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Potential Mechanisms of the Alexander Technique: Toward a Comprehensive Neurophysiological Model

Authors:

Abstract

The Alexander technique (AT) has been practiced for over 125 years. Despite evidence of its clinical utility, a clear explanation of how AT works is lacking, as the foundational science needed to test the underlying ideas has only recently become available. The authors propose that the core changes brought about by Alexander training are improvements in the adaptivity and distribution of postural tone, along with changes in body schema, and that these changes underlie many of the reported benefits. They suggest that AT alters tone and body schema via spatial attention and executive processes, which in turn affect low-level motor elements. To engage these pathways, AT strategically engages attention, intention, and inhibition, along with haptic communication. The uniqueness of the approach comes from the way these elements are woven together. Evidence for the contribution of these elements is discussed, drawing on direct studies of AT and other relevant modern scientific literature.
Cacciatore, Johnson, and Cohen. Potential Mechanisms of the Alexander Technique –
Toward a Comprehensive Neurophysiological Model. Submitted to Kinesiology Review,
July 2020.
1
Potential Mechanisms of the Alexander
Technique - Toward a Comprehensive
Neurophysiological Model
Timothy W. Cacciatore, Patrick M. Johnson, and Rajal G. Cohen
Abstract
The Alexander technique (AT) has been practiced for over 125 years. Despite evidence of its
clinical utility, a clear explanation of how AT works is lacking, as the foundational science
needed to test the underlying ideas has only recently become available. We propose that the core
changes brought about by Alexander training are improvements in the adaptivity and distribution
of postural tone, along with changes in body schema, and that these changes underlie many of
the reported benefits. We suggest that AT alters tone and body schema via spatial attention and
executive processes, which in turn affect low-level motor elements. To engage these pathways
AT strategically engages attention, intention, and inhibition, along with haptic communication.
The uniqueness of the approach comes from the way these elements are woven together. We
discuss evidence for the contribution of these elements, drawing on direct studies of AT and
other relevant modern scientific literature.
Keywords: Postural tone, body schema, body axis, muscle tone, somatic practice,
musculoskeletal pain
MECHANISMS OF THE ALEXANDER TECHNIQUE – Cacciatore, Johnson, and Cohen
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Evidence is mounting that practicing the Alexander technique (AT) has a range of
benefits. Clinical research suggests that it can help alleviate common musculoskeletal complaints
such as chronic back, neck, and knee pain (Little et al., 2008; MacPherson et al., 2015; Preece,
Jones, Brown, Cacciatore, & Jones, 2016). AT may improve responses to stress (Glover, Kinsey,
Clappison, & Jomeen, 2018; Gross, Cohen, Ravichandra, & Basye, 2019; Gross, Ravichandra, &
Cohen, 2019; Klein, Bayard, & Wolf, 2014; Valentine, Fitzgerald, Gorton, Hudson, & Symonds,
1995; Zhukov, 2019) while also improving motor performance on tasks as specialized as playing
a musical instrument or as basic as standing, walking and breathing (Austin & Ausubel, 1992;
Cacciatore, Gurfinkel, Horak, & Day, 2011; Cacciatore, Mian, Peters, & Day, 2014; Cohen et al.,
2020; Cohen, Gurfinkel, Kwak, Warden, & Horak, 2015; Hamel, Ross, Schultz, O'Neill, &
Anderson, 2016; O'Neill, Anderson, Allen, Ross, & Hamel, 2015). See Woodman (2012) for a
fairly recent clinical review. Until now, however, a comprehensive explanation for the
mechanisms by which AT operates has been lacking (Woodman & Moore, 2012).
Because of its century-long history, AT suffered scientifically from being “ahead of its
time.” Initial investigations into possible mechanisms of AT had to rely on sparse scientific
literature (see Barlow, 1946; Jones, Hanson, Miller, & Bossom, 1963) that referenced reflex
models of posture that are now known to be out of date (Davidoff, 1992). In addition, the
comprehensive and multifaceted nature of AT does not lend itself to simple experimental
designs, and the foundational science and technology needed to test the underlying ideas have
only recently become available.
In recent decades, our collective understanding of neuroscience and psychology has
progressed immensely, such that there are now solid bodies of research in which to ground our
theories and research. In the last 15 years, some reports addressing possible mechanisms of AT
have been published (Becker, Copeland, Botterbusch, & Cohen, 2018; Cacciatore, Gurfinkel,
Horak, Cordo, & Ames, 2011; Cacciatore, Gurfinkel, Horak, & Day, 2011; Cacciatore et al.,
2014; Cohen et al., 2020; Cohen et al., 2015; Hamel et al., 2016; Loram, 2013; O'Neill et al.,
2015), while other research has elaborated on concepts relevant to AT’s function.
MECHANISMS OF THE ALEXANDER TECHNIQUE – Cacciatore, Johnson, and Cohen
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In this paper, we propose a comprehensive model of the underlying mechanisms of AT.
Based on published evidence, we posit that mental phenomena, such as intention and spatial
attention, influence postural tone, the background muscle activity that stabilizes body
configuration—and that these changes in postural tone in turn affect many aspects of the motor
system. We further posit that broader research on interconnections between postural tone and
body schema may help explain changes in body-based self-perception through AT training.
Although AT affects pain and is likely to affect mood, our model suggests that those effects are
downstream from (or at least interdependent with) changes in the motor system.
A key purpose of our model is to explain AT’s generalizability, meaning that something
learned in one task carries over to other activities. By explicating the role of postural tone in
motor activity, we can start to understand how AT can have such a wide range of effects.
What Is AT?
The most common reasons people study AT are to overcome problems with chronic
musculoskeletal pain and to improve posture, general well-being, or skilled performance (Eldred,
Hopton, Donnison, Woodman, & MacPherson, 2015). AT is usually taught either in one-to-one
sessions or small group classes. Activities in sessions often include basic actions such as
standing and sitting, as well as more complex actions such as speaking, singing, walking,
running, and writing. Alexander teachers use verbal and manual guidance to assist in improving
postural coordination, kinesthetic perception, and functionality in everyday activity.
A distinguishing feature of AT is that sessions do not focus on perfecting particular
movements, practicing balance tasks, or imposing a specific postural alignment. AT differs
markedly from popular approaches to posture which emphasize effortfully lifting the head,
straightening the back, squeezing together the shoulder blades, and tensing the abdominal
muscles (American Chiropractic Association (n.d.); Harvard Medical School (n.d.); Medline Plus
(2020, February 10); National Osteoporosis Foundation (2018, August 7); Peeke, (2015, August
18)). Instead, pupils learning AT practice noticing and altering counter-productive muscular
tensions and automatic reactions that occur at rest, in anticipation of action, and during
movement. The practice of attending to posture and reaction before and during activity is thought
MECHANISMS OF THE ALEXANDER TECHNIQUE – Cacciatore, Johnson, and Cohen
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to lead to global improvement in motor behavior, reduction in anxiety and pain, and increased
self-efficacy. While AT concerns itself with improving the accuracy of body-based self-
perception, a focus of training is on not micromanaging the details of coordination. AT posits
that “non-doing” attention and intention on certain areas of the body—for example, the head-
neck region—can have cascading benefits throughout the neuromuscular system.
Reported Effects on Movement and Balance
The AT has been shown to affect at least two major categories of motor action:
movement and balance. We will discuss the proposed mechanisms for AT’s generalizability after
briefly reviewing evidence for its broad motor effects.
Movement
Evidence that AT affects movement comes from four different motor domains: rising
from a chair, walking, breathing, and movement preparation.
