Understanding the kinds of Soft Tissue Changes that can
occur after injury can help you to understand and better deal
with these not necessarily harmful pains.
Soft Tissue Changes

Changes in the soft tissues, e.g., muscles, joints, etc., re-
sulting in limited movement, have been called “contractures”
by physical therapy researchers Cummings, Crutchfield and
Barnes.16 They group soft tissue contractures into three main
categories:
1. The formation of adhesions in the muscles, tendons,
joint capsules, ligaments, etc., as a result of injury and scar
tissue formation; 17
2. Adaptive shortening in uninjured muscles and skin that
occurs as a result of altered mobility and guarding; 18
3. Joint displacements that involve restriction of move-
ment “due to malpositioning of the articular surfaces of the
joint.”19
Let’s look first at how adhesions get formed. As healing
happens, connective tissue cells begin producing new fibers
that will ‘fill in’ with new connective tissue whatever tissue
has been damaged. This process, called scarring, may begin
several days after a back injury and can continue for several
weeks until the new tissue gets layed down. While this hap-
pens, too much movement, especially vigorous end range
movement in the wrong direction, may interfere with the pro-
cess and interrupt connective tissue formation.
At some point, however, scar tissue gets formed and will
begin to mature. At this stage, inadequate movement will re-
sult in an adhesion, a shortened, stiffened area, painful at its
restricted end range. McKenzie calls this kind of condition a
“dysfunction syndrome.” 20 Movement testing can help to de-

termine if this kind of situation exists.
Pain in this case is not something to avoid. Restricted
motion associated with pain that you feel intermittently at end
range and which doesn’t worsen with repetitions means that
tightened structures are getting stretched. No damage occurs.
In fact, you must feel that type of tolerable ‘stretch pain’ for
the movement to do any good. While a newly-formed scar ma-
tures, one can apply enough beneficial stress to it through
movement so that it will reform in a strong, lengthened, un-
restricted and painless way.
Such “dysfunctions” do not result only from direct injury,
since a second type of contracture, “adaptive shortening,” can
affect even uninjured muscles and skin. These tissues can be-
come adaptively shortened over time if they do not have ad-
equate movement. Muscles, for example, can change their
length, sometimes quite quickly, if they are constantly splint-
ing a painful joint or when they otherwise become overworked
by constant contraction and fatigue.21
A third kind of soft tissue change or contracture, “joint
displacement,” can also contribute to a circle of disuse and
pain. This is not a dislocated joint. Rather, a change occurs in
the relationship between the articulating surfaces of a joint so
that normal movement is restricted. This seems similar to what
McKenzie calls the “derangement syndrome.” 22
If you have this kind of back problem, you may feel con-
stant pain. However, unlike the pain associated with inflam-
mation, symptoms will vary with the time of day and with dif-
ferent positions and movements. You may or may not be fixed
in a position of deformity. What is going on here?
According to Cummings, et al.:
...at a normal joint...bone B moves around bone A. The
articulating surfaces remain in contact and the looseness
of the capsule and ligaments allow the excursion [normal
movement] to take place...[With a joint displacement] bone

B for some reason is displaced on bone A in the starting
position. You will find that it will not be possible for bone
B to move all the way around bone A. The range-of-mo-
tion will be limited. This limitation may be caused by in-
tricacies of the articulating surfaces such as configurational
mismatches, curves of the articulating surfaces, or bits of
meniscus [cartilage pads], which may cause the joint to
lock....Another possible cause of joint limitation by dis-
placement is reflex inhibition of muscle action.23
Following the work of orthopedic physician James Cyriax,
McKenzie has argued that this kind of problem in the back
most often results from changes within the disc. According
to this disc model of joint “derangement,” small reversible
shifts of material within the disc can occur that exert constant
mechanical stress upon pain-sensitive structures of the spine.
As previously noted in Chapter 5, the disc consists of a
fibrous outer wall and a gel-like inner portion. With normal
aging, so-called “degenerative” changes, such as cracks and
fissures, can occur within the structure of the disc. As the re-
sult of trauma or as a result of abnormal asymmetrical stresses
— such as poor and prolonged sitting and frequent and pro-
longed flexion of the spine — displacement of material can
occur within the joint.24
When this occurs, something within the disc, perhaps
some of the gel material, has moved from its normal position
inside the joint. This distorted material may not then change
position as quickly as necessary when further movement re-
quires such change. Instead, pain and loss of movement oc-
curs as the joint and surrounding tissues are placed under ab-
normal stress. Severe changes in general posture-movement
patterns may occur, visible as postural deformities, as part of
a strategy to reduce the resulting pain.
This “derangement process” takes time to occur—the re-

sult, over time, of undesirable repeated movements or pro-
longed positioning. It will usually take time and the applica-
tion of the proper repeated movements and sustained positions
to make things right again.
Surgeons and other physicians are familiar with the ex-
treme state of this disorder. With a herniated disc, extruded
material presses into the surrounding tissue spaces, causing
nerve irritation and injury.
Under these circumstances, especially when it first occurs,
positions and movements will probably not have much of an
effect in reducing symptoms. Time will be needed for the
surrounding tissues to accommodate to the extruded material,
which may also shrink over time. Surgery, however, some-
times may be a good option here.
Short of this extreme, when the wall containing the gel
contents of the disc seems intact, it often is possible to re-
duce internal disc derangements . Posture-movement therapy
apparently can then change the shape and location of displaced
material and restore normal relations within the spinal struc-
tures.
Movement testing can indicate which movements and po-
sitions will reduce or abolish symptoms, or change where
symptoms are felt. With derangements, this change in where
symptoms are felt seems especially notable.25
Clinicians have observed for years that the pain resulting
from a back injury often starts in or near the middle of the back.
As it worsens it can either spread out or shift away from the
spine and into one or the other buttock or leg. McKenzie calls
this peripheralization, since symptoms have moved out to the
periphery of the body.
It has become more apparent in recent years that as symp-

toms improve they may decrease at, or move away from, the
periphery and move closer to the center of the spine. For ex-
ample, in the case of Paul, about whom I talked in Chapter 3,
the pain that he felt going into his leg and calf reduced and
disappeared as his symptoms and ability to move improved.
Concurrently, he noticed more symptoms near the center of
his back for awhile. McKenzie uses the term centralization
for this phenomenon of pain decreasing or shifting out of the
periphery and moving closer to the center. Centralization pro-
vides a consistently reliable guide for effective treatment.26
Peripheralization and centralization may correspond re-
spectively to increased and decreased joint displacement due
to distortion and disruption within a disc. Many physical thera-
pists, physicians and chiropractors still do not accept the model
of disc derangement as explained above. Nonetheless, a sig-
nificant amount of research provides evidence in its favor.27
Treatment based on this model works effectively much of the
time.
Posture-Movement Patterns & the Vicious Circle

General posture-movement patterns provide ways of deal-
ing with immediate injury and subsequent inflammation. As
healing proceeds, contractures develop in muscles and joints.
As a result, posture-movement patterns also develop as cop-
ing strategies for dealing with these soft tissue changes. As
discussed in Chapter 4, these patterns can also develop through
imitation of others, through ongoing emotional factors, e.g.,
the slump of depression, and also as default habits in the course
of your activities of daily living.
Cyriax’s assumption that “All pain arises from a lesion”
(mentioned in Chapter 8) is not correct. Sometimes your pos-
ture-movement patterns may cause pain in the absence of in-
jury or any joint or muscle problems. McKenzie uses the ex-
ample of the “bent finger.” 28 Take one of your fingers and bend
it backwards with a finger of the other hand. Bend it back as
far as you can. Make it hurt! Now relax your finger.
Do you have something wrong with your finger? If you
answered no, that doesn’t mean that your pain is ‘just in your
head’ (whatever that means!). When you bent your finger back,
you didn’t damage anything. However, the pain presumably
provided some warning of impending damage that might oc-
cur if you continued to stress the ligaments, joints, etc., of your
finger.
Some people experience back pain after long periods of
slumped sitting or standing. When tested, they appear painfree
and have full spinal mobility. McKenzie calls this kind of pain
the “postural syndrome,” because a movement examination
yields normal results and symptoms only appear with sus-
tained bad postures.29 In this case, back pain, just like the bent
finger, doesn’t necessarily indicate damage. Rather, the pain
seems to provide a warning signal. When an individual who
has this kind of condition begins to guard and restrict move-
ment because of the pain he experiences, he does exactly the
opposite of what he needs to do, which is to sit less and be-
come more active.
If poor posture-movement habits continue long enough,
they may lead to soft tissue contractures due to adaptive short-
ening. Micro-trauma and inflammation also may become
factors here.
Thinking in Other Categories

The pathways of circular causation and the multiple soft
tissue changes that can happen together at one time guaran-
tee that a vicious circle can sometimes seem like a confusing
maze. In addition to what I’ve already discussed here, Laslett
and van Wijman have listed a number of types of diagnoses
that may also be involved in a circle of disuse and back pain:
sacro-iliac joint problems, mechanical instability, facet joint

problems, spinal stenosis and psychologically-based illness
behavior.30
Whatever the problem, usually more than one tissue gets
affected when someone develops spinal soft tissue changes.
Even those areas that did not get directly injured may feel tight
and uncomfortable. Very likely muscles, joints, discs, liga-
ments, etc., all need to have normal movement restored once
an acute injury has occured. Muscles will need to recover the
strength and endurance through their full range that they may
have lost when normal movements could not occur.
Recovery of normal movement seems necessary because
continuing soft tissue changes and their concurrent posture-
movement patterns increase the likelihood of future problems.
Abnormally shortened scar tissue or adaptively shortened
muscles do not have the strength or resiliency of normal tis-
sues. They can more easily get pulled, overstretched, and
reinjured during normal activities.
Other complicating factors exist as well. For example,
various pain syndromes associated with nerve damage appear
to have a part to play in the back-related pain problems expe-
rienced by some people. Injury to a spinal nerve may result
in a vicious circle because of an increase in sensitivity to nor-
mal stimulation after the initial damage has resolved.
In the case of chronic back pain, chronic inflammation
may provide another complicating factor. This may include
originally injured tissues and secondary areas affected by a
circle of pain and immobility.31
Psychogenic Pain
One category noted above, “psychologically-based illness
behavior,” deserves further discussion. If done at all, making
this diagnosis requires extreme caution since it often repre-
sents a mistaken attempt to separate the ‘body’ (bio) from the
‘mind’ (psychosocial).
In understanding the circle of back pain and disuse, psy-

chosocial factors always need to be considered. Nonetheless,
probably only a very few people have what could be called
purely psychosocial ‘back pain’ and actually fake back prob-
lems (malinger). In addition, although some people with back
pain may dramatize or magnify it in order to gain attention,
compensation, relief from responsibilties, etc., it is not clear
that this involves more than a small number of individuals.
In Chapter 6, I briefly mentioned the related notion of
psychogenic pain. Those who apply this diagnosis consider
most back pain to have a primary psychological origin. John
Sarno, M.D., a physical medicine (rehabilitation) specialist,
advocates this view. Sarno contends that internal conflicts,
anxieties, etc., often get translated directly into muscle ten-
sion in the back which then causes pain. He believes that this
accounts for a large proportion of back problems.32
According to Sarno, the best treatment for such a prob-
lem consists of convincing the patient that his symptoms are
due to psychological conflicts. Accepting this ‘diagnosis’
often seems sufficient to solve the problem, although he does
recommend providing some level of counseling at times.
With this approach, physical therapy may serve as an ad-
junct to help promote general mobility. However, for the most
part, patients are advised to forget about special exercises,
body mechanics, etc., to stop worrying about pain, and to sim-
ply return to normal activity.
Sarno’s view of psychogenic back pain has some merit in
that it points to the importance of attitudes, anxiety and guard-
ing in perpetuating back problems. Quite likely, some of his
successes have been with individuals who had became so fear-
ful about reinjuring themselves that their self-imposed guard-
ing became a major part of their ongoing disability. In some
of these cases, anxiety reduction leading to normal, unguarded
movement may have sufficed to correct minor soft tissue
contractures.
However, sometimes a change in attitude, although nec-

essary, may not in itself be sufficient to get better. I have
worked with a number of people who, prior to seeing me, at-
tempted to exert their ‘minds’ over their back problems. They
felt like failures when they did not succeed in getting rid of
their ‘psychologically-caused’ pain. This obviously didn’t help
their ability to cope.
Advocates of the psychogenic approach to back pain have
oversimplified the relations among emotional factors, move-
ment and pain. They also underestimate the importance of the
kinds of soft tissue changes in the joints and muscles that I’ve
discussed so far. As you can see in the posture-movement
model presented in this chapter, emotional factors, soft tissue
changes and postural factors all work together to perpetuate
a circle of pain and disuse.
Faulty Effort
A simple, linear relation between so-called psychological
factors and pain does not exist. Neither does there exist a
simple linear relation between mechanical joint problems and
pain. Exclusively psychological approaches (as these are usu-
ally understood) or those that focus only on joint and muscle
mechanics cannot provide a comprehensive approach for deal-
ing with back pain.
The circular causal, biopsychosocial model presented here
does provide the basis for such an approach. This model is
supported by the work of Whatmore and Kohli on faulty ef-
fort, which they call “dysponesis”:
... “dys” meaning bad, faulty, or wrong, and “ponos”
meaning effort, work, or energy. The term [dysponesis]
thus identifies the basic nature of the condition, namely, a
physiopathological state made up of errors in energy ex-
penditure within the nervous system...If a patient’s symp-
toms have their origin in dysponesis but he is treated only

for structural disease or only to resolve psychological prob-
lems, results will be disappointing, for dysponesis is a neu-
rophysiological response pattern that will survive these
forms of treatment.33
The initial guarding (what Whatmore and Kohli call a
“bracing effort”) in the first stages of musculoskeletal injury
may serve as an appropriate way for dealing with that situa-
tion. When bracing, associated with increased sympathetic
activation, becomes an ongoing response to any experience
of discomfort with movement (even if such movement may
ultimately prove beneficial) than the guarding has become
inappropriate, a faulty effort.
Faulty effort may also initiate a back problem in the ab-
sence of any apparent injury. Bracing and also the inappro-
priate body mechanics involved in slumping and poor posture
(which can also be considered a form of faulty effort) may lead
first to warning pains in muscles and joints (McKenzie’s pos-
ture syndrome) and then microtrauma and inflammation that
can begin a circle of symptoms. It will also add additional
stress to any existing problems in the muscles and joints.
Whatmore and Kohli suggest that faulty effort can be mea-
sured through the use of biofeedback machines which show
the electrical activity associated with muscular effort. They
suggest the use of biofeedback training to recognize, reduce
and eliminate faulty efforts.
However, you don’t necessarily need a machine to observe
the signs of what F. M. Alexander called “undue effort”: held
breath, clenched jaw, tensed muscles, dilated pupils, cold,
sweaty palms and feet, etc. Many methods exist that may help
you reduce faulty effort, including study of the Alexander
Technique, other forms of posture-movement education, hyp-
nosis and relaxation methods, among others.
Chronic Pain
If you have had chronic back pain, you have been loop-
ing around a circle of pain and disuse for months or years. You
may have given up hope.
Depression, anger and fear can act like lenses that mag-
nify and concentrate pain and guarding. You can deal with
these emotions successfully with some combination of medi-
cation and counseling. In the next section, I will discuss more
about the importance of your attitude in coping with back pain.
The neurological processing of pain can also sometimes
get altered in chronic pain situations. Specific medications and
other treatments exist that work very effectively with specific
types of pain. There is a growing medical specialty of pain
management. If you have an ongoing pain problem, you may
do well to consider getting a referral to a medical doctor cre-
dentialed in this field.
When more health care practitioners begin to use and not
simply talk about the biopsychosocial approach to back prob-
lems, it will be easier for people with chronic pain to receive
a comprehensive approach to their problems that includes the
best that education, medicine, physical therapy and psychol-
ogy presently have to offer.
The Vital Circle of Recovery

On the following page, Figure 9.2 shows the stages in-
volved in entering a vital circle of pain control and recovery.
The diagram shows that getting out of the vicious circle of
disuse may start in a number of interrelated ways. Remember
that as an organism-as-a-whole-in-an-environment, you con-
stitute a complicated multi-dimensional system. Even one
small positive change can begin to make a difference to the
whole system since “we can never do merely one thing.”34
For example, if you have soft tissue changes you may on

your own or with assistance begin to improve joint and muscle
function with particular positions and movements. You can
begin to distinguish hurts that harm from hurts that don’t—a
point I will elaborate in the next chapter. Apart from specific
effects on soft tissues, gentle movement also can have impor-
tant pain-reducing effects, according to the Gate Theory dis-
cussed in Chapter 6. Improving your posture-movement hab-
its can also have an important effect in controlling pain by re-
ducing faulty effort and subsequent irritation and inflamma-
tion in muscles and joints. You can find more details about
how to improve your posture-movement habits in Section IV
of this book.
Although it can help a great deal, working on the mechani-
cal aspects of your problems may not be sufficient to deal with
your negative beliefs and emotions. If you have become over-
whelmed by pain, anxiety, depression, etc., there are medica-
tions that can help. Coaching, counseling or psychotherapy
may also have special importance in helping you move out of
the disabling circle of pain, fear, posture-movement limita-
tions and more pain.
Ultimately, it’s up to you. Perhaps the most important thing
you can do is to recognize the possibility of doing better.
Changing your attitude towards your back problem will make
other parts of the vital circle roll more steadily towards re-
covery.
When appropriate, I tell people about the ABCs of emo-
tional self-care developed by psychologist Albert Ellis, the
founder of Rational Emotive Behavior Therapy (REBT). I re-
fer them to books and, if needed, to a qualified REBT-trained
coach, counselor or therapist.
REBT is based, in part, on the ancient wisdom of the Stoic
philosopher Epictetus, who wrote that “What disturbs people’s
minds is not events but their judgments on events.” Ellis has
built upon this to describe the ABCs of emotions. “A” stands

for an Activating event, an occurence or situation with which
we deal. “B” stands for Beliefs, the judgments that we make
on events based on our experiences, expectations, assumptions
and attitudes. “C” refers to the emotional Consequences
which, Ellis posits, result from these beliefs.
The beliefs that often get us into emotional trouble are
those that involve absolutistic demands on the way circum-
stances, other people and ourselves ‘should’ be. It may be
appropriate at times to get mildly upset for more or less brief
periods when things don’t go as we prefer. However, the se-
vere and ongoing emotional distress that we feel, even under
the most dire circumstances, seems to result to a significant
extent from our belief that things must go the way we
absolutistically demand that they go.
Ellis suggests that you can learn to dispute your irrational
beliefs about how things ‘should’ be by turning these absolu-
tistic demands into liberating preferences. How does this re-
late to your back problem? It is not unlikely that you have been
making yourself unnecessarily miserable about your problem.
Since you are your own most enchanted listener, you can start
now by listening to your own self-talk for absolutistic and
unrealistic “musts,” “shoulds,” “always’s,” “nevers,” “can’ts,”
etc.
As Ellis points out in his book How To Stubbornly Refuse
To Make Yourself Miserable About Anything, Yes Anything!,
it is important to practice
...distinguishing between appropriate concern, caution,
vigilance and inappropriate anxiety, nervousness, and
panic….Whenever you have strong negative feelings be-
cause unfortunate things are actually happening to you or
you imagine that they might occur, see whether these feel-
ings appropriately follow from your wishes and desires to
have better things occur. Or are you creating them by go-
ing beyond your preferences and inventing powerful

shoulds, oughts, musts, demands, commands, and neces-
sities? If so, you are turning concern and caution into
overconcern, severe anxiety, and panic. Observe the real
difference in your feelings!35
Besides disputing your irrational demands about your
problem, you can also remember that there is life beyond your
back pain. In the search for solutions, you may have become
so over-focused on your problem that back pain threatens to
become your career. There is no need to wait until you’re
painfree before you shift your attention to wider goals and
interests. Ellis advises to
try to become involved in a long-term purpose, goal, or
interest in which you can remain truly absorbed. Make
yourself a good, happy life by giving yourself something
to live for. In that way you will distract yourself from se-
rious woes and will help preserve your mental health.36
And while you are learning to stubbornly refuse to make
yourself miserable about your back pain, cultivate your sense
of humor! Remember that “Laughter is a tranquilizer with no
side effects.” 37
In the next chapter, you will find specific guidelines on
what to do to avoid and escape a vicious circle of pain so you
can roll along a vital circle of pain control and recovery.
Chapter 10
Now What Do You Do?
Guidelines For Recovery

You can begin to use the posture-movement model pre-
sented in the previous chapter by contemplating Figure 9.1
and considering some of the ways that you may have gotten
stuck in a circle of disuse and pain.
Then consider Figure 9.2, which suggests a number of
overlapping and interconnected steps in the circle of recov-
ery which have special importance for posture-movement
therapy:
• Develop positive, realistic beliefs about your problem.
• Restore mobility, which includes reduction of unneces-
sary guarding.
• Improve joint, muscle function (reduce specific soft tis-
sue contractures).
• Improve general posture-movement patterns.
The ways these steps overlap and interconnect have ma-
jor importance. You can never merely do one thing. Improv-
ing one area will have reverberating effects on the others. This
provides a reason for the variety of approaches that can work
to help you control and recover from your back problem.
In this chapter, I present five general guidelines to help
you to reduce your back pain symptoms and to circle towards
recovery:
1. Make a secure start by getting medical help when
needed.
2. Reduce unnecessary guarding (dysponesis) which
may have reduced your mobility.
3. Index your symptoms.

4. Explore possibilities for extending your spine as you
improve joint and muscle function and increase mobility.
5. Improve your posture-movement habits.
What particular things would you like to change? These
can be specific joint or muscle problems that you have expe-
rienced, one or more aspects of your posture that you would
like to improve, one or more activities that you have stopped
or restricted and that you would like to feel more comfortable
with, among other factors.
As you read this chapter, use the various guidelines to help
you formulate some specific results that you would like to
achieve and at least one thing you can do to help bring about
each result. Remember that the more specifically you can state
things, the more likely success. Find some way, no matter how
small, to experience some success now. You can modify, add
to and/or replace your goals and “to do” list as you proceed.
Make A Secure Start

Back pain can come from many sources. Although most
of the time pain results from activity-related (posture-move-
ment) stresses, you can make a secure start by ruling out any
‘red flag’ conditions which may, at least for now, militate
against posture-movement therapy. You can do this by seeing
a medical doctor as previously detailed in Chapter 8. You are
encouraged to review that material if you have any questions
about whether or not to consult a physician. Writing down your
answers to the ‘red flag’ questions can be helpful.
Your physician most likely will not have the knowledge
or time necessary to give you specific and individualized func-
tional advice regarding your condition. However, he or she
should be able to determine the likelihood of your having a
mechanical disorder. Just knowing that you don’t have a seri-
NOW WHAT DO YOU DO? 145
ous illness can reduce your anxiety and help you to cope bet-
ter. Your medical doctor may be able to refer you to a health
care practitioner who specializes in spinal rehabilitation. Your
medical doctor can also advise you regarding anti-inflamma-
tory and pain medication that may help you deal more effec-
tively with this episode.
If you have already received a diagnosis for a chronic and/
or recurring back problem, you may also benefit from getting
medical advice if you feel depressed, have sleep problems and/
or unremitting pain. Effective medications and treatment regi-
mens exist. Family practitioners and internists are increasingly
aware of the importance of pain management. If unable to
provide such care him/herself, your physician should be able
to refer you to a pain management clinic or to a specialist in
this growing field.
Reduce Unnecessary Guarding

Soon after injury occurs, guarding (bracing) works as a
useful way of controlling pain perceptions while the processes
of healing can take place. At some point, sufficient healing
will have occurred so that the need for normal movement can
take precedence. Guarding may nonetheless continue even
though it has become unnecessary. Even at earlier stages when
some reduced movement seems appropriate, the ‘wisdom’ of
the body may overdo things with excessive guarding efforts
that take on a life of their own.
At these earlier stages of recovery from injury, unneeded
bracing may impair further healing by preventing movements
that would reduce swelling. At later stages, guarding may
prevent the remodeling of adhesions if the normal stretch pains
associated with this process are interpreted as damage. As
explained earlier, excessive and prolonged guarding may also
lead to further soft tissue contractures from adaptive shorten-
ing in the muscles and skin.
Application of the other guidelines for recovery can help

to reduce unnecessary guarding. For example, sometimes a
change in attitude and reduction in anxiety may be enough to
reduce some guarding. That’s one reason why it’s important
to get medical help initially. This may also explain some of
the successes of psychogenic approaches to treatment.
It can also help if you understand your stage of recovery
and the kind of movement-related problem you have. You can
discover this through posture and movement testing by a quali-
fied health professional. This can help you reduce fear and
anxiety about those pains that may hurt but not harm. In the
section on indexing pain, I’ll review the different kinds of pain
and what they signify in terms of desirable and undesirable
movements for different kinds of soft tissue problems.
The section following that one will then guide you through
a posture-movement sequence from Robin McKenzie’s work.
This progression of positions and movements, which empha-
sizes spinal extension (bending backwards), has often proved
useful in reducing symptoms (including guarding) and restor-
ing normal mobility.
Attention to your posture-movement habits can also make
a great difference in reducing excessive guarding and in find-
ing the appropriate amount of effort. I address this in Part IV,
which follows this chapter.
In the remainder of this section, I’ll discuss some ways
that you can directly address the issue of unnecessary guard-
ing (dysponesis).
Guarding and Breath

Sympathetic “fright, fight, flight” activation can accom-
pany the guarding mode. Your breathing pattern may reflect
this stressful emotional state. This pattern may involve rapid
shallow breathing or breath holding. Simple observation of
your breathing can help you to reduce this state and activate
the parasympathetic side of your autonomic nervous system.

This will promote general relaxation by reducing anxiety and
excessive muscle tension.
Here are two simple breathing techniques that you can do
anywhere. However, if you feel a great deal of discomfort they
may work most effectively if you lie down in as comfortable
a position as you can.
The first technique, called “the thirty-six breaths” is de-
scribed by Alice Burmeister in her book, The Touch of Healing:
Begin by counting your exhalations. (“One, exhale, inhale.
Two, exhale, inhale. Three, exhale, inhale.” And so on.)
Count until you have completed thirty-six breaths. If you
lose count, you can start again. This can be done at one
time or throughout the day, counting in four groups of nine.
Allow your breathing to unfold naturally. In time, your
breathing will automatically become deeper and more
rhythmic.1
As you practice this method, notice the movements related
to your breathing in your rib cage, your abdomen, your back
and elsewhere. As you notice these naturally occurring move-
ments, perhaps you can begin to allow them to occur more
freely. Notice what effects this has on how you feel and on
your ability to move and function.
Another breathing method that takes even less time to do
comes from Dr. Kay Thompson, a dentist and psychologist
who taught the following as a relaxation technique:
Press the tips of your index finger and your thumb together
in a circle as you take a deep breath and hold it for a count of
five. Let your breath out slowly as you release your thumb
and index fingers and let them come apart (the finger tips serve
as a cue for the change from tension to relaxation that you want
to experience here). Then take another five relaxed breaths,
counting your exhalations as in the previous method. Stay
focused on your breath. Notice where you feel relaxed as a
result of doing this. You can develop a relaxation habit by

practicing this at least three times per day. Use it whenever
you feel anxious or when you feel the need to release some
tension.2
Guarding and Movement Sensation

Guarding efforts reduce movement which reduces sensa-
tion which in turn reduces further movement. An autonomous,
unconscious feedback loop may thus develop which helps
maintain immobility and disuse. Such a loop may sometimes
play a major role in maintaining a vicious circle of pain and
disuse. Although this can be considered psychosomatic, it is
not simply a matter of belief and is not just in a person’s head.
Intervening in such a process requires having a different ner-
vous system experience of the affected parts.
For example, my wife Susan once twisted her foot. She
had pain and swelling and couldn’t step onto it. After getting
the foot and ankle x-rayed to rule out a fracture, she received
the diagnosis of a moderate sprain. Nine days later, the swell-
ing had subsided and she began to walk without crutches.
However, she limped. I guided her through a process which
involved performing a few small weight-shifting movements
in different directions and then taking a few careful steps back-
wards. This took only a few minutes, after which she walked
normally, no more limp, no pain.
Various sensory-movement techniques and hands-on
methods (sometimes called “body work”) exist. Whatever
explanations they use (sometimes highly esoteric), practitio-
ners of such methods succeed to a significant degree by es-
tablishing non-verbal trust and helping to reduce unnecessary
guarding, increase movement and improve body awareness/
sensation. Seeking out a skilled practitioner of one of these
methods may help you begin to experience normal sensations
and movements again.3 See Chapter 12 for further discussion

of body awareness and the role of reduced sensation follow-
ing injury (especially the section, Sensory-Motor Amnesia).
Guarding and the Messages of Pain

Pain may have a useful message for you. Meditation
teacher Milton Ward suggests that:
Our instinctive being constantly emanates from and seeks
a state of mental, emotional, physical and spiritual equi-
librium. All pain is a request or demand to us (our minds)
to help restore this equilibrium. It is a positive process.4
Guarding and the reduced sensation that accompanies it
can thus involve a walling off of useful messages. You may
need to bring your attention to your painful experience before
you can move on:
Instinct awareness, or pain awareness, can be remarkably
helpful. One may experience the pain in both an immobile
and an active state...If you have any long-term painful area,
you may wish to try this right now. Hold your utmost con-
centration on the very core of the pain. Go deeper and
deeper into the pain. Then, with ample patience respond
to the intent of the pain…as precisely as you possibly can.5
Ward discusses how to use pain awareness during activi-
ties like walking:
The key here is not to wait, as we normally do, for the pain
to become severe before we allow it to rise to our con-
sciousness. Instead we will watch for the very first scin-
tilla of pain. And we will respond to this pain signal no
matter how slight it is. The pain may ask you to slow down
in your walking very considerably. It may demand that you
release your abdomen. It may suggest a quite unexpected
change in your leg or foot motion, or indicate that the physi-
cal problem is entirely related to a job situation or a per-
sonal anxiety. Or a thousand other possibilities...From a

preventive standpoint, a great deal of misery could be
avoided if we would pause briefly, whenever we are en-
gaged in physical effort, to receive the instructions of our
inner system.6
Index Your Symptoms

Developing the kind of pain awareness that Ward suggests
involves the important relations among your attitudes, beliefs,
expectations and your ongoing experience of pain (indicated
in Figures 9.1 and 9.2). Talking about your symptoms in ab-
solutistic, catastrophic and unrealistic ways will focus your
attention and direct your ongoing efforts in ways that will
likely prolong a vicious circle. Talking about your symptoms
in non-absolutistic, non-catastrophic and realistic ways will
help you to focus your attention and act in ways that promote
mobility and recovery. Doing this depends upon guideline 3,
learning how to index your pain and other symptoms, that is, to
describe them as specifically as possible.
Indexing is a term from General Semantics, a practical
philosophy concerned with promoting a scientific attitude in
everyday life. In our introductory book on General Seman-
tics, Drive Yourself Sane, my wife and I define indexing as
“making our terms and statements as descriptive as possible
by emphasizing individual differences as well as similarities.” 7
This is important because:
Our word categories lead us to focus on similarities rather
than differences. Necessary and useful as this seems, how-
ever, no two individual people or things in any particular
category are ever exactly the ‘same’. No matter how simi-
lar they seem, differences remain. 8
The use of indexing comes from mathematics, where vari-
ables are given subscripts, for example x1, x2, x3, etc. In
our everyday language, the variables consist of the words
we use. We consider any statement at least somewhat in-

determinate or ‘meaningless’ in an extensional [‘fact’-
based] sense until we specify our terms using indexes.
A client had been referred to Bruce with a diagnosis of “de-
generative disc disease.” Bruce explained to him that he
needed to get a history and perform an examination. The
client appeared impatient and asked, “Doesn’t the referral
tell you what to do?” Bruce explained that he viewed ev-
ery person, even with the ‘same’ diagnosis, as an indi-
vidual, different from anyone else. “ ‘Back’1 is not ‘back’2”
he said. Following this, the patient had no difficulty coop-
erating with the examination.9
Whatever the diagnosis, indexing reminds practitioners
and their patients of each person’s individuality. You are not
a category or a statistic!
You can also index your symptoms according to where you
experience them in your body. Pain in the middle of your back is not the
same as painalong one side is not the same as painin the buttock is not the
same as paininto the thigh , etc. Use the body diagram of Figure 10.1
to index your symptoms in this way.10 Darken the area or ar-
eas where you experience pain. You can also indicate tingling
(“pins and needles”) with x’s and numbness with o’s. Changes
in the location of your symptoms can provide important guid-
ance when you are deciding to move in particular ways or to
increase your activity.
In addition, you can use indexing to specify degrees of pain
intensity and other symptoms. Some people talk and act as if
pain is an either/or quality. “Either you have pain or you
don’t.” This can lead to expecting complete and, sometimes,
immediate relief. More realistically, you can index your pain
as a process along a continuum. Pain scales like the ones in
Figure 10.2 (used by many practitioners) allow you to rate your
present pain from 0 (no pain) to 10 (the maximum you can
imagine). Indexing pain in terms of a continuum of pain may
Figure 10.1 – Body Diagram
help you to have more reasonable expectations and to fully

experience gradual changes. This may allow you to notice feel-
ing better sooner as you work towards degrees of improve-
ment rather than for all-or-nothing results.
0 1 2 3 4 5 6 7 8 9 10
Back and Buttock Pain
0 1 2 3 4 5 6 7 8 9 10
Thigh and Leg Pain
Figure 10.2 – Pain Scales

Another way to index your pain is to use chain indexes.

