Aims

This leaflet is for anyone who wants to know more about Cognitive Behavioural Therapy (CBT). It discusses how it works, why it is used, its effects, sideeffects, and alternative treatments. If you can't find what you want here, there are sources of further information at the end of this leaflet.

What is CBT?
It is a way of talking about: How you think about yourself, the world and other people How what you do affects your thoughts and feelings.

CBT can help you to change how you think ("Cognitive") and what you do ("Behaviour)". These changes can help you to feel better. Unlike some of the other talking treatments, it focuses on the "here and now" problems and difficulties. Instead of focussing on the causes of your distress or symptoms in the past, it looks for ways to improve your state of mind now. It has been found to be helpful in: Anxiety Depression Panic Agoraphobia and other phobias Social phobia Bulimia Obsessive compulsive disorder Post traumatic stress disorder Schizophrenia

How does it work? CBT can help you to make sense of overwhelming problems by breaking them down into smaller parts. This makes it easier to see how they are connected and how they affect you. These parts are: A Situation - a problem, event or difficult situation From this can follow: Thoughts

Emotions Physical feelings Actions

Each of these areas can affect the others. How you think about a problem can affect how you feel physically and emotionally. It can also alter what you do about it. An example There are helpful and unhelpful ways of reacting to most situations, depending on how you think about them: Situation: You've had a bad day, feel fed up, so go out shopping. As you walk down the road, someone you know walks by and, apparently, ignores you. Unhelpful Thoughts: He/she ignored me - they don't like me Helpful He/she looks a bit wrapped up in themselves - I wonder if there's something wrong? Concerned for the other person

Emotional: Low, sad and Feelings rejected Physical:

Stomach None - feel cramps, low comfortable energy, feel sick Go home and avoid them Get in touch to make sure they're OK

Action:

The same situation has led to two very different results, depending on how you thought about the situation. How you think has affected how you felt and what you did. In the example in the left hand column, you've jumped to a conclusion without very much evidence for it - and this matters, because it's led to:

a number of uncomfortable feelings an unhelpful behaviour.

If you go home feeling depressed, you'll probably brood on what has happened and feel worse. If you get in touch with the other person, there's a good chance you'll feel better about yourself. If you don't, you won't have the chance to correct any misunderstandings about what they think of you - and you will probably feel worse. This is a simplified way of looking at what happens. The whole sequence, and parts of it, can also feedback like this:

This "vicious circle" can make you feel worse. It can even create new situations that make you feel worse. You can start to believe quite unrealistic (and unpleasant) things about yourself. This happens because, when we are distressed, we are more likely to jump to conclusions and to interpret things in extreme and unhelpful ways. CBT can help you to break this vicious circle of altered thinking, feelings and behaviour. When you see the parts of the sequence clearly, you can change them - and so change the way you feel. CBT aims to get you to a point where you can "do it yourself", and work out your own ways of tackling these problems. "Five areas" Assessment This is another way of connecting all the 5 areas mentioned above. It builds in our relationships with other people and helps us to see how these can make us feel better or worse. Other issues such as debt, job and housing difficulties are also important. If you improve one area, you are likely to improve other parts of your life as well. "5 areas" diagram. What does CBT involve?

The sessions CBT can be done individually or with a group of people. It can also be done from a self-help book or computer programme. In England and Wales two computer-based programmes have been approved for use by the NHS. Fear Fighter is for people with phobias or panic attacks, Beating the Blues is for people with mild to moderate depression. If you have individual therapy: You will usually meet with a therapist for between 5 and 20, weekly, or fortnightly, sessions. Each session will last between 30 and 60 minutes.

In the first 2-4 sessions, the therapist will check that you can use this sort of treatment and you will check that you feel comfortable with it.

The therapist will also ask you questions about your past life and background. Although CBT concentrates on the here and now, at times you may need to talk about the past to understand how it is affecting you now.

You decide what you want to deal with in the short, medium and long term.

You and the therapist will usually start by agreeing on what to discuss that day.

The Work With the therapist, you break each problem down into its separate parts, as in the example above. To help this process, your therapist may ask you to keep a diary. This will help you to identify your individual patterns of thoughts, emotions, bodily feelings and actions.