Rising from a Chair. Alexander teachers traditionally include work with students rising
from a chair, with some teachers incorporating the activity extensively into their lessons. Studies
have found that a major effect of Alexander training on rising from a chair occurs during the
forward weight shift (Figure 1). Alexander-trained participants demonstrate a smooth weight
transfer consisting of a gradual increase in foot force and a relatively uniform forward velocity,
while control participants abruptly increase foot force and forward velocity at seat off,
suggesting a reliance on forward momentum (Cacciatore et al., 2014). These results were
consistent across a range of movement durations, from faster-than-normal (1 s) to unusually slow
(8 s). Controls were unable to mimic the smooth weight transition of teachers even when
instructed and provided with performance feedback. Controls also demonstrated changes in
spinal alignment during weight shift that were not present in Alexander-trained individuals
(Figure 2), who maintained a near-isometric spine (Cacciatore, Gurfinkel, Horak, & Day, 2011).
MECHANISMS OF THE ALEXANDER TECHNIQUE – Cacciatore, Johnson, and Cohen
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Figure 1. Coordination of sit to stand in AT teachers and controls. Adapted from Cacciatore et
al. 2014.
A. Subjects (10 AT, 10 Controls) were asked to stand up as smoothly as possible at a uniform
speed from a standardized chair position. Note that the feet were far forward (shank angle was at
10 deg) making it quite difficult to rise slowly and smoothly.
B. Forward center of mass velocity across four movement durations (1s, 2s, 4s, 8s). Mean and
95% confidence interval are shown for each group and condition, aligned to the time of seat off
(vertical dashed line). Movement durations did not differ between groups. Control subjects were
unable to prevent the abrupt increase in forward velocity for the two slower conditions and in
general used a higher peak velocity for the same movement duration. Alexander teachers were
able to perform a slow, smooth chair rise with a relatively uniform forward velocity.
C. Vertical force under the feet. Group means and confidence intervals are shown. Vertical
dashed line is seat off. Alexander teachers had an early and gradual rise in underfoot force while
control subjects had an abrupt rise just before seat off across all movement durations.
MECHANISMS OF THE ALEXANDER TECHNIQUE – Cacciatore, Johnson, and Cohen
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Figure 2. Spinal angles at three different levels for control subjects and Alexander teachers
during a chair rise. Each trace represents data from an individual subject. Alexander teachers had
far less spinal movement than control subjects, in both their necks, upper torsos and lumbar
region. Note that movement occurred during the period of changing spinal forces around seat off.
Thoracic and lumbar angles are calculated as in Figure 5. Adapted from Cacciatore, Gurfinkel,
Horak & Day, 2011.
Walking. Three studies have examined the effects of AT on gait. One study found that
following Alexander lessons, patients with knee osteoarthritis had decreased knee co-contraction
while walking (Preece et al., 2016) that correlated with decreased pain. A second study found
reduced medio-lateral center of mass displacement in older Alexander teachers compared to age-
matched controls during fast paced walking, as well as significantly smaller stride width and
lower gait timing variability (O'Neill et al., 2015). A third study found reduced trunk and head
motion but increased ankle joint motion in older Alexander teachers compared to age-matched
controls during the stance phase of gait (Hamel et al., 2016). During the swing phase, Alexander
teachers displayed greater hip and knee flexion than controls, more like the coordination of
younger subjects.
Breathing. AT is often used to improve breathing. This is reflected in the prevalence of
Alexander training in music and theater departments (including such prestigious conservatories
Control SubjectsAlexaner eacers
ThoracicLumbar Cervical
1

MECHANISMS OF THE ALEXANDER TECHNIQUE – Cacciatore, Johnson, and Cohen
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as The Juilliard School, The Royal Academy of Music and Yale School of Drama), in many
anecdotal reports (Heirich, 2011), and in several case studies (Bosch, 1997; Kaplan, 1994; Lloyd,
1986). In addition, a controlled study found improvements in several breathing measures after a
series of 20 AT lessons, while improvements did not occur in the control group. Notably, AT-
related improvements in maximal expiratory pressure, maximum inspiratory pressure, and peak
expiratory flow occurred without practicing specific breathing exercises (Austin & Ausubel,
1992). In contrast, a study of musicians did not find improvements in peak flow rates after 15
lessons, although improvements in heart rate, self-reported anxiety and musical and technical
performance were found (Valentine et al., 1995). The different result in the latter study may be
because of the prior training of the musicians (Klein et al., 2014).
Movement preparation. Two studies demonstrated improvement in movement
preparation following instructions similar to those used in Alexander lessons. Loram and
colleagues demonstrated that intentionally reducing activity in surface neck muscles while
playing the violin led to beneficial cascading effects throughout the musculoskeletal system
(Loram, Bate, Harding, Cunningham, & Loram, 2016). When subjects used visual biofeedback
to reduce neck muscle activity, leg muscle activity and galvanic skin response decreased without
hindering performance. Another study found that AT-based instructions to think of effortlessly
upright posture led to better control of step initiation, with a smoother center of pressure
trajectory, than either a relaxed posture or an effortful “core strength” approach (Cohen et al.,
2015). In addition, the AT-based instruction seemed to improve the efficiency of the anticipatory
postural adjustment, as participants decreased lateral motion of the center of pressure without
affecting its backward movement during push-off.
Balance
A number of studies have found improvements in balance after AT instruction.
Functional reach increased following Alexander lessons in a controlled study of older adults
(Dennis, 1999), and preliminary work suggests that Alexander classes also improve standard
clinical balance measures in people with Parkinson’s disease (Gross, Ravichandra, & Cohen,
MECHANISMS OF THE ALEXANDER TECHNIQUE – Cacciatore, Johnson, and Cohen
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Figure 3. Effect of brief postural instructions on motor outcomes.
A. Schematic of Light, Effortful, and Relaxed instructed postures used in two
counterbalanced within-subjects studies. From Cohen et al. 2020.
B. Total integrated muscle activity from longissimus and iliocostalis muscles at the level of
the 3rd lumbar vertebra was higher in the Effortful condition than in Light or Relaxed
conditions in 19 healthy older adults. Group means and standard error bars are shown.
Adapted from Cohen et al 2020.
C. Linear distance between shoulder and ear, determined from reflective markers, was
greater in the Light condition than in the Effortful or Relaxed conditions in 20 older
adults with Parkinson’s disease, indicating a more lengthened stature. Group means and
standard error bars are shown. Adapted from Cohen et al 2016.
D. Nineteen healthy older adults were instructed to raise their left foot and hold it up for
three seconds. In the Light condition (the top line in the plot) they came closest to
achieving this goal. Group means are shown. Adapted from Cohen et al 2020.
MECHANISMS OF THE ALEXANDER TECHNIQUE – Cacciatore, Johnson, and Cohen
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2019). In addition, two studies using AT-inspired instructions found reductions in postural sway
during quiet stance and brief single-leg stance (Figure 3) (Cohen et al., 2020; Cohen et al., 2015).
Finally, a single-subject case study found that a course of Alexander lessons led to improvements
in automatic balance reactions (Cacciatore, Horak, & Henry, 2005).
Postural Tone and the Generalizability Of AT
We propose that the range of beneficial long-term outcomes of AT study and practice are
caused by improvements in the adaptivity and distribution of postural tone, along with
concomitant changes in body schema. We elaborate on this idea below.
Postural tone
Postural muscle tone, also known simply as postural tone, is the steady yet adaptable
background muscle activity necessary for opposing gravity, stabilizing the body configuration,
and organizing coordinated movement (Gurfinkel et al., 2006; Ivanenko & Gurfinkel, 2018).
Historically, it has been difficult to study due to its small magnitude and broad distribution
throughout the body (Gurfinkel, 2009). Postural tone is generated subconsciously and differs
from voluntarily holding a posture, like clenching a fist or “standing up straight” (St George,
Gurfinkel, Kraakevik, Nutt, & Horak, 2018). Tone must also be adaptable to resist forces, such
as from stretched tissues or gravity, and to comply with forces to allow desired movement and
accommodate different postures.
