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Modern Pain Science and Alexander Technique:
How Might Alexander Technique Reduce Pain?
Mari Hodges,
1
Rajal G. Cohen,
2
and Timothy W. Cacciatore
3
1
Medicine and Health, The University of Sydney, Sydney, NSW, USA;
2
Department of Psychology & Communication, University of Idaho, Moscow, ID, USA;
3
University of College London, Cheltenham, United Kingdom
This article brings together research from the fields of pain science and Alexander Technique (AT) to investigate the mechanisms
by which AT helps reduce pain. AT is a cognitive embodiment practice and a method for intentionally altering habitual postural
behavior. Studies show that AT helps with various kinds of pain, although the mechanisms of pain reduction are currently
not well understood. Advances in pain science may give insight into how this occurs. Modern interventions with efficacy for
improving pain and function are consistent with active approaches within kinesiology. They also share similarities with AT and
may have common mechanisms such as learning, mind–body engagement, normalization of sensorimotor function, improvement
of psychological factors, and self-efficacy, as well as nonspecific treatment effects. AT likely has additional unique mechanisms,
including normalization of muscle tone, neuronal excitability, and tissue loading, as well as alterations to body schema, attention
redirection, and reduction in overall reactivity.
Keywords:embodiment, mindfulness, biopsychosocial, mind–body, mechanism, sensorimotor
Understanding the mechanisms of pain, how it affects motor
behavior, and how to manage or alleviate pain through exercise,
movement reeducation, and other interventions is a central focus of
the field of kinesiology. Alexander Technique (AT) is one interven-
tion that has received attention recently in kinesiology (Cacciatore
et al., 2020;Woods et al., 2020), primarily for its potential to improve
health and performance (Cacciatore et al., 2014;Cohen et al., 2015;
Hameletal.,2016;Johnson & Cohen, 2023;Kinsey et al., 2021;
O’Neilletal.,2015;Woodman & Moore, 2012) and, more recently,
in regard to pain. AT has been identified as one of the complementary
and alternative approaches to movement education and important
within the field of kinesiology for more fully comprehending the
integrated nature of mind and body in human physical activity
(Anderson, 2020). This perspective is consistent with modern pain
researchers’view that pain is a whole-person experience that defies
mental–physical categorization and that the mind–body dualism
traditionally emphasized by Western medicine has limited utility for
understanding pain (Crowley-Matoka et al., 2009).
Studies show that the AT helps with various kinds of muscu-
loskeletal pain (Becker et al., 2021;Little et al., 2022;Little et al.,
2008;MacPherson et al., 2015;Preece et al., 2016). Many people
come to the AT to resolve a pain condition (Eldred et al., 2015).
Two major randomized clinical trials showed reductions in long-
term back and neck pain after a course of lessons, and one smaller
trial showed reductions in chronic knee pain. These positive results
occurred even though the AT does not typically target pain directly,
instead focusing on improving neuromuscular patterns involved in
activities of daily life.
But how and why does the AT reduce pain? This article aims to
explore these questions. Pain is complex, and modern pain science
has begun to shed light on various mechanisms behind pain and its
alleviation. Recent advances in pain science may help us to
understand ways that the AT can help to reduce pain.
Over the past few decades, there has been a substantial shift in
the field of pain science that addresses many of the limitations of
past understanding. To clarify the significance of this shift for the
AT, we will review what has previously been the mainstream
model of pain—referred to as the biomedical model—along with
its shortcomings. We will then describe a contemporary model of
pain that includes previously unrecognized factors and mechan-
isms of both acute and chronic pain.
1
Finally, we will theorize how
the AT fits into this new framework.
Pain is incredibly diverse, arising from a wide range of
conditions, from a paper cut to a broken bone to fibromyalgia
to cancer, and there are multiple aspects of the pain experience,
including sensation, emotion, and cognition. While there are broad
ranges of both contributing factors and conditions, and each pain
experience is highly individual, pain emerges from a common
protective system. This system includes peripheral nerves, the
spinal cord, and the brain—all within a person within an environ-
ment—and all of which participate in the perception of pain.