Together you will look at your thoughts, feelings and behaviours to work out: - if they are unrealistic or unhelpful - how they affect each other, and you.

The therapist will then help you to work out how to change unhelpful thoughts and behaviours

It's easy to talk about doing something, much harder to actually do it. So, after you have identified what you can change, your therapist will recommend "homework" - you practise these changes in your everyday life. Depending on the situation, you might start to:

Question a self-critical or upsetting thought and replace it with a positive (and more realistic) one that you have developed in CBT

recognise that you are about to do something that will make you feel worse and, instead, do something more helpful.

At each meeting you discuss how you've got on since the last session. Your therapist can help with suggestions if any of the tasks seem too hard or don't seem to be helping. They will not ask you to do things you don't want to do - you decide the pace of the treatment and what you will and won't try. The strength of CBT is that you can continue to practise and develop your skills even after the sessions have finished. This makes it less likely that your symptoms or problems will return.

How effective is CBT? It is one of the most effective treatments for conditions where anxiety or depression is the main problem It is the most effective psychological treatment for moderate and severe depression

It is as effective as antidepressants for many types of depression

What other treatments are there and how do they compare? CBT is used in many conditions, so it isn't possible to list them all in this leaflet. We will look at alternatives to the most common problems - anxiety and depression. CBT isn't for everyone and another type of talking treatment may work better for you. CBT is as effective as antidepressants for many forms of depression. It may be slightly more effective than antidepressants in treating anxiety. For severe depression, CBT should be used with antidepressant medication. When you are very low you may find it hard to change the way you think until antidepressants have started to make you feel better. Tranquillisers should not be used as a long term treatment for anxiety. CBT is a better option.

Problems with CBT If you are feeling low and are having difficulty concentrating, it can be hard, at first, to get the hang of CBT - or, indeed, any psychotherapy This may make you feel disappointed or overwhelmed. A good therapist will pace your sessions so you can cope with the work you are trying to do It can sometimes be difficult to talk about feelings of depression, anxiety, shame or anger

How long will the treatment last? A course may be from 6 weeks to 6 months. It will depend on the type of problem and how it is working for you. The availability of CBT varies between different areas and there may be a waiting list for treatment. What if the symptoms come back? There is always a risk that the anxiety or depression will return. If they do, your CBT skills should make it easier for you to control them. So, it is important to keep practising your CBT skills, even after you are feeling

better. There is some research that suggests CBT may be better than antidepressants at preventing depression coming back. If necessary, you can have a "refresher" course. So what impact would CBT have on my life? Depression and anxiety are unpleasant. They can seriously affect your ability to work and enjoy life. CBT can help you to control the symptoms. It is unlikely to have a negative effect on your life, apart from the time you need to give up to do it. What will happen if I don't have CBT? You could discuss alternatives with your doctor. You could also: Read more about the treatment and its alternatives If you want to "try before you buy", get hold of a self-help book or CD-Rom and see if it makes sense to you Wait to see if you get better anyway - you can always ask for CBT later if you change your mind

Useful CBT web links

British Association for Behavioural and Cognitive Psychotherapies www.babcp.com Calipso website: www.calipso.co.uk Beating the Blues: www.ultrasis.com/products/product.jsp?product_id=1 For further information on Cognitive Behavioural therapy (www.psychnetuk.com/psychotherapy/psychotherapy_cognitive_behavioural_therapy.htm)

Books
The 'Overcoming' series, Constable and Robinson A large series of self-help books which use the theories and concepts of CBT to help people overcome many common problems. Titles include: overcoming social anxiety and shyness, overcoming depression and overcoming low selfesteem.