Chain indexing involves indexing what you have already in-
dexed or specified in order
…to indicate the effects of environmental conditions, lo-
cation, etc. Car1 (with a full gas tank) will not work the
same as car1 (with an empty tank). We can note this as car1,1
is not car1,2.
The chain index or, as General Semantics writer Kenneth
Keyes called it, the “where” index, helps us to recognize
“that any given person or thing may act differently when
moved to a different place or placed in new circum-
stances.”11 Not only does back patient1 not behave like back
patient2, but back patient1 after walking for 30 minutes may
have much less discomfort or no pain at all compared to
back patient1 after sitting slouched for 30 minutes. With
chain indexing we can help ourselves and others to recog-
nize the specific circumstances under which we feel pain,
comfort, anxiety, enjoyment, etc. In this way we avoid
acting as if every situation ‘is’ the same. 12
Use the table on the next page to chain index (“where”
index) your symptoms.13 Make your comments as specific as
possible as you describe what happens in each circumstance.
For example, what type of chair are you sitting in when you
feel better or worse? How long do you have to be sitting be-
fore you notice it worsening? In this way you will more eas-
ily be able to detect patterns that you can begin to make use
of immediately to reduce your symptoms. You may also note
any other activities that improve or worsen your symptoms.
The last form of indexing I will discuss is called dating.
People, places and things change with time. Dating (“when”
indexing 14) gives you a way of indexing differences in time.
As George Bernard Shaw noted, “The only man who behaves
sensibly is my tailor; he takes my measure anew each time he
sees me, whilst all the rest go on with their old measurements
and expect them to fit me.”15 You can behave sensibly like
Activity Better Worse Comments

Sitting
Rising from sitting
Standing
Walking
Bending
First thing in a.m.
As day progresses
At end of day
Lying
Moving or at rest
What Leaves You Better, Worse or In-Between? In What Way?

Shaw’s tailor by attaching dates or “when” indexes to the terms

and evaluations you use when describing your back pain.
Consider the following questions which will help you take the
time factor into account:
1. Is there any time during the day when I have no symp-
toms at all? In other words, are my symptoms intermittent
or constant (felt all the time)?
2. How do my symptoms change according to the time of
day or to what I’m doing?
3. How long have I had my symptoms?
4. In what location on my body did I first feel my symp-
toms?
5. Where are my symptoms located now?
6. Are my symptoms improving, worsening, or staying
the same since they first started?
By indexing your pain and other symptoms in these vari-
ous ways, you will become a better, more watchful observer
of your pain. Instead of seeing pain as an ‘enemy’ to be
avoided whenever possible, you will become more familiar
with it in ways that can help you deal with it more success-
fully.
What Different Pains May ‘Mean’

As a personal scientist, indexing your pain will help you
to view your symptoms as controllable variables that can mean
different things depending upon their changing location, in-
tensity and presence in different situations at different times.
If you have an activity-related (posture-movement) problem,
you will be able to see some patterns in your symptoms re-
lated to your positions and movements, time of day, and other
factors. Becoming a better observer of how your pain behaves
in relation to different posture-movement factors will help you
become more skillful in changing your actions in order to
move towards recovery.
Here are some general rules that you can use to guide
you:16
1. You are moving towards recovery when your symp-
toms change in location in your body from peripheral to
more central (closer to the spine).
2. You are moving towards recovery if your symptoms
are generally reducing in intensity. (Sometimes as symp-
toms reduce peripherally, they may increase centrally. In
this case, the centralization probably indicates improve-
ment even if the more central areas hurt more than they
did before.)
3. You are moving towards recovery when you can par-
ticipate in more of your normal activities longer with fewer
symptoms.
4. You are moving towards recovery when your symp-
toms reduce in duration and frequency (from constant to
intermittent and then, when intermittent, with shorter and
less frequent periods.
5. Intermittent pain felt only at the end range of a reduced
range of motion indicates the existence of soft tissue ad-
hesions and/or adaptive shortening. This kind of pain does
not mean that damage is occurring. Rather, it may occur
as a necessary part of improving range of motion after an
injury has healed.
6. Intermittent or constant pain which centralizes and re-
duces with a given activity and which is associated with
an increase in mobility indicates the presence of a reduc-
ing joint displacement (McKenzie’s derangement syn-
drome). The activity helps.
7. Intermittent or constant pain which peripheralizes and
increases with a given activity and which is associated with
a reduction in mobility indicates the presence of an increas-
ing joint displacement (McKenzie’s derangement syn-
drome). The activity does not help.
8. Constant pain that does not improve with any activity

or that worsens indicates the existence of a non-activity-
related problem. It may indicate inflammation or some
other condition that requires medical attention.
Explore Possibilities for Extending Your Spine

In this section, based on guideline 4, I describe a progres-
sion of positions and movements often used for treating rela-
tively simple and common back problems. Although I cannot
guarantee that it will work for you, if you first index your
symptoms to establish a baseline and then ongoingly index
the changes that occur while following the general rules above,
you may be pleasantly surprised by the results that you
achieve.
Overthrowing the Tyranny of Flexion

When I started out in the physical therapy profession,
exercises for flexing the lower back (bending forwards) were
a cornerstone of spinal rehabilitation. These often constituted
what I call a “tyranny of flexion,” because it was often as-
sumed, with little questioning, that “If your back hurts, the
first thing to try is bending forwards.” The medical, chiro-
practic and physical therapy professions are now, in part,
thanks to Cyriax, McKenzie and others, moving away from this em-
phasis.17
The tyranny of flexion encourages flexing the back even
when it unintentionally may do harm. It is now more widely
accepted that many people can rapidly improve by initially
avoiding flexion and, instead, extending their backs. How then
did flexion gain so much prominence as a treatment for back
pain?
One major reason is that, for some people, there actually
are times when flexing the back can be useful. A small num-
ber of people may actually improve by avoiding extension and
doing flexion exercises.
There are also people like Paul, described in Chapter 3,

who initially may be unable to extend and may need some time
in the forward bent position in order to accommodate an ap-
parent joint displacement which blocks the extension move-
ment. Flexing the spine may provide temporary relief even
though the problem may continue if they maintain the flexed
position. Once they can extend the spine, they can often rap-
idly reduce their symptoms, especially if, for a while, they
avoid letting their lower backs flex again. Once people in this
situation have recovered sufficiently, they may benefit from
flexing their spines in order to restore the full range of move-
ment in their backs.
Other people have bone problems that result in a narrow-
ing of the spaces for the spinal nerves (spinal stenosis). Some
may have an actual fracture and slippage of the vertebrae, i.e.,
spinal bones (spondylolisthesis). People in this situation may
benefit from not extending their backs and by flexing them to
some degree in order to open the spaces for the nerves. (Of
course, this depends on each person’s individual response to
the positions and movements.) In severe cases they may ben-
efit from surgery.
Other people have gradually lost the ability to extend their
spines. They have developed joint contractures and can’t bend
backwards without an uncomfortable stretch when they reach
the limit of their restricted range of motion. They actually need
to restore their lost range gradually. If they do not know how
to do this correctly or if they get the wrong advice, they may
interpret the pain or discomfort associated with the stretch as
a sign not to continue. This type of problem has been encour-
aged by years of poor advice from prominent back pain experts.
Unfortunately, many doctors and therapists over-general-
ized from the successful uses of flexion, in order to bolster
theories about posture and the inner workings of the back that
now seem questionable.
In my personal library, I have a number of books by promi-

nent back pain experts who have advocated controlled slump-
ing (flexing the spine) as the recommended way for most
people to sit comfortably. Some of these authorities have
elaborated physiological and anatomical reasons why people
should avoid extending their spines. According to them, one
must do a pelvic tilt to slightly flex the spine before bending
to lift.
One writer based this kind of advice on his observations
of Indian peasants who squat with a slight flattening in their
lower backs and were thought to have less back pain as a con-
sequence. When an Indian physician was asked about this, he
said, “Hell, those people are concerned about staying alive.
They wouldn’t complain about a little backache.”18
If you observe people sitting, you will see that the longer
they sit, the more likely they are to fall into a relaxed, slumped
pattern. They don’t need advice from a book to do that! People
also will tend to move around in their chairs after a period of
time spent sitting still. Some will actually arch their spines to
stretch backwards. Could it be that they are getting some re-
lief by extending their backs after a long period of slumping?
Despite years of poor advice, people have recovered from
back pain. How many people would do better by getting in-
dividualized advice that takes into account the effects of po-
sitions and movements on their symptoms?
Extending Your Spine

I don’t wish to establish a new tyranny of extension. I can’t
repeat too often (even if you feel tired of reading it) that treat-
ment needs to be based on an individualized evaluation of the
effects of positions and movements. Nonetheless, the exten-
sion routine that I will present here (derived from McKenzie’s
work) has often been found useful.19
There are some good theoretical reasons why extension

can be helpful. As noted in the discussion of spinal anatomy
in Chapter 5, the lumbar lordosis (hollow) constitutes a slightly
extended position and serves a protective function for the
spine. In addition, a modern way of life often leads to what
McKenzie has called “the frequency of flexion.” 20 The asym-
metrical pressures of constant or frequent flexion can inter-
fere with the mobility and nutrition of the discs. Extension
movements can counterbalance these asymmetrical pressures
and thus promote the normal nutrition, mobility and posture
of the spine.
There also exist good empirical reasons for extending your
spine. Extension often results in rapid relief of symptoms in
people who appear to have soft tissue joint displacements
involving the disc (McKenzie’s derangement syndrome). Prior
to McKenzie’s work, this was observed by some often ignored
practitioners who pioneered the use of spinal extension. As
far back as 1962, Otto Reinert, D.C., wrote about his use of
extension exercises for back pain. Another chiropractor, Fred
Barge, questioned the use of flexion exercises and advocated
spinal extension as well.21 James Cyriax, M.D., also described
the use of back extension exercise.22 Combined with the pos-
tural advice contained in Part IV, you may find that extension
works for you.
If you have sought medical advice as needed, ruled out
red flag situations and developed a baseline by indexing your
symptoms, you can proceed to explore the possibilities of
extension for yourself by proceeding with the following po-
sitions and movements.
Of course, I can’t guarantee results. There are too many
variables and individual reactions involved. I cannot be there
with you, the reader, to observe and guide what you do. This
position and movement sequence will more likely work for

you if :
• You have pain in your back, buttocks and thighs either in
the midline or equally on both sides, with no postural de-
formity.
• You feel worse bending forwards.
• You feel worse sitting, especially for long periods.
• Standing in one place for long periods bothers you.
• You get relief from your symptoms when you walk or lie
down flat, especially on your stomach.
• You feel better moving.
If so and if the pain that you feel is either constant or in-
termittent and goes no further than your buttock or thigh, with
no other symptoms, start with exercise #1. You can do these
exercises on a bed or the floor.
If you can’t seem to get the results you want, seek further
advice by seeing a health care practitioner experienced in this
form of posture-movement therapy.
Exercise #1– Prone Lying

Exercise #1 (Figure 10.3) is simply the position of lying
prone on your stomach. Remove eyeglasses if you wear them.
You can rest your forehead or cheek on one or both hands or
have your arms at your sides. Make yourself as comfortable
as possible.
Notice where you feel your pain. Notice the furthest ex-
tent that you feel it from the middle of your back. After spend-
ing some time in this position, do you feel that lying prone
makes the pain get worse in the most peripheral areas or spread
out further towards your buttocks or legs? If so, you would
do best to seek professional advice to get the added benefit of
therapy as you get started.
If you feel no change after 5 minutes in this position or if

you feel that the pain may be at least slightly better at the most
peripheral areas of pain, go on to exercise #2, which is an-
other static position, prone on elbows. You can move into it
directly from the position you are in for exercise #1.
Figure 10.3 – Lying Prone
Exercise #2 – Prone on Elbows

Prop yourself up on your forearms so that your elbows are
directly under your shoulders and your forearms and hands
are resting on the surface in front of you. Keep your pelvis
and legs on the floor and relax your back into a sagging posi-
tion as much as you can. Remember to breathe. Remain in this
position for two to five minutes (see Figure 10.4).
Again notice if you feel a reduction in the areas that were
at the furthest extent of your symptoms. Perhaps the pains
there have even disappeared and you feel symptoms closer to
the midline of your spine. If so, great! You are ready to go on
to exercise #3, also known as a prone press-up. If you feel no
change in your symptoms you also can go on to #3.
If you feel worse in the same areas that hurt prior to do-
ing this maneuver, you may need more time in the position of
exercise #1. If you feel that your symptoms are
peripheralizing, don’t persist. Rather, lower yourself down to
the prone position. You may find some useful advice on how
to proceed in the section ahead labeled Problem-Solving Sug-
gestions.
Figure 10.4 – Prone on Elbows
Exercise #3 – Prone Press-up

Return to the position in exercise #1. Place your open
hands palm down under your shoulders or slightly to the front
and side. This is the position in which you would put them if
you were doing a standard push-up.
The difference with the press-up is that when you extend
your arms straight, you allow your upper torso to lift while
you leave your pelvis and legs on the floor. As you can see in
the illustration (Figure 10.5), this will cause your lower back
to sag into extension.
Figure 10.5 – Prone Press-up

Before you begin, take note of your symptoms. Notice the

most peripheral location of the pain. Then perform one press-
up. Go up as far as you can tolerate. To do the most good, you
will need to get to your end range. Make sure that your arms
do all the work. Let your buttocks relax and let your back sag.
Remember to breathe.
You will need to repeat this movement about ten times,
going as far as you can go each time. If with repetitions, you
feel a lessening or disappearance of the most peripheral pain,
even if you feel more pain at or closer to the center of your
spine, this movement will probably help you to reduce and
abolish your symptoms. Rest after doing ten.
When your arms have recovered, do another set of ten,
monitoring your symptoms. The intensity and location of the
pain are perceptions that you may be able to control through
applying these movements. Your symptoms have centralized
if the pain feels reduced and/or has disappeared peripherally
while at the same time has either remained, increased or shifted
more centrally (towards the middle of your spine).23 If so then
you can rest and repeat the exercise in sets of ten up to three
or four times (depending on how much your arms can take).
When you return to the prone resting position, you may be
pleasantly surprised that you have no pain.
If so, what may have happened is that through your ex-
tension positions and movements you have squeezed the dis-
placed fluid material of the disc towards the center of the joint.
These fluid contents, which were distorting the joint and caus-
ing pain, have shifted into a more normal, neutral position in
the joint.
However, even though you may have undone the displace-
ment (derangement), the situation will not be stable at first.
You will need to follow a systematic program of exercises and
postural care for at least the next few days to turn this epi-
sode of pain into history.
Directional Preference
As McKenzie has noted, a joint displacement of the de-
rangement syndrome type is characterized by the fact that
symptoms can change location (centralize or peripheralize)
fairly quickly. Moving in the direction that increases the de-
rangement (usually flexion) creates a blockage to movement
in the opposite direction (usually extension). Unfortunately,
moving then in the direction of the blockage may also hurt.
Even though it may take some time, moving the spine in
the initially blocked direction can lead to an overall reduction
in pain and an increase in movement. If your pattern of symp-
toms is such that one direction of repeated movements in-
creases and one direction decreases your symptoms and abil-
ity to move, you demonstrate, what McKenzie calls, a direc-
tional preference in your movement pattern.24 This character-
izes a derangement syndrome.
While it will lead to long-term comfort, finding the direc-
tional preference may take some skill since it often will ini-
tially be blocked and painful to move in that direction. If you
have responded positively to exercises #1, #2 and #3, you have
a directional preference for spinal extension. If this doesn’t
seem clear, see the next section for suggestions.
If you go away from the directional preference and flex
your spine too soon, the unstable material in the disc may have
a chance to displace again. Until things have settled and the
formerly displaced tissues heal sufficiently, you will need to
maintain your lordosis curve at all times! In the following
chapters on posture and body mechanics, I will provide some
concrete suggestions on how to do this. Consult especially the
sections on sitting and folding in Chapter 13.
Problem Solving Suggestions

It seems appropriate here to provide some guidance for
those of you who do not get adequate relief of symptoms with
the prone progression. I will add a few tips here that you can
attempt on your own. If these don’t seem to work, you will
benefit from getting professional advice.
Some people with derangement type symptoms may find
that they cannot lie prone without increasing or peripheralizing
their back pain. Similarly, when standing you may find it dif-
ficult to straighten up or you may feel blocked in bending
backwards.
In this case, you can start by lying prone with one or two
pillows under your abdomen. Find out how many you need
in order not to increase your symptoms. You may need to re-
duce the pillows very gradually (it may take a half hour or
more) until you can do exercise #1 and lie flat with no increase
or peripheralization of pain.
Sometimes the deranged fluid material of the disc may just
need time to redistribute to a new position. For this very rea-
son, you may also need to give more time to each exercise
before moving on to the next one. If you move too quickly in
the blocked direction, you may simply be squeezing the de-
ranged area of the joint without reducing the derangement. If
you follow this suggestion and still do not get relief, please
seek further advice from an appropriately trained practitioner.
It is also possible that you feel your symptoms more to-
wards one side, where the derangement has occurred. Move-
ment in the extension direction may squeeze without reduc-
ing the distorted tissues of the disc, while flexion will
unsqueeze but tend to increase the extent of the derangement.
If so and if you have an obvious deformity and find your-
self bent or twisted to one side as a result of this back pain
episode, you had best get personal help from a spinal care prac-
titioner. If you have no obvious deformity, however, you may

want to try the following, if you can do exercise #1 with no
increase in symptoms, even though the other exercises in the
prone progression have not helped.
With this type of problem you will probably have a direc-
tional preference towards the painful side. To determine if this
is so, lie prone (on your stomach) and shift your hips towards
the painfree side. This will shift your trunk and lower back
towards the painful side. If the painful side is to the right,
shifting the hips to the left makes the trunk shift toward the
painful right side. If you have pain on the left you will need
to shift in the opposite direction.
You will know this maneuver is working if you feel that
the pain centralizes. You can then perform the prone progres-
sion with your body shifted in this way. If you find that this
doesn’t work seek professional advice.25
A few people who do not respond well to extension will
have back pain with blocked forward bending and a full or
increased lordosis. Those with this kind of condition will not
improve by doing exercises that encourage extension. Their
directional preference is for flexion. Exercise #5, Flexion in
Lying, likely will reduce and abolish symptoms in this case.
Postural advice will need to be modified from what is given
for posterior derangements. Again it will be best to get this
evaluated professionally.
It is also possible that you are not responding because you
do not have a mechanical back problem. Alternatively, you
may have one of the less common types of mechanical prob-
lems noted in the last chapter. An activity-related (mechani-
cal) evaluation and trial period of treatment can help you to
find solutions for your problem.
Exercise #4 - Extension in Standing

Assuming that you have been successful with the previ-
ous steps of exercises #1, #2 and #3 (the prone progression),
get yourself up slowly and carefully from the floor or bed.
Make sure that you maintain your lordosis while you bring
yourself up to standing. Walk around a bit to find out how you
feel. You may feel painfree or at least much improved. As I
mentioned, you will need to be extremely vigilant about your
posture and movements for at least the next day or two, avoid-
ing any hint of flexion in your lumbar spine.
Going through the prone progression and doing the press-
ups as often as possible (every two to three hours) will help
you to get to a painfree state and to maintain the painfree state
until the tissues stabilize. It will also help you to return to a
painfree state if your back begins to hurt again.
If you are in a situation where you cannot lie down to do
the press-ups, then exercise #4, extension in standing, can be
done as a substitute. In addition, if you have been sitting (even
if you sit correctly with a lordosis), get up frequently before
you begin to feel any return of symptoms, or when you feel
just a hint of their return, and do five or six repetitions of ex-
ercise #4 as a preventive measure.
To do exercise #4, spread your feet shoulder width apart.
Make fists and place them in your lumbar area approximately
at waist level. Your fists will serve as leverage points for the
movement. Notice if you have any symptoms and, if so, where
they are located.
Now bend backwards, extending your lumbar area, while
continuing to look forwards with your eyes open (this is a lower
back, not a neck, exercise). Make sure your knees remain easy
and unlocked and go slowly enough so that you can maintain your
balance. Extend as far as you can, noting any changes in your
symptoms. Repeat ten times. When you stop, you should not feel
any worse than you did before you began.
Figure 10.5—Extension in Standing
If you were able to get positive results with the prone pro-
gression but find that you feel worse after doing this exercise,
you will need to work for awhile lying prone. For some rea-
son, you may be particularly sensitive to the effect of your up-
per body weight in the standing position.
If you feel that extension is limited and you notice end
range pain that doesn’t get worse with repetitions, you have
stiffness in the direction of extending your back.
I have seen this condition quite often and attribute it to “the
tyranny of flexion,” having been told for years that flexion is
‘good’ and lordosis and extension are ‘bad’. If you have lost the
ability to extend your back, you will need to work on both prone
and standing extension to recover your lost mobility. A thorough
evaluation of the effects of positions and movements on your
symptoms may help you to deal with this condition.
Recovering Function
Once constant pain has become intermittent and intermit-
tent pain has become minimal, it may be time to begin the
process of recovering function. If your derangement has got-
ten reduced, the displaced material will have returned to its
normal position. By continuing with the appropriate move-
ments and correct posture, you may have maintained the re-
duction for at least a few days. In this case, you no longer need
to do the extension exercises every couple of hours.
As noted in the previous chapter, after an injury the pro-
cess of healing continues in its later phases through the for-
mation of scar tissue. The scar provides a connective tissue
repair of the damaged and torn tissues. However, if inadequate
stress is placed on the scar while it is forming and maturing
the repair will be stiff and weak. In other words, an adhesion
will have formed. Your muscles may also have gotten
adaptively shortened
So if you have been following the instructions above and
avoiding flexion, you will need to begin moving in this di-
rection again. How do you know whether it’s time? You can
tell by performing a repeated movement test of flexion in ly-
ing. This is exercise #5.
Exercise #5 - Flexion in Lying
First do one set of press-ups as usual. You should have no
pain with this, except perhaps some end range stiffness if you
are one of those who has lost some extension mobility.
Following this, turn over and lie down on your back.
Notice if you have any symptoms. You should still feel
painfree. Then bend your knees one at a time and one at a time
lift your feet from the surface you are lying on. Each knee
should come up high enough so that you can grab hold of each
one firmly. From this starting position use your hands to as-
sist and guide you as you pull both knees at the same time to-
wards your chest as far as they’ll go. Your tail bone and lower
back will lift from the surface. Then return to the starting
position.
Figure 10.6 — Flexion in Lying
If you feel some discomfort, at what point in the exercise

do you feel it? Note if you feel pain during the movement
(somewhere in mid-range) or at the end range of the move-
ment. Repeat the movement about ten times, making sure that
you go to the maximum of the end range that you can. If you
feel pain during the movement that seems to be worsening,
stop and proceed to do more extensions. You are not ready.
However, if you have pain related to stiffened adhesions
or adaptively shortened muscles, you will feel no pain during
movement. Instead you will feel some pulling pain or discom-
fort at end range that will stop when you get out of that posi-
tion. You will also feel no worse, which in this case means
painfree, after ten repetitions.
Now turn over once again to lie prone and do another set
of press-ups. You should still be able to do these as before to
full range with no pain. If so, you have a “green light” to pro-
ceed with the process.26
If you feel anything different and notice pain during press-
ups that remains after stopping, go through another prone pro-
gression. You may need to stay there awhile and do several
sets of press-ups.
This is a “red light” situation for recovering function with

flexion exercises. Since you were able to do extension in ly-
ing before with full movement and no pain, the flexion move-
ment has likely caused the blocked and painful extension. In
other words, you still have a directional preference for exten-
sion. Reduction of the derangement is not yet fully stable. Con-
tinue with the extension program as before.
You may find that things don’t seem this clear. For ex-
ample, you may find that the flexion exercise feels uncom-
fortable during movement as well as end range, but that your
ability to do the extensions afterwards is unimpaired. You can
treat this as a “yellow” light, and cautiously proceed with the
instructions for recovering function with flexion exercises.
If you are able to proceed with flexion exercises, you can
begin recovering function by starting with two or three peri-
ods of flexion exercises (ten repetitions) per day. Initially, do
a set of press-ups first. Always follow the flexion exercise with
a set of press-ups.You also should wait for several hours after
getting up before doing any flexion. Since you have increased
pressures inside the discs on first getting up, flexing too soon
in the day has a potential for causing a new displacement.
You should continue with extension in lying and stand-
ing as needed, and with proper body mechanics. You can be-
gin to return to the normal activities that you may have stopped
or reduced when your back was hurting.
Continuing Your Progress

Flexion exercises can prove useful if flexion is stiff and
limited and thus interferes with your everyday activities. Flex-
ion in lying can be done safely by following the guidelines
noted above. There are more advanced types of flexion exer-
cises that may help you further recover function if needed.
However, I do not include them here. As Cyriax noted, be-
cause of the “tyranny of flexion” many people mistakenly be-
lieve that “no-one is ‘fit’ unless he can bend and touch his
toes.” 27 Nonsense! There is no particular need for you to bend
down and touch your toes if you have no other problems.
In many cases, I believe that the flexion in lying exercise
will suffice to help recover function. If you feel that you need
to go further with flexion exercises, first get a proper evalua-
tion with repeated movement testing that can help you assess
your actual need to increase that movement and the safety in
doing so.
Flexion exercises need to be done with caution, using the
traffic light approach mentioned previously. As a general
guideline, if you have had an episode of back pain which has
benefited from extension exercises, you will be well served
by including a healthy dose of extension after doing these other
movements.
The position and movement sequence using extension was
devised by McKenzie for the simplest and most common types
of lower back pain. If my descriptions seem to fit your type
of problem, you may be able to reduce and abolish your symp-
toms by working in the way suggested here.
For more detailed advice however, you will best be served
by consulting with a practitioner who can evaluate your con-
dition and determine specifically what you need for an indi-
vidualized, self-care exercise program.
Either from reading this book or getting the advice of a
qualified spinal care practitioner, you can learn how to help
yourself feel better now. By learning self-care procedures, you
will have a skill that you can use in the future. What worked
for you this time is quite likely to work for you again in the
event of a future episode. Whenever you feel the onset of pain,
you can act immediately to cut it short and reduce the inten-
sity and duration of symptoms. If you have had a history of
recurring back pain episodes, it may be possible to reduce the
frequency of recurrences. You can research this for yourself!
Improve Your Posture-Movement Habits

Guideline #5 for dealing with back pain suggests that you
“Improve your posture-movement habits.” Although dealing
with your posture may not be sufficient in itself for treating
back pain, it remains a necessary adjunct to any comprehen-
sive therapy. Whatever the activity-related problem, your pos-
ture-movement habits will surely have a major effect on your
level of pain and well-being. Poor posture will further aggra-
vate any other soft tissue problems that exist. Good posture
will reduce stress. In the next section of the book, I discuss
some basic principles of better body use to apply when you
experience and are recovering from back pain. They also may
help reduce the probability of future problems.
Part IV
Education Solutions
Prevent the things you have been doing
and you are half way home.
- F. M. Alexander1
Chapter 11
Essentials of Body Mechanics
The Power of Posture

Chiropractors, orthopedic surgeons and physical therapists
generally agree (imagine that!) that posture constitutes an
important factor in overcoming back pain.1 By now, you may
at least have an inkling of the importance of body mechanics
and use in dealing with your back problem.
You posture-movement habits may produce or reduce pain
due to stress and strain on normal tissues. Your posture-move-
ment habits can also aggravate or reduce the pain due to pre-
existing soft-tissue problems.
Changing these habits ultimately does not depend upon
treatment or therapy. Ultimately it depends upon education and
steadfast intent. In this chapter, I provide you with some es-
sentials of body mechanics. I will also discuss some of the
constraints and requirements for learning better posture-move-
ment habits. These will help you understand and use four edu-
cational guidelines for using yourself better. These education
guidelines are listed at the end of the chapter and discussed in
individual chapters to follow.
Essentials of Body Mechanics

Good posture-movement habits (“body mechanics” or
“use”) involve coordinating the parts and the whole of your-
self in such a way that there is minimal possibility of damage
to the muscles, joints, etc., and maximal performance efficiency.
Joel E. Goldthwait, M.D., an orthopedic surgeon, provided
an analysis of what good use entails in his seminal textbook,
Essentials of Body Mechanics. The following discussion is
indebted to Goldthwait’s work.
ESSENTIALS OF BODY MECHANICS 177
As Goldthwait and his co-authors noted, every one of the

joints of your body has a range of motion, the total amount of
mobility in any direction. This range can vary among individu-
als depending on the shapes of the joint surfaces, the elastic-
ity of ligaments and the stabilizing ability of the muscles.
Extend and then flex your wrist. Notice the complete range
of motion possible in either direction. As noted in Chapter 9,
the so-called normal range of motion of any joint or set of
joints, such as the wrist or spine, can get reduced for a variety
of reasons.
Whatever your particular range of motion happens to be,
when you get to the end range or furthest point of the motion
only a slight amount of extra movement or “play” in the joint
is possible. You can observe this joint play by applying a little
external pressure at the end range of either movement of the
wrist.
This kind of end range pressure done in a controlled man-
ner, may be necessary and useful to reveal and to treat soft
tissue contractures. However, keeping a joint at the extreme
of end range may cause undesirable pain.
Initially, such pain may simply provide a warning signal.
When you bent your finger backwards until you felt discom-
fort, you experienced such a warning pain at the extreme end
range of your finger joints.
If applied too strongly, too long or too often during your
everyday activities, such end range forces may increase the
likelihood of injury.
On the other hand, when you allow your joints to work
more of the time in more neutral positions and not at the ex-
tremes of end range, you allow what Goldthwait called a “fac-
tor-of-safety motion.” Think of a joint as a hinge. If a door is
opened as far as its hinge allows, a surprisingly small appli-
cation of force might easily damage the hinge or break it. The
same force applied to the halfway open door would have little
effect.
If a joint is not locked at end range, it has some leeway to

move without creating strain. This factor-of-safety also allows
your muscles to have more of an ability to exert a protective,
stabilizing influence on the affected joints. As Goldthwait put
it, “Good body mechanics imply that all the joints of the body
are used in such a position in relation to their total range of
motion that the possibility of further motion in either direc-
tion—the factor-of-safety motion—is always present.” 2
The factor-of-safety is not just about the range of motion
within a single joint. As I mentioned previously, any move-
ment involves a chain of connections throughout the muscu-
loskeletal system. Any single joint thus can gain a factor-of-
safety from a conscious, flexible linkage with other joints. This
linkage provides a factor of efficiency as well.
Notice the difference between examples A and B on the
next page. A illustrates a person inattentively bending forwards
and flexing his spine in order to pick up a package from the
floor. B illustrates someone picking up a package by thought-
fully allowing the spine and torso to lengthen while folding
the hips, knees and ankles over the base of support of the feet.
A shows a method of movement that ‘isolates’ the back
from the rest of the body. The joints of the spine appear close
to a flexed end range position. The hips and knees are also
locked close to end range positions. These positions allow for
little factor-of-safety motion for the spine. As a result, the
lower back carries an excessive amount of the forces of lift-
ing. You know what can happen then!
With B, the forces of lifting are distributed more evenly
throughout the musculoskeletal system. Supporting muscles
stabilize the joints of the spine within more neutral positions
and away from end range. A greater factor-of-safety and ef-
ficiency exists. The back, hips, knees, ankles, the strong
muscles of the lower extremities, etc., work together to share
the effort. This allows the load to be lifted more safely and
easily. The back ‘gets by with a little help from its friends’.
Figure 11.1 — Poor Vs. Good Body Mechanics
When you allow the normal curves in your spine to be

present without reducing or exaggerating them, you allow
more of this factor-of-safety and efficiency to be present. In
order to do this you need to engage your other joints more
when squatting, lifting, etc. In this way, your spine and torso will
work at their optimal length and stability. You will function closer
to your full stature with the least amount of effort necessary.
Posture, Movement and Modern Life