AT
AT is a cognitive embodiment practice and a method for inten-
tionally self-regulating and altering habitual postural and motor
behavior (Alexander, 1932). It is a nonexercise approach that
involves nonjudgmental, nonreactive self-observation and monitor-
ing. One of the aims of AT is to reduce reactivity during activity to
promote efficient and healthy functioning and improved perfor-
mance of tasks from the mundane to the complex. Using hands-on
and/or verbal guidance combined with “sophisticated observation”
(Tinbergen, 1973), a teacher assists the learner in developing
proprioceptive, kinesthetic, and spatial awareness, in addition to
awareness of unhelpful habitual reactions and neuromuscular pat-
terns. Learners practice inhibitory and attentional skills to promote
an overall organization of the body in relation to surrounding space
Cohen https://orcid.org/0000-0001-6691-2561
Cacciatore https://orcid.org/0009-0005-6732-790X
Hodges (mari.hodges@gmail.com) is corresponding author, https://orcid.org/
0009-0007-1034-9184
1
Kinesiology Review, (Ahead of Print)
https://doi.org/10.1123/kr.2024-0035
© 2024 Human Kinetics, Inc. SCHOLARLY REVIEW
First Published Online: Oct. 8, 2024
that facilitates adaptability of muscle tone (Cohen et al., 2015).
These skills are practiced in quiet posture and during exploration of
the processes involved in attaining a simple goal, such as standing
from a chair, and then practiced in activities of daily life. Instruction
also typically includes basic anatomy.
AT has been shown to reduce pain (Becker et al., 2021;Little
et al., 2008,2022;MacPherson et al., 2015;Preece et al., 2016) and
improve dynamic modulation of postural tone (Becker et al., 2021;
Cacciatore et al., 2011;Cohen et al., 2015), postural sway (Cohen
& Hocketstaller, 2023;Gleeson et al., 2015), and movement
(Cacciatore et al., 2014;Cohen et al., 2015;Davies, 2020;
Glover et al., 2018;Hamel et al., 2016;Johnson & Cohen,
2023;O’Neill et al., 2015;Preece et al., 2016). AT has also been
found to affect psychological outcomes such as anxiety, executive
inhibition, self-efficacy, self-management, psychological well-
being, and a sense of mind–body integration (Davies, 2020;
Gross et al., 2022;Hanefeld et al., 2021;Kinsey et al., 2021;
Klein et al., 2014;McClean et al., 2015;Woodman et al., 2018).
The Biomedical Model
and Its Shortcomings
The biomedical model posits that pain is a direct indication of tissue
damage and that the underlying pathology must be treated to reduce
pain. This idea appeals to our common sense—pain feels like
something is damaged. In fact, mainstream Western medicine for
centuries has presumed that there is an underlying anatomical cause
to pain and that this relationship is proportional: more pain means
more damage. This presumption also implies that pain without
evidence of an anatomical source is not “real,”but rather imagined
or caused by psychological problems. Additionally, it ignores
evidence of the involvement of the nervous system, including the
brain, in the experience of pain. This perspective, while deeply
ingrained in today’s approaches to pain, is limited in its utility for
understanding and addressing pain (Cohen & Quintner, 2012).
To understand these limitations, let us consider some familiar
examples. Many of us may have experienced a minor—yet incredi-
bly painful—injury, such as a stubbed toe or tension headache. In
these cases, the degree of damage is far out of proportion with the
severity of the pain. In other conditions such as chronic back pain
(Hartvigsen et al., 2018), fibromyalgia (Pinto et al., 2023), or chronic
regional pain syndrome (Marinus et al., 2011), severe pain may
occur without any identifiable structural pathology. On the other
hand, athletes injured on the field may only notice the injury after the
game is over. Also, people with significant spinal abnormalities such
as disc degeneration or hernia are often pain-free or show only weak
pain correlation with the degree of abnormality (Brinjikji et al.,
2015). Likewise with rotator cuff tears, a large percentage of people
with tears have no pain (Sher et al., 1995). In fact, recent research has
found that tissue damage is not predictive of pain severity. Pain is
such a poor indicator of the state of tissues that leading medical
bodies such as the American College of Radiology (American
College of Radiology, 2024;Hall et al., 2021) and National Institute
for Health and Care Excellence (National Institute for Health and
Care Excellence, 2016) now recommend against early scans for
people with back pain in the absence of red flags.
