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Medical Rationale

Alexander Technique - The Journal of Complementary Medicine

Who can it help, and what is the evidence? John Kron reports.

Medical practitioners and celebrities are among the passionate proponents of this gentle bodywork system.

Who can it help, and what is the evidence? John Kron reports.

Alexander technique basics

Definition: an educative technique that aims to teach people how to
increase self-awareness of, and change, faulty patterns of movement and posture.

Conditions treated: although regarded as an educative (rather than a treatment) technique, a therapeutic role is recognised, as faulty patternsof movement and postures may contribute to or exacerbate: musculoskeletal problems (primarily chronic), such as low-back pain, neck pain, headaches, RSI, TMJ disorders, and joint disorders such as osteoarthritis; neurological problems involving poor balance and coordination as the primary
diagnosis, and specific diagnoses such as Parkinson's disease, stroke, multiple sclerosis; respiratory problems such as asthma; mental-health problems such as anxiety and depression

Precautions: falls in patients with poor balance.

Adverse effects: minor soreness or stiffness due to using muscles in an unfamiliar manner; dizziness in pregnant women, possibly due to a relaxation response leading to lowered blood pressure

Contraindications: none

Background and history

The Alexander technique (AT) was developed in the 1890s by a young Tasmanian, Frederick Matthias Alexander (1869-1955). At the time he was a promising actor with a debilitating inability to vocalise sounds during performances.1,2 After doctors were unable to diagnose a specific cause or remedy3, Alexander undertook a period of intense selfobservation and experiment, discovering a link between his movement, posture and breathing. Implementing specific changes to his movement patterns enabled him to reduce inappropriate tension and so vocalise normally on stage. He also observed that implementing these specific changes had positive effects on his posture and breathing. He believed his discovery could deliver benefits for general health and well-being, and before long he had flourishing practices in Melbourne and Sydney. In 1904 his reputation led him to travel to the UK where he taught eminent people, including George Bernard Shaw and Aldous Huxley, as well as numerous medical doctors, 19 of whom wrote to the British Medical Journal in 1939 urging, unsuccessfully, to include the AT in undergraduate medical training. Today there are more than 2500 AT teachers in more than 30 countries, including 250 in Australia.1 The technique is mostly taught to the general public, as well as in performing arts institutions to actors and musicians.

Rationale

The practice is traditionally regarded as, first and foremost, an educative technique, says AT practitioner Helen Thurloe, from the Australian Society of Teachers of the AT in Sydney. Hence practitioners call themselves teachers rather than therapists, and people who consult them are pupils or students, not patients or clients. However, Ms Thurloe says most teachers acknowledge a therapeutic role for the technique, as faulty patterns of movement and posture are seen as contributing to or exacerbating illness and disease.

David Moore, director of the School of FM Alexander Studies in Melbourne, says
the AT draws on seven main principles:
• use affects functioning - the way we use our bodies affects the way we function;
• psychophysical unity - the physical body and emotional and psychological processes affect each other;
• faulty sensory perception - patterns of movement and posture are learned
and become automatic, so people are usually unaware of them;
• inhibition involves learning to stop faulty patterns through increased awareness;
• primary control attributes singular importance to the relationship
between the head, neck and back that affects movement and posture in the remainder of the body;
• directions involves teaching pupils to improve patterns of movement and posture for themselves;
• end-gaining and the means whereby, which requires focusing on the process rather than the result.

The AT is largely consistent with a conventional understanding of the physiology of the body to explain its underlying mechanisms.
Dr David Garlick, former director of sports medicine programs at the University of NSW, reviewed AT in 1990 and wrote that there is evidence the brain works at a subconscious level to control the musculoskeletal system to perform postures and movements (e.g. sitting at a desk), which allows a person to direct their conscious attention towards other stimuli and activities (e.g. typing on a computer).2,5 However, when a posture or movements are faulty - for example, when sitting at a desk is performed using overly contracted muscles in the neck, shoulders, buttocks and thighs and decreased muscle tension in the lumbar region and deeper trunk muscles - a wide range of medical conditions can be
caused or exacerbated, most commonly musculoskeletal problems due to joint, ligament, muscle and soft-tissue compression and/or stress, explains Mr Moore. It may also have a detrimental effect on respiratory capacity, balance and coordination, he adds.
Teachers of the AT maintain it achieves improvement of posture and movement through a cognitive process that involves consciously changing the pupil's subconscious neural patterns.

Practice

Sessions are usually one-on-one between teacher and pupil, lasting 30-60 minutes. The first session involves an interview, assessment of patterns of body movement and posture, and education, says David Moore. 'The teacher will observe the student in ordinary activities, such as sitting, standing and walking, and perhaps also activities they spend a lot of time doing, such as sitting and playing a musical instrument,' he says. 'The teacher will then provide verbal instructions and place his or her hands on the student's body to guide the student and give a clearer idea of the faulty patterns that need to be inhibited and how to gradually direct themselves in a more balanced and easy manner.'