Free online CBT resources:

Mood Gym: moodgym.anu.edu.au Information, quizzes, games and skills training to help prevent depression Living Life to the Full: www.livinglifetothefull.com Free online life skills course for people feeling distressed and their carers. Helps you understand why you feels as you do and make changes in your thinking, activities, sleep and relationships. Fear Fighter: www.fearfighter.com (free access can only be prescribed by your doctor in England and Wales)

References
Williams C J. (2001). Overcoming Depression: A Five Areas approach. London Hodder Arnold. apt.rcpsych.org/cgi/content/full/8/3/172 Department of Health (2001). Treatment choice in psychological therapies and counselling. London: HMSO. NICE (2004). CG9 Eating disorders: Core interventions in the treatment and management of anorexia nervosa, bulimia nervosa and related eating disorders - NICE guideline January 2004 www.nice.org.uk/pdf/cg009niceguidance.pdf NICE (2004). Anxiety: management of anxiety (panic disorder, with or without agoraphobia, and generalised anxiety disorder) in adults in primary, secondary and community care. www.nice.org.uk/page.aspx?o=235395%20 NICE (2004) Depression: Management of depression in primary and secondary care. NICE Guideline December 2004. www.nice.org.uk/page.aspx?o=235626

For further information contact:

Depression Alliance, 35 Westminster Bridge Road, London SE1 7JB. Depression Alliance has 3 offices within the UK. You can contact their regional information lines via the main number 0845 123 23 20 www.depressionalliance.org National Phobics Society, Zion Community Resource Centre, 339 Stretford Road, Hulme, Manchester M15 4ZY. Provides support and help if you have been diagnosed with or suspect you may have an anxiety condition or specific

phobias. www.phobics-society.org.uk

Cognitive-Behavioral Therapy...
is a form of psychotherapy that emphasizes the important role of thinking in how we feel and what we do. Cognitive-behavioral therapy does not exist as a distinct therapeutic technique. The term "cognitive-behavioral therapy (CBT)" is a very general term for a classification of therapies with similarities. There are several approaches to cognitive-behavioral therapy, including Rational Emotive Behavior Therapy, Rational Behavior Therapy, Rational Living Therapy, Cognitive Therapy, and Dialectic Behavior Therapy. However, most cognitive-behavioral therapies have the following characteristics: 1. CBT is based on the Cognitive Model of Emotional Response. Cognitive-behavioral therapy is based on the idea that our thoughts cause our feelings and behaviors, not external things, like people, situations, and events. The benefit of this fact is that we can change the way we think to feel / act better even if the situation does not change. 2. CBT is Briefer and Time-Limited. Cognitive-behavioral therapy is considered among the most rapid in terms of results obtained. The average number of sessions clients receive (across all types of problems and approaches to CBT) is only 16. Other forms of therapy, like psychoanalysis,can take years. What enables CBT to be briefer is its highly instructive nature and the fact that it makes use of homework assignments. CBT is time-limited in that we help clients understand at the very begining of the therapy process that there will be a point when the formal therapy will end. The ending of the formal therapy is a decision made by the therapist and client. Therefore, CBT is not an open-ended, never-ending process. 3. A sound therapeutic relationship is necessary for effective therapy, but not the focus. Some forms of therapy assume that the main reason people get better in therapy is because of the positive relationship between the therapist and client. Cognitive-behavioral therapists believe it is important to have a good, trusting relationship, but that is not enough. CBT therapists believe that the clients change because they learn how to think differently and they act on that learning. Therefore, CBT therapists focus on teaching rational self-counseling skills. 4. CBT is a collaborative effort between the therapist and the client. Cognitive-behavioral therapists seek to learn what their clients want out of life (their goals) and then help their clients achieve those goals. The therapist's role is to listen, teach, and encourage, while the client's roles is to express concerns, learn, and implement that learning.

For excellent cognitive-behavioral therapy self-help and professional books, audio presentations, and home-study training programs, please click here.
5. CBT is based on stoic philosophy. Not all approaches to CBT emphasize stoicism. Rational Emotive Behavior Therapy, Rational Behavior Therapy, and Rational Living Therapy emphasize stoicism. Beck's Cognitive Therapy is not based on stoicism.