A Modern Understanding of Pain
There is now indisputable evidence that pain is not an unambiguous
consequence of tissue damage but rather a multifactorial and
multidimensional experience. In addition to physical sensation,
the experience of pain entails affective, cognitive, and behavioral
aspects. For example, pain involves unpleasant feelings, interpre-
tations, and protection of a body part. When studying pain,
researchers point not just to pain intensity but also to pain-related
fear and anxiety, mood disruptions, interference by pain in life
activities, and functioning. Research in recent decades has also
revealed previously unrecognized factors besides tissue damage
that influence pain (Raja et al., 2020). Biological, psychological,
and social factors interact with lived experience to create a unique
pain experience for every individual and every incident
(Karunamuni et al., 2021). While information from the body is
of course important, the brain uses all the information it has
available to determine whether the person or body part is in danger
and in need of protection. Information from the body can also be
amplified or driven by nervous system processes that will be
discussed below.
Pain as Protection
Many researchers concur that pain can be better understood when
viewed as one of the body’s protective systems (Moseley, 2007;
Wallwork et al., 2016). Pain promotes a variety of protective
behaviors to address threats to bodily integrity and increase the
chances of survival, like withdrawing of a limb, guarding, resting,
and seeking help. Protective responses include varying degrees of
sensitization of the peripheral and central nervous systems, motor
changes, and psychosocial behavior, which themselves influence
the experience of pain. The evolutionary advantage of pain is lost,
however, when pain endures for long periods of time. When this
happens, there is much more at play than tissue damage, and the
relationship between tissue damage and pain becomes more
tenuous.
Nociception
Nociception refers to processing within the nervous system of input
from a stimulus that damages, or has the immediate potential to
damage, the body. Nociception is occurring all the time and is
neither necessary nor sufficient for pain, meaning that nociceptive
input is merely one factor that may contribute to the experience of
pain (Wall, 1979). That experience can be modified at multiple
levels of the nervous system (Grace et al., 2014).
Sensitization
Sensitization is one mechanism by which increased pain occurs in
the absence of tissue damage, inflammation, or neural lesion
(Woolf, 2011). Sensitization refers to a reduced pain threshold
or a magnified response of the nervous system to stimuli and
heightened perception of pain. This type of plasticity involves
numerous mechanisms, including increased responsiveness of
peripheral nociceptors and spinal cord neurons, expanded receptive
field of nociceptive neurons in the spinal cord, recruitment of
increasing numbers of spinal cord neurons that encode both
noxious and innocuous stimuli (Coghill, 2020), and altered facili-
tation and inhibition of synaptic transmission (Basbaum et al.,
2009).
Sensitization adds extra protection by changing the way
signals are processed in the nervous system. For example, a
sunburn increases the sensitivity of the nervous system such that
a light brushing of the skin or a shower can be painful despite lack
of harm. The heightened sensitivity contributes to preventing future
2HODGES, COHEN, AND CACCIATORE
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potentially damaging behavior. While the increased tenderness
from a sunburn resolves in a matter of days, sustained changes
throughout the nervous system can occur and become an important
contributor to persistent pain.
Sensitivity can become problematic when it becomes overly
protective (Luo et al., 2014), as in the case of osteoarthritis or
chronic back pain. In chronic pain conditions in particular,
increased sensitivity can act to perpetuate pain independent of
the state of the tissues (Basbaum et al., 2009). Osteoarthritis is an
example of a condition in which a sensitized nervous system
contributes to joint pain. Evidence for this sensitization includes
greater sensitivity to pain in areas remote from the painful joint as
well as the weak correlation between structural damage and pain
(Gwilym et al., 2009;Horga et al., 2020;Lluch et al., 2014).
Sensitization may also contribute to, or become a driver of, other
pain conditions such as back pain, temporomandibular joint
disorder, headaches, and phantom limb pain even without corre-
sponding damage in the tissues (Giummarra et al., 2007;Woolf,
2011).