Examples of verbal instructions include: 'Allow the neck to be free and the head to move up', 'Release your shoulders out to the sides', 'Let the torso lengthen and widen', 'Let the legs release away from the torso'. Improvement in symptoms can be felt during or immediately after the first session, although more commonly after several sessions, says Mr Moore. Lessons are continued after improvement in symptoms, with the aim of achieving a long-term educative change. As a result, the average pupil attends 30 sessions, initially twice a week and later once a week, he says. However, there are variations in treatment approaches. Michael Fox, a physiotherapist and AT teacher in Launceston, Tasmania, uses the practice as a treatment modality as well as an educative tool. He spends five or six sessions with patients, then refers onwards if there is no improvement in symptoms.

Evidence

Investigators of the AT have performed observational case-control studies since the mid-20th century; however, there is a paucity of recent scientific research on the technique, although some individual studies have shown positive results. A 2003 systematic review found four controlled clinical trials that met their inclusion criteria, but only two were methodologically sound and clinically relevant. One of the two studies was a 2002 randomised controlled trial investigating 93 people with Parkinson's disease, which found significant improvements in selfreported disability, as well as reduced measures of depression7 - see JCM 2003;2(2):88. The other study found improvement in pain and disability in patients with back pain. Positive results from pilot studies include improved motor control and reduced pain in people with low-back pain, improved balance in healthy older women at risk of falls, and improved respiratory function as measured by spirometry. However, although the AT has been suggested by some proponents as being beneficial for asthma, a 2005 Cochrane review could find no trials for chronic asthma meeting their selection criteria, and therefore no meta-analysis could be conducted.

Education, associations and registration

In Australia, most teachers complete three years of training that is recognised by the Australian Society of Teachers of the AT (AUSTAT), which has 150 members. Another 100 teachers are members of smaller associations. There are no registration requirements for AT teachers in Australia.

Integration

General practice - GPs can regard the AT as one of a number of musculoskeletal educative methods that have a therapeutic benefit, such as Feldenkrais (which posits that working on any part of the body will influence the whole, whereas AT emphasises head-neck-back alignment), and workplace postural education. Patients can be referred to an AT practitioner through AUSTAT at www.austat.org.au. Alternatively, GPs may integrate the method more fully. 'In my practice I apply educative techniques that I have learnt through reading and also as a student of the AT for some years,' says Dr John Troy, a GP in Fremantle, WA. 'Patients presenting with musculoskeletal and pain-management problems are the ones that primarily gain benefit. However, I also apply it to other presentations, such as older patients at risk of falls due to poor balance.' Dr Troy says GPs who see many patients with musculoskeletal and pain problems may gain benefit from personally participating in the practice. 'The AT is such a sensory approach that the best way to learn is to experience it,' he explains.

Pharmacists

Pharmacists familiar with the AT can recommend it as a normal part of counselling where, for example, a customer is receiving medications for a musculoskeletal problem or pain management and the pharmacist observes faulty patterns of movement and posture.

References

1 The Society of Teachers of the Alexander
Technique. URL http://www.stat.org.uk/pages/
historypage.htm, accessed 27 June 2005.
2 Rathbone M, 'Helped by a better body language',
Australian Doctor, 12 April 2002, pp 51-2.
3 Australian Society of Teachers of the
Alexander Technique. URL http://www.
alexandertechnique.org.au/MP5.html, accessed
30 June 2005.
4 Alexander FM. The Use of the Self. London:
Orion, 2001.
5 Garlick D. The Lost Sixth Sense - A Medical
Scientist Looks at the Alexander Technique.
Sydney: University of NSW, 1990.
6 Ernst E, Canter PH. The Alexander technique:
a systematic review of controlled clinical trials.
Forsch Komplementarmed Klass Naturheilkd
2003;10(6):325-9.
7 Stallibrass C, Sissons P, Chalmers C.
Randomized controlled trial of the Alexander
technique for idiopathic Parkinson's disease.
Clin Rehabil 2002;16(7):695-708.
8 Vickers AP, et al. The impact of the Alexander
technique on chronic mechanical low back
pain. Unpublished report, 2000.
9 Cacciatore TW, Horak FB, Henry SM.
Improvement in automatic postural
coordination following alexander technique
lessons in a person with low back pain.
Phys Ther 2005;85(6):565-78.
10 Dennis RJ. Functional reach improvement in
normal older women after Alexander Technique
instruction. J Gerontol A Biol Sci Med Sci
1999;54(1):M8-11.
11 Austin JH, Ausubel P. Enhanced respiratory
muscular function in normal adults after lessons
in proprioceptive musculoskeletal education
without exercises. Chest 1992;102(2):486-90.
12 Dennis J, Cates C. Alexander technique for
chronic asthma. The Cochrane Database of
Systematic Reviews 2005(2):CD000995. URL
http://www.cochrane.org/cochrane/revabstr/
AB000995.htm, accessed 17 June 2005.

John Kron is a medical journalist. The Editor thanks Michael Shellshear, BA, NAUSTAT, NLP, ATMS, President of the Australian Society of Teachers of the Alexander Technique, for his kind assistance in the peer review of this article.

Reprinted with permission from The Journal of Complementary Medicine 2005;4(5):31-6, www.jnlcompmed.com.au