musle learning therapy (MLT) part 1

Commonwealth Club Speech on Muscle Learning Therapy (MLT)

The following speech was delivered to the Silicon Valley Forum of the Commonwealth Club of California on 2/5/98

This speech was originally presented to an audience and has subsequently been edited in order to facilitate the written word. In so doing, new or corrected material were transcribed and subsequently added. D.E.


Dennis L. Ettare, MA

Biofeedback Associates of California (BAC)


Why is it that today, with an ever-improving workplace and increased attention to worker comfort, why are more people are getting injured than ever before? It wasn’t very long ago that people were sitting in worse workstations, doing eight to ten hours of data entry, using a mouse and a keyboard, yet not getting injured as today. Also, curiously, why is it that something as violent as breaking concrete with a jack hammer hasn’t produced the same quantum leap in injuries we have seen in the less physical environments of offices and manufacturing today?

Those curiosities eventually led to a better understanding of chronic muscle pain in general and specifically, repetitive strain injuries. For over 20 years, Biofeedback Associates of California (BAC) has provided a specialized therapy to promote the reduction of injuries, get people feeling better faster and yet all the while not affecting work porductivity.

BAC’s clinical findings have shown that when people are trained to reduce the muscle loading that occurs during work, there is an 80-90% success rate in reducing pain and keeping people at work, or at least getting them back very quickly. How that has been accomplished is what I wish to share with you today because the alternative (reduction of the workload or trying to change jobs) is seldom a practical alternative.

The two major questions we face today in health care regarding chronic muscle pain (such as repetitive strains), are the following: The first regards understanding the actual event at the tissue level and the second, most importantly, concerns how we can affect significant change.

So, without paralyzing ourselves with theoretical abstractions and solutions requiring fundamental changes in the human psyche, and without fooling ourselves that we can invent the perfect work site or magic pill, it is my intention to give concrete alternatives you can take with you today. Some readers will find these solutions quite different than anything heard before but at the same time it is my hope that they may recognize certain concepts, themes and problems starting to fall into place.

In the end, I hope you will hear enough to jump-start the process of adapting real solutions to the real problems facing workers world wide.

Until recently, a major factor contributing to the lack of a clear treatment protocol has been the fact that researchers did not fully understand the physiology of muscle tension and muscle pain. They were also puzzled because they knew that pain can’t be felt in muscle tissue. That fact is due to our basic anatomy. In order to feel pain, you need free pain receptors in the muscle fibers. There just aren’t any free pain receptors in muscle fibers. Otherwise, you would feel pain every time you moved. Recently, however, the interesting mechanism by which people do feel muscle pain, along with the actual events that initiate it, have been researched and published. First, I need to briefly bring you up to date on what muscle pain actually is, as we know it today, and second, how its discovery has now, finally, opened a doorway into providing clinicians with the very method required to help reduce muscle pain.

The relatively few pain receptors that reside in your muscles are not freely accessible to their surroundings. They are protected by a hard capsule inside small anatomical sites called muscle spindles. They are about the size of a rice grain. These spindles, randomly placed throughout all skeletal muscles but more concentrated at the back of the neck, are filled with liquid and contain even tinier muscles called intrafusal fibers. And now getting to the main point, the muscle spindles contain most of your pain, pressure, and stretch receptors. The surrounding capsule protects those receptors from the constant movement of adjacent muscles. It saves you from feeling pain during simple movement.

It is very interesting, as research provides better answers, how those receptors can eventually become irritated. They have recently been shown to become irritated when people are overloaded, intense, focused, overworked, hyper vigilant, worried, and/or overwhelmed. That begins to explain why you often hurt more when you have more things going on in your life. It’s especially true at work where there exists an unrelenting drive and intensity surrounding workloads along with their accompanying responsibilities and pressures. Your pain, in other words, is not in your head. It is in your muscles. And it resides there because of real work loads, real responsibilities, and difficult goals. They are not imagined problems. They are very real because they come from the real world of what is expected of you. The proof of their real existence is that if you don’t attend to those factors, you may lose your job. That seems like an adequate reality test to me.

Muscle spindles, can develop, over time, into very tender and painful areas. They can also feel sore, achy, and stiff. Inevitably, if they become very irritated, they can develop into what are called trigger points, or places of tenderness. In addition, they can feel like a ‘knot’ when the encased liquid inside the spindle moves less easily. Eventually, those knots can feel like a ‘golf ball’ when the band of muscles surrounding the muscle spindle itself also tightens. Your first reaction to that kind of discomfort will be to want a massage. Afterward it may feel better but it won’t stop other spindles from starting up. In other words, if your workload has increased recently, but more importantly, if you have accepted that responsibility, you have a higher probability that you will hurt more. And correcting the hurt doesn’t correct the origin of the problem.

I know, I can just hear everyone saying how tempting it is to accept more work when everything moves faster and everyone expects more. You may even feel it is politically correct to keep doing more, too. You also may feel it is impossible to refuse to do more work when your job may be at stake (that is a compelling argument). And finally, you may be right to worry. Between downsizing, work restructures, and industry moving to other parts of the world, you can’t afford an injury affecting your chances of survival.

Health care professionals have few options for the treatment of chronic muscle pain. They can inject the trigger points, or try to reduce the pain through massage, heat, acupuncture, medication, posture, education, exercise, or joint adjustments. In the end, however, those methods only help to get you through the moment, they don’t change the future. At best they provide temporary relief, as a bandage might. Admittedly, bandages do sometimes feel very good and they can serve the immediate purpose of getting through a recurrence. You may even need such a ‘bandage’ to just get through the week. But bandages are also very seductive. You may get so used to them that you feel you no longer have a problem.