Cognitive-behavioral therapy does not tell people how they should feel. However, most people seeking therapy do not want to feel they way they have been feeling. The approaches that emphasize stoicism teache the benefits of feeling, at worst, calm when confronted with undesirable situations. They also emphasize the fact that we have our undesirable situations whether we are upset about them or not. If we are upset about our problems, we have two problems -- the problem, and our upset about it. Most people want to have the fewest number of problems possible. So when we learn how to more calmly accept a personal problem, not only do we feel better, but we usually put ourselves in a better position to make use of our intelligence, knowledge, energy, and resources to resolve the problem. 6. CBT uses the Socratic Method. Cognitive-behavioral therapists want to gain a very good understanding of their clients' concerns. That's why they often ask questions. They also encourage their clients to ask questions of themselves, like, "How do I really know that those people are laughing at me?" "Could they be laughing about something else?" 7. CBT is structured and directive. Cognitive-behavioral therapists have a specific agenda for each session. Specific techniques / concepts are taught during each session. CBT focuses on the client's goals. We do not tell our clients what their goals "should" be, or what they "should" tolerate. We are directive in the sense that we show our clients how to think and behave in ways to obtain what they want. Therefore, CBT therapists do not tell their clients what to do -- rather, they teach their clients how to do. 8. CBT is based on an educational model. CBT is based on the scientifically supported assumption that most emotional and behavioral reactions are learned. Therefore, the goal of therapy is to help clients unlearn their unwanted reactions and to learn a new way of reacting. Therefore, CBT has nothing to do with "just talking". People can "just talk" with anyone. The educational emphasis of CBT has an additional benefit -- it leads to long term results. When people understand how and why they are doing well, they know what to do to continue doing well. 9. CBT theory and techniques rely on the Inductive Method. A central aspect of Rational thinking is that it is based on fact. Often, we upset ourselves about things when, in fact, the situation isn't like we think it is. If we knew that, we would not waste our time upsetting ourselves. Therefore, the inductive method encourages us to look at our thoughts as being hypotheses or guesses that can be questioned and tested. If we find that our hypotheses are incorrect (because we have new information), then we can change our thinking to be in line with how the situation really is. 10. Homework is a central feature of CBT. If when you attempted to learn your multiplication tables you spent only one hour per week studying them, you might still be wondering what 5 X 5 equals. You very likely spent a great deal of time at home studying your multiplication tables, maybe with flashcards. The same is the case with psychotherapy. Goal achievement (if obtained) could take a very long time if all a person were only to think about the techniques and topics taught was for one hour per week. That's why CBT

therapists assign reading assignments and encourage their clients to practice the techniques learned.

Cognitive behavioural therapy

Published by BUPA's Health Information Team April 2004 Cognitive behavioural therapy (CBT) is a short-term psychological treatment which is particularly suitable for specific, focused problems ranging from phobias and panic attacks to eating disorders and depression. Mental health problems are common, and affect many adults. Depression, anxiety and phobias are among the most frequently diagnosed disorders. A range of different treatments are available to address mental health problems. A course of medication is sometimes prescribed to help control emotions and to improve mood. "Talking treatments" are used, either on their own or in conjunction with medication. Common "talking treatments" include psychotherapy and counselling. These vary in length and content but have the general aim of examining the thought patterns and behaviours which characterise the mental health problem, and sometimes the past experiences which continue to influence it.

What is CBT?
CBT is a combination of cognitive therapy, which examines unwanted thoughts, attitudes, and beliefs (called cognitive processes) and behavioural therapy, which focuses on behaviour in response to those thoughts. CBT is based on the belief that most unhealthy modes of thinking and behaving have been learned over a long period of time. Using a set of structured techniques, a CBT therapist aims to identify thinking that causes problematic feelings and behaviour. The client then learns to change this thinking which, in turn, leads to more appropriate and positive responses. For example, negative thoughts usually lead to upsetting or angry feelings which then affect our mood and our behaviour. If a person is unable to counter such thoughts with a more positive stance, a negative spiral ensues and perceptions of a situation can become distorted. CBT encourages the person to challenge their beliefs about themselves and their abilities so that they achieve a more realistic view of the situation. Negative automatic thought patterns

"I'm so fat and so useless and I'll never manage to do anything about it." "If I go outside, I have to cross the streets and then I might be attacked or knocked down by a car. I can't leave the house. I have to stay here on my own."