Sensorimotor Disruptions
A wide range of sensorimotor disruptions are also associated with
chronic pain. These include changes in the brain’s representations
of body parts and other widespread changes in the brain (Moseley
& Flor, 2012). Changes occur, for example, in relation to height-
ened attention (Clauwaert et al., 2018), inhibition (Staud, 2012),
and body schema (Bray & Moseley, 2011;Martinez et al., 2018;
Moseley & Flor, 2012). For example, a reorganized lumbar spine
representation in brain regions involved in sensory processing and
motor control has been observed in people with low back pain
(Goossens et al., 2018). Altered postural control and impaired
balance have also been observed in people with chronic neck pain
(Ruhe et al., 2011). People with persistent low back pain exhibit
reduced lumbar proprioception and have increased postural sway.
Altered position sense may contribute to development and perpet-
uation of back pain (Goossens et al., 2018). Likewise, people with
fibromyalgia have been shown to have postural control deficits
(Trevisan et al., 2017), which have been linked to impaired cervical
joint position sense (Reddy et al., 2022).
It is also clear that pain is associated with substantial and
diverse changes in the distribution of postural muscle activity and
movement coordination (Hodges & Tucker, 2011;van Dieen et al.,
2019). One such tendency is an overactivation of superficial
muscles with concurrent deactivation of deeper muscles in people
with chronic neck (Jull & Falla, 2016;Jull et al., 2008) and back
pain (Hodges & Danneels, 2019;van Dieen et al., 2019). However,
in general, the relationship between pain and motor control has
been tricky to study because of the highly individual nature of
motor changes to pain (Hodges & Danneels, 2019;van Dieen
et al., 2019).
While much remains to be learned about the relationship
between brain changes and pain, there is now growing evidence
that sensorimotor disruptions actually predict or even contribute to
chronic pain (Alshehri et al., 2024;Brumagne et al., 2019;Tanaka
et al., 2021). There is also some evidence that pain-related
plasticity can be reversed. For example, cognitive behavioral
therapy for chronic pain (Lazaridou et al., 2017;Seminowicz
et al., 2013) and hip arthroplasty for painful hip osteoarthritis
(Gwilym et al., 2010) have both been shown to reverse brain
changes. Moreover, these changes were correlated with improve-
ment in people’s pain. This supports the idea that plasticity plays a
role in perpetuating pain.
Psychosocial Factors
There is substantial evidence that psychological and social factors
are closely linked to pain (Linton & Shaw, 2011;Michaelides &
Zis, 2019). For example, people with posttraumatic stress disorder
or significant adverse experiences in childhood are at greater risk of
increased pain sensitivity and chronic pain (Meints & Edwards,
2018). Likewise, distress, fear, expectations, and beliefs about back
pain strongly influence pain intensity and the likelihood of devel-
oping back pain-related disability (Hartvigsen et al., 2018). In fact,
emotions influence processing of noxious stimuli (such as injury or
temperature extremes), reflex withdrawal from a noxious stimulus,
and pain perception (Rhudy et al., 2005). Also, the contextual
factors around an injury such as a hostile work environment, poor
sleep, or concurrent health issues may heighten a sense of threat
and increase sensitivity to pain (Moseley & Arntz, 2007;Timmers
et al., 2019). Contextual factors surrounding a treatment, including
practitioners’negative beliefs, can induce a nocebo effect (i.e.,
physiological changes brought about by expectations of negative
outcomes; Rossettini et al., 2018). The social context within which
an injury occurs and sociodemographic factors such as education
level and minority status have also been shown to influence pain
and the transition to chronic pain (Booher, 2019;Borsook et al.,
2018). Even other people’s responses to the pain can influence it
(Nees et al., 2022). Often, these threatening contextual factors are
broad and outside of conscious awareness. Essentially, anything
that can influence the brain’s evaluation of threat can influence pain
(Moseley & Flor, 2012).