Such optimal movement may exist in a healthy young
child. Constantly active, she will tend to move as her focus of
interest changes. Given a short attention span, this likely
means that she moves a lot! The postural variety resulting
from this more or less constant movement means that she does
not spend a great deal of time in one position, hanging at the
end range of her joints. Even though her posture is not con-
scious, it may appear quite good.
When she begins going to school, working with comput-
ers, watching more television, etc., this situation can change.
Spending more time sitting in chairs in static positions will
lead to postural monotony. She will probably spend more time
with her joints at or near end range, with a reduced factor-of-
safety motion in her joints. The child’s posture-movement hab-
its, again not conscious, will begin to look more like that of
the sedentary adults around her.
The kind of sedentary adult life-style that a child can
‘slump’ into is based to a large extent on the conditions of
modern life. Too many people sit too much of the time. We
live in a car-culture where walking is usually not a required,
or sometimes even a safe, way to get from home to work to
stores, chores, friends, play, etc. More and more people spend
hours a day sitting in front of computer screens at work and
play.
Even those who have jobs that involve more movement
and activity, i.e., gardeners, waitresses, factory workers, etc.,
often end up doing repeated activities involving stereotyped
movements and slumped positions that reduce postural vari-
ety and the factor-of-safety in their joints.
As we have already noted, variations of movement and
pressure are required to maintain adequate circulation to the
discs. Postural monotony in asymmetrical, usually flexed
positions thus interferes with the optimal nutrition of the spine.
The ‘cure’ for an inactive life-style often involves recre-
ational exercise such as running, aerobics, weight training, etc.
Yet working out at the health club can have its own perils.
Posture-movement habits developed during the course of
everyday life do not suddenly get dropped when someone
exercises. Just take a look in any fitness center at the people

sitting crouched over their exercise bikes. Unfortunately, ex-
ercises that get taken up to improve fitness may actually im-
peril one’s musculoskeletal health because they are done with
insufficient attention to body mechanics and use.
Body Mechanics and Exercise

The basics of optimal body use (we might call it the “eth-
ics of the body”) have relevance across different times and
cultures. Although no two people are exactly the same in all
respects, we humans do share a common structure and deal
with gravity and other forces in a similar way.
However, schools of thought differ as to how to achieve
this optimal body use. Traditional rehabilitation practice has
focused on correcting posture and body mechanics through
stretching and strengthening exercises. This remains a major
emphasis of many health-care practitioners. Though such
exercises may help, emphasizing exercise to improve body
mechanics seems fundamentally mistaken.3
Of course, you do need a minimal level of strength and
range of motion to maintain optimal posture. However, it is
not clear the extent to which exercises to strengthen the rel-
evant muscle groups and improve joint range of motion are
necessary to achieve and maintain this condition.4 Even if you
exercise with the most advanced machines to superbly stretch
and strengthen your back, butt, abdominal muscles, etc., this
won’t suffice to keep you from slumping when you’re sitting
in a restaurant eating your soup.
Every sports trainer knows about the “specificity of train-
ing.” Working out and stretching may be important prerequi-
sites for skilled performance. Eventually though, an athlete
needs to practice the actual activities of his particular sport in
order to train the musculoskeletal system to its peak. To get
good at a skill, you need to practice that skill in the way you’ll
actually want to perform it.
In a similar way, to get good at the skill of using yourself

with better body mechanics when you sit, stand, squat, etc.,
you need to practice this skill when you are sitting, standing,
squatting, etc.
Sometimes a person’s posture does seem to improve to
some degree after starting a course of exercises. Part of this
may come about as an indirect side effect of increasing gen-
eral activity and thus reducing postural monotony, improving
energy level and conditioning important muscles.
Postural improvement, to the extent that it occurs in this
case, may also come about because the person has somehow
developed greater body awareness in the course of exercise
training. Good fitness trainers will consistently emphasize the
importance of proper technique and form while exercising.5
The importance of learning good use has begun to get a
glimmer of recognition with an approach to back rehabilita-
tion called “spinal stabilization,” which retrains a person to
control and maintain a stable position of the spine while per-
forming various exercises.6
Experience and research with the Alexander Technique
indicate that focusing on exercising the specific muscles in-
volved is not necessary to establish this control. This is con-
sistent with Perceptual Control Theory as well. Learning how
to support yourself in an upright position in sitting primarily
depends on your desire to sit better, on developing a clear and
accurate internal standard of upright posture and on actually
spending time working to perceive yourself sitting in this way.
It’s a ‘spiral’ process of circular causation that gets refined
and developed with time and practice. Supporting yourself in
a lengthened and upright manner, you will automatically ex-
ercise and condition the muscles that you need to support
yourself in that position. This, in turn, will make it easier for
you to support yourself in a more lengthened and upright manner.
‘Exercise’ systems such as Hatha Yoga, Qigong and Tai

Chi also go beyond a purely muscle training approach. Ques-
tionable metaphysics aside, these disciplines have much to of-
fer because they can provide a number of interesting ways to
develop the kind of awareness and control of body use that
I’ve been talking about here.7
It may seem that I am ‘down’ on exercise. This is not the
case. In no way do I wish to discourage you from working
out in a gym, if that’s what you want to do. Weight training,
aerobics (cardio-pulmonary) exercises of various kinds, and
stretching can benefit you greatly. They can benefit you even
more, while further reducing the probability of injuring your-
self when doing them, if you apply an awareness of body me-
chanics as you exercise and in your daily living.
Learning Better Use

Many spinal care practitioners consider it important to help
their clients with their body mechanics and use. It has been
shown that simple instructions in posture and body use can
make at least an incremental difference in how one feels and
moves. This is especially so with people in pain who feel es-
pecially motivated to sit and move ‘correctly’.8
However, facilitating deeper change in a person’s man-
ner of use requires something more than an instruction book-
let or the cursory instruction usually available in a busy physi-
cal therapy, chiropractic or medical clinic.
An important constraint to learning involves your ‘feel-
ing’ of what is ‘right’ or ‘natural’. Your habits of use devel-
oped mostly unconsciously over the course of your life. In
terms of the perceptual control model discussed in Chapter 7,
you likely have your postural ‘thermostat’ set at a particular
level that is mostly a function of what you’ve gotten used to.
Like Jeremy, the young man in Chapter 4 whom I attempted
to help with his posture, what feels right to you may not actually
be very good for you. Your bad habits may feel ‘right’ simply
because you’re used to them.
Related to this, you quite likely also have gaps of aware-
ness as well as misconceptions and faulty perceptions in re-
lation to your body. Our perceptions and ideas function like
internal cognitive maps of our bodies and environments.9 It
may be something of a shock to you to realize that your per-
ceptual map of your body is not the same as your body itself.
Like any map, it necessarily leaves out some things and may
in fact be highly inaccurate. This is just what F.M. Alexander
found when working on himself.
For example, when students are guided manually to un-
lock their knees and hips and stand with greater length and
balance, they often report at first that they feel as if they are
leaning far forwards. A glance in the mirror demonstrates to
them that this is not so. Becoming aware of this ‘mismatch’
between what you see and what you kinesthetically sense can
serve a very useful purpose. Realizing the fallibility of your
senses can remind you to continue to check, refine and im-
prove your use. In this way your body sense can become more
reliable with time.
These constraints limit what can be learned from a book.
Even with the most detailed written instructions possible, I
have no knowledge of how any one reader may translate these
instructions and apply them. Intensive, one-on-one instruction
is required for learning consistent, long-term and habitual
better use. Nothing can match personal instruction from some-
one knowledgeable. Here we enter the realm of the Alexander
Technique of posture-movement education.
In my own practice, clients with back pain get some of
the Alexander Technique educational work to supplement the
activity-related therapy I provide. In addition, anyone who is
interested can take PostureSense® group classes (based on the
Alexander Technique) to learn and practice essential body mechan-
ics.10 Those who wish to go still further can take individualized
lessons in the Alexander Technique of posture-movement edu-

cation. Alexander Technique training in mindful body mechan-
ics provides one of the best ways I know to learn long term
habits of better body use.11
Research by Wilfred Barlow, M.D., David Garlick, M.D.,
Frank Pierce Jones, Ph.D., Chris Stevens and others has dem-
onstrated some of the effects of Alexander Technique lessons.
These writers have also discussed the requirements for learn-
ing better use in everyday life.
Learning better body use involves actually experiencing
better use. With exposure and repetition, perceiving good use
in your own body will lead to your developing a reliable in-
ternal reference standard for good use.12 This may seem like
a bit of a “Catch 22.” To learn good use, you need to experi-
ence good use. To experience good use, you need to learn good
use. Personal instruction can help you resolve this apparent
dilemma.
The teacher must provide a good enough personal stan-
dard in his or her own posture-movement behavior to ad-
equately provide this instruction. The teacher’s body use sets
a visible example of poise for the student. The teacher’s good
body mechanics are also conveyed non-verbally through
manual contact with the student. This skill requires a level of
non-verbal art that involves a significant amount of training
to acquire.
There also are internal requirements on the part of the stu-
dent of good use. Developing better postural control depends
on your will to learn it. You need to want to develop better
use. This desire will keep you on track towards your ultimate
goal of feeling and moving better.
As you begin to observe yourself more, you may discover a
certain resistance in yourself to doing so. Except for exceptional
times, paying attention to your use may not seem ‘natural’. On
the other hand, some of you reading this may already be paying
too much attention to yourselves in ways that are not helpful.
If you find that you are getting obsessive about your pos-
ture, it may be useful to forget about it for awhile. Spastic self-
preoccupation is not advisable. Avoid tying up your brain in
a pretzel by trying to sit up ‘straight’.13
It may help if you realize that your habits of use are re-
lated to your habits of attention. I want to help you learn con-
structive conscious control of yourself. This means that with
the proper instruction and practice, you will be able to expand
your field of attention to include your ‘outward’ focus on
whatever end you want to achieve (what you are doing) along
with an ‘inward’ awareness of how you are doing what you
are doing (your use). This ‘ought’ to and can be a relaxed, even
interesting, way of doing things.
How much are you allowing the optimal length of your
spine, right where you are now? If you ask yourself this ques-
tion with an inquiring attitude, what kind of difference can it
make in your reading position now? This kind of awareness
can become easier with practice.
This awareness involves being able to apply your im-
proved posture-movement patterns to your activities on a
moment-to-moment basis. Doing this requires a set of cogni-
tive skills called “thinking in activity” by the philosopher John
Dewey, who was a student of the Alexander Technique. These
skills of awareness include the ability to “inhibit” and “direct,”
discussed in Chapter 4 and further explained in the next chapter.
To best assure that you understand the basic principles of
body use, I recommend individualized lessons in the Alex-
ander Technique with a qualified teacher. These lessons can
assist you to more deeply internalize a new body awareness
and moment-to-moment better use. This can set you off in the
right direction for continuing on your path of self-care.
As I said before, improving your body mechanics is not
an all or nothing process. I have observed that the four-ses-
sion PostureSense® class and/or a short course of ten or fewer
Alexander Technique lessons can lead to significant observ-

able changes in a motivated student’s habits. There are also
other therapeutic systems and exercise approaches that may
help you to improve your use.
Even given the superiority of personal instruction, work-
ing on yourself with written instructions from a book may also
help you to some degree. In the next several chapters, I will
present four general rules of ‘mindful’ body mechanics and
some ways to apply them in your daily activities. These rules
have been developed as flexible guidelines for you to apply
as you work on your own to improve your use.
Here are the guidelines:
1. Make body awareness a daily practice. (Chapter 12)
2. Experience your full stature every day as often as you
can. (Chapter 13)
3. Design your personal environment for better use. (Chap-
ter 14)
4. Practice postural variety in your daily life. (Chapter 15)
How can you apply these to begin to move yourself towards
better body use in your daily life?
Chapter 12
Practice Body Awareness
The first guideline for better body use is: Make body
awareness a daily practice.
The Limits of Awareness

Practicing body awareness may not seem easy at times.
We all have a certain amount of psychological inertia. We tend
to move in the well-worn grooves of what we give our habitual
attention to and what we ignore. We often function in a lim-
ited state of awareness that psychologist Ellen Langer calls
“mindlessness.”1
In such a state, our attention runs more or less on auto-
matic and our behavior seems less-than-optimally sensitive
to the conditions surrounding us and inside of us. At such
times, our experience may seem like something that happens
to us, not something that we have an opportunity to shape as
we like.
On the other hand, we also can function at times with a
less automatic, more alert state of awareness in which we are
more open to what is going on around and in us, i.e., Langer’s
“mindfulness.” We can look at things from more than one per-
spective.
At such times, novelty and the present context become
important. We are open to new information. What we attend
to becomes more something we do and less something that
happens to us.
The difference between this alert state of awareness and
the more automatic state of attention noted above may be a
matter of need, interest or skill, among other factors.
Someone who likes melons and knows a lot about produce
may go to a food store with melon on his list, look at the dif-
PRACTICE BODY AWARENESS 189
ferent melons, sniff and poke one and then another until he
finds one that seems just right. Someone else, with less inter-
est and knowledge and more distractions may go to get a
melon and put the first one he comes to into his basket. When
asked why he picked that one he may say, “A melon is a
melon.”
I have been describing relative states perhaps on opposite
ends of a continuum of consciousness. Indeed, a certain
amount of automatism seems like a necessary feature of our
cognitive landscape.
As a mapping system, the brain cannot include in our
awareness all of the information that it processes. Our aware-
ness, as Korzybski pointed out, is necessarily an abstracting
process—as the brain/nervous system selects some experi-
ences to attend to, it filters out other aspects.2 We often use
repetitive patterns. We can thus save time and energy by put-
ting our information abstracting equipment on automatic.
In this way our habits free us from having to focus our
limited attention on repetitive tasks and concerns. However,
we need the ability to go beyond our habits, to extend the limits
of our awareness. Otherwise we can lose our ability to respond
effectively to new and different situations that arise. Instead
of serving us, our habits can become our masters.
Experience and Words

In order to improve your posture-movement habits, you
need to become more mindful of what you do and how you
do it (your tensions, body posture, etc.). This will require that
you bring yourself out of the automatic mode of awareness
more often.
One important distinction to remember when doing this
is the difference between the world of non-verbal experience
and the world of words.3
Try this experiment: Pinch your ear lobe! Do it now. Now

keep pinching it and say, “I’m pinching my earlobe.” Now stop
pinching your ear lobe and say “I’m pinching my ear lobe.”
(You will not get any benefit from this if you don’t actually
do it. Words will not suffice.)
This experiment illustrates that the territory of the non-
verbal experience of the pinch is not the same as the word-
maps you may use to talk about it. Whatever you say about
your experience, for example “ouch” or “it hurts,” is not it.
Nonetheless, in various ways, your habitual beliefs, em-
bodied in your way of talking about your experience, can di-
rect what you do and thereby experience ongoingly. This hap-
pens through the circular, feedback process of perceptual con-
trol discussed previously. How you talk about things will set
the internal standards or reference levels that will determine
what perceptions you control for. In this way, your habitual
mode of awareness can be perpetuated by what you say to
yourself.
Simply having an awareness of this can make a difference
in what and how you experience. You can discover more ac-
curate, more useful ways of talking to yourself about your-
self and what you experience, including your experience of
pain.
For example, I once taught at a seminar held on a college
campus. My wife and I were staying in a room in the college
dormitory, near the designated women’s bathroom. The men’s
room was a long way down the hallway in the opposite wing
of the dormitory. I woke up in the middle of the night with a
full bladder. Trudging out to the hall, I looked around and
briefly contemplated using the women’s room but decided to
“do the right thing” and began the long trek to the men’s room.
The trip started out with a sense of urgency that wasn’t helped
by my telling myself, “Oh boy, this is awful. I don’t know if
I can hold it… ohh, it’s uncomfortable…it’s such a long way
down the hall.” However, having gotten in the habit of listen-

ing to myself and knowing that what I said to myself could
make a difference in what I experienced, I began a different
kind of self-talk. “My muscles work very well to hold things.
What wonderful control. I can make it to the bathroom. I’d
prefer not having to walk so far, but it’s not so bad.” Let me
tell you, I felt very proud of my self-talk that night.
As general semanticist and psychologist Wendell Johnson
noted years ago, your most enchanted listener remains your-
self. What you say to yourself can sometimes affect what you
experience. Johnson illustrated the point with this light verse:
A rose with onion for its name
Might never, never smell the same —
And canny is the nose that knows
An onion that is called a rose.4
Sensory Awareness
Even though we live and experience our lives on what
Korzybski called “the silent, unspeakable” non-verbal level
of existence, it seems that we are endlessly talking to our-
selves. As suggested in the last section, our self-talk can keep
us stuck in habitual, unconscious, unhelpful patterns if it is
based mostly on unquestioned verbal definitions. On the other
hand, if we talk to ourselves in factual ways that keep us open
to the possibilities of new experience, we can adapt better to
what is happening within and around us.
Eventually, a large part of living in this fact-based, expe-
riential way (what general semanticists call an “extensional
orientation”) involves not just learning how to talk differently
to ourselves but also how to turn down the volume of the words
inside our heads. This means practice at looking, listening,
tasting, feeling, etc., at the silent, unspeakable level. Turning
down the volume of our internal chatter gives us more of a
chance to receive new signals and thus to learn new things
about the world and ourselves. Not only can this make us more
adaptable to changing circumstances; it can also make life
more fun.
An approach to living that offers some suggestions for
doing this is the educational practice known as “Sensory
Awareness” taught by Charlotte Selver. Selver, who now has
a number of her students teaching this work, studied with Elsa
Gindler, a physical education teacher in Germany in the early
part of the twentieth century.5
Gindler had no effective medical treatment available
when she contracted tuberculosis. She had little money and
could not afford going to a sanatorium, which at the time,
before the advent of effective antibiotic treatment, was where
such patients went in order to improve their chances of sur-
vival. She did, however, have some hope that by observing
herself, how she breathed and moved, she might at least not
interfere with whatever capacity her system had to fight the
infection.
She found that when she could get out of her own way,
remain present here and now, and keep her attention on the
actual processes of breathing and moving, she could function
more easily.
Some time later, when she encountered her doctor in the
street, he seemed surprised at her appearance of good health.
Indeed Gindler lived for many more years and taught others,
including Selver, her unique form of psycho-physical educa-
tion.
Sensory Awareness work (which I studied with Charlotte
Schuchardt Read, a student of Selver) uses questions and ex-
periments to direct your attention non-verbally to what is go-
ing on in and around you. In this way, you can learn to stay
more in the present as you sense your organism-as-a-whole-
in-an-environment connections.
I would like to give you a taste of a sensory awareness

experiment right now. As you read the following, allow your-
self time to observe and respond:
What are you doing right now, non-verbally?
How can you allow yourself to feel the support of what
holds you up?
How much do you need to hold yourself up?
Where do you feel unnecessary tensions?
Do you feel tension in your jaw?
Do you feel tension in your face?
Where do you feel ease?
How clearly can you feel yourself breathing?
Remember that directing your attention in this way takes
time. When you focus unnecessarily on labeling and explain-
ing, you may miss something important going on in and
around you.
Listen to whatever sounds come to you right now…Do
you find yourself labeling what you hear? Listen again and
this time, if you begin to label sounds, just notice that you are
doing it and come back to the sounds again…
Touch the cloth of your clothes. Notice the sensations in
your fingers, your hands. Allow the sensations to travel where
they will. Move to a different part of your clothes. Notice any
different sensations.
Choose something to look at. Without words, take in what
comes to your eyes. Continue looking; what else comes to
you?
Get up and walk around. Sense the movement of your feet
and legs, the movement of your arms, the shifts of your torso.
Consider the sounds, sights, and aromas around you as
structures to explore. Pick an object, such as a stone or a pen-
cil. Examine it closely, silently for several minutes. Use ‘all’

of your senses: see, hear, touch, taste, move, etc. How well
can you do this without labeling or describing?
You may find that you quickly fall into speech, perhaps
talking to yourself about something else. Perhaps you scold
yourself for not performing the task ‘correctly’. You may also
find yourself congratulating yourself verbally for remaining
on the non-verbal level. If you find yourself doing these things,
just notice it and go on. With practice, you’ll find it easier to
stay focused on the non-verbal level.
You may have noticed that I used the word “allow” in some
of my instructions for non-verbal awareness. Part of doing this
work involves allowing yourself to experience whatever you
experience at the moment, accepting what you find.
People who work with me sometimes object that they want
to change, not accept themselves as they presently function.
However, as Gindler discovered, I find that people benefit
from allowing themselves to experience whatever occurs. That
doesn’t mean you have to like what you experience. None-
theless, positive changes can occur more easily when you’re
not denying or fighting what you experience. To control what
you want to control, you have to experience it first.
My dear friend and teacher Charlotte Schuchardt Read has
expressed this attitude beautifully in an interview on her sen-
sory awareness work:
This involves getting in touch with ourselves, and accept-
ing what goes on. It's so important, I feel, to accept—not
to criticize—ourselves, as in: "Oh! I shouldn't do this! I
shouldn't do that!" But to accept what goes on. We all have
built up habits over the years and we all could function a
little better than we do. But to allow what we feel is needed
—this is a big thing, you know. It really is so fundamen-
tal, at least in my view. Do we need more air? Do we need
more keen observation? Do we need more silence? Oh,
that's another important aspect of it, isn't it? To be able to be quiet.6
For example, I have used this approach for foot and leg
cramps. I find that when I allow myself to focus on the sensa-
tions, noticing with interest (and varying degrees of difficulty)
how the ‘pain’ feels, how the muscles twist…the cramp of-
ten disappears.
The Wedge of Awareness

Perhaps in reading this you have become a little more
aware of your awareness. Your nervous system gives you the
power to do this—the power of self-reflexiveness. Self-reflex-
iveness allows you actively to bring awareness to what was
previously out of awareness. In this section I will show you
how to apply the Wedge of Awareness, developed by General
Semantics teacher Milton Dawes, to make practical use of this
self-reflexive ability in order to improve your body awareness
and posture-movement habits.7
Self-reflexiveness refers to the fact that you can make a
map of a map. You can make a statement about a statement.
This self-reflexive characteristic of our language reflects the
underlying self-reflexive characteristic of our nervous sys-
tems, the ability to be conscious of our consciousness.
Whenever you find that an experience has stopped you
short, you have made use of this self-reflexive capacity. For
example, you’ve probably at some time in your life made a
mis-step going down stairs because you ‘thought’ that there
was another step to go down when there wasn’t. Until the mis-
step happened, you weren’t aware that you had assumed that
there was another step. This “oops” moment gave you a bit
of unintentional awareness. You became aware of your level
of awareness.
This kind of moment can begin to bring an aspect of choice
into where you give your attention. It can lead to the practice
of intentional awareness. Imagine yourself in the dark in an
unfamiliar house, unable to find the light switch and having
to go down some stairs. At such a time, as you carefully feel

your way step by step, you may experience the kind of ac-
tive, alert awareness that I refer to here. With intentional
awareness, you make a deliberate decision to experience
something specific and your attention is very much alive,
awake and alert.
A wedge shape seems like an especially good symbol for
such a moment of awareness. A wedge, like the kind that holds
a door open, has a small edge through which it initially acts.
This tiny tip gives it an effective point of action that allows
the wedge to fit between the door and the floor. Another ex-
ample of a wedge, an ax, has a very narrow cutting edge, which
serves as its effective point of action. When you become aware
of the automatic, ‘mindless’ aspects of your behavior you give
yourself a Wedge of Awareness (WOA), also called Wedge
of Consciousness (WOC).
You deliberately can seek out such moments. For example,
if you habitually wear your watch on one wrist as most people
do, switch it to the other wrist and notice the effect. You’ll
probably find that you have many “oops” moments through-
out the day.
You also can ‘WOA’ yourself when you bring some in-
tentional wedges to your ongoing activities. By applying a
‘thin wedge’ of awareness to a task, you can set clear, doable
goals, no matter how small, that can be done even in one brief
moment, here and now.
Astronaut Story Musgrave, in an interview discussing his
repair work on the Hubble Space Telescope 368 miles above
the Earth, described how you can do this:
“I have these little interrupts [WOAs] and they go off all
the time. I’m doing a space walk, and the interrupts say,
‘Look at the Earth, the sky, or inward. What are you feel-
ing right now? Listen to your body.’ It’s an attempt to be a
total participant, and at the same time getting the job
done.”8
Instead of this brief, incremental method of becoming

‘mindful’, i.e., changing habits, etc., we often do the oppo-
site by ‘applying the blunt side of the wedge’ to our goals and
to ourselves. You may set grand goals for yourself and attempt
to change many things at once. For example, you may decide
to practice sensory awareness twenty-four hours a day. This
kind of approach seldom works.
In order to improve your posture-movement habits, you
need to become more aware of what you do and how you do
it. You will do best by starting modestly, taking brief moments,
wedges, to observe yourself in action. You can practice sen-
sory awareness by noticing one thing, one moment at a time.
As you become more aware of your body use, you will
become more aware of other aspects of your life and the world
around you. This works in reverse as well. Giving yourself
time to pause and look at the scene around you or to sense
how you’re breathing, gives you a way of wedging yourself
that will enhance your ability to move.
Interestingly enough, you will find that wedging yourself
over time has a cumulative effect. Just as the size of a large
area can be found by adding its small incremental parts, you
may find that controlling small increments of your attention
may add up to whole new habits of sensing and moving.
Stop right now and notice what you are doing. Give your-
self a moment or two to answer each of these questions —
not verbally but by noticing what you sense and feel:
Where are you located in space?
Where are you in relation to the corners of the room you’re
in?
Are you sitting in a chair or on a couch?
Can you feel what you are sitting on?
Can you feel your feet on the floor?
Are you sitting erect or slumping or somewhere in be-

tween?
Are you holding your breath or are you letting your breath
flow freely?
What movements do you feel related to your breathing?
Do you allow enough space for your breathing?
Do you notice any tensions or pains at the moment?
What would you need at this moment to feel more com-
fortable?
How much of the length of your spine can you experience?
What kind of difference have these questions made in how
you feel right now? You can wedge yourself by asking your-
self these kinds of ‘sense-able’ questions. They will help you
live more ‘mindfully’ as you observe and improve your hab-
its of body mechanics and use.
You may even find it useful to get a small rubber or
wooden wedge to place on your desk, work area or other place
where you can see it often. Whenever you look at or handle
the wedge you can remember to make and take a wedge of
awareness.
Awareness, Inhibition and Direction

F. M. Alexander employed two dimensions of awareness
that are important to remember as you work on improving your
body mechanics and use. He called these dimensions “inhi-
bition” and “direction” (see the previous discussion in Chap-
ter 4) and they can easily be understood in terms of the wedge
of awareness.
As you may recall from his story of self-discovery, in
Chapter 4, Alexander found that when he decided to do some-
thing habitual like reciting a sentence, he found it difficult to prevent
his old habits of misuse. If he immediately began to do the action,
he pulled his head back, etc. Initially he was not even aware
that he was continuing with his old habits of tension and
malposture.
At some point, watching himself in his mirrors, etc., he
realized that, despite his best intentions, he was continuing to
tense and shorten himself while speaking. At the moment that
he became aware of this, he was functioning at the “oops” level
of awareness.
He began to realize that, at the critical moment when he
decided to speak, the habit of tensing, pulling his head back,
etc., seemed to get set off automatically unless he consciously
decided to pause and delay his action. He called this process
of having the notion of doing something and then delaying or
not doing it immediately,“inhibition.”
Bringing even a momentary pause into the chain of deci-
sion-making provided what Alexander discovered to be a
means of developing new and better habits of using himself
in speaking and other activities. “Inhibition,” in the way I am
using it here, does not refer to repressing any aspect of your
behavior. Rather, stopping and pausing allows a wedge of
awareness to enter a situation. Inhibition, in this sense, con-
stitutes a ‘negative’ dimension of awareness.
“Direction” is the term used in the Alexander Technique
to refer to a ‘positive’ dimension of awareness. A direction
consists of an internal instruction that you give yourself in
terms of a result you want to perceive. A direction can be given
with words or images or just an internal desire to experience
something in a certain way.
Alexander studied the conditions of better use in his own
body. He came to understand that when he actually allowed
his “neck to be free, to allow the head to go forward and up,
to allow the back to lengthen and widen” the loss of voice that
he had habitually experienced didn’t happen.
While inhibiting his old response to the idea of speaking,

he would project directions for better use by actually saying
those words to himself. He found that the words, when their
meanings had become clear through non-verbal exploration,
pointed his awareness towards better use.
Alexander found that the process of giving directions
worked best if he didn’t try to do the directions. In other words,
he found that he also had to inhibit any immediate action to
carry out the directions. Instead, when he became aware of
anything he was doing, say tightening his neck, that seemed
incompatible with a particular direction, such as ‘freeing the
neck’, he could simply stop doing the undesired action.
Inhibiting and directing can be considered as two sides of
a wedge of awareness. Pausing (inhibiting) allows time for
projecting (directing) a new pattern in place of automatic be-
havior. Conversely, when you give directions, such as “Let
my neck be free” you automatically insert a pause into your
habitual way of doing things. This is Dewey’s “thinking in
activity,” mentioned at the end of the last chapter.
This notion of the wedge of awareness has broad impli-
cations for all sorts of behavior besides body mechanics. Al-
exander and other thinkers, such as Feldenkrais, have sug-
gested that our body use constitutes a ‘pivot’ of habit in gen-
eral. It is an intriguing notion that focusing on body mechan-
ics in this ‘mindful’ way may provide a useful basis for de-
veloping the skill of thinking in activity in other areas of life.
Learning how to apply the wedge of awareness (which
includes inhibition and direction) in relation to your body me-
chanics involves developing a conscious control system that
you can ‘insert’ into your more or less automatic sequences
of actions in daily life. In terms of Perceptual Control Theory,
you can gradually ‘recalibrate’ your body image towards a
better standard of use. This standard becomes a conscious
reference level that helps you to direct yourself in activity any
time you choose.
Mapping the Body