Aims of CBT
CBT aims to help people challenge their negative beliefs and to think about times when they have achieved things, or to see what happens to other people in similar situations. Once they are thinking more realistically, they are encouraged to imagine how they would go about confronting a feared situation. They are helped to expose themselves gradually to real-life scenarios. This work takes place within the context of a collaborative therapist/client relationship in which people decide jointly on the goals to work towards and plan homework assignments and session topics together. The aim of CBT is to provide the client, within a limited timescale, with the insight and skills to improve their quality of life. The client should continue to cope and to progress once therapy is finished. Who can benefit from CBT? People who would benefit from CBT include those with the following specific, focused problems:

anxiety and panic attacks depression obsessive-compulsive disorder drug or alcohol problems

other addictions, such as pathological gambling eating disorders chronic fatigue syndrome phobias

Finding a therapist
Access to CBT on the NHS tends to vary across the UK. A number of health professionals use CBT in their treatment, including clinical psychologists, psychiatrists, nurses and social workers. Your GP will be able to give you information about accessing local services and about the length of waiting times. You can also look for a CBT therapist who offers treatment within private practice. Practitioners vary in skill, training and experience. While there is no government-regulated body for psychotherapists, the British Association of Behavioural and Cognitive Psychotherapies (BABCP) and the UK Council for Psychotherapy (UKCP) hold registers of accredited practitioners. Contact the BABCP or search their website for a list of therapists in your area who practice in the NHS and privately. There is a wealth of self-help information around CBT which may be useful, especially for those people who are not sure whether to take the next step in finding a therapist. Some mental health teams and GP surgeries have good computer and CD-based CBT programmes to help with anxiety and depression. Ask your GP for details.

How CBT treatment works

CBT is a short-term treatment which takes 8 - 20 individual, weekly sessions. The number of sessions will depend on the type of problem and on the commitment of the client. Each session will last for either 50 minutes or one hour. The aim of treatment is for the client and therapist to work in partnership to identify patterns of thought and behaviour which are causing problems, and to plan a structured way forward with agreed practical objectives. The success of CBT depends on the active participation of the client in the whole process, so there is an initial interview which enables the client to decide whether they want to go ahead with the therapy. It also enables the therapist to judge the client's commitment, and decide whether this sort of therapy is suitable. At this session, the client is asked to outline their specific problems and the goals which they'd like to work towards. This information informs the planning for subsequent visits, including the treatment aims and tasks. Further sessions involve discussing agreed topics in a problem-focused and practical manner. A key part of the treatment is the homework assignments devised by the client with the therapist. These may include reading material or specific tasks which give the client the opportunity to test out and practice techniques learned, or to expose themselves gradually to feared situations. Common CBT techniques include challenging irrational beliefs, replacing them with alternative ones, thought stopping, graded exposure, assertiveness and social skills training, and relaxation techniques.

Is CBT suitable for me?

Clinical trials suggest that CBT has been successful in addressing various emotional problems. It has been shown, in the short term, to be as effective as medication for the treatment of many non-severe depressive and anxiety disorders. It is also possible that, longer term, the effects of CBT will continue to protect the client from further illness. People who finish medication may be at greater risk of relapse compared to a CBT clients, who have learned principles and strategies to sustain their recovery.

Cognitive Behavioural Therapy in London

Efficacy is a London cognitive behavioural therapy service of accredited therapists. We have a highly trained and experienced team of eight cognitive behavioural therapists all accredited with the British Association of Behavioural and Cognitive Psychotherapy (BABCP).

We are located close to Victoria Station in Westminster and Monument in The City of London, providing accessibility across central London.

There are many different forms of psychotherapy, of which Cognitive Behavioural Therapy is one. Choosing what type of psychotherapy is right for you can be a daunting task so this site gives an overview of what Cognitive Behavioural Therapy is and how you can expect to benefit from it. If you decide Cognitive Behavioural Therapy is right for you, and are looking for a cognitive behavioural therapist in London then you might be interested in learning more about the service we offer. The aim of this site is twofold: Firstly it is to give you an overview of this London therapy service and cognitive behavioural therapy to help you understand more about the psychotherapy and decide if it is for you. Secondly if you decide you would like an assessment then you can see how to make contact with a cognitive behavioural therapist in London.