Axial postural tone (in the neck and torso) is especially important as the spine is central
and connects the limbs to the torso. Thus, stabilizing the axis is key for mediating interactions
between limbs and for coordinating the limbs and torso into a functioning unit (Gurfinkel et al.,
2006). Because the spine is made up of separate vertebrae, it is inherently unstable and must be
stabilized by postural tone (Lucas & Bresler, 1960). This stabilization process is complex and
redundant – one can stabilize the spine with different combinations or distributions of muscle
actions: deep vs surface; medial vs lateral, and so on (Gurfinkel et al., 2006; Moseley, Hodges, &
MECHANISMS OF THE ALEXANDER TECHNIQUE – Cacciatore, Johnson, and Cohen
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Figure 4. Surface neck muscle activity was altered following a series of 10 AT classes in 10
adults with chronic neck pain. Adapted from Becker et al. 2018.
The top figure shows peak sternocleidomastoid activation as a percent of reference voluntary
contraction (10s supine head raise) at the 5 standardized neck flexion levels of the cranio-
cervical flexion test. Testing sessions were five weeks apart. Relative muscle activation was
higher in the two baseline sessions (B1, B2) than in the two post-intervention sessions (P1,
P2). Group means and standard errors are shown. The lower figure shows a power spectrum
of sternocleidomastoid activation during two trials from the same subject at the same flexion
level before and after classes. The biggest difference was a decrease in low-frequency activity
after classes, suggesting a decrease in muscle fatigue
MECHANISMS OF THE ALEXANDER TECHNIQUE – Cacciatore, Johnson, and Cohen
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Gandevia, 2003). Crucially, tone needs to be regulated in a way that stabilizes the torso while
also allowing for mobility (Ivanenko & Gurfinkel, 2018).
Postural tone must be orchestrated across body regions. Multiarticular muscles, which
cross multiple joints, are prominent in the body, especially in the body axis. When a muscle that
crosses multiple joints exerts force, that force cannot simply be counteracted locally by co-
contracting (as is the case, for instance, with a single flexor vs a single extensor). Instead,
unbalanced tension in a multiarticular muscle may cause tension to spread across the body
(Loram et al., 2016). Such a spreading mechanism could cause spinal stiffness from poor axial
support to lead to stiffness in more distal joints, interfering with breathing, balance and mobility.
AT affects postural tone. We propose that Alexander training changes the distribution
of postural tone and makes tone more adaptive. Consequently, a person can be compliant or
resistant to external forces as appropriate to the situation.
Distribution of tone. Several studies suggest that AT changes the distribution of tone.
Notably, AT seems to shift axial muscle activity from superficial to deeper muscles. This was
first demonstrated by asking participants to sit in three ways: with their usual posture, with
“greatest height”, and with Alexander guidance. The Alexander guidance reduced superficial
neck muscle activity compared to the other two conditions (Jones, Hanson, & Gray, 1961). More
recent evidence comes from a study of people with neck pain (Figure 4), in which surface neck
muscle activity decreased during a neck flexion task following 10 group AT classes (Becker et
al., 2018). While either of these findings could indicate an overall reduction in muscle activity,
other work has shown a tendency for activity in deep and superficial neck muscles to be
negatively correlated, suggesting a shift in distribution of tone (Jull, Falla, Vicenzino, & Hodges,
2009). At first glance, it seems inefficient to activate deeper muscles which have smaller moment
arms and are thus less powerful than superficial ones. However, the deeper axial muscles such as
semispinalis and deep multifidus may allow for more precise control of position and movement
as they are shorter range and cross fewer joints than superficial muscles such as
sternocleidomastoid and trapezius. When considered collectively, the shorter range muscles have
more degrees of freedom than the more superficial muscles (Moseley et al., 2003).
MECHANISMS OF THE ALEXANDER TECHNIQUE – Cacciatore, Johnson, and Cohen
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Figure 5. Sagittal spinal curvature in Alexander teachers and age-matched control subjects
during quiet stance. Subjects were unaware of what was being assessed. Unpublished data
from Cacciatore and Horak collected at Oregon Health and Science University.
Top. Back curvature in a representative control subject and Alexander teacher.
Middle: Placement of motion capture markers.
Bottom: Mean and standard error of spinal curvature of 14 controls and 15 Alexander teachers,
defined as the sums of the three thoracic angles and two lumbar angles shown in the middle
panel. Alexander teachers had lower thoracic and lumbar curvature than controls, indicating a
redistribution of postural tone.
MECHANISMS OF THE ALEXANDER TECHNIQUE – Cacciatore, Johnson, and Cohen
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Figure 6. Axial postural tone in Alexander teachers and age-matched control subjects.
Adapted from Cacciatore, Gurfinkel, Horak, Cordo & Ames, 2011.
A. Diagram of Twister device used to measure postural tone. Shown in the configuration for
twisting the trunk between the shoulders and the pelvis. Very slow rotation of the platform
(+/- 10 deg, 1 deg/s) caused twisting. Hinges insured that only torsion was stabilized so
that postural support was necessary. A torque sensor measured resistance to twisting.
B. Resistance to twisting of the neck, trunk, and hips for 15 controls and 14 Alexander
teachers. The bottom trace indicates platform rotation. Each trace represents torque data
from a single subject across a multi-minute trial in which the region was twisted back and
forth several times. Alexander teachers had substantially lower resistance across all three
axial levels as indicated by the flatter torque traces.
C. Shift in neutral position during twisting, calculated from the shape of the resistance trace.
At all three levels, Alexander teachers had a greater shift in neutral position, indicating
more adaptable postural tone that yielded to the imposed motion. Group means and
standard error are shown. In AT teachers the neutral position of the neck and hips adapted
nearly the full magnitude (10 deg) of the imposed twisting.
10°
C
0
5
10
A
B
Hips NeckTrunk
ControlAT
Neutral Position Shift (°)
Control SubjectsAT Teachers
T
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Twist e
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MECHANISMS OF THE ALEXANDER TECHNIQUE – Cacciatore, Johnson, and Cohen
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Evidence that AT changes tone distribution also comes indirectly from observed changes in
postural alignment. Unpublished data show that Alexander teachers have reduced spinal
curvature during quiet stance compared to age-matched controls (Figure 5). Crucially, changes in
postural alignment are typically not directly instructed or manipulated in Alexander training and
therefore most likely result from a change in postural tone rather than voluntarily adopting a
position (Cacciatore et al., 2005).
Adaptivity of tone. To facilitate both stability and mobility, postural tone must adapt to
comply or resist depending on the circumstance.
Compliance. Three studies found that Alexander training improves compliance in the
body axis. This evidence was obtained via Twister, a device that assesses postural tone in
standing participants (Gurfinkel et al., 2006). The device measures the resistance to very slow
twisting of axial body regions. The measured resistance reflects the postural tone of all muscles
that cross the twisted region. As the device does not provide support, tone is required to remain
upright. Thus, the device measures postural tone and not stretch reflexes or voluntary action.
Alexander teachers were found to have half the neck, trunk and hip stiffness of matched controls
(Figure 6) (Cacciatore, Gurfinkel, Horak, Cordo, et al., 2011). Increased compliance was also
found in the trunk and hips following a course of 20 AT lessons compared to a control
intervention, after remaining stable during a pre-intervention baseline period (Cacciatore,
Gurfinkel, Horak, Cordo, et al., 2011). Another study found increased trunk compliance
following brief AT-based instructions compared to other postural instructions (Cohen et al.,
2015). Increases in axial compliance reflect increased adaptivity of tone (Cacciatore, Gurfinkel,
Horak, Cordo, et al., 2011; Gurfinkel et al., 2006).
Resistance (Matching). Several observations suggest that AT improves the ability to
accurately counteract imposed forces to maintain an intended position. Many activities common
in Alexander lessons involve matching forces in a postural context. This appears to be achieved
dynamically rather than by stiffening via co-contraction. Figure 7 shows the ability of a seated
AT teacher to precisely counteract unpredictable forces on the back, transmitting these forces
through their feet to the ground and remaining stationary. The control subject was not able to
precisely match the forces.