The brain seems to store what we perceive as a system of
internal cognitive maps that represent the experience of our
bodies and external environments. These internal cognitive
maps provide the checkpoints that we use to set our goals and
achieve our purposes.9
The limits of our actions, including how well we use our
bodies, depend on the quality of our internal maps. Yet no map
is perfect. No map is identical to the territory it represents.
This ‘obvious’ statement leads to the non-obvious truth that
your body map is not the same as your body and can some-
times mislead you.
Neurologist Oliver Sacks, in his book The Man Who Mis-
took His Wife for a Hat, demonstrates this phenomenon clearly
in the extreme cases of people with serious brain damage. After
certain kinds of strokes, for example, people may not recog-
nize that their arm or leg belongs to them.10
Even those of us with normal brains easily can misperceive
our bodies. This is what Alexander discovered when he was
trying to change his body use. Dr. Wilfred Barlow documented
this also in a study of army recruits who were asked to stand
up without pulling their heads backwards. The recruits largely
reported that they succeeded, although independent observa-
tion found the reverse.11
A map also does not cover all of the territory. There is a
great deal going on in the body that we never perceive. At any
one time the limits of our body awareness are confined by our
span of attention and our habitual perception. Nonetheless,
practicing body awareness can help you purposefully extend
the range and accuracy of your cognitive body map.
Alexander Technique teachers Bill and Barbara Conable
have elaborated the notion of what they call “Body Mapping”
in some detail. As they point out, just studying your own
anatomy and learning the parts, their relations and movements

more accurately can help you gain better control of your body
use.
One useful way you can do this is to review Chapter 5,
especially the section “A Personal Anatomy Tour.” If you
haven’t already done so (or even if you have) look at the pic-
ture of the skeleton and find the parts of the body on yourself.
Other ways to begin to better map your body include:
getting a full body massage, getting a foot massage, soaking
in a jacuzzi, having a ‘bodywork’ session such as Rolfing,
Body Harmony, Shiatsu, etc., and, of course, pursuing a course
of posture-movement education, i.e., the Alexander Tech-
nique.
Sensory-Motor Amnesia
Our body maps are not static and unchanging. They con-
tinue to be built and to develop through the constant barrage
of sensations from muscle, joint and touch receptors as we
move and interact with other people and other aspects of our
environments. There is evidence that we require movement,
touch and other kinds of experience on an ongoing basis in
order to maintain a healthy body image. As anthropologist
Ashley Montagu wrote, “The raw sensation of touch as stimu-
lus is vitally necessary for the physical survival of the organ-
ism…” 12
When an area becomes injured, this incoming information
may become limited. We can become protective of the part
with guarding and bracing efforts. As a result of a drop in ‘nor-
mal’ sensation, your body map may develop a blank spot that
can affect your movements and well being. Pioneer posture-
movement educator Thomas Hanna referred to this blank spot
as “sensory-motor amnesia.”13
When a severe enough injury has occurred, this feeling
of a blank or “dead” area has been found to correlate with
reduced neural activity in the sensory cortex, which has been

measured by evoked-potential studies of the brain. This can
occur not only with brain or nerve damage but as a result of
peripheral injuries as well.14
Oliver Sacks writes about this phenomenon in his book,
A Leg to Stand On, which recounts his own experience with a
severe injury. While hiking, he fell and completely tore the
tendon attachment of the muscle that extended his left leg. As
he wrote, even after it had been surgically repaired and given
time to heal, “I had come to question the integrity, the very
existence, of my leg…”15
Sacks recounts the extraordinary process he went through
to begin to walk. At first he did not even feel that the leg he
was moving was his own. He had developed a profound sense
of “alienation” from his leg and his normal self-image. What
had to get re-mapped were not only the injured leg but also
the daily actions that the leg had been involved with and the
very sense of self he had before his injury.16
Sacks found that the process of recovery came in jumps
and starts, with a number of reversals. One thing that acceler-
ated this process was the advice of a wise physician he con-
sulted who asked, “What do you enjoy doing?” When Sacks
replied that he loved to swim, the doctor made a phone call
and immediately sent him over to a pool for a rehabilitative
swim.
Sacks got to the pool, changed into trunks and hobbled
with his cane to the side of the pool to meet the lifeguard who
was expecting him. The young man challenged him to a race,
grabbed the cane out of his hand and pushed him into the pool.
After their race, Sacks stepped out of the pool and found that
he was walking normally again. (This appears similar to the
story of my wife’s sprained foot, told in Chapter 10 in the sec-
tion on Guarding and Movement Sensation.)
As Sacks describes it “…unexpectedness, spontaneity,

somehow evoking a natural response, …lay at the heart of [his
doctor’s] theory and practice of therapy — the finding of some
activity which was natural and meaningful, an expression of
a will that found delight in itself…” 17
Can this sort of thing happen with injuries to the back? If
you are recovering from a back or neck injury, this notion of
‘sensory-motor amnesia’ may have some relevance for you.
If you find that you still are not functioning quite normally
even if you are free or mostly free from pain, it may be useful
to find what you really enjoy doing and start doing it.
For example, to encourage spontaneous movement, find
some music with a good rhythm that you enjoy (I like Billy
Idol’s “Dancing With Myself ”). Close the door and blinds so
no one will see you (if you find dancing with yourself embar-
rassing) and move to the music. As you explore the possibili-
ties of movement, stay attentive to your back so you can re-
spond sensitively to feelings of comfort and discomfort. You
can move as quickly or slowly, as much or as little as you feel
comfortable doing. “There's nothing to lose and there's noth-
ing to prove.”18 Let the music move you.
Enjoying this and some of the other bodily experiences
mentioned in this chapter will help you begin to re-extend your
body map and begin to feel your bodily self, beyond pain, as
a source of happiness and enjoyment.
Chapter 13
Experience Your Full Stature
The second guideline for better body use is: Experience

your full stature every day as often as you can.
In this chapter we explore what full stature means, what
it doesn’t mean, some ‘recipes’ for experiencing more of your
full stature and some ways to begin experimenting with it in
your daily life.
I have already noted the fallibility of our internal cogni-
tive maps.1 Our body maps are not our bodies. Our body maps
are not complete and can always be revised and improved.
These limitations must be faced if you wish to cultivate your
use. They also prevent me from guaranteeing that you can
achieve an adequate standard of use simply by reading this book.
Nonetheless, it is possible to improve on your own to some
degree by ‘wedging’ yourself. These pages can provide the
background you need for improving how you do this.
Full Stature - What It Doesn’t—and Does—Mean

One of the major problems that people have with trying
to improve their ‘posture’ involves trying to impose a static
and unchanging map of body use on themselves and others.
“Sitting up or standing up straight” gets translated into the
action of holding yourself in a stiff and unyielding way.
What happens when people try to ‘fix themselves up’ by
holding such stiff and rigid postures? Not only doesn’t it work
very well—it also imposes another layer of misuse on the
body. Think of an army recruit standing rigidly at attention:
shoulders pulled back; chest puffed out; back arched in a hy-
perextended pose; knees locked; etc. That is not what I mean
by “full stature.”
Instead, full stature implies the total volume or space of

your body. Practically, this involves keeping all your joints
as open and unlocked as possible, with plenty of factor-of-
safety motion present.
Because of the mechanical linkages of all of the parts, this
is more likely to happen when you allow your spine, the cen-
tral axis of your body, to lengthen within its natural curves.
When you are lengthening your spine in this way, your anti-
gravity system works at its best. You are encouraging what
Goddard Binkley, a teacher of the Alexander Technique, called
“the expanding self” 2 and are ready for dealing with the world.
Imposition of a rigid standard on yourself can happen even
if you intellectually understand what good use entails. It oc-
curs especially if you assume that you can automatically ap-
ply your understanding to your non-verbal actions.
Rather, full stature needs to be something that you expe-
rience non-verbally. When you have developed an adequate
internal standard, a non-verbal map of full stature, you can
direct yourself to better use without holding or trying.
Viewing the rules of good use as rigid and inflexible has
some relation to a rigid and inflexible manner of holding your-
self. In my teaching, I work at helping people establish better
use without absolute rules.
It does not seem realistic to expect anyone to be length-
ened at his or her full stature 100% of the time. If you use
yourself well 75% of the time, your use will probably be bet-
ter than 98% of the population. Full stature is a standard that
you can apply to your postural behavior, while knowing that
no cosmic law says that you cannot slouch. So by all means
slouch whenever you want to. Slouch consciously when you
do and become aware of the results.
My basic guideline remains choice. Realize that when you
have the ability to choose how you use yourself you have more
of a chance to control pain and to move with more grace and
efficiency. But by all means don’t ‘should’ on yourself.
EXPERIENCE YOUR FULL STATURE 207
Constructive Rest
Constructive rest is a term used by Lulu Sweigard, a writer
on body mechanics whose work parallels the Alexander Tech-
nique.3 I like the term “constructive rest” because it empha-
sizes the possibility of actively restoring yourself during your
waking hours. A constructive rest position places the body so
that gravity assists in releasing the muscles and opening the
joints to help you experience more of your full stature.
Spending from ten to twenty minutes in constructive rest
once or twice a day will give you an opportunity to give your-
self space, both figuratively and literally. When you feel your-
self in a slump and having trouble holding yourself up, even
five minutes of constructive rest can help you restore your-
self.
Here, in summary, is a simple and effective constructive
rest position. I discuss details in the following paragraphs. Lie
on your back on a firm surface, with your knees bent and feet
‘standing’ apart, so that your legs can balance with no mus-
cular effort. Your body will be lying symmetrically with equal
parts on either side of an imaginary line through your mid-
section and in line with your spine. Your head will rest on
enough books so that it is not tilted backwards on your neck.
The front of your neck as well as the back of your neck should
lie relaxed and open. Your head should neither be unduly pro-
truded (pushed forward) nor overly retracted (shifted back).
Ideally, the top of your head is directed in an imaginary line
away from your tailbone (see Figure 13.1).
In this position, the curves of your lower back and neck
will be reduced and will approximate a straight line. Do not
try to force your lower back or neck ‘straight’. If you have
found benefit in extending your lower back, you can place a
small towel roll or other support under your lumbar spine to
support the curve, which can reduce pressure on your discs.
Your arms can be positioned to rest at your sides in such

a way that they are easily supported on the surface you are
lying on. They can also be placed so that your hands rest over
the front of your torso on your belly. The important thing here
is minimum effort.
Figure 13.1 — A Constructive Rest Position
For your lying down surface, a carpeted floor or a wooden

floor covered with a blanket will be fine. A firm surface that
feels comfortable and that allows you to sense your back is
most desirable. Make sure that you are warm enough and have
a sheet, blanket or afghan available to cover yourself with if
necessary. Have four or five paperback books ready to sup-
ply head support. You may have to experiment with different
numbers of books. You can place them where you plan to rest
your head. The ‘give’ of the books should also have a balance
of firmness and comfort. If the back of your head feels sensi-
tive put a small cloth or layer of foam on top of the book on
which you rest.
There are many ways to get yourself into your construc-
tive rest position. Whatever method you choose, take time to
pay attention to the process by which you bring yourself to
the floor. Stay with yourself and with lengthening your spine
as you do this.
Once you are lying down, use enough books under your
head so that the length of your neck is as unimpaired as pos-
sible, both in the back and front. The ideal is just a sufficient
number of books for your head not to be tilted backwards. If
parts of your neck seem stiff, do the best you can. Don’t force
anything. Support the back of your head with one or both
hands when you lift it in order to avoid any sense of strain-
ing, when, for example, adding or removing books.
If you are lying down on your back with your legs out
straight, you will need to bring your knees up in order to bal-
ance them and also to help your back release. As you bring
up your knees, continue to breathe normally and continue to
free your neck. Don’t tighten it or your back.
The thought of your legs lengthening out from your pel-
vis, knees releasing away from your hip sockets, will help you
to keep the joints of your legs open and released. Let your feet
come as close to your buttocks as possible without strain and
far enough apart from one another to allow you to release the
muscles around your hips and buttocks. Your legs eventually
should be able to balance without any muscular effort.
You may want to gently lift your bottom up from the floor
so that your pelvis and part of your lower back is raised. Then
gently let your back and buttocks return to the floor. You may
feel at this point that your back is making more contact with
the floor. In this horizontal position, the curves will not neces-
sarily need to be as accentuated. But don’t try to force them flat.
I like to encourage people to use a lumbar support if they
can. If you want to use a towel roll or other lumbar support,
place it under your back when you lift up. I particularly like
to use the Spinatrac™ posture tool, a gentle curve made of firm
plastic that feels comfortable and unobtrusive.4
Another adjustment you can make is to ‘iron out’ your up-
per back. To do this gently, reach one hand towards the ceil-
ing and slightly across the midline to the opposite side. Do
this with the thought of lengthening your arm from shoulder
to fingertips. As you do this, notice that your shoulder blade
can gently release away from your spine. Gently let your arm
settle back down. You can do the same with your opposite hand
and shoulder blade.
Once you have gotten yourself into this constructive rest

position, you can bring your awareness to your full length and
width by repeating your directions to yourself. This provides
a good way of scanning your body for tensions and allowing
them to release. You can actually say the words to yourself:
• Let my neck free…
• To let my head go forwards and up...
• To let my back lengthen and widen…
• To let my shoulders release apart from each other...
• To let my arms lengthen and release from my shoulder
to elbow to wrist and hand and out my finger tips…
• To let my legs release from my pelvis…lengthening from
my hips to my knees…knees to ankles… from my heels
to my toes…
When you want to get up from constructive rest, take
enough time to keep the awareness of lengthening, widening
and releasing that you now have. Roll onto your side and con-
tinue with thoughts of lengthening up along your spine. To
get yourself up you can come onto your side…onto hands and
knees…onto one knee…and up to standing, using a chair for
support if you need it. Feel what it’s like standing again. Walk
around a bit. How do you feel? How can you continue to
lengthen and widen, as you remain up and about?
Sitting ‘Up’
If you want to sit for longer periods with less chance of
irritating your back, you will need to learn how to sit ‘up’ —
to support yourself at your full stature when sitting. When sit-
ting at full stature, you will be lengthening throughout your
spine while maintaining its normal curves.
Your neck will be releasing and lengthening to allow your
head to balance forwards and up on top of your lengthening
spine. Meanwhile your back and torso will be lengthening and
widening. The joints of your spine will have sufficient fac-

tor-of-safety motion. They will not be positioned at end range.
In order for this to occur, your postural muscles, including your
deep spinal extensors and abdominal muscles, will have to
engage sufficiently to support this lengthened stature.
Instead, as we have seen, exactly the opposite typically
happens—the seated slump wherein the back is at the extreme
of flexion, with the joints at end range and hanging on over-
stretched spinal ligaments. In this slump, your postural
muscles are not ‘asked’ to work and they don’t.
People often ask me what type of chair is best for them to
use. Some types of chairs and seat designs do seem more
mechanically advantageous. However, depending on chairs
for support often doesn’t work. No chair is perfect. Chairs are
often designed more for visual aesthetics than for better body
mechanics. Shaping our bodies to such questionable seating
leads to collapse and strain rather than true support.5
My best advice is to learn how to sit at your full stature
supported and unsupported. This will help you develop a stan-
dard by which to judge which chairs and seats help you to do
this better. Here I will provide you with some simple ways to
begin to work on your own to learn better sitting with and
without a back support.
A useful chair for practicing sitting is a simple kitchen or
dining room chair with a back. The seat height should allow
your knees to go no higher than hip joint level. In fact, hav-
ing your knees a bit lower than your hips can facilitate a more
neutral position for your back and legs. You can achieve this
with a wedge cushion, for example, which creates a forward
sloping seat (there are even special chairs that do this).6 Your
seat should allow you to let your feet rest easily on the floor.
The seat depth, its distance from front edge to chair back,
should support your thighs without digging into the backs of
your knees when you sit against the chair back.
Supported Sitting
To sit using the back of the chair, scoot your bottom all
the way back until you feel the base of your spine against the
chair back. You should be able to feel the mid-parts of your
sit bones on the seat below you. If you lack sufficient built-in
‘padding’ of your own make sure the seat has enough for com-
fort. Now you will be able to let your back’s full length and
width rest against the chair’s back support, which ideally will
come up to shoulder level.
There has been some controversy about the use of lum-
bar supports. Although there may be occasional exceptions,
in general I agree with Cyriax, who wrote as early as 1945
about the importance of maintaining the lumbar lordosis when
sitting.7 Maintaining the lordosis has been advocated by some
medical doctors for more than a century as a vital part of good
sitting posture.8 Maintaining a sitting lordosis probably has
importance for you.
A lumbar roll can help you to do this. Sitting with a lum-
bar roll has been shown to help reduce symptoms in patients
with sciatica.9 It’s important to be able to adjust the size and
position of the support. Built-in supports don’t adjust as eas-
ily as portable rolls. You will probably do better with a simple
portable roll that you can move from chair to chair. Even a
rolled-up towel can work in a pinch. The support should be
placed at the level of your lower lumbar area and should “con-
form with the curve” there.10 Even as you sit with your sup-
port, remember to direct yourself to let your neck release to
allow your head to balance up on top of your lengthening
spine. You will need to work to ensure that you don’t protrude
your head and neck.
Sitting supported by a chair back is not as demanding on
the postural muscles as unsupported sitting. It will be a use-
ful position to sit in for brief periods if you are just getting
back to sitting after a back injury.
There is a major disadvantage in sitting against a chair

back with a lumbar support. When you are sitting and work-
ing or eating, etc., you are not likely to stay still. As soon as
you move, you will no longer have the external support. So
you need to know how to sit with your full stature unsupported.
Unsupported Sitting
Unsupported sitting means no outside support. Instead,
you will be sitting with good internal support from your own
postural mechanisms, that is, your anti-gravity muscles, discs,
etc. You can begin to get a feel for sitting up unsupported by
experimenting with what McKenzie calls “the slouch over-
correct” maneuver.11
This is an advanced ‘exercise’ to be done when you have
recovered from an acute episode of back pain. View it as an
experiment primarily for your awareness. It is based on the
principle that sometimes by experiencing the extremes of a
condition, you can begin to recognize where the ‘golden mean’
(desirable neutral state) exists.
To perform this maneuver, slide yourself away from the
back support so you are sitting near the edge of the chair, feet
on the floor. Feel where your sit bones are making contact with
the chair. Think of your sit bones as the ‘feet of the pelvis’
and find out where the mid-point of these ‘feet’ are located.
Now, roll backwards with your whole pelvis so that you
go back towards the ‘heels’ of your sit bones. Then roll fur-
ther so that you are beginning to sit on your tailbone. As you
do this, your lower back will begin to lose its lordosis, then
flatten until it is in full flexion. If you continue to face and
look forwards, this maneuver with your pelvis will automati-
cally cause your head and neck to protrude in front of your
body as your head tilts backwards on your neck. You will be
in a maximally slumped position. This is the “slouch” phase
depicted on the left of Figure 13.2.
Figure 13.2 — “Slouch Overcorrect” Maneuver
Next comes the “overcorrect” phase depicted on the right

side of Figure 13.2. Continuing to face and look forwards, roll
your pelvis forwards so that you are moving towards the ‘toes’
of your sit bones. Go as far as you can so that you feel as if
you are beginning to sit more on your thighs. Your lower back
will extend into an exaggerated lordosis or hollow arch. If you
continue to face and look forwards you will notice that your
spine will lengthen a bit as the back of your head rolls for-
wards in relation to your upper neck and your head and neck
will be in relative retraction (pulled back over your body) from
its previous protruded position. If you feel a strain in your
lower back you are probably in the fully arched or overcor-
rected position. We call this “overcorrected” because it exag-
gerates a ‘good’, neutral, sitting posture.
Now let yourself return to the previous slouched position.
Go back and forth between the slouched and the overcorrected
positions. You can do this five to ten times. Get a feel for the
change in the overall shape of your spine. Notice what effect

the two extremes have on your relative height, on your breath-
ing, etc.
With the last overcorrected movement that you make, ease
out of it about 10 to 15%, so that you feel you are about at
‘neutral’. Your weight will be centered over the mid-portion
of your sit bones. Your back will be slightly, not exaggerat-
edly, arched. Think of freeing your neck, of your head bal-
ancing up on top of your spine, your back and torso lengthen-
ing and widening. Remember to allow yourself to breathe. This
balanced, neutral sitting posture is depicted in Figure 13.3.
McKenzie recommends doing five to fifteen repetitions
of this maneuver, three times a day, for three to four days or
longer.12 It may take at least several weeks for balanced sit-
ting to become habitual.
Figure 13.3 — Balanced Neutral Sitting

When you are familiar with the mid-position of balanced

neutral sitting, you can also begin to practice building your
sitting endurance. You gradually can extend your unsupported
sitting to longer periods of time as you become more com-
fortable with it and as your muscles and joints become more
adjusted. Working in this way, you will begin to train your-
self to sit ‘up’ with your full stature.
Leaning Forwards in the Chair

Direct your attention to the changes in the position of your
head, neck and upper back that you’ve just experienced. The
protrusion of your head and neck in the slouched position is
often the actual starting point of an active slouch in daily life
because of the desire to bend forwards or to see better what’s
in front of you. Done frequently, this can lead to an habitual
protruded head and the familiar “dowager’s hump.”
In order to avoid this habitual distortion of your body, you
need to learn how to move your whole torso as a unit when
you lean forwards. As Ron Dennis, Ed.D., founder of
PostureSense®, says, “Fold, don’t bend your body.”13 This
applies both when you sit and stand. Later, I will discuss how
to apply this while standing. Now, you can take yourself
through the steps of doing this while sitting.
Sitting to the best of your ability with your full stature,
think of leaning forwards by coming up and over your hip
joints with your whole torso lengthening. Pause (inhibit) be-
fore actually carrying out this movement. Then give yourself
these directions: “Let my neck stay free, to let my head bal-
ance up on top of my lengthening spine, to let my back
lengthen and widen.” Then you can stay with this sense of
length up through your spine as you let yourself flex at your
hip creases.
If you are actually doing this you will roll forward over
your sit bones. As illustrated in Figure 13.4, your head, neck
and back will remain in a constant relation with each other as
they fold up and over as a unit at the hip joints. Doing this in
front of a mirror can help you to make sure you are actually
doing what you think you are doing.
Figure 13.4 – Folding In Sitting
Standing With Poise

Poise implies not only a certain manner of bodily use but
also a certain psychological attitude, one of composure, calm
and presence of ‘mind’. This connection between bodily atti-
tude and ‘mental’ attitude only seems like an interesting co-
incidence because of the persistent separation of ‘body’ and
‘mind’ in our culture. In fact, since what we separate as ‘body’
and ‘mind’ actually involves an organism–as–a–whole–in–an–
environment, bodily use will necessarily have ‘mental’, emo-
tional aspects.
Learning how to stand with poise at your full stature will
help you to function more comfortably when standing. It can
also help you become more calm and present in any situation.
This seems especially important when you find yourself in

front of others, for example, while giving a presentation. Be-
low I present some basic guidance for helping you explore
“active, alerted”14 standing at your full stature.
There is a range of possible ways to slump while stand-
ing.15 The weight is often shifted towards the balls of the feet.
The knees will often be locked in hyperextension. The pelvis
may be shifted forwards as the person hangs with the hip joints
locked in extension. The lumbar spine curve may appear ei-
ther at the extreme end range of hyperextension or flattened
and even flexed in the opposite direction. The rest of the spine
will often be shortened in some degree of collapse, with the
head and neck protruded. The head may tilt backwards on the
upper neck while the upper back forms a flexed hump.
To explore your own standing, stand up. Without trying
to change anything, notice if you can observe any of the fac-
tors mentioned in the previous paragraph or anything else that
seems especially prominent. When you notice a ‘fault’, con-
gratulate yourself, since you have noticed something that you
didn’t notice before. This provides you with a potential wedge
of awareness that can lead to positive change.
Exploring Your Base of Support

Begin to explore your base of support.16 Do this with your
shoes off. Spread your legs apart so that your feet are approxi-
mately shoulder width apart. Let your toes point gently for-
wards and perhaps a bit outwards to the sides. See if you can
allow your kneecaps to point in the same direction as your toes
without forcing.
Let your knees be easy and unlocked (that doesn’t mean
bending them appreciably but rather not holding them stiffly
in full extension). Begin to notice where your weight is dis-
tributed over your feet. Do you feel more weight over one
foot? Where on your feet do you feel most of your weight,

towards the toes, heels or throughout the whole foot? Perhaps
one foot feels different than the other.
Think the directions of “letting my neck release to let my
head balance up on top of my lengthening spine” as you gen-
tly let your whole body move over your ankle joints to come
forwards towards the balls of your feet. As you do so, don’t
lose your balance or let your heels raise. The movement will
be small. Then shift backwards towards your heels without
losing balance or letting your toes raise up. Remember to keep
your knees unlocked. Continue to direct your whole spine into
length while you free your neck.
If you don’t feel secure about your balance while doing
this, stand with your back to a wall or a chair and with some-
thing like a chair or shelf in front or to the side that you can
hold onto.
Now shift forwards and backwards again, towards the
balls, then the heels of your feet. After about ten or so repeti-
tions of this, let your weight come to rest near your heels. To
find where your weight is most evenly balanced on your feet,
shift slightly forwards. This is likely to be somewhat closer
to your heels than you are used to. Think of your whole foot
lengthening and widening as it makes contact with the ground.
Remember to keep your knees easy and unlocked. Place the
tips of your fingers along your groin crease and gently direct
your hip joints to unlock and stay back. Think of lengthening
up along your spine, your head balancing up on top of your spine.
If you have been able to follow these instructions accu-
rately, you will find yourself in a basic balanced stance that
permits more of your full stature. It does seem that the head,
neck and back lead the rest of the body into length. However,
in a circular fashion, finding greater balance in your base of
support seems to provide the necessary foundation for your
head, neck and back to lead you.
Weight–Shifting for Side-to-Side Balance

There are other experiments you can do to explore and
enhance your standing stature, to stand with poise. For ex-
ample, with feet shoulder-width apart and knees and hips
unlocked, let your neck release your head to balance up on
top of your spine as you lengthen and widen your back. As
you continue lengthening up, let your whole body shift fully
onto your right foot without lifting your left from the floor.
Then shift over to your left foot. Go back and forth so that
you are weight–shifting right and left five to ten times. Go
slowly enough to experience what is happening in yourself
while you do it. Make sure you don’t poke your ‘hips’ out to
the side. Keep your trunk level (don’t bend to the side) and
keep your knees as easy and unlocked as possible.
The purpose of both the front-to-back and side-to-side ex-
periments is to help you get a greater sense of your possi-
bilities of balance in standing. The most balanced standing
involves an unstable equilibrium where your joints are un-
locked (with a factor-of-safety present) and your muscles are
ready to ‘kick in’ automatically when needed. When you are
standing with this kind of balance, you will be standing ‘still’
but will be able to allow continuing movement.
I want to emphasize here that in standing there is no one
correct way to position your feet. In asking you to do the above
experiments with your feet standing side by side, I don’t want
you to infer that you ‘should’ necessarily always stand like
that in your everyday activities, though you sometimes can.
Your choices are many. For example, you can find a comfort-
able and balanced way of standing by having one foot slightly
in front of the other with your weight mostly on the back foot.
However you choose to stand, continue with a few wedges of
awareness to release, lengthen, widen.
Standing with Your Center

I once gave some Alexander Technique lessons to an acu-
puncturist who told me that it seemed to him we were doing
a form of Qigong [pronounced chee gung], “energy healing”
in Chinese.17 I later discovered a Chinese term that seems es-
pecially related to the ‘mindful’ body mechanics I teach. The
term “diao shen” stands for “regulating the body.”18
As I’ve explored this area, I’ve discovered that Eastern
traditions of martial, meditative, movement and healing arts,
like Tai Chi Chuan, Zen, Qigong and Yoga, share some con-
nections with what I’ve been presenting here. One does not
need to adhere to traditional Oriental medical theory to ac-
knowledge useful aspects of these practical arts. Among these
useful aspects is an emphasis on the importance of posture.
Kenneth S. Cohen, in his book The Way of Qigong, sum-
marizes traditional Chinese advice on posture that correlates
closely with more modern systems of teaching about body
mechanics, such as the Alexander Technique:
…when practicing qigong, keep in mind the fol-
lowing: relax the whole body, especially the joints;
keep the neck relaxed and the head suspended deli-
cately over the spine; the jaw is also relaxed, with the
tongue generally touching the upper palate; sink the
shoulders and elbows; maintain a relaxed but erect
spine, centered and stable; maximize contact between
the feet and the ground, feeling your body’s weight
dropping through the feet; release the sternum; the
spine is long and extended; the hips are relaxed. Do
not use force! Be aware of what you are doing! The
abdomen is relaxed, and the breath feels as though it
is sinking into it.19
This last instruction deserves special attention. The level

of the lower abdomen (where the center of gravity is located
in standing) is called the “dan tian” in Chinese, “hara” in Japa-
nese. Philosopher and psychotherapist Karlfried Graf Von
Dürkheim called this “the vital centre of man [and woman].”
Martial artists advise one to “sink the qi or ki [hypothetical
vital ‘energy’] to the dan tian or hara.”
In practice, this involves bringing your awareness of
breath-related movement into your center and releasing any
needless tensions there. As you do this you can imagine your
breath as a white light or ‘energy’ going into the area (use of
such imagery may help you direct your awareness better even
as you realize that what you imagine may not be happening
in the way you imagine it).
To get a better sense of your center, stand and place one
hand palm down over your belly just below your navel. Place
the back of your other hand behind your back between the
lumbar and sacral levels so it comes even with your front hand.
Imagine the midpoint between your hands. Without forcing
anything, think about the movement related to your breath
coming into the area between your hands. As you continue,
you may be able to feel your hands move with your breath-
ing. As you feel more of the movement of your breath in your
lower abdomen and back, locate the place where your breath
seems to be expanding from inside yourself. Notice any other
movements in your chest, abdomen and back related to your
breathing.
Awareness of your center area can improve your sense of
connection between your legs and torso and thus enhance your
balance and support in standing. Therefore, in addition to the
basic Alexander Technique directions, you may benefit by
adding attention to your center:
• Free your neck...
• To allow your head to balance forwards and up on top of

your spine...
• To allow your back (torso) to lengthen and widen...
• As you bring awareness and breath to your center...
• Etc...
Here is another experiment to bring a sense of your cen-
ter into standing and balancing. It involves imagining a pen-
cil-thin laser beam that originates in your center and flows up
through the length of your body and out the top of your head.
With each part of the exercise, you can imagine the path the
laser beam takes on the ceiling related to the path in which
you are moving.
Gently bring your hands over the center area with one hand
on your lower belly and the other on your lower back. As you
free your neck, let your head balance up on top of your spine
by imagining that your head is suspended from above by a
string like a marionette. Let this thought help you to lengthen
up along your spine. With awareness of your head balancing,
and of your center, move your feet shoulder width apart.
Imagine the pencil-thin laser beam flowing up from your cen-
ter and through the length of your body and out the top of your
head.
Then, keeping your hands over your center or allowing
them to hang at your side, begin to let your weight shift from
one foot to the other as you did in the previous side-to-side
experiment. Imagine the laser beam making a horizontal line
as it meets the ceiling while you shift side to side. Be aware
of how your center point moves along that same line. Con-
tinue shifting five to ten times.
Now slightly shift your weight forwards and backwards,
toes to heels and back again. Don’t put yourself off balance.
You can continue with your hands over your center if you wish.
Imagine that the laser beam from your center goes out the top
of your head and makes a vertical line on the ceiling. In your
imagination, see how your center point is also moving along
that vertical line. Do this five to ten times.
Now shift over the base of support of your feet in a clock-
wise circle so that the imaginary laser beam from your center
forms a clockwise circle on the ceiling as it goes out the top
of your head. Remember to free your neck and to breathe. After
five to ten times clockwise, go in the opposite direction so that
the imaginary circle on the ceiling will be going counterclock-
wise. With each of these movements your weight will be shift-
ing over your feet to the side, back, other side, front, again to
the side, etc.
You also can do the above exercises while focusing your
attention on the movement of your center over the base of
support of your feet or on the shifting pressures in your feet
themselves. Once you coordinate yourself while doing these
movements, you will be balancing yourself with whole body
awareness in head, center and feet. After you stop, stand qui-
etly, then walk around a bit. Notice how you feel.
Practicing such ‘mindful’ experiments in standing balance
will make it easier to apply a wedge of awareness to yourself,
whether you are standing in a line or in front of a group giv-
ing a presentation. You can also bring this awareness to your
walking. When you walk you can bring your awareness to the
shifting of weight over your feet, to the movement of your
center, to how your head balances, etc.
Full Stature for Full Breathing and Vice Versa

F. M. Alexander was known as “the breathing man” when
he first developed his work in Australia.20 Both he and his stu-
dents became aware that, when they functioned more often at
their full stature, their breathing tended to improve as well.
Other workers in the field of body mechanics have noted

the relation of breathing and posture. Goldthwait explained
how the drooping chest that accompanies a chronically flexed
spine reduces the factor-of-safety motion in the ribs. By keep-
ing the points of connection of the abdominal muscles and the
diaphragm too close together, it also interferes with the opti-
mal action of these ‘breathing’ muscles.21
Research by John H. M. Austin, M.D., and Pearl Ausubel
indicates that people who have had Alexander Technique les-
sons show significant improvement in some respiratory func-
tion measurements compared to those who have not had les-
sons.22 This has obvious relevance for singers, actors and many
musicians whose work directly depends on their breath. Per-
haps that explains in part why people from these professions
have been among the most eager students of the ‘mindful’ me-
chanics of the Alexander Technique.
Even if you’re not a singer (except in the shower) or an
actor (except on the ‘stage’ of life), this has relevance for you.
By exploring the relation of your breathing and stature on your
own, you can begin to benefit from the wedges of awareness
you gain.
Start by bringing yourself into a slump either sitting or
standing. Let your head protrude as far as possible in front of
your body, head tilting backwards on your neck, back col-
lapsed, etc. (I hope that this has begun to feel unpleasant!)
Notice how much space you have in your neck, torso and
abdomen. Bring your attention to your breathing. What move-
ments can you sense in relation to your breathing?
Now free your neck and let it move back over your spine
without straining as you allow your head to tilt forwards (in
relation to your upper neck). As you do this your head will
also move up to balance on top your spine, leading the rest of
your body up into greater length. Allow your spine to lengthen,
your back and torso to lengthen and widen, etc. Make sure
you’re not holding or tensing unnecessarily to do this. Notice

how much space you’re allowing yourself now. Bring your
attention to your breathing once again. What movements do
you now sense in relation to your breathing?
By becoming more aware of the differences between these
two extremes of posture, you can enhance both your stature
and your breathing. By lengthening and widening your torso
to approach your full stature, you will be allowing the opti-
mal space for your breathing. In turn, making sure that you
are allowing your breathing and the natural movements related
to it ensures that you are not tensing your postural muscles
with unnecessary effort.
In the previous section, I described a way of enhancing
the space for breathing by locating your center area with your
hands and letting this area release as you let the movement
related to your breathing come into it.
Another method for enhancing your breathing consists of
a procedure from the Alexander Technique known as The
Whispered Ah.23 This procedure works as a set of guidelines
for becoming aware of different aspects of your use that go
into your breathing and voice. It also provides a means of
stimulating your breathing and voice.
The Whispered Ah is done in a stepwise fashion, with
awareness given at each step to freeing your neck, lengthen-
ing up along your spine, etc. The steps:
1. Direct your neck free, to allow your head to balance
forwards and up on top of your spine, to allow your back
and torso to lengthen and widen.
2. Let the tip of your tongue go behind your lower teeth
(lips remain gently closed, teeth apart).
3. Let a smile come to your face by thinking of something
amusing. If you can’t think of anything that makes you
smile, fake it! There you go.
4. Notice your breath going in (inhalation) and out (exha-

lation). When you have a sense of the rhythm of your
breathing…
5. Exhale through your mouth with a whispered and au-
dible “Ahhhh” as you let your mouth open (your tongue
pointing your jaw forwards as you let your jaw release
open).
6. At the end of this easy exhalation of “Ah,” let your lips
gently close as you allow air to come in through your nose.
That is the end of a single cycle of the Whispered Ah. You
can then return to step 1 and repeat the cycle five or six times.
As you follow the steps you will realize that there are a
lot of things to keep track of. Remember especially not to
prepare for step 5 by trying to take in a breath. Let the “Ah”
come as a result of the previous inhalation. One of the things
that you can discover doing the Whispered Ah is that what
many people do to take in a deep breath, that is, actively in-
haling by sucking in or gasping for a breath, is not necessary.
The inhalation will take care of itself after you fully exhale.
You can let the inhalation happen.
The Whispered Ah can also help you become aware of the
movements in your ribs and abdomen and of the possibilities
for releasing your face and jaw. It provides a good warm-up
that you can do prior to singing or speaking or at any other
time that you want to enhance your breathing.
Dynamic Use in Standing