The Cognitive Behavioural Therapists

An accredited cognitive behavioural therapist will have had training as registered health professionals before starting post graduate psychotherapy training. So we have competently trained practitioners, providing reassurance that your well-being is in the hands of registered professionals. For information on the rigorous training click here. All therapists hold dual positions with Efficacy and senior positions in the NHS or an academic institution. Positions in the NHS or academia are managing or coordinating a specialist CBT service.

What is Cognitive Behavioural Therapy?

Cognitive behavioural therapy, or CBT, is a way of helping people to cope with stress and emotional problems. It helps us to look at the connections between how

we think, how we feel and how we behave. It particularly concentrates on ideas that are unrealistic. These often undermine our self-confidence and make us feel depressed or anxious. To find out more click here to find what is Cognitive Behavioural Therapy. What makes cognitive behavioural therapy stand out from other forms of therapy or counselling is the emphasis on evidence based practice and you can read more about this here for evidence on Cognitive Behavioural Therapy. To the patient this means that they are receiving up-to-date professional therapy based on the very latest research.

What Happens in Cognitive Behavioural Therapy?

Generally the duration of therapy is 6-18 sessions so becoming your own therapist is an important part of cognitive behavioural therapy. Both the therapist and the patient work together in a collaborative relationship with an atmosphere of transparency. Click here to learn more about what happens in cognitive behavioural therapy.

Problems Cognitive Behavioural Therapy Can Help With

Below are some problems that cognitive behavioural therapy can help you with. The service is offered in Victoria, London and Monument near London Bridge.

To find out more click here for issues cognitive behavioural therapy can help with.

Definition of Efficacy: Efficacious adj. capable of or successful in producing an intended result; effective. [C16: form L efficax powerful, efficient, from efficere to achieve]

efficacy or, efficaciousness n. (Collins Concise Dictionary)

Lumbar Spine
Physicians use a code to number each of the 24 vertebrae in the spine. The low back officially begins with the lumbar region of the spine directly below the cervical and thoracic regions and directly above the sacrum. The lumbar vertebrae, L1-L5, are most frequently involved in back pain because these vertebrae carry the most amount of body weight and are subject to the largest forces and stresses along the spine. The true spinal cord ends at approximately the L1 level, where it divides into many different nerve roots that travel to the lower body and legs. This collection of nerve roots is called the "cauda equina," which means horse's tail and describes the continuation of the nerve roots at the end of the spinal cord. Vertebrae The vertebral body is a thin ring of dense cortical bone. The vertebral body is shaped like an hourglass, thinner in the center with thicker ends. Outer cortical bone extends above and below the superior and inferior ends of the vertebrae to form rims. The superior and inferior endplates are contained within these rims of bone. Pedicles The pedicles are two short rounded processes that extend posteriorly from the lateral margin of the dorsal surface of the vertebral body. They are made of thick cortical bone. Laminae The laminae are two flattened plates of bone extending medially from the pedicles to form the posterior wall of the vertebral foramen. The Pars Interarticularis is a special region of the lamina between the superior and inferior articular processes. A fracture or congenital anomaly of the pars may result in a spondylolisthesis. Intervertebral Discs Intervertebral discs are found between each vertebra. The discs are flat, round structures about a quarter to three quarters of an inch thick with tough outer rings of tissue called the annulus fibrosis that contain a soft, white, jelly-like center called the nucleus pulposus. Flat, circular plates of cartilage connect to the vertebrae above and below each disc. Intervertebral discs separate the vertebrae, but they act as shock absorbers for the spine. They compress when weight is put on them and spring back when the weight is removed. Intervertebral discs make up about one-third of the length of the spine and constitute the largest organ in the body without its own blood supply. The discs receive their blood supply through movement as they soak up nutrients. The discs expand while at rest allowing them to soak up nutrient rich fluid. When this process is inhibited through repetitive movement, injury or poor posture, the discs become thinner and more prone to injury. This may be a cause of the gradual degeneration of the structure and function of the disc over time. Facet Joints Joints between the bones in our spine are what allow us to bend backward and forward and twist and turn. The facet joints are a particular joint between each vertebral body that help with twisting motions and rotation of the spine. The face joints are part of the posterior elements of each vertebra. * Each vertebra has facet joints that connect it with the vertebrae above and the vertebrae below in the spinal column. The surfaces of the facet joints are covered with smooth cartilage that help these parts of the vertebral bodies glide smoothly on each other. Ligamentum Flavum The ligamentum flavum is a strong ligament that connects the laminae of the vertebrae. The term "flavum" is used to describe the yellow appearance of this ligament in its natural state. The ligamentum flavum serves