MECHANISMS OF THE ALEXANDER TECHNIQUE – Cacciatore, Johnson, and Cohen
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Perhaps the most common example of force matching in AT is in rising from a chair. Up
through weight shift, rising from a chair can be treated as a matching task, where gravity acts to
incline the trunk and also flex the knee and ankle by translating the femur forward. Closely
opposing these flexor torques with hip, knee and back extensors weights the feet smoothly
(analogous to the situation in Figure 7) and produces a quasi-static action, so that the movement
can be performed without relying on momentum. To perform this task well, one must activate
extensor muscles to match the sensory input while preventing excess tension that hinders
forward progression of the body mass over the feet. Alexander teachers may impart this skill in a
lesson by applying forces to a pupil’s back or neck and varying the movement trajectory
unpredictably so that the pupil cannot pre-plan a trajectory and must rely on a matching strategy.
Other observations support the hypothesis that AT improves force matching. The reduced
medio-lateral center of mass displacement in AT teachers’ gait is consistent with better matching
of contact forces from the ground up through the kinematic chain of body segments (O'Neill et
al., 2015) . Reduced medio-lateral movement in walking is sometimes seen in AT lessons; it
seems to arise through attention to postural conditions in the whole body, as opposed to focusing
on transiently stabilizing leg joints.
Postural tone affects movement and balance. As the research on AT and tone
indicates, changes in distribution and adaptivity of tone affect movement and balance. In the
broadest sense, tone is a foundational system that affects other aspects of motor behavior via
mechanical mechanisms (Gurfinkel, 2009; Ivanenko & Gurfinkel, 2018). As muscle tone
underlies postural support, it exerts a general mechanical influence on movement and balance
coordination by determining a “postural frame” for the body (Cacciatore et al., 2014). When tone
is high and unmodulated, a body segment becomes stiff, hindering its motion.
The data on Alexander teachers rising from a chair compared to untrained controls
indicate how more adaptive postural tone could help teachers solve the movement challenge of
standing smoothly from a chair across a range of speeds. Alexander teachers’ spines remained
near isometric during weight shift, indicating that spinal torques were being closely counteracted
during this period of changing axial forces (Cacciatore, Gurfinkel, Horak, & Day, 2011).
However, their spinal stability when rising from a chair was unlikely to result from high spinal
MECHANISMS OF THE ALEXANDER TECHNIQUE – Cacciatore, Johnson, and Cohen
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stiffness because teachers showed high compliance in Twister. Therefore, we can posit that AT
teachers near isometric spines during weight shift resulted from dynamically matching the
varying axial forces. In contrast, controls experienced greater changes in spinal alignment, yet
likely higher stiffness in their hips and knees. A biomechanical model found that tone-related hip
and knee stiffness could account for the inability of control subjects to smoothly rise from a chair
by hindering the forward progression of the center of mass towards the feet (Cacciatore et al.,
2014).
In the chair rise task, Alexander teachers displayed similar differences compared to
control subjects across the full range of movement speeds, including an earlier and more gradual
rise in foot force and a slower peak forward velocity. Interestingly, for the fastest movements
(with an unattainable target speed), control subjects recruited hip flexors to speed up the
movement by propelling their trunks forward, whereas Alexander teachers only displayed
extensor moments (Figure 8). This suggests that even at high speeds, Alexander teachers still
Figure 7. Resistive response to unpredictable loading applied to subjects’ backs. Unpublished
data from Cacciatore and Day, collected at Institute of Neurology, University College London.
Loading was applied with a force transducer as subjects sat with their feet on a force platform
and were instructed to not let their torsos move. The Alexander teachers (N=2) exhibited a
tight correlation between underfoot force and back force, indicating a precise resistive
response that closely matched applied loading. In contrast, control subjects (N=2) had a much
more variable relationship between back force and underfoot force, indicating a delayed and
less precise stabilization to loading. Peak forces were approximately 50N.
MECHANISMS OF THE ALEXANDER TECHNIQUE – Cacciatore, Johnson, and Cohen
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used a matching strategy, rather than a pre-planned movement strategy of flexing to move their
body mass over the feet then extending to stand up (Cacciatore et al., 2014). In particular, the
earlier and smoother rise of vertical foot force in Alexander teachers across all conditions (e.g.
Figure 1) indicates they were closely opposing gravitational forces throughout the weight shift.
Together, these findings suggest that Alexander teachers were solving the movement challenge
of smoothly rising from the chair at different speeds by adaptive use of their postural system.
In general, the body axis requires ongoing postural support to coexist with motor action.
Failure to adequately support the trunk with intrinsic muscles could lead to the recruitment of
longer range, more distal muscles for support, thereby interfering with limb movement through
spreading (Loram et al., 2016). The results of Anderson and colleagues showing that Alexander
teachers walk with reduced trunk motion but greater limb motion are consistent with the
hypothesis that AT leads to improved deeper axial postural support, thereby preventing the
spread of tension to limb muscles that would otherwise hinder leg joint motion (Hamel et al.,
Figure 8. Normalized hip torque during the 1s chair rise in Alexander teachers and controls.
Data from Cacciatore et al. 2014 as calculated from inverse dynamics.
Positive indicates net extensor torque, negative indicates net flexor torque. The dashed vertical
line indicates seat off. Mean and 95% CI for each group is shown. Note that only the control
group used a hip flexor torque at the start of the action to propel the trunk forward (black
arrow). Alexander teachers avoided use of hip flexor torque, suggesting that they used a force
matching strategy.
MECHANISMS OF THE ALEXANDER TECHNIQUE – Cacciatore, Johnson, and Cohen
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2016). The improved step initiation from AT-inspired postural instructions is also consistent with
improved action of the limbs through better axial postural support (Cohen et al., 2015).
Adaptability of postural tone may also affect balance. While one might think increased
stiffness would improve balance stability, the biomechanics of balance are complex (Latash,
2018), and in practice stiffness has been found to be detrimental. In healthy subjects, increased
stiffness impairs both static and dynamic balance (Nagai, Okita, Ogaya, & Tsuboyama, 2017;
Nagai et al., 2013; Warnica, Weaver, Prentice, & Laing, 2014; Yamagata, Falaki, & Latash,
2018). In patients with Parkinson’s disease, high neck (Franzen et al., 2009) and hip stiffness
(Wright, Gurfinkel, Nutt, Horak, & Cordo, 2007), as assessed by Twister, correlated with poorer
balance and motor performance. This suggests that axial tone can affect balance-related
activities, which are largely performed by the limbs. Note that balance could be compromised by
failing to stabilize the spine from interaction torques caused by moving a limb. Thus, good
balance may require precisely modulating axial tone to counteract such interaction torques.
Body schema
Body schema is the set of internal representations of the body that the motor control
system relies on when planning and executing movement. In order to plan an action, the motor
system integrates noisy sensory information from different sources into a coherent model of
current body geometry (Gurfinkel, 1994; Head & Holmes, 1911; Medendorp & Heed, 2019).
This model must also include the range of possible positions and movements. As body schema is
used as a central reference for posture, movement planning, and execution, its accuracy,
precision, and integration with the motor system are likely to have widespread motor effects
(Haggard & Wolpert, 2005; Ivanenko et al., 2011).
Postural tone and body schema are similar in that both concern neurophysiological states
rather than sequential processes like action, and both are particularly suited to influence motor
behavior in general (Gurfinkel, 2009; Ivanenko & Gurfinkel, 2018; Medendorp & Heed, 2019).
Gurfinkel and colleagues proposed that tone and body schema work together to govern postural
organization and provide a foundation for movement and balance (Gurfinkel, 1994; Gurfinkel,
Ivanenko Yu, Levik Yu, & Babakova, 1995; Gurfinkel, Levick, Popov, Smetanin, & Shlikov,
1988).