There is a danger that my written descriptions here have
appeared to emphasize static ‘posture’ at the expense of dy-
namic use. This dynamic aspect is difficult to convey in print.
So I want to emphasize that functioning with a more full stat-
ure is not about becoming a more full ‘statue’.
The Alexander Technique distinguishes itself as a form of
body mechanics training because of its emphasis on dynamic
posture or use within movement. Beckett Howorth, M.D., de-

fined dynamic posture as
...posture in motion or in action or in preparation for ac-
tion. It includes the transitions between the static
positions...and also activities such as pushing, lifting...
[etc.]...Good dynamic posture implies the use of the body
or its parts in the simplest and most effective way, using
muscle contraction and relaxation, balance, coordination,
rhythm and timing as well as gravity, inertia and momen-
tum to optimum advantage. The smooth integration of these
elements of good dynamic posture results in
neuromusculoskeletal performance which is easy, grace-
ful, satisfying and effective and represents the best in the
individual physical activity, as well as in the physical ac-
tivity of the individual.24
Because of this dynamic element, the suggestions that I
give here can provide you with only the bare beginnings for
better use. Static words cannot necessarily give you the same
kind of dynamic experience that you get in a PostureSense®
class or in an Alexander Technique lesson. Both involve vary-
ing degrees of verbal and manual guidance by a teacher as you
perform different activities of daily living.25
Another danger when following these or any other sug-
gestions involves not spending enough time observing your-
self before trying to change things. I urge you not to hurry to
fix yourself. Instead use the suggestions in this book as start-
ing points for body awareness and self-observation. The ef-
forts you make to observe yourself more closely in your ev-
eryday activities will result in more substantial improvement
than if you immediately try to move with ‘perfect’ posture.
You need to taste, chew and digest whatever suggestions
I give you so that you can apply what you find useful for your-
self. Trying to ‘be right’ may only mean that you are ‘swal-
lowing whole’ what I say here without ‘chewing’ it sufficiently
for yourself. You can explore for yourself what works and what
doesn’t work, using my suggestions as guidelines. This can
be a cyclic or, rather, a spiral process — starting with a pic-
ture of your desired goals for better movement; self-observa-
tion while moving; revised goals; self-correction; etc. The
resulting knowledge of better use will be your own.
Let’s apply this attitude of observing and spiraling self-
improvement to an action we do every day: bending forwards.
Bending activities may include bending at the sink, bending
to pick something up from the floor, shoveling snow, vacu-
uming, sweeping, lifting, etc.
Our eyes are located in the front of our heads (though my
wife also seems to have eyes in the back of her head!) and
our hands work more easily in front than behind. This means
that we often lower ourselves in order to deal with some as-
pect of the environment located in front of and below us. We
may also bend forwards in standing up and in lowering our-
selves to sit down.
Bending is often a troublesome action for those with back
pain. Indeed, acute episodes of mechanical back pain often
begin with a forward-bending motion. What typically happens
to your stature when bending the way that you usually do?
Start with some self-observation. You may decide, for
example, to notice what happens to your stature—the relations
among your head, neck and torso—when you wash your hands
at the sink. You can pick this as something to observe for the
day. Initially, don’t try to change anything. Simply find out
what you are doing. (Simple is not necessarily easy!)
At first you may find that you already have bent over be-
fore you remember that you intended to observe yourself.
That’s okay—it’s a wedge of awareness. Just remind yourself
to observe yourself the next time you bend over at the sink.
What do you observe when you go to bend over?
Do you protrude your head and neck?

Do you find that your head gets tilted backwards or for-
wards on top of your neck?
To what degree does this happen?
What is the overall shape of your spine and torso?
Is your upper or lower back rounded into flexion?
How much do you flex at the hip joints?
Do you flex your knees at all?
How are you balancing yourself?
Do you feel strain, tension or pain anywhere?
What happens to your breathing?
It may take some time to get more of a sense of what you
actually do. Using a mirror or mirrors to see a forward and
side view, as Alexander did, can help you get a more accurate
picture of yourself as you bend. Getting a friend or other out-
side observer can often help as well.
Folding in Standing
The idea of bending may have become so connected with
losing your full stature that you may find it more helpful, as
Ron Dennis suggests, to think about folding rather than bend-
ing your body.26 This has also been called squatting. It involves
lowering and raising your center of gravity, while maintain-
ing your full stature and balance over your feet, while fold-
ing at your hips, knees and ankles in varying degrees. Dis-
covering how to fold to maintain more of your full stature can
result in greater efficiency and reduced injury. A mirror can
help as you take yourself through the next phase of dynamic
use to practice folding rather than bending while standing.
Start with no concern at all for any practical activity like
lowering yourself to the sink; you are simply experiencing
yourself moving. Begin by bringing yourself to full and bal-

anced standing. Free your neck; let your head balance up on
top of your spine as if suspended from the top of your head.
Allow your spine to lengthen in its curves as you let your back
lengthen and widen, your torso lengthen and widen. Let your
breast bone drop as you let your spine lengthen. You can bring
your legs wide apart with your feet pointing forwards and
knees unlocked. Let your hips stay back. Bring your attention
to the center area of your lower abdomen and pelvis.
Think of folding rather than bending, and pause—don’t
do it yet! (a moment of inhibition). Think of yourself getting
drawn upwards from the crown of your head as you continue
to lengthen your spine. Then let your knees fold, letting them
move gently over your feet as you think of them releasing
away from your hip joints.
At first just let your knees and hips fold just enough so
that your center, the center of gravity of your body, sinks
slightly lower while your spine and torso stay vertical. You
won’t necessarily be folding your knees very far. Do not force
anything.
Pause and return to the directions of releasing your neck,
letting your head go out from the top of your spine as your
spine lengthens. Then let your hip joints release back as you
let your knees fold more. You may find that your torso has
begun to incline forward. Let your arms hang freely from your
shoulders. You will find yourself in a mini-squat, as seen in
Figure 13.5.
If you continue to apply the Alexander Technique direc-
tions accurately, your spine will continue to lengthen in this
position (with your spinal curves intact) and you will basically
be hinging your whole torso over your hips, knees and ankles.
Alexander called this a position of mechanical advantage and
worked at helping his students to learn how to get into it reli-
ably. The students in his first teacher training class called it

“monkey position.”27 This way of maintaining full stature
while lowering your center of gravity and folding your hips
and knees and ankles over your base of support provides the
basic skills for the more advanced abilities of deeper squat-
ting, as well as lunging and lifting.
Figure 13.5 — Folding In Standing:

Squat (“Monkey”) Position
If you’re not sure of what you’re doing, it’s not a scandal

to get help. Take your time to clarify the instructions and to
observe what you actually do as carefully and accurately as
you can.
When you are clear about this basic folding or squatting
maneuver, you can begin to apply it to activities like lower-
ing yourself to wash your hands, picking up something from
the floor, sitting down, etc. I suggest following Alexander’s steps:
1. Start with the idea of lowering yourself at the sink to

wash your hands (for example).
2. Pause—inhibit carrying out the action.
3. Give yourself the basic directions, i.e. freeing your neck,
to let your head balance up off the end of your spine, to
allow your torso to lengthen and widen, etc.
4. Go back to the idea of lowering yourself by folding…at
which time you can again pause and direct without carry-
ing out the action …or
5. Continuing to direct yourself to lengthen, let your knees
go forwards and out from your hips, hips releasing as you
lower your center and bring yourself to the sink.
6. Once you’ve lowered yourself to the level you need
…return to observing your head, neck and back. Have you
been able to continue to lengthen, widen and maintain your
full stature? 28
This process may seem unduly drawn out. However, it
remains one of the best ways I know to learn how to experi-
ence your full stature every day as you fold rather than bend.
If you practice in this way, you will learn how to “think in
activity” (inhibit and direct) more quickly and more easily as
you move. Eventually, moving with awareness can become a
habit.
Chapter 14
Design Your Environment
Some of you may remember a famous scene from the

1950s television show “I Love Lucy,” in which Lucille Ball’s
character gets work in a candy factory boxing chocolates on
an assembly line. The candy moves faster and faster down the
conveyor belt. Lucy stuffs the chocolates everywhere, into the
boxes, into her mouth, into her clothing, etc., to no avail. More
and more, faster and faster, those ‘damned’ chocolates keep
on coming.
The science of ergonomics studies how to fit the work
environment to the worker.1 All too often, as in Lucy’s ex-
ample, exactly the opposite happens. We end up fitting our
selves to our environments, not only at work but also at home
and at play.
Our environments include the objects we interact with and
their spatial arrangement. They also involve the time element,
the rhythm and schedule of activity that comprise our daily
life-style.
The third and fourth guidelines for ‘mindful’ body me-
chanics will help you take control of your personal ergonom-
ics. They are: Design your personal environment for better
use; Practice postural variety in your daily life. These two
guidelines build on what you already have learned. They also
work together and reinforce each other. They are based on the
premise that you have some control over your environment
and can better shape it to suit yourself.
In this chapter, I present some things to consider when
assessing and modifying your personal environment. In the
following chapter, I offer some simple steps for increasing
DESIGN YOUR ENVIRONMENT 235
postural variety in your daily life. Some of these comments

serve as a review of previous material, here specifically ap-
plied to guidelines three and four.
Your Personal Environment
Your personal environment, your life space, includes the
clothes you wear, external aids like eyeglasses, furniture and
placement of furniture at home and work, car seating, etc.
What standards do you apply to decide whether your life space
helps or hinders your use?
The criteria that I have presented in previous chapters can
serve as general guidelines for your efforts to improve your
personal environment. Basically, change seems warranted if
any aspect of your personal environment reduces the factor-
of-safety motion in your joints and keeps you from function-
ing at your full stature. This includes any environment that
encourages monotonous or asymmetrical end range position-
ing and repetitive forces on your spine and other joints.
As an example of how to explore alternatives, I will briefly
discuss a few typical problems and solutions below. Since your
problems are unique, what I suggest may not precisely apply
to you. You can adapt the suggestions or seek professional
advice if you need more intensive problem solving.
Clothing
Let’s look at clothing, the part of the environment closest
to your skin. Its effect on your body and use may be easy to
ignore. Tight jeans, for example, can restrict movement in hips
and legs in such a way that folding with a lengthened spine
becomes impossible. This means that someone wearing such
jeans will be forced to bend with the lower back flexed. Solu-
tion?—wear looser-fitting slacks, at least when you’re going
to squat or lift.
Inadequate or inappropriate shoes also can create literal

‘sore points’ for body use. Take high heels, for example. A
woman wearing high heels is basically standing on her toes.
There also is tremendous pressure on her heels. This type of
shoe has a strong tendency to push the lower back into an
extreme of lordosis, an end range position which, if held with-
out respite, may contribute to strain and pain.
Street and athletic shoes that have gotten worn out or that
don’t provide adequate pressure relief or support can also
contribute to back problems. Simply becoming aware of these
difficulties will provide some obvious solutions, i.e., new
shoes, a padded insert, etc. A visit to a podiatrist for advice
may also help a great deal.
Become aware of the choices you make when you buy
clothes and shoes. To what extent do you want fashion to serve
as a guide? To what extent do you want freedom of movement
to prevail? What other criteria do you use? Answers to these
questions can serve as important wedges of awareness.
Vision Aids
Poor vision also can create problems for use. Difficulties
with vision often can lead to eyestrain and to protruding your
head and neck to get closer to what you are trying to view or
read. Larger print for ease of reading, a reading stand, better
lighting, a new eyeglass prescription, and vision aids such as
a hand magnifier or a screen magnifier for your computer are
some of the things that can help you to modify your visual
environment. In this way, you can reduce the need to strain
and misuse your eyes, head, neck and back.
Seating
Have you taken a good look at your favorite chairs and
sofa? Seating that makes it easy for you to sit erect with the
full length of your stature may be difficult to come by. Some-
times, as I mentioned previously, a simple dining room or
kitchen chair may serve you best. Once you’ve learned how
to sit upright unsupported, you can assess what any particu-
lar seat may require to make upright sitting as easy as pos-
sible.2
In general, as previously mentioned, any seat at least ought
to allow your knees to rest squarely at hip joint level. How-
ever, having your knees even a bit lower than your hips often
can be beneficial as it can makes sitting with some lordosis
easier.3 If the seat height is not adjustable, you can use a small
wedge (don’t confuse this with the “wedge of awareness”) or
cushion(s) on the seat to elevate your hips.
Does your seat allow your feet to rest on the floor? If not,
perhaps you need a different chair. Lowering the seat if pos-
sible or placing supports under your feet, e.g., phone books,
may provide another solution.
What about the seat depth, the distance from front edge
to chair back? This should give your thighs support without
digging into the backs of your knees when you sit against the
backrest. If the seat isn’t deep enough, you probably need
another chair. If it seems too deep, you may be able to place
some large cushions or other firm support to fill in some of
the extra space behind your back.
What about lumbar support? As mentioned previously, if
you have benefited from a lumbar support you may be better
off using a portable one that you can move and reposition,
rather than one that is built into the chair (unless this is ad-
justable).
The firmness of the seat bottom and of the chair back are
also important factors. Sagging chair backs and bottoms mean
that your own back and bottom are likely to sag as well. New
upholstery sometimes helps. Sometimes you can modify sag-
ging furniture with extra padding, pillows or supports, even
boards. Sometimes, though, you may be better off selling or
giving away your chair or sofa.
Alternative types of seating are definitely worth explor-

ing. High stools and perches that allow you to rest midway
between standing and the ‘normal’ sitting position are avail-
able. These can make it easier to rest your legs while retain-
ing the normal curves of your spine.
Another alternative is the Scandinavian “Balans” chair that
tilts the pelvis forwards while supporting the knees. This also
encourages sitting with the natural spinal curves.
People have also experimented using large blow-up gym-
nastic balls as seats. If your balance is adequate, a ball large
enough to sit on with your knees slightly lower than your hips
can allow you to sit upright and lengthened while allowing
gentle movement.
Beds
Occasionally, some people may feel better sleeping on a
sagging surface. However, for the most part, firmer means
better, up to a point. Most people do better with pillows and
beds that support and encourage the naturally lengthening
curves of the spine — not too soft, not too hard, just right.
Sometimes sag occurs, not because of your mattress, but
rather because of inadequate mattress support such as worn
bedsprings. In this case, placing a plywood board under the
mattress sometimes can provide the necessary amount of firm-
ness.
If extending your spine and avoiding flexed postures has
helped you, you may need to work on not curling up into a
fetal position at night. Although you can’t control what hap-
pens while you sleep, you can start out in a more neutral
position on your back, or on your side with your legs more or
less extended and your back lengthened.
You also can support your lumbar curve by sleeping with
a lumbar roll. Use a rolled-up bath towel, with a diameter of
several inches and held together by rubber bands. Folding the
towel in half first can make rolling it a bit easier. If you lay
out the belt of a bathrobe inside the towel before you roll it,
you can use the protruding ends of the belt to tie the roll around
your middle. Commercial devices are also available.4
Your pillow provides the sleeping surface for your head
and neck. Sleeping with too many pillows can encourage pro-
longed flexed, protruded or asymmetrically tilted head and
neck positions. In general, a thinner pillow can work better
than a thicker one to keep your head and neck in alignment
with the rest of your spine. Also, in general, I advise people
to use a pillow that has some sort of movable stuffing rather
than a solid fill. The movable stuffing will conform better to
the shape and weight of your head.
If you have had neck problems when lying down, using a
neck roll for support often can help. You can use a small towel,
rolled up to give it its maximum length. The roll can measure
a few inches in diameter—just large enough to support the
space under your neck without bringing your head and neck
out of neutral alignment as your head rests on the pillow. This
can be placed inside the pillowcase along the lower edge of
your pillow. A cylinder of foam of similar size can sometimes
work well. Commercial neck rolls and pillows are available.5
Of course, these are general suggestions. Your particular
problems are specific to you. Therefore you may need to make
very specific adjustments to suit your distinctive needs. If you
have a sore back or neck when lying down at night, you would
do well to get individualized advice about sleeping surfaces
and positions from a professional as part of a comprehensive
evaluation.
Other Home Furnishings

Your home has many surfaces, areas and furnishings that
can help or hinder healthful body mechanics to some degree
or other. These may include storage cupboards and shelves;
desks, tables and counters to work upon, eat from, etc.; and
other furnishings such as toilets, sinks, tubs, showers, etc., to
use and to navigate around.
As with many aspects of design, there are standard or
average dimensions for these parts of the home environment.
Since the average remains that which no one individual quite
‘is’, this can be a problem.
One factor is paramount — your individuality. We all have
the same parts, more or less. But our heights, shapes, sizes,
etc., can vary considerably. For example, two people with
torsos that are more-or-less the same length may have differ-
ent arm and leg lengths. With clothing it’s somewhat easier
to mix and match various sizes and dimensions to suit your
individual size and shape than it is with furniture and other
parts of your life space.
The dimensions of individual furnishings need to suit you.
If you are able to get your home furnishings constructed to
suit your personal dimensions you’re lucky. Sometimes, for
things like counter and sink heights, a readymade variety of
dimensions may be available from which to choose. Adjust-
able height surfaces may be available. If not, it may still be
possible to make adjustments.
As a general rule, a work surface should allow you to sit
and stand at your full stature without crouching or reaching.
That means that you shouldn’t have to stay bent over in order
to use a work surface.6 You also should not have to continu-
ally reach above shoulder height.
To create an optimal life space, you need to consider the
mutual relations of the different parts of your personal envi-
ronment. How you arrange things within storage areas and
upon work surfaces, as well as the spacing and arrangement
of your furniture, sometimes can make a tremendous differ-
ence for your ease of use. An overly crowded and constricted
space may encourage you to constrict yourself. Since your
personal environment likely includes others, you will also

need to consider the dimensions of those who share your
space. How can you negotiate and arrange things in a friendly
fashion so that all involved can function at their best?
The criteria that I have presented in previous chapters can
help serve as general guidelines for your efforts to improve
the surfaces and spaces of your environment:
• To what extent will you need to get into and maintain
cramped, awkward, asymmetrical, end range positions?
• Can all of the joints of your body function with some
factor–of–safety motion?
• Are you able to work at your full stature, sitting or stand-
ing?
• Are things arranged to encourage postural variety? This
will be discussed further in the next chapter.
Car Seating
The same advice regarding chairs and other seating ap-
plies to car seats. Car seat design has, to some extent, improved
over the years. Adjustable built-in lumbar supports can be
helpful. Portable wedges, lumbar rolls, etc., can be used to
modify even less-than-desirable seating. Consider the seating
as part of a new car purchase decision.
At Work
A reasonably humane society will provide a safe and pleas-
ant work environment for all workers. What that actually
means in concrete terms for workers in both sedentary and
more active occupations seems a matter for some debate.
For more sedentary occupations, desks, chairs, computer
keyboards, mice, computer displays, etc., provide multiple
opportunities for encouraging misuse. The previous discus-
sion on home seating and work surfaces applies at the office as well.
Some occupations involve tending machinery, frequent

lifting, etc., even so-called ‘sedentary’ office jobs. Evidence
exists that frequent, heavy lifting in awkward positions may
be encouraged by cramped and otherwise unsuitable work
spaces and can cause spinal damage.7 Vibrating machinery
and vehicles, etc., may increase the possibility of injury for
workers not protected by vibration-reducing equipment and
seating.
We can hope that workers and employers can work to-
gether to pinpoint specific hazards and develop reasonable
solutions for the work environment. For example, dollies,
forklifts and environmental re-design can reduce some of the
dangers of repeated heavy lifting, etc. Vibration-dampening
springs and seats can be used to protect workers from shak-
ing equipment.
Sometimes environmental design for better body mechan-
ics may require changing job requirements, scheduling and
the number of workers employed. For example, nurses and
nursing aides have consistently high rates of back injuries.8
Could this have something to do with their typical work en-
vironments? Nursing homes and hospitals often operate with
too few caretakers who have too many patients requiring full
or partial lifting in the course of their daily care. One or two
patients needing such help may put an undue burden on al-
ready overworked hospital staff and on the patients for whom
they’re trying to give good care.
Those hospitals and nursing homes that want to reduce the
significant problems with back injuries among the nursing
staff have many possible solutions available to improve the
work environment. These may include, among other things:
extra staffing, flexible staffing, readily available ergonomic
aids such as patient lifting devices and other assistive devices
for patient care. Note: industrial back belt devices may seem
to provide adequate support for preventing back problems.
Research suggests otherwise.9 Don’t allow yourself to be fooled.
My own emphasis is on helping people learn and flexibly

apply basic principles of use. First and foremost, whatever
work situation you find yourself in, realize that it is possible
to improve your working environment, sometimes with very
simple changes. Persist in your search for a better way! And
as you design and reshape your work and other environments
to better suit your needs, include the need for postural variety
as discussed in the next chapter.
Chapter 15
Increase Your Postural Variety
Children’s attention spans drive them to shift and move

often during their waking hours. By the time we hit adulthood,
however, we have learned to hold our attention to external
tasks for longer and longer periods of time. This may mean
that we spend longer and longer periods in one or more re-
stricted positions, making limited, repeated and stereotyped
movements. We can call this combination of prolonged posi-
tioning and/or stereotyped movement postural monotony.
[Note: I am using the term “postural” here as shorthand for
“posture-movement” which I intend to refer to both static and
dynamic aspects of your posture-movement habits.]
Postural monotony becomes a problem when it leads you
to find it more and more difficult to maintain your full stature
easily. When this occurs, you may begin to sag—the protec-
tive muscles don’t work as well so that spinal joints move into
end range and lose their factor-of-safety. As a result, you can
feel fatigue and a sense of strain or even pain. After a period
of postural monotony, you may feel stiff and ‘rickety’, when
the tissues, which have temporarily adapted to one position,
begin to move again.
Postural variety, on the other hand, involves allowing
enough change of position and movement throughout the day
such that you can keep strain and fatigue to a minimum.1
As you develop greater body awareness, you naturally will
tend to become more responsive to your own needs for pos-
tural variety. You live in a universe of rhythm and change that
includes you. Can you stand absolutely still with no move-
ment at all? No! You breathe, your heart beats, your blood
flows, etc. Just listening more often to your own internal feed-
INCREASE YOUR POSTURAL VARIETY 245
back can tell you if change needs to happen. As you’re read-

ing this, do you feel any need to shift or stretch? Go ahead,
yawn, stretch, move!
Designing Your Environment for Variety

As noted in the previous chapter, promoting postural va-
riety is an important criterion to follow when you look at ways
to design your personal environment. As Galen Cranz suggests
in her book The Chair, “Probably the single most important
principle of body-conscious design is to use design to keep
posture varied and the body moving.”2 How you arrange things
in the space around you can enhance your efforts to vary your
posture and thus increase your sense of comfort and your
ability to operate efficiently.
For example, you may have an arrangement which allows
you to file while still remaining at your desk. However, you
may encourage better use by having your file cabinet placed
so that you have to stand up from your desk and walk a few
steps to file things.
If you have a multi-task job to do, you might consider cre-
ating various stations that allow you to do different phases of
the work in different places and positions.
If you have alternative types of seating available, you may
be able occasionally to switch chairs in your work area dur-
ing the day. A reading stand may allow you to do some work
while standing. Some types of seating, such as a gymnastic
ball, will encourage you to move while using them.
The ability to alternate work and rest can also be built into
your environment. Do you have a place at home or work where
you easily can get into the constructive rest position? The ba-
sic idea is to design your environment to allow for greater pos-
sibilities for healthful alterations of position and movement.
This is somewhat different from the old “time and motion
studies” approach to work efficiency, since body awareness
has primary importance here.
Relieving Postural Monotony

It’s probably inevitable that you will sometimes continue
some positions or unidirectional movements longer than you
would have liked. In either case, you can follow a simple pos-
tural variety principle: Get out of prolonged positions or re-
peated directions of movement as soon as possible and go the
other way.3 This principle can help you reduce strain and pre-
vent pain and irritation to your back and other parts of your
body.
The most common monotonous positions and movements
for the back involve flexion. Flexion frequently occurs with
prolonged sitting and repeated bending. Let’s look at how to
apply the postural variety principle to these common activi-
ties.
You can learn how to sit with better body mechanics for
longer periods of time. However, despite your best intentions,
the best seating, lumbar supports, etc., if you sit long enough
you will tend to start losing your full stature and go into some
degree of flexion.
Therefore, when sitting gets prolonged, follow the correc-
tive principle by getting out of the chair, standing upright and
bending backwards (the Extension in Standing exercise in
Chapter 10). If you get up frequently enough (before you be-
gin having pain) and bend backwards five or six times, you
will be doing yourself a tremendous favor. You may feel some
stiffness at first. This should ease up with repetitions of the back-
ward-bending movement. If you notice increasing or
peripheralizing pain or other symptoms as you repeat the
movement, stop. You may need to get professional advice.
Slumped sitting can also involve protruding your head and
neck in front of your spine and torso. A corrective to the pro-
truded head and neck position is to …that’s right… move them
the other way with the chin-tuck exercise (head/neck retrac-
tion).4 This has also been called the “hen” exercise because
the movement of your head back and forth looks something
like the movements a hen makes when it walks.5
This movement, used by many rehabilitation profession-
als, goes in the opposite direction of the protruded head posi-
tion. Remember that with the protruded position you poke
your head and neck in front of the rest of your body. At the
extreme of this position, your head will be tilted backwards
in relation to your upper neck while your lower cervical area
will be flexed more (making the upper back “hump” you’ve
quite likely seen).
To do the chin-tuck movement, sit or stand upright. Now
move your head and neck back over the rest of your spine. If
your eyes continue to look forwards, you will be bringing your
chin in (tucking it) closer to your throat, while your head ac-
tually tilts forwards and moves up in relation to your upper
neck. The flexed hump in your lower neck area will reduce.
Go as far as you can in this direction (you can add a little
guidance and extra stretch with one or two hands on your chin
gently pushing backwards). Return to a relaxed position (no
need to return to an exaggeratedly protruded one) and then
repeat the tuck motion five to ten times. Figure 15.1 illustrates
the movement.
As with the lower back exercise, you may feel strain ini-
tially with this movement but this should not increase as you
repeat it. If you feel increasing or peripheralizing pains or other
symptoms, don’t persist. These corrective movements can be
done whenever you have been sitting for a prolonged period,
as, for example, with long car rides, plane trips, sitting in a
meeting, a classroom or in a theatre. Whenever you can do
so, take a break, get out of your seat, stand and move the other
way. When you find it difficult to get out of your seat, you
may still be able to move your spine to some degree in the
opposite direction.
Figure 15.1 – Hen Exercise (Chin-Tuck)
Repeated or prolonged bending activities in standing

might include such activities as vacuuming, shoveling, gar-
dening and lifting. The elegant solution regarding these ac-
tivities involves doing them with your full stature in a biome-
chanically advantageous manner. In other words, you will do
these activities by folding in a way that keeps your spine in
a lengthened state. However, some of us may fall short of this
at least some of the time. Even when you use yourself well,
these activities may cause strain if repeated or prolonged
enough. Therefore, you need to get out of this kind of posi-
tion with some frequency and…that’s right…go the other way.
Five to ten standing backbends at sufficient intervals during
an activity may be enough to avoid the onset of problems.
Postural Variety and Fitness
At one time, most people didn’t have to worry about get-
ting enough exercise. Vigorous physical activity was the rule
for a much larger percentage of the population. For example,
if people wanted to get somewhere, for the most part they
walked. Of course, life wasn’t perfect and more people may

have suffered from ‘back-breaking’ physical labor than at
present.
Now, sedentary occupations are much more common.
Many people spend most, if not all, of their working hours
sitting. Many of us may consider ourselves lucky in not hav-
ing to work very hard doing physical labor in order to survive.
Yet this has led in part to other problems, such as what some
observers see as a rise in ‘back-breaking’ inactivity, as well
as obesity and stress-related disorders. Both for your back and
for your general well-being, find/create more posture-move-
ment variety for yourself by increasing your activity and fit-
ness level.
You can start by making an honest account of your daily
activities for a week. What percentage of the time do you sit,
walk, stand, lie down (rest), sleep (in what position?), exer-
cise (doing what?), sports and recreation (what and how
much?) in a typical day?… in a typical week? Analyze the data
you’ve collected. Is there some type of activity that you don’t
get enough of ? It doesn’t seem as if most people have the prob-
lem of not sitting enough.
If you get little or no physical exercise, you can start to
get more, here and now. If you are over the age of 35 or have
a current medical condition, including pain or other symptoms,
consult your medical doctor first.6
Aerobic activities (those that improve cardiovascular con-
ditioning) provide a good basis for any exercise program.
Walking remains among the simplest and easiest of aerobic
activities. Done for 30 to 40 minutes, 3 to 4 times per week at
a level of comfortable exertion, a walking program can pro-
vide a good foundation for a general exercise program.7
It is better to start slowly and easily. Don’t push too hard.
Rather, do less that you think you can do. You can start by
walking one block for example, then gradually progress to two
blocks, three blocks, half a mile, a mile, etc. As you walk, take
a few wedges of awareness to free your neck, let your head
balance forwards and up on top of your lengthening spine, to
let your back and torso lengthen and widen.
You will need to decide for yourself how much exercise
is enough for you. No absolute rule exists. Reporting on ex-
ercise research, Washington Post writer Carol Krucoff states,
“Lifestyle activity—such as taking the stairs instead of the el-
evator and parking in the farthest space rather than the one
closest to your destination—can provide health benefits simi-
lar to those of a traditional, gym-based workout, according to
a 1997 study called Project Active, performed at the Cooper
Institute for Aerobics Research in Dallas.” 8 There are a num-
ber of components that enter into “physical fitness,” includ-
ing cardiovascular endurance, flexibility, strength, coordina-
tion, balance, etc. Different programs of exercise may empha-
size these components in varying degrees and in different
ways. Your choices about what and how much to do will be
influenced by your health needs and your recreational interests.
If you have started a basic walking program and are look-
ing for more vigorous workouts, you can explore aerobics
exercises such as running, or group classes such as aerobic
dance, kickboxing, etc. Strength training may be useful as well
and has been shown to help people recovering from back in-
juries and those who have been dealing with chronic pain. To
avoid unnecessary problems make sure you have a qualified
instructor and have necessary medical clearance. Find out
about any special classes for people who have had back prob-
lems. Those that feature “spinal stabilization” may have par-
ticular usefulness.
Your back health and safety must be a major consideration
in any exercise program you do in addition to a basic walking
program. My personal favorite as an exercise system is the
gentle, awareness-based approach of Tai Chi. I have practiced
this graceful movement discipline since 1985. Tai Chi began

in China as a martial art, yet can be done purely for exercise.
It can help you to develop greater balance and coordination.
The principles and practice of Tai Chi reinforce the body me-
chanics approach of the Alexander Technique. Tai Chi is re-
lated to a whole group of exercises called Qigong, which you
also may find useful to explore.
You can find Tai Chi instructors in more and more places.
Observe a class or two, talk with the instructor, find out about
the person’s philosophy and background, and choose one who
seems right for you. Forms of practice may vary but teachers
of whatever type follow a central core of posture and move-
ment-related principles. I advise choosing a teacher who can
help you learn the practical aspects that can be done without
the need to follow any belief system.9
Yoga can also provide a ‘mindful’ approach to exercise.
There are many different forms, some more vigorous than
others. Flexibility and breathing receive special emphasis.
Again, find an experienced teacher who emphasizes practi-
cal aspects and can individualize the instruction to fit your
particular needs.
It can be useful to discuss your individual health concerns
with an appropriate health-care provider. Your personal phy-
sician will be able to give you general guidelines on exercise
related to your back and other health issues you may have. A
physician may also be able to provide you with advice about
how to get more information on exercise to meet your per-
sonal health and life-style goals. A rehabilitation professional,
such as a physical therapist, can also advise you on exercise
issues related to any activity-related back or other movement
problems you have had.
For questions related to recreational sports, you might do
well to get additional advice from a professional instructor in
that particular activity. For example, if you like to ski you can
get advice from a professional ski instructor on the kind of

conditioning that you need to ski safely at your skill level and
to get to the next level as well.
Whatever exercises and sports you do, remember the im-
portance of how you do what you do, your use. Robert
Rickover, Alexander Technique teacher and author of the book
Fitness Without Stress, has written that “It isn’t only the num-
ber of miles run, the time spent doing aerobic exercises, or
the heaviness of the weights lifted that matters. Far more
important is the quality of our movements — our balance and
coordination and our ease of breathing.”10 An Alexander Tech-
nique teacher can help you learn to apply the principles of good
use and body mechanics to improve the quality of any of your
fitness activities. Applying the principles of good use to your
other activities of daily living will enable you to enjoy what I
call “the athleticism of everyday life” as well.
Postural Variety and Rest