to protect the neural elements and the spinal cord and stabilize the spine so that excessive motion between the vertebral bodies does not occur. It is the strongest of the spinal ligaments and often has a thinner middle section. Together with the laminae, it forms the posterior wall of the spinal canal. Spinal Cord The spinal cord is part of the central nervous system of the human body. It is a vital pathway that conducts electrical signals from the brain to the rest of the body through individual nerve fibers. The spinal cord is a very delicate structure that is derived from the ectodermal neural groove, which eventually closes to form a tube during fetal development. From this neural tube, the entire central nervous system, our brain and spinal cord, eventually develops. Up to the third month of fetal life, the spinal cord is about the same length as the canal. After the third month of development, the growth of the canal outpaces that of the cord. In an adult the lower end of the spinal cord usually ends at approximately the first lumbar vertebra, where it divides into many individual nerve roots (L1). Spinal Canal The spinal canal is the anatomic casing for the spinal cord. The bones and ligaments of the spinal column are aligned in such a way to create a canal that provides protection and support for the spinal cord. Several different membranes enclose and nourish the spinal cord and surround the spinal cord itself. The outermost layer is called the "dura mater," which is a Latin term that means "hard mother," indicating that early anatomists had at least a rudimentary sense of humor. The dura is a very tough membrane that encloses the brain and spinal cord and prevents cerebrospinal fluid from leaking out from the central nervous system. The space between the dura and the spinal canal is called the "epidural space". This space is filled with tissue, vessels and large veins. The epidural space is important in the treatment of low-back pain, because it is into this space that medications such as anesthetics and steroids are injected in order to alleviate pain and inflammation of the nerve roots.

* Bellenir, K. Health Reference Series: Back & Neck Disorder Sourcebook. Detroit, MI: Omnigraphics, Inc.; 1997.

neuroscience of motor behavior

There is no one unified defined theory for how the brain and central nervous system (CNS) controls human movement. There are several theories that explain many aspects of motor behavior but none that can explain all features of brain function and movement control. However, what is known about CNS control of movement makes compelling and informative reading. This page is a series of related and unrelated interesting examples of human CNS functioning and human motor control that in part confirms the ideas of Dr

Moshe Feldenkrais and his method of movement education and human learning. Recent advances in the neuroscience of movement organisation are challenging and expanding some of the traditional models of human movement organisation. The models of fixed, hardwired neural networks that can be defined by anatomical connectivity are being replaced by more dynamic, modifiable models generated and maintained by the CNS that can only be properly defined when functional connectivity is considered (Selverston 1992).