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Changes in body schema could also underlie changes in the adaptivity of tone. In the case
of Twister, for example, if the trunk is represented as only one or two large blocks, the motor
system will not have a sufficiently detailed model to interpret the subtle incoming sensory
information and respond by precisely modulating the distribution of tone (Cacciatore, Gurfinkel,
Horak, Cordo, et al., 2011; Cohen et al., 2015). Conversely, if the tone is rigid and
undifferentiated so that the trunk moves as only one or two articulated blocks, this is likely to
affect how the trunk is represented in the body schema (Gurfinkel, 1994).
One way of understanding the body schema is by analogy to a detailed reference manual
to the body that the motor system can access all or part of as needed. If, for whatever reason, the
motor system fails to access the needed part of the reference manual, the output of the motor
system will be less accurate (V.S. Gurfinkel, personal communication, 2003).
While there is no direct evidence that AT changes body schema, several anecdotal
observations support its relevance to AT practice. For instance, AT lessons commonly use
attention to the body and peripersonal space to influence tone, and it is common for pupils to
report changes in perception of their body configuration during an AT lesson. When we describe
protocols for assessing body schema to Alexander teachers (e.g., Parsons, 1987), there is
widespread acknowledgement that these body schema tasks resemble the type of spatial attention
used in AT. (Over 100 teachers were surveyed informally during a series of workshops 2016-
2020). Finally, chronic back pain and hand pain are associated with deficits in body schema,
suggesting that improving it may be a component of AT pain reduction (Gilpin, Moseley,
Stanton, & Newport, 2015; Moseley & Flor, 2012). The possible connections among body
schema, postural tone, and motor control suggest an intriguing area of potential research on
changes in body schema through AT instruction.
Model of AT Mechanisms
Our basic model is shown in Figure 9. In this section, we describe the model’s block
elements, followed by the numbered interactions between them. Postural tone (possibly in
interaction with body schema) forms the central node in our model. In AT, spatial and body
schema phenomena are thought to be deeply interwoven with tone, as described above. Changes
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20
in tone lead to changes in the perception of the structural organization of the body, and an
improved body percept facilitates further improvements in tone. Filled arrows indicate an
evidence base that includes direct research on AT. Open arrows indicate an evidence base from
relevant scientific fields, with future research needed to establish the relevance to AT.
We suggest that the body axis plays a central role in AT because of the critical function of
postural tone in this region, due to the spine’s instability and its central location, which requires
that axial tone mediates interactions between limbs. The deep spinal muscles may be particularly
important because their shorter spans offer greater degrees of freedom when considered
collectively to counter forces (Moseley et al., 2003). Deep spinal muscles also provide intrinsic
support for the neck and trunk, in a way that gives a stable base for movement while minimizing
the undesirable spreading of tension into the limbs. Thus, failure to adapt axial tone could lead to
whole-body restrictions that could manifest as jerky, uncomfortable, or poorly controlled
movement. Correcting this failure could have wide-ranging benefits. The neck may be especially
crucial due to its proximal location at the top of spine and direct role in orienting the head
(Loram et al., 2016).
Figure 9. Proposed model of AT. Postural tone and body schema form the hub of the model.
Grey filled arrows indicate relationships that are corroborated through published data on AT.
Open arrows indicate relationships supported by experiments not directly on AT. See text for
explanation.
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The model proposes that postural tone interacts with executive processes, motor acts,
emotional regulation, and pain.
1. The first arrow indicates the influence of executive function on postural tone in
Alexander study and practice. This includes the processes of directing attention to
postural tone and body schema, applying inhibitory control to motor planning and
execution to prevent automatic patterns of muscle activation, and monitoring departures
from postural intentions.
The AT process of “directing” involves applying specific intentions to postural tone,
body schema, and spatial awareness. Changes in tone from AT-based instructions
suggest that executive function can influence tone and body schema (Cohen et al., 2020;
Cohen et al., 2015). This process may be related to what movement scientists call
“kinesthetic motor imagery,” (Chiew, LaConte, & Graham, 2012), although such studies
mostly examine the mental representation of overt movement rather than mental
representations of desired postural states (c.f. Gildea,Hides, & Hodges, 2015).
The AT process of “inhibiting” may refer to the undoing or prevention of unnecessary
tensing, whether at rest, in anticipation, or during an action. In a lesson, it may also refer
to preventing the planning of an action, such as when rising from a chair using a
matching strategy. The Alexander process of inhibiting may also refer to a more general
intentional calming of the nervous system (see John Nicholls in Rootberg, 2018).
2. The second arrow indicates how motor behavior is influenced by postural tone and body
schema. In general, tone affects mobility because excess stiffness interferes with joint
motion and balance (Cacciatore et al., 2014; Warnica et al., 2014). Local stiffness may
be important, but spreading may also be crucial, for example poor support of the torso
during a chair rise might cause excess leg tension that hinders forward motion of the
torso. Counteracting external forces, particularly along the spine, allows some motor
tasks to be performed quasi-statically, such as rising from a chair or lifting a leg in
dance. Also, preventing undesirable preparatory tensing improves movement and
balance (Cohen et al., 2020; Cohen et al., 2015; Loram et al., 2016).
Body schema may directly affect movement (other than via influencing tone):
Alterations in body schema affect the body reference used to plan action. For instance,
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Alexander teachers often help pupils perceptually understand the location of their hip
joints, which facilitates leg joint flexion, particularly in pupils who “bend at the waist.”
In addition, pupils may avoid using joints or muscles with a history of pain or injury,
leading to a reduction in the representation and functionality of these areas. Improving
the body schema by bringing attention to these “lost” areas in relation to the whole-body
organization may help previously disengaged areas become re-engaged in movement.
3. The third arrow indicates the influence of motor behavior on postural tone. Chair work
in AT, for instance, is not about learning to stand up with a particular movement
trajectory. Performing movement tasks with particular constraints acts to inform and
influence postural state. For instance, standing up with a smooth weight shift requires
matching adaptation in extensor muscles of the back and legs, thereby acting to train the
distribution and adaptivity of tone. The study from Loram and colleagues provides
another example of how a movement constraint can affect posture. Instructions and
biofeedback to minimize neck tension while playing the violin led to changes in
coordination that extended far beyond the neck to other regions playing postural roles
(Loram et al., 2016).
4. The fourth arrow indicates the influence of postural tone on executive function.
Evidence supporting this claim comes from a recent preliminary study that found
improved performance in the Stroop task (a measure of inhibitory control) and increased
backward digit span (a measure of working memory) following a series of AT classes
(Gross, Ravichandra, Mello, & Cohen, 2019). Another study found performance on this
same test of inhibitory control to be associated with habitual posture and executive
function. Young adults with a habitual forward neck posture perform worse on the
Stroop task and self-report lower levels of mindfulness than those with more neutral
neck posture (Baer, Vasavada, & Cohen, 2019). While not conclusive, these findings
suggest that skills used to learn AT may lead to improved executive function and
awareness.
5. The fifth arrow indicates the influence of postural tone on emotion regulation. (Although
emotional state is known to affect tone, this is a more general phenomenon, and we will
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23
not address it here.) There are several possible explanations for an effect of AT on
emotional regulation. One possibility is that adaptable or reduced tension in the chest,
abdomen, and back (without collapsing the body axis) leads to deeper, slower breaths,
which downregulates a chronically overactive sympathetic nervous system (Breit,
Kupferberg, Rogler, & Hasler, 2018; Jerath, Crawford, Barnes, & Harden, 2015).
Another possibility is based on embodied cognition, which emphasizes that our
experience of emotions relies on our interpretation of bodily sensations, including
sensations of muscle tension. It is therefore plausible that activating postural patterns
associated with being calm, alert, and confident will facilitate these feelings (James,
1894; Winkielman, Niedenthal, Wielgosz, Eelen, & Kavanagh, 2015; Osypiuk,
Thompson, & Wayne, 2018). Finally, recent evidence indicates that axial motor regions,
central to AT, may have a large influence in the regulation of the adrenal response to
stress (Dum, Levinthal, & Strick, 2016).