Perhaps we could call this the Age of Faster But Not Nec-
essarily Better. With all the ‘labor-saving’ and ‘time-saving’
devices we have, such as cellular phones, pagers and faster,
more powerful computers and internet connections, many
people have more work with less time to do it.
This makes it even more important to include rest as a
necessary element in finding/creating posture-movement va-
riety for yourself. Look again at your daily and weekly ac-
count of activities. How much time do you allow for sleep?
How much time for resting during the day? As devotees of
‘faster’, many of us don’t give ourselves sufficient time for
sleep or for adequate rest.
This can have a significant effect on back and other mus-
culoskeletal problems. With fatigue, we can easily become
more preoccupied and inattentive to what we are doing. Judg-
ment may get reduced. We can sag into our joints more eas-
ily, moving out of our factor–of–safety range and into stress-

ful, sustained end range positions. The protective functions
of the muscles may not work as quickly to protect our joints
from sudden stresses and jolts.
One of the minimum pieces of ‘homework’ I ask clients
to do is to lie down for 15 to 20 minutes at least once a day in
constructive rest position. I often have to persist in this request
from week to week because, as easy as it seems, many people
don’t find it easy to get themselves to do it even once a day.
Rest is not an absolute but a relative quality. One of the
‘secrets’ of efficient movement mechanics is what writer
Aldous Huxley called “relaxation in activity.”11 This quality
of rest and repose during skilled activity can be seen clearly
in performances of great skill such as the play of Tiger Woods
and Michael Jordan, the dancing of Ginger Rogers and Fred
Astaire, and the piano technique of Artur Rubinstein. Anato-
mist and anthropologist Raymond Dart, M.D., a student of the
Alexander Technique and of human movement, said, “In ev-
ery game and craft perfect relaxation of the unwanted muscles
is the key to skilled performance.”12
A simple way to begin experiencing more of this sense of
relaxation in activity is to practice pausing when you can in
the midst of an activity. Give yourself a wedge of awareness
and ask yourself a few questions suggested by Milton Trager,
M.D., founder of the Trager approach to movement education:
What can feel freer? What can feel easier? What can feel
lighter?13
Find out what needs less tension, more movement, and
experience your sense of your body there. For example, per-
haps you have been sitting at the computer for awhile. Your
hand has been pressing onto the mouse and feels tight and
tense. Let go and let your arm hang at your side. Give your
hand a gentle shake so that you can feel your thumb and each
of your fingers move. How can you let this movement feel
easier, softer, lighter? Allow the movement to go into your

wrist, forearm, elbow, arm, shoulder. After about a minute let
your hand rest. Notice any changes. Does this hand feel any
different from the other one? As you bring your hand back to
the mouse, how can you continue feeling lighter and easier
there? Practicing this kind of gentle, ‘mindful’ movement can
help you to avoid undue effort and find more relaxation in
more of what you do.
A related principle of use is one elaborated by John
Mennell, M.D., that I call relative rest.14 When recovering
from an injury, you may not need to stop moving the injured
part completely. Rather, you can find a certain threshold of
activity, which, if you stay below it, will allow you to be ac-
tive to some degree without impairing the healing process.
Indeed, relative activity during relative rest can help you feel
and function better sooner.
Sometimes easing up on one particular kind of activity,
position or movement may be sufficient. In addition, as you
recover from injury you may be able to begin regular activi-
ties just by reducing the speed or duration of a particular
movement.15 This is useful to remember in athletics and also
when you are getting back to doing regular household or work
activities. It won’t hurt — and will help — to tell yourself to
“take it easy,” “take it slow” and “take it a little bit at a time,”
especially if you actually listen to yourself.
You can also use this advice for preventing injuries when
starting a new activity or skill. For example, a runner may do
well to reduce speed a bit when first adding mileage. In any
task that you do, you might do well at first to make haste
slowly.
Consult your health care provider as to what activities,
positions, etc., to avoid altogether, and for how long. This is
especially important when you currently are dealing with back
pain. However, staying flat on your back in bed usually is not
a useful approach to functioning better faster.

Another contributor to an understanding of rest in daily
life is Ernest Rossi, Ph.D., a psychologist who has explored
ultradian rhythms. These are daily biological rhythms that
occur during our period of waking consciousness. Ultradian
rhythms involve times of externalized, focused activity of
around 90 minutes in length, interspersed with more internal-
ized periods of brain/body restoration and repose of around
20 minutes in length.
Be assured that when you find yourself daydreaming,
going to the water cooler, looking for a snack, or yawning or
stretching during your workday, you are doing what comes
naturally. These ultradian periods of rest do not necessarily
come at the time that your boss schedules a coffee break. They
come as part of a natural cycle and are related to body pos-
ture and use. You can learn to make use of these times more
consciously.
By recognizing when you seem to be entering a “rest”
period, for example if you are having difficulty concentrat-
ing, you can learn how to make the most of it rather than fight
it. If it is possible, this can be a good time to stretch, yawn,
get up and move around, get a snack or take a nap.
If you can do it, a twenty-minute nap can be just the thing
you need to restore yourself for the next phase of working
activity. Winston Churchill, a great leader against Nazi tyr-
anny during World War II, was known for his ability to take a
quick nap, sometimes for just a few minutes, when he had the
opportunity. Churchill helped save the free world and I guess
the naps didn’t hurt.
Employers often short-sightedly think that their workers
need to be ‘busy’ and buzzing around like worker bees the
entire day in order to function efficiently. This unphysiologi-
cal ‘nonsense’ may lead to exactly the opposite result. More
is not necessarily better. In a more enlightened time, perhaps
we can expect employers to provide more opportunities for

their employees to nap openly. It remains to be seen what ef-
fects this could have on rates of back injuries.
If a nap doesn’t seem practical, just pausing to look out
of a window, take a deep breath or close your eyes for a mo-
ment will help you to function better. If you’re feeling tired
or distracted, changing how you sit, looking into the distance,
moving into a new position or shifting to a new activity also
can help to revive you. Different tasks may require different
amounts of attention. Moving to a routine and relatively
‘mindless’ task may be useful after work requiring a high
degree of concentration.
You can pump up your ability to stay awake and alert by
taking breaks, taking a nap, ingesting caffeine, exercising, etc.
This only goes so far. You can’t stay awake and alert forever.
Eventually, getting adequate rest means that you must get
sufficient sleep.
Inadequate sleep will lead to excessive fatigue which will
interfere with your ability to function and feel better with less
pain. If the demands from work and home become extreme,
you may neglect or feel unable to sleep sufficiently. In addi-
tion, pain may interfere with your ability to sleep well and thus
may contribute to a spiral of more fatigue and pain.
Discuss any sleep problems you have with your medical
doctor.16 If pain interferes with your sleep, the proper medi-
cations can help. Getting help in dealing with emotional
stresses also can make a difference. Take care of other under-
lying medical problems, such as allergies, that may interfere
with sleep. Sleep disorders are gaining greater recognition and
more physicians specializing in this area are available if spe-
cialized testing or treatment seems needed.
Guidelines for Reducing Stress

Stress expert Hans Selye,M.D., once said “Variety of ex-
perience is not only the spice of life but possibly the key to
longer life.”17 Practicing postural variety may not increase
your life span but, along with the other rules of ‘mindful’ body
mechanics, it can help you live the life you have with greater
ease and effectiveness.
Here again are the four general rules of ‘mindful’ use:
1. Make body awareness a daily practice.
2. Experience your full stature everyday as often as you
can.
3. Design your personal environment for better use.
4. Practice postural variety in your daily life.
As the last four chapters show, these flexible guidelines

work together. By finding small ways to apply these principles
in your everyday life, you can use them to develop better
posture-movement habits for yourself. To the extent that the
pain you’ve experienced depends on your use, these principles
can help you reduce your musculoskeletal stress and gain
greater control of your life.
Conclusion
The obscure we see eventually;
the completely apparent takes longer.
- Edward R. Murrow1
Chapter 16
Preventing Back Pain
Problems and Solutions

Back pain problems have vexed humans throughout his-
tory. Documented records of back pain and sciatica go as far
back as the ancient Egyptians and Greeks.1 Starting in the latter
half of the twentieth century, there has occurred a documented
rise in healthcare expenses and in lost productivity due to back
pain disability. Does this indicate a significant change in the
percentage of the population experiencing back pain now as
compared with previous times? Not necessarily. Some have
suggested that the rise in disability related to back pain may
have come about more as an unintended consequence of some
of the measures (such as inappropriate illness benefits) used
to deal with the problem.2 Some so-called solutions—passive
treatments and rest—may have resulted not only in increased
disability but in diagnostic confusions and treatment impasses
as well.
However, the situation is changing. Many health care pro-
fessionals now recognize that common back pain has impor-
tant mechanical (activity-related or, as I have termed it, pos-
ture-movement-related) aspects. Treatments now put a greater
emphasis on the use of activity and exercise. There is also
greater recognition of the need to understand the
biopsychosocial nature of back pain—how mechanical and
other so-called physical factors interact with a person’s psy-
chological states and social environments.
Unfortunately, these understandings may get little more
than lip service. Practitioners may not go beyond giving gen-
eralized advice on attitude, activity and exercise. If each per-
son with back pain functions as a unique individual, such gen-
PREVENTING BACK PAIN 261
eral advice is not sufficient. A broadly interpreted scientific

attitude sees the individual as paramount. Therefore, treat-
ments and advice need to be tailored specifically to each
individual’s condition.
The posture-movement model of pain and recovery (pre-
sented in Chapter 9) provides a biopsychosocial framework
for understanding your individual condition. The therapy and
education guidelines which follow this will help you to func-
tion as a personal scientist in relation to your individual back
problem. Using the guidelines for posture-movement therapy
(presented in Chapter 10) you can explore how different, spe-
cific positions and movements may produce, increase, de-
crease or abolish your symptoms. Applying the guidelines for
posture-movement education (presented in Part IV) you can
explore how your particular moment-to-moment posture-
movement habits (your body mechanics/use) affect how you
function. Can applying these principles help you as an indi-
vidual to deal more effectively with back pain? I think so.
Personal and Group Research

There is a great deal that we don’t know about back pain.
More definitive answers to many questions will require a great
deal more high quality research than has presently been done.
Such research will include using statistical studies of large
groups of people in randomized, controlled clinical trials. This
kind of research is difficult to do well, can be misinterpreted
and may neglect or downplay the factor of individuality. None-
theless, such studies are needed to make good generalizations
about the percentage (relative frequency) of people in similar
groupings who can be presumed to respond (or not respond)
to various treatments.
However, it seems like a great mistake to assume that no
other kinds of data have value or that we don’t know anything
now. Dr. Stephen Barrett and Dr. William Jarvis, two advo-
cates for high quality information and research in healthcare,

have pointed out that, “Although controlled trials are impor-
tant, many scientific truths are derived from other types of
careful observation.” 3
Many different types of evidence point to the value of the
principles of posture-movement therapy and education. I have
provided references for some of this evidence in the Notes
section. I include as evidence the kinds of observations you
can make in your own personal research to explore your pos-
sibilities for feeling better. You don’t need to take my word
for it or accept questionable beliefs or practices. With very
little expense, you—as a personal scientist—can test, in your
own life-laboratory, the power of posture-movement prin-
ciples, using this book as your lab manual.
Admittedly, there are limitations to this kind of personal
research. Individuals can easily jump to definite conclusions
about cause and effect relations between treatments and re-
sults, based on their fallible and limited experience. It is easy
for individuals to fool themselves and/or be fooled by others.
That’s how quackery works. In the case of back pain, we can
mistakenly confuse the presumed benefits of a given treatment
with the actual benefits of the passage of time alone. In actu-
ality, reasonable conclusions about health matters are often
difficult to reach. Nonetheless, an advantage of a posture-
movement approach is that it is sometimes very easy to ob-
serve immediate cause and effect relations among positions,
movements and signs/symptoms.
Another related limitation of the kind of personal research
discussed above is the difficulty in making very definitive con-
clusions about groups of people based on the experience of
one or a few persons. This doesn’t mean that anecdotal evi-
dence should simply be tossed aside. Rather, conclusions sug-
gested by anecdotal or case evidence need to be held rather
tentatively until supported by further research that allows
greater generalization.
I have used and documented the benefits of posture-move-

ment therapy and education for my individual clients, as have
many other therapists who use such methods. I may be wrong,
but my experience strongly suggests that for most people, the
kind of posture-movement therapy I discuss in this book, in
combination with posture-movement education such as the Al-
exander Technique, is superior to other methods presently used
for common back problems.
I’d like to highlight here two studies which support this
view. One focused on chronic pain patients; they were found
to experience significant improvements in pain relief and the
ability to function when using the McKenzie Method of pos-
ture-movement therapy.4 In another study, the Alexander
Technique was taught as part of a comprehensive pain man-
agement approach for chronic pain patients. Patients rated
these posture-movement education sessions as one of the most
significant interventions they experienced.5
These studies suggest great possibilities, but more detailed
and comprehensive long term studies with controls need to
be done. What outcomes might result from a well-designed
program for back patients that integrates posture-movement
therapy, for example the McKenzie approach, with posture-
movement education using the Alexander Technique? I pre-
dict greater benefits compared with other kinds of treatment.
Controlled studies done with large groups of people testing
this hypothesis have yet to be done. In the meantime smaller,
less extensive research studies continue to show the promise
of posture-movement therapy and education.
Preventing Back Pain

Is it possible to prevent back pain using the principles of
this book? I think so. But I can’t say with the utmost certainty.
Unfortunately, we so far lack the strongest level of scientific
evidence here. Large scale, controlled studies will need to be
carried out in order to more definitely determine whether it is

possible to reduce the number of episodes of back pain in the
general population, reduce the duration of episodes, reduce
the severity and frequency of recurrences, and reduce the time
away from normal activities and work. However, I believe
that some preliminary evidence exists and that the question
is worth pursuing.
I have had a number of episodes of neck and back pain
over my adult years. As I have learned and applied the prin-
ciples in this book, I have been able to reduce the severity,
duration and frequency of these episodes. Although I have
modified my activities at times, I have never had to take time
off from work for back or neck pain. My posture, as noted by
a number of independent observers, has improved as I have
gotten older.
I have observed and recorded similar results with the cli-
ents who have come to me with back and neck problems. Other
practitioners using the kinds of posture-movement therapy and
education described in this book have had similar results.
Many different types of published research are available which
point to the value of these approaches. Although some may
disagree, I believe that at this point enough evidence exists to
make it irresponsible of me not to present this information here.
One claim that I feel confident in making is that there exists
a clear relation between posture (posture-movement habits) and
pain. A large body of research supports this. In one study, espe-
cially worthy of note, researcher Stover Snook, Ph.D., and col-
leagues, “showed significant reductions in pain intensity” in in-
dividuals with chronic, nonspecific back pain who were taught
to control (avoid) lumbar flexion in the early morning hours af-
ter waking. Individuals received instructions in how to get out of
bed without bending and how to avoid all bending, sitting and
squatting for the first two hours (reaching devices were supplied
as well as special urinals for the women to use while standing).
Participants were instructed that slight bending was okay after
two hours and that after six hours they could do their normal
activities. Extreme bending was to be avoided at all times.
Participants were required to keep a daily diary to moni-
tor pain intensity, functional disability/impairment and medi-
cation use. The control group was given ‘sham’ exercises to
do (these included the traditional pelvic tilts and knees-to-chest
exercises favored by flexion enthusiasts). After six months of
treatment, participants experienced significant reductions in
pain levels (18–29%) compared to the control group (6–9%)
and had related reductions in disability/impairment and medi-
cation usage. The control group then received the experimental
treatment and experienced similar improvements.
The researchers concluded:
In a small sample of relatively unselected subjects with less
than 50% compliance, chronic low back pain was signifi-
cantly reduced without medication, manipulation, exer-
cises, injections, or surgery. The reduction in pain was ac-
complished by a change in behavior. It was concluded that
controlling lumbar flexion in the early morning is a form
of self-care that has the potential for reducing pain as well
as costs associated with chronic, non-specific low back
pain.6
Snook’s study supports the emphasis in this book on the
importance of posture-movement habits as well as the impor-
tance of neutral postures, the natural curves of the spine, and
reducing the frequency of flexion.
Robert Pula has noted that, “If something goes without
saying, it often goes even better with saying.” It ‘goes with-
out saying,’ then, that ‘bad’ posture will not automatically and
absolutely guarantee that you will have back pain. Rather, it
will increase the probability that you may have back pain. Con-
versely, ‘good’ posture will not automatically and absolutely
guarantee that you will never have back pain. Rather, it will
increase the probability that you will have fewer, less severe
back problems.
Future Directions
I feel fairly sure that, as a society, we will not make sig-
nificant inroads into preventing back and other musculoskel-
etal problems until we tackle a number of related issues.
First, healthcare consumers need to take more responsi-
bility for their own musculoskeletal health. In turn, healthcare
providers need to be able to teach them how to do this. Too
many people still look for the magic of passive treatments
which too many healthcare providers have been too willing
to supply. If you have read this far, I hope that you have be-
gun to realize that the primary responsibilty for your back
belongs to you.
As a healthcare consumer you will do well to expect the
following from providers:
• Adequate diagnosis which includes detailed attention to
posture-movement factors
• Individualized instruction in self-treatment using your
own positions and movements (exemplified by the
McKenzie Method)
• Manipulative therapy when needed to assist the self-care
process and not as a cure-all7
• Adequate individualized instruction in body mechanics
based on scientifically-based principles of good use and
human learning (exemplified by the Alexander Technique).
Second, consumers need to look for “body-conscious de-
sign” in furniture, automobiles, and living/working environ-
ments. People interested in promoting their musculoskeletal
well-being will need to take greater responsibility in design-
ing their own environments. By seeking out seating and equip-
ment that promote better use and postural variety, they will
make it more likely that designers, furniture makers, and oth-
ers will take these issues more seriously.
Third, although the question of workplace ergonomics

remains controversial, businesses need to cooperate with their
employees to provide more worker-friendly,‘body’-friendly
environments. Enlightened businesses will work to create pi-
lot projects that can show the effectiveness of ergonomics/al-
ternative management programs to reduce worker injuries and
disability expenses. In the long run, this will benefit workers,
businesses and society.8 An important point here: in the work-
place as elsewhere, ‘psychosocial’ and ‘physical’ factors do
not exist as separate elements in isolation from one another.
Some occupational health researchers at present seem to be-
lieve that they can separate them. In actuality they can only
do so verbally.
Fourth, a concerted effort needs to be made to teach all
children the principles of posture-movement care as presented
in this book and elsewhere. Primary prevention of back pain
will not happen if children are never encouraged to discover
the optimal ways to sit, stand, bend, lift, etc. Elite team sports
for the few need to be deemphasized to the extent that they
reduce physical education opportunities for all children. Pos-
ture-movement education, one of the “non-verbal humanities”
(as Aldous Huxley called it)9, can be integrated with health,
music, science and other aspects of the curriculum.
Pilot programs and some initial research have already been
done, including the Chelsea, Massachusetts School Survey in
1923-24 where children were taught remedial body mechan-
ics10, various schools run by F.M. Alexander and/or his stu-
dents, Ann Mathews’ research teaching the Alexander Tech-
nique in a public school classroom, Jack Fenton’s Alexander
Technique–based movement classes with English school chil-
dren, and Michelle Arsenault’s two-year pilot project teach-
ing Alexander Technique-based body mechanics to New York
City school children in the context of the science curriculum.
Arsenault’s project and her book, Moving To Learn, has

inspired the founding of The Moving To Learn Society. The
Society has the following purposes:
1. To promote among parents, teachers, school authori-
ties, and the general public the understanding and practice
of scientific body mechanics by the school children of this
nation, in the interest of both more effective learning and
lifelong health and well-being.
2. To conduct educational activities, including but not
limited to conferences, lectures, courses, workshops, pub-
lications, and research, relative to the foregoing.11
If not taught properly, body mechanics education could
become as dull and deadly as the boring sex education class
in a Monty Python skit. When taught well the subject of body
mechanics and use has a great deal of intrinsic interest for both
children and adults. Arsenault’s book contains reports from
her pilot project and detailed lesson plans that will be of in-
terest to anyone concerned with this subject. Her work teach-
ing children about their own bodies and selves demonstrates
the importance not only of the actual content but also of the
support and encouragement given them to explore their own
capacities.
Fifth, at the other end of the age spectrum, we need to
change our attitudes about older people. Pain and deformity
are not inevitable as we grow older. It is possible to reduce
back pain and other types of musculoskeletal pain among the
elderly. It is possible, as well, to prevent or reduce the bent,
stooped postures that many people associate with old age. I
have known many older people, some but not all of them Al-
exander Technique teachers, who have been able to retain an
appearance of poise that younger people might envy. It is best
to start young. However, posture-movement habits can be cul-
tivated and improved at any age and surprising changes may
occur.
Back to the Source

There is a common source for solutions—not only for back
pain, but also for other problems that beset us humans. That
common source consists of the natural, childlike potential for
learning and change that all of us are born with but gradually
tend to lose as we grow older.
We have a great deal to learn from children. In his book
Growing Young, Ashley Montagu lists some of the valuable
traits of childlike (not childish) behavior: curiosity, imagina-
tiveness, playfulness, open-mindedness, willingness to experi-
ment, flexibility, humor, energy, receptiveness to new ideas,
honesty, eagerness to learn and the ability to love.12 It is pos-
sible to encourage these qualities in our children and to culti-
vate and renew them in ourselves.
In this way, you can continue to grow young as you age
chronologically. If you accept the unity and inseparability of
‘mind’ and ‘body’, then these childlike qualities all have a
psycho-physical nature.13 What is the relation of these quali-
ties or their lack to so-called ‘physical’ and ‘mental’ health?
How do they find expression in your posture-movement pat-
terns?14 This qualifies as a whole new domain for research that
has barely begun to be developed.15
In the meantime, you don’t need to wait for more formal
research or for other people to change. What can you do for
yourself right here and now, as you explore your own possi-
bilities for back pain solutions?
Notes
Epigraph
1. Rosten, Leo Rosten’s Treasury of Jewish Quotations, p. 259
Dedication
1. Yiddish term “rhymes with ‘bench.’ from German: Mensch: ‘person.’
Plural: menshen. 1. A human being...2. An upright, honorable, decent
person...3. Someone of consequence; someone to admire and emulate;
someone of noble character...To be a mensh has nothing to do with suc-
cess, wealth, status [or gender]. A judge can be a zhlob; a millionaire can
be a momzer; a professor can be a shlemiel; a doctor a klutz; a lawyer a
bulvon. The key to being a ‘real mensh’ is nothing less than—character:
rectitude, dignity, a sense of what is right, responsible, decorous. Many
a poor man, many an ignorant man, is a mensh.” (Leo Rosten, The Joys
of Yiddish, p. 237)
Usage Note
1. Qtd. in Kodish and Kodish, pp. 180-181
Introduction
1. Whyte, The Next Development In Man, p. 9
Chapter 1
1. Waddell, p.135
2. Waddell, p. 135-136
3. Deyo, p. 50
4. McKenzie’s texts for clinicians are The Lumbar Spine: Mechanical
Diagnosis and Therapy, The Cervical and Thoracic Spine: Mechanical
Diagnosis and Therapy and The Human Extremities: Mechanical Diag-
nosis and Therapy. McKenzie’s more popularly-oriented books are Treat
Your Own Back, Treat Your Own Neck and 7 Steps to a Pain-Free Life.
The application of this approach to other musculoskeletal problems
can also be found in Mark Laslett’s clinical textbook, Mechanical
Diagnosis and Therapy: The Upper Limb. McKenzie’s work is built
upon the pioneering work of Dr. James Cyriax. See Cyriax’s Text-
book of Orthopaedic Medicine and Illustrated Manual of Orthopaedic
Medicine. The article “Spinal Therapeutics Based On Responses To
Loading” by Gary Jacob, D.C., and Robin McKenzie, provides an
illuminating and comprehensive presentation of “the underly-
NOTES 271
ing philosophic and practical perspectives of the McKenzie approach…” (p.225).

See also the articles by John Barbis and by Wayne Rath and Jean Duffy Rath.
5. The term “Cognitive-Kinesthetic Education” comes from Ron Dennis, Ed.D.
(personal communication). Michael J. Gelb’s book, Body Learning: An Intro-
duction to the Alexander Technique and Robert M. Rickover’s Fitness Without
Stress serve as brief introductions for the general reader. Wilfred Barlow, M.D., a
physician who studied, taught and did research on the AT, also wrote a sound,
science-based and readable introduction, The Alexander Technique: How To Use
Your Body Without Stress. The essays of Curiosity Recaptured, edited by Jerry
Sontag, show AT applications to a variety of areas of interest. I also recommend
Deborah Caplan’s book, Back Trouble. Caplan, a physical therapist and Alex-
ander Technique teacher, provided a view that complements my own. F. M.
Alexander’s own writings are well-worth reading and provide many ‘gems’ for
the serious student . See his Articles and Lectures: Articles, Published Letters and
Lectures on the F. M. Alexander Technique, edited by Jean M. O. Fischer. Also
see The Books of F. Matthias Alexander published by IRDEAT (the Institute for
Research, Development and Education in the Alexander Technique).
6. Dennis’s definition of AT is in his outcome research article on AT and balance,
“Functional Reach Improvement in Normal Women After Alexander Technique
Instructions.”
7. Barrett Dorko’s book Shallow Dive: Essays on the Craft of Manual Care and
the essays on his website (http:barrettdorko.com/index.htm) provide an espe-
cially important scientific and humanistic perspective on the effectiveness of such
educational methods. Dorko, an innovative and skillful practitioner of physical
therapy, has developed Simple Contact, a profound way of encouraging pain-
relieving activity which involves “...a technique of communication, either verbal
or manual, designed to enhance another's awareness and expression of their spon-
taneously occurring internal processes.”
8. “Might not the individual man, each in his own personal way, assume more of
the stature of a scientist, ever seeking to predict and control the course of events
with which he is involved?” (George A. Kelly, A Theory of Personality: The
Psychology of Personal Constructs, p. 5)
9. If you have more curiosity about what taking a scientific approach to living
entails, read Drive Yourself Sane: Using the Uncommon Sense of General Se-
mantics, written by me and my wife, Susan Presby Kodish. Also see the book
edited by Susan, Developing Sanity in Human Affairs.
10. Howe and Greenburg, p. 496
11. Rosten, p. 302
12. Runkel, pp. 175-176
Part I – Problems and Solutions

1. Allen, quoted by Laurence J. Peter, Peter’s People, p. 184
Chapter 2
1.This and other stories about patients are as true as I can make them
while changing names and other identifying data.
2. Deyo, p. 50
3. Deyo, p. 49
4. See article “Prevalence of Back Pain — By Quality of Study” which
reports these figures from the study by R.C. Lawrence et al., “Estimates
of the Prevalence of Arthritis and Selected Musculoskeletal Disorders in
the United States.”
5. Deyo, p. 50
6. Deyo, p. 50-51
7. See Dana Greene’s “Abstracts That Discourage Treatment Based on
Imaging Results Alone.”
8. Boden
9. See Deyo, p. 50 and the article by Cherkin et al., “Physician Variation
In Diagnostic Testing For Low Back Pain.”
10. Waddell, p. 244
11. Waddell, p. 243
12. See “Major Sciatica Treatment Proves Ineffective In Landmark Ran-
domized Trial,” reported in The Back Letter. Also see Deyo, pp. 51-52,
as well as Bigos, et al., and the Royal College Guidelines.
13. See Bigos et al., under the subheading “Physical Agents and Modali-
ties.”
14. Waddell, p. 398
15. McKenzie, The Lumbar Spine, p. 2
16. Deyo, p. 51
17. See J.A. Rizzo et al., “The Labor Productivity Effects of Chronic
Backache in the United States.”
18. See Elaine Thomas et al., “Predicting Who Develops Chronic Low
Back Pain in Primary Care: A Prospective Study.” “About 30% of pa-
tients [in a group of 180 patients studied] continued to have disabling
back pain after 12 months.”
NOTES 273
19. This study was reported on in “Acute Back Pain Benign But Fre-
quently Persistent” in The Back Letter. Only 37% of patients studied
reported complete pain relief in the study done by Reis and associates
printed in “A New Look at Low Back Complaints in Primary Care” in
Journal of Family Practice, 48 (4): 299-303 (1990) .
20. One study showed disabling recurrences at rates between 8% and
14% from 3 to 6 months after an initial episode. Recurrence rates were
20% to 35% between 6 to 22 months after an initial injury (see Timothy
S. Cary, “Recurrence and Care Seeking After Acute Back Pain: Results
of a Long-term Follow-up Study”).
21. See Deyo, p. 52. Also see Samanta and Beardsley’s article, “Low
Back Pain: Which is the Best Way Forward?” and “Exercise Beneficial
for Low Back Pain” in PT Bulletin, August 30, 1999.
22. See Deyo, p. 52.
23. Qtd. in “New UK Back Pain Guidelines” in The Back Letter
24. See The American Academy of Orthopaedic Surgeons, Low Back
Pain, available at www.aaos.org under patient education: spine: patient
education brochures.
25. See Moffat and Vickery, pp. 123-124.
26. See the American Chiropractic Association (ACA) “Policies On Public
Health.”
Chapter 3
1. Licht, in Basmajian, p. 1
2. Cyriax, Textbook of Orthopaedic Medicine, Vol.1, p. 484
3. Kamenetz, in Rogoff, p. 8
4. Licht, p. 4
5. Ackerknecht, p. 58
6. Waddell, p. 241
7. Cyriax, op. cit., p. 348
8. Maitland, Vertebral Manipulation, p. 3
9. Jacob and McKenzie, p. 225
10. McKenzie, The Cervical and Thoracic Spine, p. 103
Chapter 4
1. Waddington, p. 24
2. “What I Believe,” in Alfred Korzybski Collected Writings 1920-1950,
pp. 643-663
3. Science and Sanity, 5th Edition, p. liii
4. See Note 1, Chapter 3 above.
5. “Late nineteenth century singing teachers advised students to develop
upright posture..., full chest breathing..., and the correct opening of the
mouth without any muscular strain..., before the actual singing lessons
would start.” Staring, p. 135
6. Staring, pp. 205-239
7. Cohen, pp. 27-28
8. Staring, pp. 34-37
9. Licht, pp. 20-23
10. Qtd. by Staring, p. 35
11. In The Books of F. Matthias Alexander. New York: IRDEAT
12. Staring’s two volume work, The First 43 Years of the Life of F. M.
Alexander, provides overwhelming support for this statement.
13. Bouchard and Wright, p. 135
14. Macdonald, p. 86
15. James, Talks with Teachers, p. 64
16. James, pp. 210-211
17. Alexander, The Books of F. Matthias Alexander, p. 416. See Lulie
Westfeldt’s discussion of Head-Neck-Back relations in her book,
F. Matthias Alexander: The Man and his Work.
18. See Von Durckheim’s book Hara: The Vital Center in Man, Chapter
5–The Practice of Right Posture.
19. Staring, pp. 25-26
20. Qtd. by Staring, p. 23
21. Ibid, p. 23
22. Qtd. by Staring, p.39
23. Ibid, p. 40
24. Alexander, The Books of F. Matthias Alexander, p. 420
NOTES 275
25. Staring, p. 170