Sooner or later, however, you will need to correct the inappropriate muscle behavior that got you into trouble in the first place. There aren’t any passive interventions or therapies (i.e. the things people do to you) that can change inappropriate muscle behavior while you work. Taking breaks are nice but they can’t undo damage already done. And ‘bandages’ certainly can’t change excessive muscle loading. If you inject or massage an active muscle spindle to get rid of pain, another spindle, inevitably, will be available to take over the job of hurting. If you are behind in your work or you have bitten off more than you can chew, even specific medication that relaxes muscles can’t force you, against your will, to relax.

The real culprit, the origin of what we today call “muscle pain”, is due, principally, to the following: 1) an increased workload, 2) a more constricted work site, 3) along with faster tools, 4) an acceptance of increasing responsibilities, and finally 5) the body’s response to all of this with an increase of sympathetic activity firing into muscle spindles. In other words, the real culprit is real life. But the mechanism by which real life sets you up for injury may be due to a combination of two factors. The first involves mechanical insults to the tissues and this is the basis for the ergonomic solution to the problem. But there is recent research suggesting another mechanism contributing to the problem and it comes directly from an increased hyper vigilance and intensity on the part of the ‘driven’ worker to perform ever faster and better.

The amazing thing is that the highly performing, conscientious, and focused worker has recently been shown, and proven, to be more likely to get injured. In other words, the better workers are more likely to get injured because they try harder. More on how that happens later. But don’t get discouraged. I am leading up to a better understanding of the problem so that you will understand and relate to the surprise solution waiting for you.

The combination of trying to do more and doing it faster can, in other words, be deadly. Together they contribute to an increased vigilance and arousal level (chemically) of the body.

But since workers can’t afford to reduce the workload or eliminate responsibility in today’s world, they invariably try to solve the problem by exercising harder, getting stronger, trying to avoid thinking about the pain, putting up with pain, and/or expecting the health care system to fix them. Well, I hate to be the bearer of bad news but healthcare really has no solutions for you. In fact, they are just as puzzled as you are (at least the informed and honest ones are). What’s more, the system doesn’t like dealing with these problems because it has no real solutions. It prefers dealing with injuries it can help. There are no quick fixes for chronic muscle pain and consequently you will be lucky to just get good eye contact from those in health care. The muscle physiology of the problem doesn’t allow for quick fixes. That’s the bad news. But there is good news.

The good news is built upon the observation that when muscle loading is reduced during work, the body’s chemistry and electrical activity also changes. Usually this can be only accomplished by stopping or reducing work loads and/or responsibilities. Recovery inevitably occurs over time when that happens. In fact, that seems to be the only way recovery, until now, has had a chance of occurring. Unfortunately, most people don’t have the luxury of being able to reduce workloads, or become irresponsible, change jobs and/or wait around for years to feel better. Everyone hopes for the discovery of the magic pill allowing them to work hard yet feel no pain. Everyone is so overwhelmed by work and worries that we all hope for the quick fix.

Wouldn’t it be wonderful if someone could just train us to work hard, use less muscle and, because of the training, not get injured? If we could just FORCE muscles to behave themselves, then recovery would naturally occur while we did our work.

Of course, the real stumbling block in getting muscles to behave themselves stems from the fact that few people know how to force muscles do the right thing, especially within a tough work environment. If the training isn’t forced or induced, as compared to getting people ‘educated’, there isn’t much chance of it generalizing into the intensity of the real working world. So, in the end, the inevitable difficulty lies not in understanding the problem (although many still have missed that point, too) but instead in how to get the muscles to behave themselves while at the same time not altering the quality and quantity of work.

To that end, BAC has developed over many years what has turned out to be a very effective training algorithm. The specialized training was developed from the observation of other professions requiring equal demands on the musculoskeletal system. They included various training methods observed in sports, music, martial arts and other disciplines demanding excellent muscle control during severely stressful conditions. The emerging model has(over years of development) successfully transferred that same training model so familiar in sports or music into the intense and challenging world of the work environment.

The hypothesis comes from the observation that if training for a demanding sport or musical performance can prepare you for the extreme conditions of competition, why can’t it also prepare you for the incredible demands of work?


At the same time, why can’t training also help those who are already in pain and injured? After all, since evidence already exists supporting the fact that muscle loading causes/irritates pain, it makes sense that reduction of that loading along with reduced sympathetic tone will also reduce a major component in the origin of chronic pain.

The training concept (or solution) was at once both simple and complex. The simple part was based on standard practices of just putting people through specialized tasks of repetition and reinforcement and then making sure they showed up for the training appointments. The rest happened on its own. Performance became automatic and assured excellent results even if the person had little coordination or little command of English. Performance under duress was the goal for everyone. Very similar to the environment workers face today. The more complicated part, instead, was in finding the experts to do the training. The same difficulties can be found in teaching a musical instrument or any other activity requiring muscles. Biofeedback Associates of California has developed a formula, or method, to help reduce the contributing factors in muscle pain. It is called MLT or Muscle Learning Therapy/Training. Biofeedback instruments are used as a tool to facilitate the learning process along with a very complex set of training interventions.

The requirements in a typical work place today are much like those of the well-trained athlete or musician. Workers have the same needs and are under the same kinds of pressures. Workers have to deal with performance, stress, unreasonable expectations, peers and subordinates wishing to take their place, personality conflicts, home conflicts, age, mental fatigue, and, eventually, physical exhaustion.

How can we expect untrained workers to succeed unless they, too, are given the skills required to perform? The worker requires, and eventually should expect, excellent training and instruction to avoid injury on the job. People are not born knowing how to play soccer, or ride a bike or how to correctly use muscles while working, unless they are taught. Since we still find people getting injured in ergonomically corrected workstations, evidently the complete solution has not yet been found. The external environment has been addressed. It is time to address the internal environment, i.e. the world of muscle loading and sympathetic overload.