6. The sixth arrow indicates the influence of postural tone on pain. Most of the clinical
trials showing AT’s effectiveness for pain have not examined mechanisms; the
preliminary evidence to date points to postural tone as a potential cause of AT-related
pain reduction. A small study found that a shift from surface to deep neck muscle
activity during a neck flexion task following AT lessons was associated with a decrease
in neck pain (Becker et al., 2018). Another intervention study found that decreased knee
co-contraction during gait following AT lessons correlated with decreased knee pain in
patients with knee osteoarthritis (Preece et al., 2016). Note that this study also
demonstrated an absence of changes in pain-anticipatory brain activity, supporting the
idea that postural tone underlies AT’s reduction in pain rather than a central mechanism
such as a general therapeutic effect.
Possible Underlying Neural Mechanisms
The phenomena involved in AT, such as postural tone, body schema, executive function,
movement, balance, anticipatory tensing, matching, spreading etc., almost certainly span a wide
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24
range of brain structures and processes. These can broadly be categorized into feedforward and
feedback influences on postural state (Figure 10). The neural substrates of some of these
phenomena are themselves poorly understood – especially the core element of postural tone.
Figure 10. Feedforward and feedback influences on postural state relevant for AT.
Postural tone and body schema form the core of the model. The left side of the diagram shows
feedforward influences from executive attention, inhibition, and motor plans onto postural
tone and body schema. The right side shows feedback influences on to postural state from
sensory receptors. Adapting tone and matching forces must occur through these feedback
pathways. Spreading of tone is indicated centrally, however this may also occur through
feedback pathways. See text for further explanation.
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With only two reports of measured neural activation associated with AT to date, it may seem
premature to speculate about the neural underpinnings of AT (Preece et al., 2016; Williamson,
Roberts, & Moorhouse, 2007). However, with this caveat in mind, we think it may be
informative to relate our model to neural structures.
We predict that many aspects of AT affect tone-regulating (tonogenic) structures and related
pathways. For instance, the influence of AT on adaptivity and distribution of tone via spatial
attention might occur through frontoparietal pathways involving body schema that then project to
tonogenic brain regions such as the brainstem. Executive processes might influence tone in
feedforward-planned actions via frontostriatal loops with involvement of cingulate cortex. Tone
regulation to facilitate adaptivity and matching of forces could occur via feedback pathways
through various brain levels and structures, such as brainstem, premotor cortex, and parietal
cortex. It is also possible that sensorimotor brain rhythms are involved in shaping the tonic
matching process. We start by briefly describing the neural regulation of postural tone and body
schema and then consider how various brain pathways may affect these in the context of AT
phenomena.
Brainstem and Central Regulation of Tone
Regulation of tone is poorly understood; modern explanations have moved away from a
reflex-centered model to one that involves complex central regulation from the brainstem, basal
ganglia, and other structures such as the vestibular nuclei, and cerebellum (Davidoff, 1992).
Neural integrators in the brainstem may be fundamental to generating the sustained activity for
tone from more transient signals (Shaikh, Zee, Crawford, & Jinnah, 2016). The only brain scan
data available on AT, from a single-subject pilot study (Williamson et al., 2007), found activity
in brainstem regions that participate in tone regulation (Mori, Kawahara, Sakamoto, Aoki, &
Tomiyama, 1982; Takakusaki, Chiba, Nozu, & Okumura, 2016). Thus, it is possible that AT
influences tone through connections from higher attentional areas to brainstem tonogenic
regions. In general, axial body regions are subserved by different brain pathways than those
controlling limbs, which may partially explain why axial tone is special in AT (Lawrence &
Kuypers, 1968). While peripheral feedback loops undoubtedly contribute to tone generation,
central regulation permits the learning of skills. The various aspects of postural tone, such as
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distribution, adaptivity, and spreading across the musculature, provide a complex palette with
which AT may operate.
Conceptualizing tone as a state of readiness rather than a state of muscular tension may
be relevant for understanding AT. Bernstein famously used an analogy of a musician pressing a
string down on the neck of a violin as readiness, since this determines the note but doesn’t
produce a sound until it is bowed (Bernstein, 1967). This concept of tone as readiness may
explain the ability of the body to automatically resist or comply with external forces according to
the tonic state prepared in advance. For instance, as Alexander teachers lean forward when
preparing to rise from a chair, the precise matching of forces on their spines could be due to the
configuration of tonic axial support and feedback loops before the action starts.
Sensorimotor Feedback Loops
Adapting tone to comply with external forces and adapting tone to match external forces
both require incorporating sensory information via feedback loops. However, these two
processes are fundamentally different in one respect: compliance allows changes in the body’s
position, while matching forces keeps position the same – or allows slow changes with very low
acceleration.
Compliant adaptation. As compliant adaptation causes changes in body posture that
persist after the applied forces are removed, the feedback loops for yielding must converge on
the tonogenic brain areas to change the set point of tone. Compliant tone regulation occurs
through lengthening and shortening reactions, which decreases activation when a muscle is
lengthened and increases it when the muscle is shortened (Gurfinkel et al., 2006; Sherrington,
1909). While the pathways that produce this adaptation are not understood, the long latencies and
variability of the process are consistent with cortical involvement (Miscio, Pisano, Del Conte,
Colombo, & Schieppati, 2006). Compliance can be temporarily enhanced, such as through the
Kohnstamm procedure (Gurfinkel et al., 2006). This childhood game of pressing one's arm
outward against a wall for a minute then observing it float up effortlessly induces adaptable tone
(Gurfinkel et al., 2006). Thus, AT may be engaging Kohnstamm-like processes that selectively
upregulate specific brainstem and spinal cord circuits that contribute to motor behaviour
(Ivanenko et al., 2017).
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Resistive adaptation. In contrast to compliant adaptation, force matching in AT does not
require a change to tonic set points and therefore may occur through other stabilization
processes. Thus, while the increase in extensor activity during a chair rise may come from
increased output of tonogenic structures, the increase in activity may also arise from other
pathways such as those that require the intention to not let the body deform. Feedback loops
through parietal cortex, primary motor cortex, or the cerebellum might be involved.
While tonic activity is relatively rare in motor cortex, it’s possible that the cortex
participates via sensorimotor rhythms (Shalit, Zinger, Joshua, & Prut, 2012). Some sensorimotor
rhythms couple cortical activity to muscles, to sensitively facilitate brain-muscle communication
(Oya, Takei, & Seki, 2020). Enhanced sensorimotor rhythms contribute to tonic activation of
muscles during voluntary maintenance of a position (Kilavik, Zaepffel, Brovelli, MacKay, &
Riehle, 2013). While this muscle activation does not meet the definition of postural tone, as it
depends on a voluntary intention, it may be relevant to the matching process we have described
in AT lessons.
Stabilization also occurs by feedforward mechanisms when the brain can predict forces in
advance. Such feedforward mechanisms are relevant to the preparatory activity that occurs
before an action takes place, such as pulling the head forward prior to walking (Baer et al.,
2019). in addition, preparing to tap a finger causes anticipatory stabilization all the way up the
arm into the back before the finger movement is even made, because activating finger muscles
without proximal stabilization would lead to unwanted changes in wrist and arm angles (Caronni
& Cavallari, 2009).
Fronto-Parietal Circuitry, Inhibition, and Body Schema
Abundant research has demonstrated the importance of parietal cortex, including the
temporal parietal junction, for body schema. (Di Vita, Boccia, Palermo, & Guariglia, 2016). The
parietal cortex is also involved in the representation of space around the body and is activated by
body-related words (Iriki, Tanaka, & Iwamura, 1996; Rueschemeyer, Pfeiffer, & Bekkering,
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28
2010). Thus, attending to spatial relationships of the body or peri-personal space, as in Alexander
“directing,” may engage the frontoparietal network, including body schema regions.