26. Staring, p. 40
27. James, pp. 192-193
28. James, p. 193
29. James, pp. 194-195
30. James, p. 187
31. Cohen, p. 93
32. Huxley, “The Education of an Amphibian” in Tomorrow and Tomor-
row and Tomorrow and other essays, pp. 15-16
33. Ron Dennis, Personal Communication, Oct. 25, 2000
34. Science and the Modern World, p. 5
35. Sherrington, Man on His Nature, p. 153
36. Sherrington, The Endeavor of Jean Fernel, p. 89
37. In recent years, Dennis has suggested the notion of “skill” as a foun-
dational formulation for posture-movement education. Dennis has char-
acterized the achievements of Alexander and others in terms of their
expansion of the possibilities for acquiring and improving the skills of
body support and movement in everyday life. See Dennis’ articles, “Pri-
mary Control and the Crisis in Alexander Technique Theory” and “Poise
and the Art of Lengthening.”
38. See Dennis’ definition of the Alexander Technique in the first chap-
ter of this book. See also his discussion of “un-exercise” at http://
www.posturesense.com/FAQ.htm
Part II – Necessary Background

1. Ibn Paquda, qtd. in Rosten, p. 285
Chapter 5
1. Anonymous, qtd. in Macnab, p. 19
2. Brunnstrom, p.11
3. Qtd. in Smallheiser, p. 3
4. Kapandji, p. 20
5. Lumbar syndromes, 61.94%; cervical syndromes, 36.1%; thoracic
syndromes, 1.96% according to Kramer, p. 13
6. Kramer, p. 18. Much of the discussion on the disc is indebted to

Kramer’s work.
7. Kramer, p. 26
8. See Kapandji, p. 40 and Kramer, pp. 28-29. Fennel and associates
demonstrated these internal movements in their study, “Migration of the
Nucleus Pulposus within the Intervertebral Disc during Flexion and Ex-
tension of the Spine” Spine 21 (23): pp. 2753-2757 (1996).
9. Kramer, p. 8. McKenzie (1990) points to research studies that support
this notion of displacement of material inside the disc. See references on
pp. 48, 204, and 206 of The Cervical and Thoracic Spine.
10. Cyriax, The Slipped Disc, pp. 74-75
11. Brunnstrom, p. 42
12. See “The Double Spiral Mechanism of the Voluntary Musculature of
the Human Body,” in Dart. This was originally published in British Jour-
nal of Physical Medicine,13 (1946). Also see Kapandji, pp. 101 and 102.
Implications of spirally-arranged musculature for posture-movement edu-
cation are presented in Troup Mathew’s article, “Blessed Helicity.”
13. Dennis, “Poise and the Art of Lengthening”
Chapter 6
1. Melzack and Wall, p. 122
2. Ibid, p. 35
3. Ibid, pp. 41-47
4. Ibid, pp. 47-49
5. Ibid, pp. 124-127
6. Cyriax and Cyriax, Illustrated Manual of Orthopaedic Medicine, pp. 10-11
7. Robert P. Pula, writer/teacher of General Semantics (lecture notes)
8. “IASP Pain Terminology” from Merskey and Bogduk, Classification
of Chronic Pain, pp. 209-214
9. See Melzack and Wall, pp. 222-239.
10. See Candace Pert’s The Chemistry of Emotion for a firsthand ac-
count of the discovery of the endorphins and endorphin receptors. Rossi’s
The Psychobiology of Mind-Body Healing discusses the implications of
the existence of these communication molecules.
NOTES 277
11. Melzack and Wall, p. 402

12. The diagram and discussion are based on Alfred Korzybski’s model
of human perception/cognition presented in his article, “The Role of Lan-
guage in the Perceptual Processes,” in Alfred Korzybski Collected Writ-
ings 1920-1950, p. 683-720. This model is presented and discussed in
Drive Yourself Sane.
13. Cyriax, Textbook of Orthopaedic Medicine, Vol. I, p. 569
Chapter 7
1. See Robert Fritz, The Path of Least Resistence and Creating.
2. William T. Powers, Making Sense of Behavior: The Meaning of Con-
trol, p. 7
3. The example of the driver staying in the lane is from Making Sense of
Behavior, pp. 8-11.
4. A brief, non-technical introduction to Perceptual Control Theory is
Powers’ book Making Sense of Behavior. Also see Richard J. Robertson’s
article “Control Theory.” Powers’ Living Control Systems I and II and
Behavior: The Control of Perception also contain many interesting ar-
ticles. Other treatments of this important, paradigm-shifting approach to
the human sciences include Introduction to Modern Psychology: The
Control-Theory View by Richard J. Robertson and William T. Powers,
Richard S. Marken’s Mind Readings: Experimental Studies of Purpose,
Philip J. Runkel’s Casting Nets and Testing Specimens and Gary Cziko’s
The Things We Do.
5. Richard J. Robertson, “Control Theory,” p. 170
6. See Runkel, p. 109 for another diagram of a negative feedback control
loop. Runkel’s chapter “Control Theory” in his book Casting Nets and
Testing Specimens provides a brief, authoritative account of Perceptual
Control Theory.
7. Robertson, op. cit.
8. See Powers’ essay “Possible Levels of Perception and Control” in the
appendix “Reference” of Making Sense of Behavior, pp. 135-152.
9. Robertson, op. cit., p. 171
10. Powers, Making Sense of Behavior, p. 55
11. Neev, pp. 9-13
12. Ford, p. 91
13. Wall, Pain: The Science of Suffering, p. 177
14. Wilfred Barlow, M.D., first discussed “postural homeostasis” in

“Physical Education Research” in More Talk of Alexander, pp. 90-101,
and later in The Alexander Technique, pp.79-82.
Part III – Therapy Solutions

1. Wall, Pain: The Science of Suffering, p. 100
Chapter 8
1. Waddell, pp. 10-11. The general categories of “simple backache,”
“nerve root pain,” and “possible serious spinal pathology” is thoroughly
presented in Waddell’s Chapter 2, “Diagnostic Triage.”
2. Ibid, p. 10
3. Ibid, p. 11
4. The notion of “red flag” situations and the list of questions is derived
from Waddell, pp. 10-12.
5. The Anatomy of Judgement, pp. 138-139
6. Cyriax and Cyriax, Illustrated Manual of Orthopaedic Medicine, p. 23
7. See Mark Laslett, Mechanical Diagnosis and Therapy: The Upper
Limb, Chapter 2, “Diagnosis”, pp. 20-22.
8. Geoffrey D. Maitland “The Maitland Concept: Assessment, Examina-
tion, and Treatment by Passive Movement,” in Twomey and Taylor, p.
137
9. Ibid, p. 138
10. Ibid, p. 138
11. Jacob and McKenzie, in Liebenson, p. 227
12. See Paula Van Wijmen, “The Use of Repeated Movements in The
McKenzie Method of Spinal Examination.” Also see Gary Jacob and
Robin McKenzie, “Spinal Therapeutics Based On Responses To Load-
ing.”
13. Jacob and McKenzie, p. 225
14. Qtd. in Feyerabend, p. 194
Chapter 9
1. Previous circular models of pain reactions (common in the literature)
have not explicitly traced feedback loops to the extent that this one does.
See Paris; Cummings, et al.; and Waddell.
2. Waddell, pp. 225-228
NOTES 279
3. Arthur Koestler, The Act of Creation, qtd. in Danysh, p. 79

4. Wall, Pain:The Science of Suffering, p. 48
5. Ibid, p. 34
6. Ibid, p. 36
7. Ibid, pp. 125-140
8. Consciousness, p. 235
9. Wall, p. 51
10. Ibid, pp. 49-51
11. Ibid, p. 52
12. Liebman, p. 38
13. McKenzie, The Lumbar Spine, pp. 22-24
14. Wall, p.145
15. Ibid
16. See Cummings, Crutchfield and Barnes, Soft Tissue Changes in
Contractures, p. 3.
17. Ibid, pp. 3-5
18. Ibid, pp. 86, 105
19. Ibid, p. 113
20. McKenzie, The Lumbar Spine, pp. 11-12; Chapter 10, “The Dys-
function Syndrome,” pp. 95-108
21. Cummings et al., pp. 72-110
22. The Lumbar Spine, Chapter 11, “The Derangement Syndrome”; The
Cervical and Thoracic Spine, pp. 35-37
23. Cummings et al., pp. 113-114
24. See Kramer, pp. 28-29. Kramer placed asymmetrical pressures on
lumbar disc specimens that had been removed from spines. His book
provides measurements and photographs that demonstrate the movement
of material within the disc. He reported that “Asymmetrical loading causes
the nucleus pulposus [the inner gel portion] to move to an area of the
disk which carries less load; forward bending causes it to move posteri-
orly, backward bending moves it anteriorly and lateral bending moves it
to the opposite side” (p. 28). He concluded that “Postures of the spine
which result in decentralization of the nucleus pulposus due to asym-
metrical loading of the intervertebral segment play an important role in

the pathogenesis and in the prophylaxis of intervertebral disk disease”
(p. 29).
25. McKenzie, The Lumbar Spine, p. 22. Also see The Cervical and
Thoracic Spine, Chapter 7, “The Phenomenon of Pain Centralisation.”
26. Research studies that explore the Centralization Phenomenon include:
Donelson, Silva, and Murphy, “The Centralization Phenomenon: Its
Usefulness in Evaluating and Treating Referred Pain”; Audrey Long,
“The Centralization Phenomenon: Its Usefulness as a Predictor of Out-
come in Conservative Treatment of Chronic Low Back Pain”; and Mark
Werneke et al, “A Descriptive Study of the Centralization Phenomenon:
a Prospective Analysis;” among other studies.
27. See Dr. Stephen Kuslich et al., “The Tissue Origin of Low Back Pain
and Sciatica: a Report of Pain Response to Tissue Stimulation During
Operations on the Lumbar Spine Using Local Anesthesia.” Kuslich, a
spine surgeon, explored the possible sources of back pain with research
done on patients receiving back surgery. The patients got a local anes-
thetic that allowed them to remain conscious. Dr. Kuslich stimulated
many anatomical structures around the site of each operation. Kuslich
and his colleagues found that structures such as the joint capsules on
either side, most ligaments of the spine, as well as the muscles of the
back, seemed surprisingly insensitive. They also found that while the
disc itself did not seem sensitive, the posterior (back) wall of the disc,
especially the outer portion, did. Also especially sensitive was the ad-
joining posterior longitudinal ligament. Both of these structures produced
back pain when stimulated. Stimulating the outer spinal covering (called
the dura) along with the disc wall caused pain in the buttock and thigh.
Kuslich could reproduce leg pain by stimulating the spinal nerve root.
All of these structures receive stress during a disc derangement and will
be affected in the order noted above as a derangement gets bigger. This
could explain the pain pattern commonly seen during peripheralization.
It does not seem implausible that these structures could also get relieved
in the reverse order (centralization) with a derangement capable of get-
ting smaller in size.
Also see Donelson, Aprill, Medcalf, and Grant, “A Prospective Study
of Centralization of Lumbar and Referred Pain: A Predictor of Symp-
tomatic Discs and Annular Competence.” In this study, Dr. Ron Donelson
and colleagues were able to show that those people whose symptoms
centralized with repeated movement testing had problematic but intact
NOTES 281
discs as indicated by discograms. Those who did not respond well to

repeated movements were less likely to have intact discs. Discography
is a technique for visualizing the inside of a disc with x-ray. A radio-
opaque dye gets injected into a disc. The spread of the dye and changes
in its position in relation to movements can indicate the integrity of the
disc. Discography injection can also produce or increase symptoms in
problematic discs.
28. The Cervical and Thoracic Spine, pp. 22-23
29. The Lumbar Spine, Chapter 9, “The Postural Syndrome” and The
Cervical And Thoracic Spine, Chapter 13, “The Cervical Postural Syn-
drome,” Chapter 14, “Treatment of the Cervical Postural Syndrome,”
and the “Treatment” section of Chapter 25, “The Thoracic Spine”
30. See their article “Low Back and Referred Pain: Diagnosis and A
Proposed New System of Classification.”
31. Cummings, et al., pp. 127-145
32. See Sarno, Healing Back Pain.
33. Whatmore and Kohli, pp. 102-103
34. Garrett Hardin, Filters Against Folly, p. 58
35. Ellis, pp. 19-20
36. Ellis, p. 144
37. Arnold Glasow qtd. by Laurence J. Peter in Peter’s Quotations: Ideas
for Our Time, p. 286
Chapter 10
1. The Touch of Healing, p. 21
2. See Kay Thompson, D.D.S., Therapeutic Uses of Language.
3. These include a wide range of educational and/or healing practices,
including acupressure, the Alexander Technique, Body Harmony, Con-
tinuum Movement, cranio-sacral therapy, the Feldenkrais Method,
Ideokinesis, Jin Shin Jyutsu, massage, mindfulness meditation,
myofascial release, Qigong, Rubenfeld Synergy, Rolfing, Sensory Aware-
ness, Shiatsu, Simple Contact, the Trager Approach and Zero Balancing,
among others. Mention here doesn’t necessarily mean unqualified en-
dorsement by me of the particular theory or practice associated with a discipline.
4. Ward, The Brilliant Function of Pain, p. 18
5. Ibid, pp. 30-31
6. Ibid, pp. 31, 32-33

7. Kodish and Kodish, p. 210
8. Ibid, p. 171
9. Ibid, p. 170
10. A version of this kind of figure is used by many healthcare profes-
sionals dealing with musculoskeletal pain.
11. Keyes, p. 141
13. I derived the list of activities from the examination questionaire used
by Robin McKenzie. Clinicians of many different schools of therapy use
similar lists when questioning patients.
14. Keyes, p. 119
16. These general rules of thumb (or back) are derived from the work of
McKenzie and associates.
17. Gary Jacob, D.C., discusses some reasons for overemphasizing flex-
ion in his article, “Specific Application of Movement and Positioning
Technique to the Lumbar Spine, Considering Theoretical Formulation
and Therapeutic Application.”
18. Livingstone, p. 82
19. These exercises come from McKenzie’s text, The Lumbar Spine and
his self-care guide, Treat Your Own Back. You can find an accessible
introduction to McKenzie’s treatment approach in 7 Steps To A Pain-
free Life.
20. The Lumbar Spine, p. 18
21. Reinert’s and Barge’s writings are referenced in the informative ar-
ticle by Barrale et al., “Manipulative Management of Lumbar Disc
Bulge.”
22. Textbook of Orthopaedic Medicine, Vol. I, p. 535
23. McKenzie, “Re: Understanding Centralisation,” p. 6
24. McKenzie and May, The Human Extremities: Mechanical Diagnosis
& Therapy, p. 311
25. You can go to http://www.mckenziemdt.org/ on the World Wide
Web to find a credentialed or diplomaed practitioner of McKenzie’s
NOTES 283
approach to mechanical diagnosis and therapy near you. In the United

States you can call (800) 635-8380 for a referral. There are also prac-
titioners of other approaches to activity-related therapy who may be able
to help you.
26. The traffic light metaphor of green, red and yellow lights was cre-
ated and developed as a guide for treatment by physical therapists Jean
Duffy Rath and Wayne Rath. See Van Wijman, p. 25.
27. Cyriax, The Slipped Disc, p. 76
Part IV – Education Solutions

1. Alexander, Articles and Lectures, p. 198
Chapter 11
1. See Chapter 2, The Problem with ‘Posture’, and related notes 24, 25
and 26.
2. Goldthwait and others, p. 37. See pp. 32-37 for a discussion of general
factors that enter into body mechanics. The book by Goldthwait et al.
has long been out of print. You may be able to find it in a used book
store. The region of motion where a factor-of-safety exists seems equiva-
lent to what spine biomechanics researcher M.M. Punjabi calls the “neu-
tral zone” of spinal motion (“The neutral zone is the initial portion of the
[range of motion] during which spinal motion is produced against mini-
mal internal resistance.” [Julie M. Fritz et al, p. 890]) Punjabi refers to
the end range area of motion as the “elastic zone” (“...the portion nearer
to the end-range of movement that is produced against substantial inter-
nal resistence” [Ibid]). According to Punjabi, normal spinal stability de-
pends upon the ability “to maintain the spinal neutral zones within physi-
ological limits so that there is no neurological deficit, no major defor-
mity, and no incapacitating pain” (Ibid, p. 891).
3. My analysis of exercise closely follows Alexander’s arguments in his
first book Man’s Supreme Inheritance in The Books of F. Matthias Alex-
ander. In particular, see Chapter II, “Primitive Remedies and Their De-
fects” and his discussion of the case of John Doe, pp. 19-23 and 61-63.
4. “Physical therapy, like any other discipline, has its share of dearly
held beliefs. Perhaps none is stronger than the notion that static and dy-
namic postures are directly related to muscular strength. This is not true.”
(Barrett Dorko, “A Big Mistake.”) See Dorko’s article for “references
and commentary from peer-reviewed literature [that] support [his] con-
tention that strength and posture are unrelated.”
5. As an example of this see Flowers’ and Caputo’s brief discussion of

posture and spinal alignment in their book on strength training , pp. 15-
16.
6. In their article, “Spinal Stabilization Exercise Program,” Jerry Hyman,
D.C., and Craig Liebenson, D.C., review this approach to spinal reha-
bilitation and posture-movement education. They state a basic “rule for
training the ‘failed back’: Find the painfree range of motion or func-
tional range” (p. 294). This accords with Goldthwait’s emphasis on the
factor–of–safety motion.
7. See Jill Coleman’s book, Water Yoga (which can be used in and out of
the water). Also see Kenneth Cohen’s, The Way of Qigong. Aat Dekker’s
article, “The Tao of Korzybski?” provides a rare and necessary formula-
tion of Tai Chi and related practices (Qigong) in terms of ‘western’ neu-
rophysiology and scientific humanist philosophy. For another treatment
of Tai Chi that avoids questionable metaphysics, see the work of Will-
iam C. C. Chen, Body Mechanics of Tai Chi Chuan.
8. See “Can An Educational Booklet Change Behavior and Pain In
Chronic Low Back Pain Patients” by B.E. Udermann et al.
9. This notion, seen within the context of Perceptual Control Theory,
qualifies as what Edmund C. Berkeley called a “Thousand Horsepower
Idea.” Korzybski was perhaps the first to explore the notion of mapping
in relation to nervous system functioning, language and behavior in Sci-
ence and Sanity (1933). Somewhat later (1943) related notions were taken
up by Kenneth Craik in his discussion of internal models in the brain in
The Nature of Explanation (see the entry under his name in R. L. Gre-
gory, The Oxford Companion to the Mind). A recent work on cognitive
maps is that of Ervin Laszlo and others, Changing Visions. You can find
an introduction to Korzybski’s practical approach to using these notions
in everyday life in Drive Yourself Sane.
10. Information on PostureSense ® classes is available at
www.posturesense.com
11. For further information on the Alexander Technique and referrals to
certified AT teachers in your area, you can phone the American Society
for the Alexander Technique (AmSAT) at (800) 473-0620 or 413-584-
2359. You can also get information and a list of certified teachers at the
AmSAT website, http://www.alexandertech.com/ You can also write to
AmSAT, P.O. Box 60008, Florence, MA 01062 for further information,
a certified teachers list and a booklist .
12. Pula, p. 64
NOTES 285
13. An old limerick warns of the problems associated with spastic self-
preoccupation:
The centipede was happy quite
Until the toad in fun,
Said,“Pray, which leg goes after which?”
This led his brain to such a pitch,
He lay distracted in a ditch
Considering how to run.
Chapter 12
1. Langer, Mindfulness, p. 1
2. Drive Yourself Sane, pp. 36-48
3. Much of the material in this and the next section comes from Chapter
8 of Drive Yourself Sane, “Non-verbal Awareness,” and from an article
of mine,“Emptying Your Cup: Non-verbal Awareness and General Se-
mantics” published in ETC: A Review of General Semantics.
4. From Wendell Johnson’s book entitled, appropriately enough, Your
Most Enchanted Listener (p. 5)
5. Three excellent books about this discipline are Charles Brooks’ Sen-
sory Awareness:The Rediscovery of Experiencing, Betty Winkler Keane’s
Sensing: Letting Yourself Live, and Carola Speads’ Breathing: The ABC’s.
You can also find more at the Sensory Awareness Foundation website at
http://www.sensoryawareness.org/index.html
6. “Charlotte Schuchardt Read on Sensory Awareness” from videotaped
interview with Louise Boedeker (April, 1999) in Sensory Awareness
Foundation Newsletter, Summer 2000. Available at http://
www.sensoryawareness.org/newsletter/summer00/charlotte.html
7. See “On Conscious Abstracting and a Consciousness of Abstracting”
(Part I) and (Part II) by Milton Dawes. Also see his article, “The Wedge
of Consciousness: A Self-Monitoring Device” located on the Institute of
General Semantics website at http://www.general-semantics.org/ Click
on the Basics button.
8. From newspaper article (now lost) in The Baltimore Sun, dated some-
time in the late 1990s
9. Now neuroscientists consider the notion of maps in the brain a stan-
dard part of their science. See the article “Localization of Brain Func-
tion and Cortical Maps” in R. L. Gregory’s The Oxford Companion to
the Mind. See also Note 8 for Chapter 11.
10. Sacks, The Man Who Mistook His Wife For A Hat, pp. 55-58
11. Reported in Barlow’s The Alexander Technique (pp.17-18). The origi-
nal study was published in 1947 as “An Investigation Into Kinaesthesia”
in British Journal of Physical Medicine 10 (81) and reprinted in Barlow’s
book, More Talk of Alexander, in Chapter 8, “Physical Education Re-
search.”
12. Montagu, Touching, p. 401
13. See Hanna’s book Somatics.
14. Oliver Sacks, in an article on “Nothingness” in the Oxford Compan-
ion to the Mind, writes: “Blockage to the spinal cord or the great limb
plexuses can produce an identical situation [to that of brain injury], even
though the brain is intact but deprived of the information from which it
might form an image…Indeed it can be shown by measuring potentials
in the brain during spinal or regional blocks that there is a dying away of
activity in the corresponding part of the cerebral representation of the
‘body-image’…Similar annihilations may be brought out peripherally,
either through nerve or muscle damage in a limb, or by simply enclosing
the limb in a cast, which by its mixture of immobilization and encase-
ment may temporarily bring neural traffic and impulses to a halt” (pp.
564-565).
15. A Leg To Stand On, p. 98
16. “Dr. Michael Merzenich and his collaborators…have shown
that…brain pathways for registering touch sensations are not hard wired,
but remain fluid in adulthood.” (Montagu, p. 289)
17. A Leg To Stand On, p. 150
18. From the song “Dancing With Myself,” words and music (1980) by
Billy Idol and Tony James, on the album Billy Idol
Chapter 13
1. Alexander referred to this as “unreliable sensory appreciation.”
2. The title of Binkley’s book on the Alexander Technique, wherein he
gives an account of his lessons with F. M. Alexander
3. Lulu Sweigard detailed her work in body mechanics education, which
she called “ideokinesis,” in her book, Human Movement Potential. She
was a student of Mabel Ellsworth Todd, another pioneer in the field of
posture-movement education, whose own book is called The Thinking Body.
4. Call 715-284-5381 to order the Spinatrac™ posture tool for $15.90
with shipping.
NOTES 287
5. You can learn a great deal about chairs, sitting and body use from
Galen Cranz’s book, The Chair. Cranz, an Alexander Technique teacher
and professor of the sociology of architecture, gives not only a fascinat-
ing history of chairs but also provides helpful suggestions for what she
calls “body-conscious design.”
6. See A.C. Mandal, “Balanced Sitting Posture On Forward Sloping Seat.”
7. The Slipped Disc, p. 79
8. “...the first doctor to advocate a lumbar convexity to the chair to sup-
port [the] lumbar spine in lordosis was Taylor of New York in 1864.”
(Cyriax, The Slipped Disc, p. 79)
9. Williams, Hawley, Van Wijman, McKenzie, “A Comparison of the
Effects of Two Sitting Postures on Back and Referred Pain”
10. See Egill Snorrason’s article, “Exercise for Healthy Persons,” pp.
901-903, published in 1965.
11. McKenzie, The Lumbar Spine, pp. 86-87; The Cervical Spine, pp.
161-163
12. The Cervical Spine, pp. 162-163
13. See www.posturesense.com, “About PostureSense®.”
14. Tucker, Active Alerted Posture
15. See Kendall and McCreary, Muscles: Testing and Function. Third
Edition, Chapter 8, “Muscle Function in Relation to Posture,” pp. 269-
316. This chapter provides excellent detailed photos and descriptions of
a variety of static postural faults. McKenzie describes a couple of typi-
cal standing slumps in The Lumbar Spine, pp. 90-91.
16. I have derived the movement experiments for standing balance from
Moshe Feldenkrais, Awareness Through Movement, pp. 77-78.
Feldenkrais studied the Alexander Technique when he was formulating
his own system of posture-movement education.
17. See Kenneth J. Cohen, The Way of Qigong. In this well-written and
scholarly book, Cohen advocates traditional notions of Chinese medi-
cine. This includes the theory of Qi (pronounced chee), an unseen vital
substance containing the ‘essence’ of life. Cohen sees this theory as
complementary with modern science. The phenomena that Cohen writes
about may have potential significance for health. Many of the practices
that Cohen teaches appear to have value. How to talk about and explain
them remains an important question. I am not sure that the theory of Qi
has any more usefulness for modern biology and medicine than the now
abandoned theory of phlogiston has for chemistry (see Conant, On Un-
derstanding Science, pp. 81-101).
18. Cohen, p. 86
19. Cohen, p. 96
20. Alexander’s earliest known writings from 1894 to 1908 concerned
“vocal and respiratory re-education.” See his Articles and Lectures.
21. Essentials of Body Mechanics, p. 56
22. Austin and Ausubel’s research paper can be found in The Alexander
Technique: Published Research, available from the American Society
for the Alexander Technique.
23. See Freedom to Change by Frank Pierce Jones, pp. 21-22.
24. Beckett Howorth, M.D., “Dynamic Posture,” Journal of the Ameri-
can Medical Association, Aug. 24, 1946, p. 1402
25. “In animal studies the term ‘reafference’ has been used to describe
the neural excitation that follows sensory stimulation produced by vol-
untary movements of the animal doing the sensing. The principle of
reafference applies in teaching the Alexander Technique whenever the
pupil is encouraged to move voluntarily while the teacher facilitates some
aspect of the anti-gravity response” (Jones, p.157).
26. www.posturesense.com, “About PostureSense®”
27. Jones, pp. 69-70
28. See The Use of the Self, Chapter I, “The Evolution of a Technique” in
The Books of F.M. Alexander. In the last few pages of this chapter, Alex-
ander describes the steps I’ve noted here as a way of working—thinking
in activity—that you can apply to anything you do. (pp. 427-429)
Chapter 14
1. See the Web page of OSHA, the Occupational Safety & Health Ad-
ministration, http://www.osha-slc.gov/SLTC/ergonomics
2. The Chair, p. 158. Cranz provides recommendations for chairs and
chair use that I generally endorse with this exception—I often advise the
use of lumbar supports. See Chapter 13, herein, on Supported Sitting.
3. See Note 6, Chapter 13.
4. McKenzie, The Lumbar Spine, pp. 91-92
NOTES 289
5. McKenzie, The Cervical Spine, pp. 167-168

6. For sitting, Mandal recommends a desk height measuring one half of
your standing height and a chair height reaching one third of it (“Bal-
anced sitting posture on forward sloping seat”). He also recommends
sloping desk surfaces that tilt the work up towards the user.
7. See article “Spinal Overload” published in The Back Letter.
8. See Pheasant and Stubbs’s, “Back Pain in Nurses: Epidemiology and
Risk Assessment.” For a general treatment of occupational injuries, see
Work-Related Musculoskeletal Disorders.
9. Wassell et al., “A Prospective Study of Back Belts for Prevention of
Back Pain and Injury.”
Chapter 15
1. In his 1975 book, The Gravity Guiding System, Robert Mannat Mar-
tin, M.D., wrote, “[Man] is compelled to live in a potentially backache-
producing environment of relentless, unidirectional gravity. However,
through his ability to employ postural variety, he can live successfully
and comfortably in such an environment. Planned and properly guided
postural exchange is the prime tool for prevention and correction of com-
mon backache and many, many other physical problems” (p. 7). Martin
advocated the varied use of six basic postures: the erect, horizontal, flexed,
extended, brachiated (hanging by arms) and inverted (upside-down) po-
sitions.
2. Cranz, p. 185
3. I’ve based this principle on the work of many individuals. John M.
Barbis, a professor of physical therapy at Thomas Jefferson University,
expressed the underlying viewpoint well in his article “Prevention and
Management of Low Back Pain.” Here he emphasized the importance of
“balancing flexion and extension” and “the prevention of prolonged load-
ing or repetitive motions in one direction.” (pp. 66-67)
4. McKenzie, The Cervical and Thoracic Spine, pp. 116-119
5. Stoddard, pp. 69, 73
6. My recommendations on when to consult your physician are based on
American College of Sports Medicine guidelines (Bazley, p. 45).
7. Bazely points out that “The prescription of ‘3 to 4 times per week, 30
to 40 minutes per session’ has become known as ‘the fitness formula’
and is the frequency and duration of exercise needed to stimulate an
aerobic effect and help prevent disease. It will take approximately 11 to

12 weeks to reach the desired aerobic level, and exercise must be main-
tained over a lifetime in order to continue to maintain the aerobic and
protective benefit” (p. 45). Recent research indicates that this fitness
formula is not as fixed as perhaps once thought. Shorter periods of time
(10 minutes or less) that add up to the 30 or 40 minute total may provide
substantial benefits. “Walking bouts of only five minutes—when added
up to 30 minutes per day on most days of the week—can improve car-
diovascular health and body composition, according to a study published
last year [1999] in Preventive Medicine. Stair climbing, done for 2 1/4
minutes, six times a day, conferred ‘considerable health benefits on pre-
viously sendentary young women,’ this same journal reported in April
[2000].” (Krucoff)
8. “Got No Time For Serious Fitness Training? The Long and Short of It;
Exercise: Researchers now say that little ‘sparks’ of activity throughout
the day can offer health benefits.” Los Angeles Times, 12/04/00, pp. S1,
S8
9. See the website of Grand Master William C.C. Chen for a listing of
teachers certified by him: http://www.williamccchen.com/
Also see the T’ai Chi Chih homepage for information about this simpli-
fied Tai Chi exercise form which I have found useful and easy to learn:
http://www.taichichih.org/index.htm Also see the book by Master Justin
Stone. You might also find useful the related practice of Zhan Zhuang
(pronounced “Jan Jong”). Zhan Zhuang, a standing meditation/exercise,
translates from Chinese as “standing like a tree.” See Master Lam Kam
Chuen’s book The Way of Energy and his website http://www.chi-
kung.org/chikung-e/index.htm
10. Fitness Without Stress, p. 11
11. “The art of combining relaxation with activity has been invented and
reinvented by the teachers of every kind of psycho-physical skill” (Aldous
Huxley, “The Education of an Amphibian,” in Tomorrow and Tomorrow
and Tomorrow, p. 18).
12. Dart, Skill and Poise, p. 8
13. See Trager and Guadagno.
14. “Rest means rest from function or weight bearing, not from move-
ment. Movement must be maintained” (Mennel, p. 126).
15. Discussed in the book EEVeTeCh by Dr. Rob Roy McGregor. The
letters EEVeTeCh stand for five basic factors that McGregor suggests
NOTES 291
need to be addressed in order to reduce and prevent sports injuries: E –