Novel Interventions
Overwhelming evidence of nervous system changes and psycho-
social influences on pain, as well as reconceptualization of pain as
protective rather than indicative of damage, has led to a shift in the
understanding and treatment of pain. Newer interventions for pain
and related disability based on this shift take an active approach
toward treatment, including behavior change and sensorimotor
retraining, a more effective approach that is consistent with AT
and other large-scale approaches in kinesiology to promote health,
such as the American College of Sports Medicine’s“Exercise is
Medicine”campaign (Thompson et al., 2020).
One new intervention for chronic disabling low back pain is
cognitive functional therapy, which consists of first identifying the
many factors contributing to each individual’s pain and disability,
including movement patterns, posture, cognition, emotion, behav-
ior, social and lifestyle related aspects (Kent et al., 2023). Identifi-
cation of individual factors is followed by tailored education about
pain. Finally, individuals learn relaxation techniques and active
strategies for gradually changing thoughts, posture, movement, and
lifestyle habits. This approach is designed to engage the individual
actively in management and recovery rather than promoting a
passive attitude toward treatment, as is typical of a biomedical
approach. A recent large trial (Kent et al., 2023) showed that
cognitive functional therapy led to strikingly large and sustained
reductions in pain and disability, in contrast with older, more
conventional interventions for chronic musculoskeletal pain, which
typically show short-term, but not long-term, reductions in pain.
These results are similar to those found by the large study on AT for
chronic back pain (Little et al., 2008), which also found a substan-
tial sustained reduction in pain and disability.
Another new intervention involves graded sensorimotor retrain-
ing that addresses the altered pain processing that disrupts sensori-
motor ability (Bagg et al., 2022). This psychophysical intervention
A MODERN PAIN SCIENCE LENS ON ALEXANDER TECHNIQUE 3
(Ahead of Print)
was designed to alter how people think about their body in pain,
how they process sensory information, and how they move. After
learning about pain, participants engaged in various activities
involving proprioception and active movement, including tactile
acuity tasks, observation and mental rehearsal of different body
configurations, and a gradual progression to physical movement.
These activities are intended to reestablish nonprotective patterns of
neural activity and movement (Wallwork et al., 2016). A recent large
trial found that graded sensorimotor training led to modest and
sustained improvements in low back pain (Bagg et al., 2022).
As a result of the new understanding of how closely linked
psychological experience is to pain, the mind is now considered a
central tool to address pain. This is in stark contrast to the
biomedical model and to simple stretching and strengthening based
approaches. It also paves the way for interventions that incorporate
a mental component, like the AT.
How Might Alexander Technique
Reduce Pain?
Advances in pain science may shed light on how the AT acts to
reduce pain. AT mechanisms may overlap with the mechanisms of
newer interventions that are supported by modern pain science, as
well as many of the nonspecific effects of older and newer
interventions. In addition, there may also be unique mechanisms
specific to the AT that reduce pain. Below, we provide descriptions
of some aspects of an AT lesson that may play a role in the pain
reduction observed with AT.
Specific Effects
Touch
In addition to nonspecific benefits of touch, touch in the AT lesson
is also specifically used both to assess and to invite change in the
postural state of the student. AT touch draws attention to a region
while encouraging nonreactivity, thereby providing feedback that
promotes changes in tension. For example, a teacher might touch a
student’s neck and back, helping to redistribute postural tone by
encouraging lengthening of the student’s spine or widening of the
back, depending on the student’s presentation. A teacher might also
gently move a student’s head to promote an adaptive state of tone.
Rather than imposing a particular position, AT touch invites
adaptive postural tone. This is important because of the highly
individual nature of posture and motor control in relation to pain
(van Dieen et al., 2019).
Mind–Body Engagement
A teacher will use verbal and other means to engage the student’s
mind in relation to their body and space. The concept of mind–body
unity behind this guidance is similar to the unified person perspec-
tive advocated by leading pain researchers (Moseley, 2019). The
teacher may ask the student to notice specific parts of their body, for
example their neck or feet, without judgment or attempt to change.
This kind of accepting attitude has been shown to be associated
with movement improvements and other pain-related outcomes
(Hughes et al., 2017;Vowles et al., 2007;Wetherell et al., 2011).