1. body scheme:
from reflex to central organisation Since Sherrington (1906) defined the stretch reflex concept for movement and posture organisation, a simple reflex structural model for movement and posture has prevailed (Lackner 1988; Woollacott and Shumway-Cook 1990; Baev and Shimansky 1992). Many recent studies on the central nervous system control of movement and posture question this reflex concept and instead propose more dynamic models for posture and movement organisation (Lackner 1988; Gurfinkel et al 1988; Lacquaniti et al 1990). A central representation of body biomechanical characteristics or a BODY SCHEME including the length of limb segments, the sequence of their linkage, the position of limb segments in space and the shape of the body's surface has been proposed (Clement et al 1984; Lackner 1988; Gurfinkel et al 1988; Roll and Roll 1988). These parameters do not have any specific individual sensory modality but are generated from the transformation of sensory information from virtually all receptor systems of the body (DiZio and Lackner 1986; Gurfinkel et al 1988). A postural control system organised on the basis of an internal model operating with highly integrated information from many sensory systems could possess a much wider range of functional possibilities than a system based on the interactions between single level reflexes (Gurfinkel et al 1988). The illusory and real effects produced by tendon vibration (Gurfinkel et al 1988; Lackner 1988; Roll and Roll 1988), altered gravity conditions (Clement et al 1984) and cat responses to platform movements (Lacquaniti et al 1990) has lead to this proposal that the CNS of humans and vertebrates generates an internal representation of body geometry. Lacquaniti et al proposed that posture in the cat is maintained by the control of a preferred silhouette image of the geometrical configuration of the limbs rather than by the regulation of the projection of the centre of gravity onto the support surface. This body scheme is thought to be largely an unconscious model of body biomechanics (Gurfinkel et al 1988). Lackner (1988) induced changes in perceived limb length and trunk contour by the manipulation of sensory input and suggested that the body scheme is maintained as a dynamic organisation and that is potentially modifiable.

Feldenkrais (1972) maintained that this body scheme can be brought into active awareness and significantly modified by learning . Movement lessons (Awareness Through Movement) were specifically designed by Feldenkrais to enhance the brain's body scheme. Attention to body segment (eg limb, spinal segment) length, movement, interactions, relation to gravity, timing, ease vs effort during gentle movement sequences improves coordination, control and awareness of movement. If there is pain at one point, this is significantly "appeased" (and not cured or fixed) by improving local and global movement control. Currently in the diagnosis and treatment of low back pain, for example, attention is primarily focussed to the area of pathology (Jayson 1992). Local motion segment (one joint) biomechanics and muscle strength are the focus. A "movement diagnosis" based on global functional parameters related to the body scheme (eg motor control of the trunk, ie pelvis, spine and head relations and functions), as well as the local movement issues could greatly improve diagnosis and management of low back pain.

2. motor image
Bernstein (1967) proposed that the CNS must create a "motor image" for the performance of movement. This image represented the form of the movement to be achieved, not the temporal sequences of neural impulses that produces it. Berthoz (200) called it a "blue print" for action. That is the movement is stored as an image of the form of the movement and not as a transformation into neural impulses. He also assumed that common actions, like walking, reaching, running, and throwing were organised as synergies to reduce the number of degrees of freedom for the CNS to store and effect. Hence in these actions only a small part of the CNS sets the motion in action. Similarly, Reed (1988) proposed that animals and people do not move by contracting muscles or displacing their limbs but by coordinating subsidiary actions. The organism controls movements and postures in space rather than displacements in space-time. Muscular contractions and limb displacements are a consequence of intention and action rather than the operating elements of the CNS.

3. central pattern generators

In decerebrate cats, stimulation of the mid brain evoked an entire normal gait pattern (Shik and Orlovsky 1976). Activation of the entire locomotor pattern could be turned on and off like a switch. This means that the neural network is tuned to a complete global motor function and not to individual motor elements such as muscles. Since then single cell and multiple cell central pattern generators for many rhythmical behaviours like locomotion, chewing, scratching, singing, posture , swimming, jumping, feeding and flight have been identified in

many vertebrates and invertebrates (Pearson 1993). The neuronal network for the Tritonia escape swim system is shown in figure 1. With activation of the C2 cell, the I cell is inhibited and the DSI cells become excitatory resulting in swimming (Getting 1989). Inhibition of C2 results in the DSI cells functionally inhibiting each other via the I cell resulting in no swimming. CPG'S have been shown to be enormously modifiable by neuromodulation (mainly amines and peptides) (Selverston 1992; Pearson 1993). Neuromodulators can facilitate, depress, initiate, modify and completely reorganise the motor behaviour of the CPG . These regions of the brain for motor control are homologous from reptiles to primates suggesting phylogenetically old and unchanged systems (Grillner & Wallen 1985). Do CPG'S for locomotion, breathing and other rhythmical behaviours exist in human brains? Are they as functionally re-organisable as animal CPG'S? What role might they play in musculoskeletal disorders?