The parietal cortex also participates in other functions that may be relevant to AT. For
instance, it is involved in both global motor inhibition and the motor inhibition of selective body
regions (Desmurget et al., 2018; Kolodny, Mevorach, & Shalev, 2017). This parietal function
may be relevant to the “embodied” inhibition Alexander teachers describe, as it incorporates
spatial attention and body awareness. In contrast, executive inhibition is nor typically described
as relating to bodily attention (Aron, 2011). Parietal cortex also contributes to the sense of
agency, the perception that one controls one’s actions (Glover et al., 2018).
Recent research has shown that pain alters the somatotopic mapping in sensory and motor
cortices. For instance, cortical representations of the neck are altered in people with recurring
neck pain (Elgueta-Cancino, Marinovic, Jull, & Hodges, 2019). Moreover, repetitive sensory
experiences can disrupt sensory processing over time, causing distorted neural representations of
the body. This can lead to focal hand dystonia (Byl & Melnick, 1997; Loram, 2015). Addressing
body representations appears to have a positive effect on pain (Moseley & Flor, 2012). This may
involve correcting neural representations of the body (Loram, 2015).
Frontostriatal Circuitry, Beta Rhythms, and Motor Plans
Action plans, such as those used to kick a ball, type on a keyboard, or open a door, are
generated in the motor cortex, supplementary motor area (SMA), and basal ganglia through
frontostriatal loops. This circuitry is involved in the initial assembly of a motor plan from
subcomponents, and in selecting, launching, halting, or preventing execution of plans. The basal
ganglia also influence muscle tone, via connections to brainstem (Martin, 1967; Takakusaki et
al., 2016). Thus, this circuitry may contribute to the triggering of undesirable changes in tone,
such as the preparatory tension a professor might experience when approaching a podium to
lecture. It follows that the same circuitry would be involved in redressing problems with tone,
especially when the tone is associated with a motor plan.
Brain rhythms in the basal ganglia and sensorimotor cortex may contribute to inhibition
of action plans in contexts where matching forces is a more appropriate response. Beta rhythms
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29
(13-30 Hz) are thought to sustain static posture, preventing the launch of motor plans (Kilavik et
al., 2013; Solis-Escalante et al., 2019). Thus, upregulating beta rhythm may inhibit the launch of
a movement plan, facilitating the use of a matching strategy.
Support for the idea that AT engages frontostriatal circuitry comes from observations that
people with Parkinson’s disease (a neurodegenerative disease affecting basal ganglia along with
other brain areas) have especial deficits in regulating postural tone, executive function,
movement planning/preparation, and body schema (Amboni, Cozzolino, Longo, Picillo, &
Barone, 2008; Cohen, Horak, & Nutt, 2012; Moustafa et al., 2016) – all functions apparently
addressed by AT. Evidence indicates that AT is helpful for people with PD, which suggests that
AT may target regions such as the frontostriatal circuitry that are disrupted in PD (Gross,
Ravichandra, & Cohen, 2019; Stallibrass, Sissons, & Chalmers, 2002).
Prefrontal Cortex, Cingulate Cortex, and Executive Function
Because AT lessons engage with pupils’ goals and ask pupils to make decisions, brain
areas associated with executive function are almost certainly involved. Multiple subregions of
the prefrontal cortex are associated with goal-setting, decision-making, and proactive inhibitory
control (Aron, 2011). In addition, the cingulate cortex is involved in monitoring the environment
for deviations from intended outcomes and activating corrective responses (Pearson,
Heilbronner, Barack, Hayden, & Platt, 2011).
Speculation on the Nature of Hands-On Instruction in AT
Although AT can be taught without manual contact, a particular form of hand contact is
cultivated in AT teacher training, and one-to-one lessons usually include some touch. This can be
as simple as a teacher putting a hand on a particular part of the pupil’s body (e.g., ribcage or
upper back) to bring the pupil’s attention there. However, most pupils agree that there is
something “special” about the hands-on work of an Alexander teacher beyond just the choice of
where to make contact. Ideally, the postural tone of an Alexander teacher is adaptively
distributed from the axial motor system out to the limbs, so that the hands do not “grab,” or
“push,” nor are they “relaxed.” From a mechanical perspective, this may give a sort of
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30
springiness. A skilled teacher can intentionally combine resistance and compliance in a
sophisticated way that facilitates the organization of the pupil’s tone. To the student, the hands
are perceived as supportive and guiding even when the actual contact force is very light. A
similar quality of manual contact has been observed in expert ballroom dancers and practitioners
of the “soft” martial arts, such as Tai Chi and Aikido.
Anecdotal evidence from teachers’ experience suggests that body schema may partially
underlie AT hand contact. It appears that teachers expand their body schema through this contact
to include the body configuration and muscle tensions of the pupil. This may be related to the
well-established phenomenon by which primates expand their body schemas and sense of
peripersonal space to incorporate tools (Iriki et al., 1996). We speculate that Alexander teachers’
extensive experience enables them to incorporate the complex kinetic structure of a human form
into their body schema, in order to understand and communicate tensional patterns and bodily
awareness (Soliman, Ferguson, Dexheimer, & Glenberg, 2015).
Discussion
Model Strengths
Our model is broad and ambitious, with the goal of explaining as many AT-related
phenomena as possible while attempting to remain relatively simple. Our model explains effects
seen in a wide variety of AT research studies, including reduced lateral motion during gait,
smoother rise from chair, reduced activity in surface neck muscles, longer neck and spine,
greater compliance to slow rotation of the body axis, steadier balance, and improved automatic
postural coordination. It accommodates a large range of teaching styles, including verbal
instructions, hands-on work, traditional procedures, and activity work. It explains why the skills
learned in AT generalize to so many different activities, including those that are not directly
addressed in an AT lesson. It explains why the work focuses on the body axis and does not
address body parts in isolation, and why and how AT’s focus on the body axis is distinct from
popular models that focus on “core support.” By showing how body schema and tone are deeply
intertwined, it may reconcile differing perspectives about the role of sensory feedback in AT. It
describes how the engagement of the body schema may contribute to the increased sense of
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31
agency often described after lessons. We also present an outline of a plausible neural model that
awaits further elaboration and testing.
Model Limitations
The largest limitation we encountered in developing this model is the paucity of
published data to constrain it. We have therefore relied in part on anecdotal observations from
Alexander practice, such as for the incorporation of body schema. Moreover, there may be
multiple different body schemas which may extend beyond parietal cortex (Ivanenko et al., 2011;
Medendorp & Heed, 2019). In addition, the section on neural mechanisms is based on almost no
direct data of what brain regions are active when practicing AT. The most well-established tool
for brain imaging is magnetic resonance imaging, which requires subjects to lie down; this
complicates the study of postural phenomena.
Our model does not address every relevant question, such as why postural tone is not
optimal in the first place or how the AT learning process occurs over time. Both of these topics
have been explored by Loram and colleagues by treating motor selection and sensory processing
as part of a feedback loop which becomes unstable for postural phenomena (Loram, 2013;
Loram, 2015). This may be relevant for understanding the process of learning AT. Finally, there
is no data on how touch is used in AT, so our discussion on AT touch is supposition.
Conclusion
We have argued for a model of AT that is centered on postural tone and body schema,
with changes in motor behavior, emotional regulation, and pain mostly downstream from those
central changes. We have supported this model with research findings where possible. As more
basic science progress is made, the model will evolve.
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32
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... AT is educational, teaching self-management and self-care with movement as a key feature, and it is learnt both cognitively and experientially; it is taught by teachers to students in small groups or one-to-one lessons (Woods et al., 2020). AT affects posture, but not through direct control or effort; AT teachers aim to help students improve general functioning and coordination in day-to-day tasks by encouraging a non-doing, attentive awareness and a clear intention to prevent unconscious reactions, both before and during movement (Cacciatore et al., 2020). The teacher uses spoken guidance alongside gentle hand touch to communicate to, and guide, the student (Kinsey et al., 2021). ...
... The teacher uses spoken guidance alongside gentle hand touch to communicate to, and guide, the student (Kinsey et al., 2021). Common activities for a lesson are sitting, standing and walking, along with other more complex tasks available if appropriate, for example singing or running (Cacciatore et al., 2020). ...