Equipment, E – Environment, Ve –Velocity, Te – Technique, and C –
Conditioning.
16. “Of all the practices known to be associated with good health, sleep
is the most fundamental. The most basic step you can take to improve
your health is to figure out how much sleep you need and to see that you
get it” (Hobson, The Chemistry of Conscious States, p. 226).
17. In an interview with Selye in Denis Brian’s Genius Talk: Conversa-
tions with Nobel Scientists and Other Luminaries (p. 271)
Conclusion
1. Murrow’s Law in Peter, Peter’s People, p. 204
Chapter 16
1. Waddell, pp. 45-46
2. Waddell, p. 83
3. “How Quackery Sells,” p. 14
4. Long, “The Centralization Phenomenon: Its Usefulness as a Predictor
of Outcome in Conservative Treatment of Chronic Low Back Pain (a
Pilot Study)”
5. Fisher, “Early Experiences of a Multidisciplinary Pain Management
Programme”
6. Snook et al., “The Reduction of Chronic Nonspecific Low Back Pain
Through the Control of Early Morning Lumbar Flexion: A Randomized
Controlled Trial”
7. Manipulative treatment cannot cure disease. As a form of mechanical
therapy, it seems especially useful when self-treatment measures have
proven insufficient. Then, in the cases that require it, manipulation—
passive movements to the joints applied by the therapist—can result in
improved symptoms and increased mobility and allow a person to suc-
cessfully proceed with self-treatment. Manipulation can be unsafe and
promote dependency when not preceeded by repeated movement testing
and preliminary self-treatment.
Unfortunately, some chiropractors have fabricated the view that their
profession has some special claim to doing manipulation. They are pres-
ently lobbying many state legislatures to prevent physical therapists from
performing manipulation. In actuality, while manipulation has been used
for centuries, the system of chiropractic was founded relatively recently,
in the 1890s, on the basis of what many medical professionals—and

even some chiropractors—now consider exaggerated claims and ques-
tionable evidence.
Manipulative treatment has often, although certainly not always, been
abused by a significant number of chiropractors. Stephen Barrett, M.D.,
discusses and documents questionable chiropractic practices in his ar-
ticle, “The Spine Salesmen.” Also see the article, “Chiropractic: Does
the Bad Outweigh the Good?” by Samuel Homola, D.C. and the books,
Inside Chiropractic by Homola and Chiropractic: The Victim’s Perspec-
tive by George Magner.
Many chiropractors continue to base their work upon scientifically-im-
plausible theories and practices. Fortunately, some chiropractors ques-
tion and seek to move beyond them. Some chiropractors practice some
form of posture-movement therapy and/or education, as discussed in this
book. Some belong to the National Association for Chiropractic Medi-
cine, an organization which has renounced “the historical chiropractic
philosophy that subluxation [a vague and medically unaccepted diagno-
sis, as many chiropractors use it] is the cause of disease” (Barrett, p.
167). Responsible chiropractors acknowledge the paucity of scientific
research on the usefulness of manipulative treatment and are working
with their colleagues in other fields to correct this situation.
8. Esteemed spine researcher Alf Nachemson, M.D., writes “The direc-
tion from today’s available studies is fairly clear: examine, encourage,
exercise, pay attention to psychosocial deterrents to function, and in-
volve the workplace in the rehabilitation of those with work
disability...Work can actually be remedial...Politicians, union leaders, and
patients must all understand this life-saving message. An early disability
pension endangers your life.” (A. Nachemson. 2000. Preface. In Neck
and Back Pain: The Scientific Evidence of Causes, Diagnosis and Treat-
ment. Edited by A. Nachemson and E. Jonsson, xi. Philadelphia: Will-
iams & Wilkins. Qtd. in “Life-Saving Prescription,” The Back Letter)
9. Huxley, p. 31
10. Arsenault, pp. 231-232
11. Arsenault, p. 234. You can contact The Moving to Learn Society at
4246 Peachtree Rd. #6, Atlanta, GA 30319
12. Growing Young, p. 2. Montagu once said “The idea is to die young as
late as possible.” William T. Powers had something similar in view when
he said “I have finally figured out what I want to be when I grow up:
dead.” (Making Sense of Behavior, p. ii)
NOTES 293
13. In regard to the unity and inseparability of ‘mind’ and ‘body’, Montagu
wrote “...mind and brain are definitely not synonyms...the development
of the human mind depends on contact with other human beings in a
human society...Mind represents the expression of the social organiza-
tion of the nervous elements of the whole body...Regard every part of
your nervous system in its total relations as comprising your mind...no
amount of manipulation would cause your little finger to perform the
tricks necessary in the playing of the piano, for example, if some sort of
nervous organization had not occurred within it. The nerve structures in
your little finger are as necessary as those in your brain. For the purpose
of piano playing they are both indispensable parts of your mind. The
pianist’s fingers are culturally quite as highly organized as his brain must
be in order to read the music which his fingers help to produce. He has
the score, literally, ‘at his finger tips.’ ” (On Being Intelligent, p. 4-9)
14. “...every bit of relevant evidence indicates that infirmities and break-
downs are much less likely to occur in those who have retained a youth-
ful spirit than in those who have succumbed to the self-fulfilling proph-
ecy of aging, and have aged in accordance with what is ritually expected
of them...limberness diminishes with reduced movement...ideas, feel-
ings, playfulness also diminish with reduced expression. The diminished
become quiet, withdrawn, unexpressive...it is not the years that diminish
us. It is the way we have learned to live them, giving up a little of our
true selves at each step.” (Montagu, Growing Young, pp. 199-203)
15. See the works of Alexander, Brooks, Edwards, Feldenkrais, Hanna
Montagu and Sharaf.
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Uderman, B.E., et al. 2000. Can an educational booklet change behavior and pain
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Van Wijman, Paula M. 1994. The use of repeated movements in the McKenzie
method of spinal examination. Reprinted 1995 in The McKenzie Institute,USA
Newsletter 3 (2). Originally published in Modern manual therapy of the vertebral
column, Second Edition, ed. Boyling & Palastanga, Chapter 42.
Von Durkheim, Karlfried Graf. 1962, 1977. Hara: The vital centre of man. Translated by
Sylvia-Monica von Kospoth in collaboration with Estelle R. Healey. London: Unwin.
Waddell, Gordon. 1998. The back pain revolution. Edinburgh: Churchill Livingstone.
Waddington, C. H. 1977. Tools for thought: How to understand and apply the latest scien-
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Wall, Patrick. 2000. Pain: The science of suffering. New York: Columbia University Press.
Ward, Milton. 1977. The brilliant function of pain: A yogic understanding of pain.
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Werneke, Mark, D. Hart and D. Cook. 1999. A descriptive study of the centraliza-
tion phenomenon: A prospective analysis. Spine 24: 676-683.
Whatmore, George B. and Daniel R. Kohli. 1968. Dysponesis: A neurophysiologi-
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Whitehead, Alfred North. 1925, 1948. Science and the modern world: Lowell
lectures, 1925. New York: Pelican Mentor.
Wassell, James T, Lytt I. Gardner, Douglas P. Landsittel, Janet J. Johnston, Janet
M. Johnston. 2000. A prospective study of back belts for prevention of back pain
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Westfeldt, Lulie. 1964, 1986. F. Matthias Alexander: The man and his work. Long
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Whyte, Lancelot Law. 1950. The next development in man. New York: Mentor Books.
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INDEX
A Leg to Stand On 203 Austin, John H.M. 225
ABCs of emotions 141 Ausubel, Pearl 225
Abercrombie, M. L. J. 108 Autonomy 94
Absolutism 141, 150, 206. See also Awareness 52, 77, 183. See also
Self-talk Sensory Awareness
Abstracting process of brain/nervous body 148, 149, 182, 183, 188,
system 189 See also Maps 244–245
Acceptance 96, 97, 194 dimensions of 198
Ackerknecht, Erwin H. 34 intentional 195
Actions 89 of pain 149, 150
Activity-related 11, 13, 15. See also use of imagery 222
Mechanical; Posture-Movement wedge of 195–198
pain 22, 25, 98–99, 104, 108, 113, Awfulizing 79, 150
114, 155
Back. See Lumbar; Spine: lumbar
Actors 225
Back belts 242
Adaptive shortening 128
Back pain 73
Adhesions 128
activity-related 104, 113. See
Adults 180, 244
Activity-related: pain
Aerobics 183, 249
anatomical sources 280-281
Aging 73–74, 106, 268
chronic 26, 80, 138, 145, 263
Alexander, F. Matthias 45-49, 52,
controlling 98, 140
100, 137, 184, 198, 199, 224
costs 25
contribution of 52-3
history of 260
Alexander Technique 14, 137, 182,
natural history 106
184–185, 186, 187, 199, 202,
‘non-specific’ 111, 118
207, 221, 225, 228, 232-233,
nurses and 242
251, 252, 263, 288
passive treatments 260
directions 48, 51, 199, 222–223
posture and 264
teaching children 267–268
posture-movement model
Altered mobility 122, 125
119, 120, 121, 139
An Essay on the Prevention and
prevalence 68, 275
Rational Treatment of Lateral
prevention, future directions in 266
Spinal Curvature 49
psycho-social factors 135
Anatomy tour 64, 202
recurrent 26, 173
Anecdotal evidence. See Evidence
referred 80
'Anti-gravity’ system 77. See also
responsibility for treatment 266
Muscles: extensors
rise in disability 260
Anxiety 97, 135, 140, 141
self-limitation 25, 26
Arsenault, Michelle 267, 268
vibration and 242
Astaire, Fred 253
Ball, Lucille 234
Athleticism of everyday life 252. See
Barbis, John M. 289
also Skill
Barge, Fred 160
Attention 97, 99, 149, 150, 185–186
Barlow, Wilfred 185, 201
Attitudes, Beliefs, Expectations 58,
Barnes, Marylou R. 128
79, 85, 86, 95, 96, 122, 124,
Barrett, Stephen 261
140, 141, 150, 190
INDEX 309
Bazely, Robert D. 289 Centralization 36, 132, 156, 280-281

Bedrest 23, 24, 34 The Chair 245, 288
Beds 238 Chairs 54, 211, 236–237
Behavior: The Control of Perception Change 183, 194, 235, 269
93 positive 138, 144, 194
Bending 101, 178, 216, 229, 230, 248 resistence to 99, 183–184
Bent finger example 133 Chelsea, Massachusetts School
Bifurcation of nature 43 Survey 267
Binkley, Goddard 206 Chemical pain 127
Biofeedback 137 Chemistry of pain 82
Biopsychosocial 119, 136, 138 Chen, William C. C. 62
Body Harmony 15, 202 Childlike potential 269, 292, 293
“Body mapping” 201. See also Children 99, 179–180, 244
Maps; Brain: maps body mechanics education 268
Body mechanics 30, 137 See also learning from 269
Posture preventing back pain in 267–268
essentials of 176 Chin-tuck exercise 41, 246–247, 248
good vs. poor 178-179 Chiropractors 21, 23, 25, 34, 176,
‘Body’-‘mind’ 42–43, 44, 134, 269, 291-292
293 Choice 88, 206, 236
“Body work” 148 Chronic pain 26, 80, 134, 138, 145,
Bones 59 263
Bouchard, Ed 45 Churchill, Winston 255
Bowel/ bladder problems 107 Clothing 235–236
Brain 189, 293 Coaching 140
evoked-potential studies 203 Cognitive-Kinesthetic education 14
maps 284, 285, 286 Cohen, Kenneth S. 221, 287
pathways 286 Cold packs. See Passive therapy
Breathing 146, 224 Conable, Barbara 201
'exercises' 147, 226 Conable, Bill 201
posture and 225 Conditions 97
Burmeister, Alice 147 constant 88
varying 90
Cancer pain 79 Congenital analgesia 125
Car seats 241 Connective tissue 59
Cardio-pulmonary (Cardiovascular) Consciousness 43, 124, 189
183, 249 Consequences
Cartilage 59 emotional 141
Catastrophizing 79, 150 Constructive rest 207–210, 253
Causation Continuum
circular 85, 92, 133, 182 of consciousness 189
consciousness and 124 of exercise/manipulation 116–117
establishing 262 of pain 151
Center 222 of therapy and education 15
locating 222, 226 Contractures. See Soft tissue changes
Control 88 asymmetrical pressures on 72, 74,

constructive conscious 186, 200 77, 130, 160, 279-280
hierarchy of 94–95 bulging 22
negative feedback 90, 91, 92 degeneration 73, 130
reorganization 95–96 derangement 130-132, 280-281
systems 94 function 72
Control theory. See Perceptual herniated 22, 23, 35, 131
Control Theory intervertebral 71
Corrective movement 246 intradiscal displacement 74, 130
Counseling 140 movements within 72–73
Cranz, Galen 245, 287, 288 structure 71, 130
Crutchfield, Carolyn A. 128 annulus 71
Cummings, Gordon S. 128, 129 nucleus 71
Cybernetic psychology 90 Discography 281
Cyriax, James 34, 38, 109, 110, 111, Distraction 87
130, 132, 160, 172, 173, 212 Disturbances 89, 93
Donelson, Ronald 281
"Dan tian". See Center Dorko, Barrett 271, 283
“Dancing With Myself ” 204 “Double spiral”. See Muscles:
Dart, Raymond 76, 253 diagonal arrangements
Dating See Indexing: “when” Drive Yourself Sane 150
Dawes, Milton 195 Dysfunction syndrome 129
Deciding 94 Dysponesis. See Effort: faulty;
Deformity 106, 129, 130 Faulty effort
Dennis, Ronald J. 14, 53, 54, 77, 216,
230, 275 Effort
Depression 138, 140 bracing 137
Derangement syndrome 129, 130, faulty 136-137
131, 160, 280 undue 137
Design Electrical stimulation. See Passive
"body-conscious" 245, 266, 287 therapy
Dewey, John 53, 186, 200 Ellis, Albert 140, 141, 142
Deyo, Richard 11 Emotions 97, 138, 141
Diagnosis 104–105, 117, 151 Endorphins 83
definition 108 Ends and means 100
difficulties of 22, 23, 108–109 English Minus Absolutism 8
labels 111, 112 Environment 93, 120, 124
musculoskeletal 109 designing your 234, 245
specific tissue 110–111 worker-friendly 267, 292
word origin 108 Epictetus 140
Directional preference 165 Ergonomics 234, 267
Directions 50, 51, 198–200 Essentials of Body Mechanics 176
negative 51 Ethics 52-53
positive 51 Ethics (Spinoza’s) 51
Disc 71 Evaluation 58, 85, 119
INDEX 311
EEVeTeCh 290 Feedback 61, 119, 148, 190

Evidence 262 negative 90, 91, 92
anecdotal 16, 262 Feldenkrais Method 15
clinical 111-112 Feldenkrais, Moshe 200
Evidence-based practice 27-28 Fenton, Jack 267
Examination 104-105 See also Fitness 248–252, 289-290
Positions/Movements: testing Fitness Without Stress 252
Exercise 26–27, 33. See also Flexion 65
Swedish Gymnastics avoidance in early morning 264–
aerobic 183 265
breathing. See Breathing: exercise 36, 265
'exercises' flexion in lying 170
cardio-pulmonary 183, 249 green, red, yellow lights 171
chin-tuck 41, 246–247, 248 progression from 172
Chinese 33, 44, 47, 221. See also frequency of 160
Tai Chi; Qigong tyranny of 157
extension 37. See also Extension Folding 100–101, 178, 216
flexion 36, 265 in sitting 216–217
Greek and Roman 33, 44 in standing 230–232
Hindu 33, 44, 47. See also Yoga Ford, Edward E. 97
Japanese 47 Fright, fight, flight. See Nervous
slouch-overcorrect 213–214 system: autonomic: sympathetic
to improve posture 52, 181, 182, Fritz, Julie M. 283
283 Future directions 266
weight training 183
Western approaches 33, 44-45, 47 Garlick, David 185
The Expanding Self 206 Gate theory 81
Experience 83, 84–85 General feedback theory of human
non-verbal 122, 189, 190, 191 behavior 90
Exposure and repetition 185 General Semantics 43, 150, 191, 195
Extension 48, 65, 160 Gindler, Elsa 192, 194
exercise 37 Glasses 236
extension in standing 168, 246 Goals 92, 100, 142, 144, 201
problem solving 166 Goldthwait, Joel E. 176, 177, 178,
progression from 170 225, 283
prone lying 161 “The Gospel of Relaxation” 46
prone on elbows 162 Gradualness 249–250
prone press-up 163, 164 Growing Young 269
Extensional. See Orientation: by fact; Guarding
Scientific attitude 75, 125, 126, 127, 135, 137, 145–
146, 202
Facet joint problems 134 Guidelines
Factor-of-safety motion 177, 178, for better use 187, 257, 261
225, 283, 284 to improve your personal environ-
Fatigue 252–253 ment 235, 241, 245
Faulty effort 136-137 to reduce back pain 143, 146, 261
Habits 39, 41, 46, 49, 54, 66, 87, 90, Inflammatory disease 107, 120
133, 140, 176, 189, 200 Inhibition 50, 198-200
Handbook of the Movement Cure 45 by repression or negation 51
Hanna, Thomas 202 by substitution 51
Happiness 142 Injury 107
“Hara”. See Center initial 120, 122
Head-neck-back relations 47 Input 93, 94
Heat packs. See Passive therapy
“Hen” exercise 247, 248. See also Jacob, Gary 35
Chin-tuck exercise James, William 46, 51, 52
Hippocrates 33, 34, 38 Jarvis, William 261
Hobson, J. Allan 124, 291 Johnson, Wendell 191
Home furnishings 239–241 Joint capsule 59–60
arrangement 240 Joint displacements 128, 130, 132
Homeostasis 90, 96 See also Disc: intradiscal
postural 99 displacement
Howorth, Beckett 228 Joints 59, 177
How To Stubbornly Refuse To Make end range 115, 177
Yourself Miserable About factor-of-safety motion 177, 178
Anything Yes Anything! 141 hip 67
Human skeleton 63. See Spine range of motion 177
breast bone (sternum) 65 sacroiliac 65
pelvis 65, 66 synovial 59, 70
ilium 65 Jones, Frank Pierce 185
sit bones (ischial tuberosities) 67 Jordan, Michael 253
ribs 65
thighbone (femur) 67 Kaltenborn, Freddy 34
Huxley, Aldous 52, 253, 267, 290 Kelly, George A. 271
Hyman, Jerry 284 Keyes, Kenneth 153
Hypnosis 79 Kinesthetic Ventures 45
Kohli, Daniel R. 136
“I Love Lucy” 234 Korzybski, Alfred 43, 44, 189, 191,
Ideokinesis 15 284
Idol, Billy 204
Illness behavior 134. See also Pain: Labels 111, 112
psychogenic Langer, Ellen 188
Indexing 150 Language 43, 85, 141, 150, 190
chain (“where”) 153 Laslett, Mark 109, 113, 133
definition 150 Laughter 142
pain intensity 151 Learning 95, 96, 97, 228–229, 269
symptom location 151 constraints to 183, 184
“when” (dating) 153 requirements for 185
Individuality 28, 38, 116, 150, 151, spiral process 229
159, 240 Lengthening 77–78
Inflammation 120, 123, 157 Liebenson, Craig 284
Lifting 178, 242
INDEX 313
Ligaments 59 Merzenich, Michael 286

anterior longitudinal 70 Method of possibilities 16, 17, 28, 32
posterior longitudinal 70 Mindfulness 185, 188
Ling, Pehr 44–45 Mindlessness 188
Lumbar “Monkey" position. See Folding: in
lordosis 66, 212 standing
supports 212, 237, 238–239, 241 Montagu, Ashley 202, 269, 292, 293
vertebrae (bones) 68 Monty Python 268
Morphine 82
Macdonald, Patrick 45, 49 Movement
Maitland, Geoffrey 34, 112 chain 62, 76, 76–77, 178
Manipulative techniques 25, 33, 34, corrective 246
111, 291-292 sensation 148, 202–204
The Man Who Mistook His Wife for a Moving To Learn 268
Hat 201 Moving To Learn Society 268
Maps 3, 111, 118, 189 MRI (Magnetic Resonance Imagery)
cognitive 184, 201, 205, 284, 285 20, 22
Martial arts 221, 222 Muscles 59
Martin, Robert Mannat 289 breathing 225
Massage 33, 202 diagonal arrangements 76
Mathews, Ann 267 extensors (anti-gravity) 76
McGregor, Rob Roy 290 flexors 76
McKenzie Method 263. See resting length 76
Mechanical: diagnosis and 'spasms' 74–75
therapy strains 75
McKenzie, Robin 12, 13, 35, 36, 38, tension 135
113, 114, 116, 117, 118, 128, Musgrave, Story 196
129, 131, 132, 133, 137, 146, Musicians 225
159, 160, 173, 213, 215 Myelogram 35
Mechanical. See also Activity-related
diagnosis and therapy 13, 113, 116, Nachemson, Alf 292
117 Naps 255–256
forces 114 Neck 64
instability 134 chin tuck exercise 246-247, 248
pain 11, 108, 113, 114 constructive rest for 207-210
Mechanisms 43 neutral erect position 48
Medical doctors 21, 23, 34, 104-105, pain 39-41
117, 144–145, 249, 251, 256 prevalence of 68, 275
pain management 138, 145 postural guidelines 187
Medication 25, 145, 256 protruded head position 40
Medicine 28, 42 role in posture 47-48
Melzack, Ronald 81, 83 sitting positions 213-215, 216
Mennell, John 254, 290 sleeping positions 238, 239
Mensh 3, 270 supports 239
'Mental' factors 42 vision and 236
Neev, Elan Z. 96 cancer 79

Nerve root pain 104 centralization 36, 132, 156, 280-
Nerves 281
afferent 61 chemistry of 82–83
autonomic 70 chronic 80, 138, 145, 263
efferent 61 control of 88, 90, 97, 98
peripheral 60 definition 81
spinal 60, 70 function of 79–81
cauda equina 70 gate theory of 81
Nervous system. See also Brain management 138, 145
autonomic 70, 126 meanings of 155-157
parasympathetic 126 medication 108, 145
sympathetic 126, 137 nervous system processing of
central 60 84, 124
chemistry of 82 psychogenic 80, 135, 136
functions 44, 124 referred 80
peripheral 60 reflex withdrawal 122–123, 125
processing of pain 84, 138 scale 40, 151
Neuro-Musculo-Skeletal (NMS) Palliative treatment 36
system 59, 76 Paris, Stanley 34
Neuropeptides 82 Passive therapy 23, 24
Non-verbal. See Experience: non- Perceptions 49, 84, 89, 184
verbal control of 93
Non-verbal humanities 267 hierarchy of 94–95
Nurses 242 of pain 83, 98
self-sensing 99
‘Objective’ 43-44 Perceptual Control Theory 58, 99,
Observing 97, 111, 155, 185, 228, 262 182, 200
Obvious 53, 201 Peripheralization 131, 156, 280
Older people 268 Personal scientist 15, 28, 38, 84, 97,
Onion called a rose 191 262, 271. See also Evidence;
Organism-as-a-whole-in-an-environment Scientific attitude; Research
44, 62, 88, 125, 138, 192 Phantom limbs 80
Orientation 191 Physical therapy 21, 29, 33, 34, 42,
by definition 191 51, 112, 157, 176, 251
by fact 151, 191 Pierce, Frank Jones 185
Orthopedic surgeons 23, 29, 176 Pillows 238, 239
Osteopaths 34 Pinch experiment 190
Osteophytes 73 Placebos 79, 124
Podiatrists 236
Pain 81 Poise 77, 185, 217
and posture 264 Positions/Movements
as warning 79, 80–81, 133, 177 asymmetrical 235
awareness 150 passive 113, 116, 116–117. See
behavior 34 also Manipulative techniques
INDEX 315
repeated 113 model 119, 120, 121, 143, 261, 278

self-generated 113, 116 therapy 12, 13, 33-38, 116, 117–
sustained 113 118, 131, 263
testing 114, 115, 131 PostureSense® 184, 186, 216, 228
Possibilities 17, 32, 245, 269. See Powers, William T. 89, 90, 93, 96, 292
also Method of possibilities Preferences
Postural liberating 141
change 183 Prevention 31, 263–265
exercises 52, 181, 182, 283 future directions 266
set point (homeostasis) 99 "Primary control" 47
'thermostat' 183 Principles of Psychology 46
Postural monotony 77, 180, 244 Protruded-head position 40
relieving 246 Psychogenic See Pain: psychogenic
Postural syndrome 133, 137 Psychosocial factors 119-120, 267, 292
Postural variety 77, 179–180, 244, 289 Psychosomatic 148
and fitness 248–252, 289-290 Psychotherapy 140
and rest 252–256 Pula, Robert 265
design for 245 Punjabi, M. M. 283
principle 246, 289
Posture. See Body mechanics; Use Qi 287-288
and breathing 225 Qigong 44, 52, 183, 221, 251
and pain 264 Quackery 262
'bad' 265
control 90, 99–101 Rational Emotive Behavior Therapy
definition 30 (REBT) 140
dynamic 31, 77, 227–228 Read, Allen Walker 8
evolutionary adaptation 66 Read, Charlotte Schuchardt 192, 194
good 30, 41 Recurrent pain 26, 173
'good' 265 "Red flags" 105, 144
habits 41 Referred pain 80
importance of 29, 176 Reinert, Otto 160
instruction 29, 183, 184 Relative rest 254, 290
sitting. See Sitting Relaxation in activity 253, 290
standing. See Standing Repeated movements
static 30, 205, 227 testing 113
Posture-movement 13, 31, 108, 244 Research 16, 17
continuum of therapy and personal 262
education 15 statistical 28, 261
education 14, 39, 185, 263 Resistence to change 99
general patterns 122, 130, 132. Responsibility 266
See also Guarding Rest 252, 252–256
habits. See also Habits Results 89, 100, 144, 160
improving 197. See also Rickover, Robert 252
Learning: spiral process Robertson, Richard J. 90, 93
methods 98-99 Rogers, Ginger 253
Rolfing 15, 202 Skill 97, 253, 275

Rose with onion for its name 191 Sleep 291
Rossi, Ernest 255 positions 238–239
Roth, Mathias 45, 49, 52 problems 145, 256
Rubinstein, Artur 253 Slouching 206, 211, 216, 225
Runkel, Philip J. 17 “Slouch overcorrect” maneuver 213
Slumping. See Slouching
Sacks, Oliver 201, 203, 204, 286 Snook, Stover 264
Sacro-iliac problems 134 Soft tissue changes
Sarno, John 135 local 122, 126–127
Scar tissue 128 Specificity of training 181, 181–182
Sciatica 24, 26, 104 Spicer, Scanes 47
Scientific attitude 15, 29, 113. Spinal
Seating 236–238, 289 canal 69
car 241 cord 69–70
Sedentary life-style 180, 249 curves 66, 179, 206
Self-care 15, 31, 32, 35, 38, 113, 116, 173 deformity 106, 129, 130
Self-preoccupation 186, 285 elastic and neutral zones 283
Self-reflexiveness 195 lengthening 76–77
Self-sensing 99 rehabilitation 145, 157, 182, 292
Self-talk 85, 141, 150, 190, 191 stability 283
Selver, Charlotte 192 stabilization 182, 250, 284
Selye, Hans 257 stenosis 134, 158
Sensations 49 Spinatrac™ posture tool 209
fallibility of 49, 184, 205 Spine 64
immediate impact 84, 120, 122–123 cervical 64
of movement 148–149, 202–204 atlas 64
Sensory Awareness 44, 52, 192 axis 64
experiments 193, 197–198 coccyx (tailbone) 65
“Sensory-motor amnesia” 149, 202 lumbar 65, 66. See also Lumbar
Shaw, George Bernard 53, 153 motion segments of 68
Sherrington, C. S. 53 sacrum 65
Shiatsu 202 Spinoza 51
Shoes 236 Spondylolisthesis 158
Short History of Medicine 34 Sports 251–252, 267
‘Should’ 141, 206 Squatting. See Folding: in standing
Silent, unspeakable level 191. See Standards 77, 92, 185, 200, 206
Experience: non-verbal Standing 53, 217–218
Simple backache 104 basic balanced 219, 220, 221
Simple Contact 15, 271 feet position 220
Singers 44, 47, 225, 274 slumped 218
Sitting 210, 217 weight-shifting experiments
balanced, neutral 215 centering 223, 224
supported 212 front-to-back 218–219
unsupported 213 side-to-side 220
INDEX 317
Stature Vicious circle of disuse and pain

full 205–206, 227 121, 127, 148
Stevens, Chris 185 Vision 236
Stimulus-response 88 Visualization. See Awareness: use of
Stoic philosophy 140 imagery
Stress 257 Vital circle of pain control and
'Subjective' 42, 124 recovery 138, 139
Surgery 24, 131 Von Dürkheim, Karlfried Graf 222
Swedish Gymnastics 44–45
Sweigard, Lulu 207 Waddell, Gordon 11, 34, 104, 119
Symptoms 39, 131, 132, 150, 155 Waddington, C. H. 43
meanings of 155–156 Walking 249, 250
Systems Wall, Patrick D. 81, 83, 97–98, 123,
change 88, 138 125, 126, 127
theory psychology 90 Ward, Milton 149
Watchful waiting 25
Tai Chi 62, 183, 221, 250–251 The Way of Qigong 221
Teaching 97, 184, 206 Wedge of awareness. See Awareness,
skill 185 wedge of; Consciousness
Tendons 59 Weight training 183
Thermostat 90, 91 Whatmore, George B. 136
"Thinking in activity" 186, 200, 233 Whispered Ah 226, 227
Thompson, Kay 147 Whitehead, Alfred North 43, 53
Time factor 155 Wholistic Healing 96
Torso 67–68 Will 52, 176, 185
The Touch of Healing 147 Woods, Tiger 253
Trager Approach 15, 253 Work
Trager, Milton 253 environment 241
Trial and error 96, 99 hazards 242
re-design 242
Ultradian rhythms 255 sedentary 241
Ultrasound. See Passive therapy surfaces 240
“Un-exercise” 54, 55 Worker-friendly environments 267
Use 30, 46, 100, 176, 185 Wright, Ben 45
See also Body mechanics; Wyke, Barry 87
Posture: dynamic; Posture-
Movement: general patterns X-rays 22, 107, 109
The Use of the Self 45, 50
Yoga 183, 251
van Wijman, Paula 133 Young people 106
Variable 92
Variety Zen 221
of experience 257 Ziman, John 118
Verbal level 85

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BACK PAIN

Bruce I. Kodish, Ph.D., P.T.

I wish to thank all those who read one or more versions

Welcome to Back Pain Solutions! If you are currently ex-

Is It Possible To Feel Better?

You wake up one morning feeling stiff in your back. “What

Back pain can have multiple causes. Some of the appar-

Posture-Movement Therapy and Education

Activity-related (mechanical) back pain varies with activ-

therapy should have the ability to diagnose or screen for non-

Harmony, the Feldenkrais method, Ideokinesis, Rolfing, Sen-

• Clarify your problem. This can include uncovering your

The Method of Possibilities

Social science researcher Philip J. Runkel has proposed a

Back Pain Problems

“She killed herself,” a friend of mine told me of a co-

She did not return to his office.

Back Pain Problems

The Diagnostic Daze

For physicians and other health-professionals, who want

Questioning Traditional Treatments

For years, a few lonely voices challenged this emphasis

Karen’s experiences with chiropractic treatment represents

When Time Doesn’t Heal All Wounds

As Karen learned, she was indeed likely to improve some-

Activity and Exercise

discussed earlier. Rest is out. Activity is in. Most practitio-

some advocates of this approach emphasize the usefulness

lows such a scientific approach can help you in applying it to

The Problem with ‘Posture’

Posture is defined as the relative arrangement of the parts of

“Posture” and “movement” are not necessarily opposites.

Half-Mast and Full-Sail Self-Care

you need for understanding your back problem and specific

Back Pain Solutions I:

The year was 1981, the place a busy hospital in Pittsburgh.

An New Old Approach to Back Pain

As Erwin H. Ackerknecht noted in his Short History of

Physical therapist Robin McKenzie has also advanced

After five minutes his symptoms had not significantly

elogram had been cancelled. He was discharged the follow-

Back Pain Solutions II:

The Problem of Habit

Since I had to leave soon, I reviewed the importance of

Education and ‘Body’–‘Mind’ Unity

learned in physical therapy school emphasized the ‘body’ as

considered a construct made by our nervous system, and

Ling, had particular importance in both the medical and non-

came a well-known teacher of his technique, listed these as

backwards, or letting it slump into this position, can encour-

Figure 4.1 – Head Back and Down vs. Forward and Up

A phrase used by Alexander summarizes this second, more

Surely...if it is possible for feeling to become untrustwor-

do. He could also see that he was doing what he wanted to

Our everyday skilled acts may involve unnecessary effort

How Your Back Works

Your beliefs play a large part in helping or not helping you