... AT, a holistic, indirect approach, can facilitate feelings of confidence, calm and alertness (Cacciatore et al., 2020) and has been shown to help manage performance anxiety in musicians (Valentine et al., 1995). It supports well-being (Jones & Glover, 2014) and can increase embodiment (Jones & Glover, 2014;Wenham et al., 2018). ...
Thesis
Full-text available
Objective: Alexander Technique is an embodied, holistic practice most often researched as a method to support those in chronic pain or other medical conditions. It is starting to be recognised as having some psychological benefits, although a scoping literature search suggests no research into whether self-compassion may be cultivated through Alexander Technique has been conducted. Method: Research has been conducted on other embodied practices and self-compassion. The databases PsycArticles, PsycINFO, Psychology and Behavioural Science Collection, and Google Scholar were searched for this literature in June 2021, with references also examined. An integrative literature review was conducted, and a mixed analysis approach used to interpret quantitative and qualitative data. Results: Quantitative results indicated that embodied practices help self-compassion and mindfulness. Qualitative data was used to identify four interrelated themes: (1) Learning embodied mindfulness and embodied self-kindness (2) Interconnectedness with self and others (3) Choice: what I do and how I do it (4) Transformation: becoming different in my life. These reveal that self-compassion is nuanced. The results were correlated to the Alexander Technique to identify similarities. Conclusions: Embodied practices can support self-compassion in a measurable and nuanced way. They also offer additional benefits, which increase with practice and ultimately lead to transformation. It is possible that this self-compassion is experienced more deeply due to its embodied nature. The qualitative results can be clearly linked to the experience of learning AT, indicating that it may also be a route to self-compassion.
... The physiological mechanisms of the AT are not understood (Woodman and Moore, 2012) although Cacciatore et al., (2020) suggest that changes in postural tone and body schema play a role in demonstrated clinical effects. Klein et al., (2014) summarise: the AT is a psycho-physical method that helps release unnecessary muscle tension to re-educate detrimental movement patterns through intentional inhibition of unwanted habitual behaviours. ...
... Stallibrass et al. (2005) however, found there was a wide level of variation and level of commitment. These findings highlight the learning process that proponents of the AT ascribe to (Alexander, 1932(Alexander, /2018Cacciatore et al., 2020;Woods et al., 2020). ...
... This could theoretically account for fewer attempts at direct muscular control in activities and therefore less energy depletion. Other authors (Cacciatore et al., 2020) suggest benefits from learning the AT arising from a change of postural tone and body schema. ...
Article
Background The postpartum is a transitional period and potentially challenging time of heightened vulnerability for women where self-care is compromised. Mothers can ignore their needs while prioritising baby care. The Alexander Technique (AT) is a holistic self-management technique shown to be effective in managing some psycho-physical tension issues and heightening self-efficacy and self-care. The AT has potential to help compromised aspects of maternal well-being in the postpartum. Objective To explore how women familiar with the AT use it for the key postpartum issues of Sleep and rest, one of three superordinate themes identified in a qualitative interview study. Design Semi-structured interviews via Skype. Research approach: Interpretative Phenomenological Analysis. Participants Seven women, with varying levels of AT experience, 4-13 months postpartum. Findings Participants used a variety of self-care strategies through modifying their self-management with respect to Sleep and rest. Identified sub-themes were the ‘knitting‘ of maternal and infant sleep, how participants rested using the AT and recognising maladaptive habits. Key conclusions Further research into the AT as an approach to supporting perinatal well-being is warranted. Implications for practice The AT has significance for self-management, self-care, addressing maternal needs for rest, restorative sleep as well as tension issues in the postpartum.
... The theories developed here may link with existing models of the AT. Cacciatore et al.'s [57] neurophysiological model of the AT is largely based in the physical but does include 'emotional regulation' resulting from improvements in postural tone and body schema. This is similar to our first pathway of non-physical outcomes (Theory 1), in that it involves the direct impact of physical improvement on the non-physical. ...
... Further research could be a large-scale evaluation considering all the theories, or a subset of them, such as how difficult emotions are managed within AT lessons, or which people experience mind-body integration and how. Future research could also usefully integrate our theories with physical models such as Cacciatore et al.'s [57] to develop a fully psychophysical model of the AT. ...
Article
Introduction : The focus of previous research on the Alexander Technique (AT), a psychophysical self-management approach, has mainly been in musical performance, physical change, and health outcomes such as pain. This rapid realist review aimed to understand psychological and non-physical outcomes of the AT, and how they may be generated. Methods : Using a rapid review approach, papers with relevance to non-physical outcomes were identified using backward and forward citation searching from two key systematic reviews and consultation with AT experts. Results : Thirty-six documents were included for analysis, which resulted in 8 evidence-informed theory statements on how and for whom non-physical outcomes can be generated by AT lessons. A variety of non-physical outcomes of the AT were found, including improved general wellbeing and increased confidence to address present and future challenges, as well as identifying that difficult emotions can arise in lessons. Two main causal pathways were identified – 1) improvements in physical wellbeing leading directly to psychological wellbeing; and 2) an experience of mind-body integration leading people to apply AT skills to non-physical situations. Conclusions : The AT may be a useful approach in a range of settings for psychophysical, long-term outcomes, and further research is warranted. We suggest a number of recommendations for practice and further research, including for AT teacher training and the need for mixed-methods research in the AT, and factors which support a person to gain benefit, such as openness to self-management and support to attend regular lessons.
Article
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Background: Alexander technique private lessons have been shown to reduce chronic neck pain and are thought to work by different mechanisms than exercise. Group classes may also be effective and would be cost-effective. Design: A two-group pre-test/post-test design. Participants were assigned to either a general Alexander technique class or an exercise class designed to target neck pain. Both groups met over 5 weeks for two 60 min sessions/week. Participants: A total of 16 participants with chronic neck pain (aged 50+/−16 years) completed this study. Interventions: The Alexander class used awareness-building methods to teach participants to reduce habitual tension during everyday activities. The exercise class was based on physical therapy standard of care to strengthen neck and back muscles thought to be important for posture. Measures: We assessed neck pain/disability, pain self-efficacy, activation of the sternocleidomastoid muscles during the cranio-cervical flexion test, and posture while participants played a video game. Results: Both groups reported decreased neck pain/disability after the interventions. Sternocleidomastoid activation decreased only in the Alexander group. Conclusion: In this small preliminary study, Alexander classes were at least as effective as exercise classes in reducing neck pain and seemed to work via a different mechanism. Larger, multi-site studies are justified.
Article
I am not sure by what fortunate circumstance I was invited to contribute to this special issue of Kinesiology Review . However, I am deeply honored to be part of an issue with such esteemed scholars and colleagues. Like many, my introduction to the field of kinesiology was through sports, but my inspiration to pursue kinesiology as a career was the result of an injury that ended my sporting ambitions. My career is characterized by little planning, large amounts of dumb luck, a willingness to explore some paths that are less well trodden, and deep and enduring friendships that have resulted from a spirit of teamwork and collaboration. The work has been hard, the hours have been long, but the payoff has been enormously gratifying. The overarching lesson from my career for emerging scholars is to have an adventurous spirit and seek out excellent mentors and collaborators.
Article
The Alexander technique is an educational self-development self-management method with therapeutic benefits. The primary focus of the technique is learning about the self, conceptualized as a mind–body unity. Skills in the technique are gained experientially, including through hands-on and spoken guidance from a certified Alexander teacher, often using everyday movement such as walking and standing. In this article the authors summarize key evidence for the effectiveness of learning the Alexander technique and describe how the method was developed. They attempt to convey a sense of the unique all-encompassing and fundamental nature of the technique by exploring the perspectives of those engaged in teaching and learning it and conclude by bringing together elements of this account with relevant strands of qualitative research to view this lived experience in a broader context.
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