The teacher may then cue the student to embody qualities such
as fluidity, support, or freedom or to encourage a certain spatial
relationship within or between body segments, such as the length
and width of their back. Such embodied cues are referred to by AT
practitioners as “directing.”For example, a cue such as “let the
back lengthen and widen”may encourage a student to reimagine
the configuration of the back, promoting changes in muscle tone
and overall postural state. The student is specifically asked to
“think”the cue and not to “do”it, consistent with the idea that AT
promotes remapping rather than repositioning. There is evidence
that promoting embodiment of particular physical characteristics
like size and strength is beneficial for pain. For example, one pilot
study showed that embodiment of a strong, wide back led to a
reduction in back pain (Nishigami et al., 2019). In a study of
symptomatic knee osteoarthritis, illusory resizing of the knee led to
significant reductions in knee pain (Stanton et al., 2018).
AT directing, guided by feedback from a teacher, may engage
and normalize body schema (Cacciatore et al., 2020). This proce-
dure may be similar to interventions involving tactile acuity
training and mental judgments of observed body positions, which
are also thought to address disturbed body schema (Bray &
Moseley, 2011;Moseley & Flor, 2012). Such tasks could act to
reengage and recruit disengaged body regions that have “dropped
out”of working body schema with the presence of pain (Moseley &
Flor, 2012). AT lessons often involve directing while performing a
functional task such as walking or bending. This way of performing
the task integrates multiple senses and thus may improve sensori-
motor disruptions, proprioception, and spatial acuity—all of which
are relevant to pain (Moseley & Flor, 2012;Wallwork et al., 2016).
Changes in Postural Tone
Postural tone refers to background muscle activity across body
regions that enables both stability and movement in gravity. Some
studies suggest that AT influences the distribution of postural tone.
For example, one study found that AT teachers have greater
adaptivity in their axial muscles than age-matched healthy controls
(Cacciatore et al., 2011). Another study showed that even a few
minutes of instruction in an AT-based approach to posture can
increase this adaptivity (Cohen et al., 2015).
AT lessons often involve activities or procedures that can be
viewed as experiments. These “experiments”allow the teacher and
the student to observe how the student’s mental changes affect their
postural tone and the activity itself. For instance, it is common for a
teacher to guide a student from sitting to standing in a slow way that
highlights the difficult-to-prevent tendency to use momentum and
lurch forward at seat-off. The teacher helps the student alter their
postural state, for instance, while the student is seated, through
encouraging them to release tension and mentally engage with the
configuration of their body. Any resulting changes in effort and
smoothness can then be observed as the student rises from the chair.
One study found that AT teachers are able to do this task more
smoothly than age-matched controls; biomechanical modeling
indicated that the difference could be explained by the greater
adaptability of the AT teachers’postural tone (Cacciatore
et al., 2014).
Changes in postural state brought about by AT are likely to
include changes in the excitability of neural circuits that regulate
tone (Cacciatore et al., 2011;Gurfinkel et al., 2006). These same
circuits have been hypothesized to underlie pain-related motor
disruption (Hodges & Tucker, 2011). Changes in postural state
may have various specific effects that relate to pain, including
(a) changing the loading on painful regions, (b) normalizing
sensorimotor function (Meier et al., 2019), (c) changes in excit-
ability (Hodges & Smeets, 2015), and (d) reducing protection from
pain (Hodges & Tucker, 2011). These changes in postural tone and
stiffness observed following AT lessons could also account for
reported reductions in knee and neck pain (Becker et al., 2021;
4HODGES, COHEN, AND CACCIATORE
(Ahead of Print)
Preece et al., 2016), perhaps via changes in excitability. In particu-
lar, the lower stiffness and higher adaptivity of muscle tone from
the AT (Cacciatore et al., 2011) could act to decrease prolonged
static or inappropriate tissue loading (Hodges & Smeets, 2015).
Self-Efficacy and Overcoming Fear Avoidance
AT’sinfluence on pain is likely mediated by improvements in self-
efficacy and reductions in fear avoidance. A large, randomized,
controlled trial on AT for back pain (Alexander technique lessons,
exercise, and massage) found significant reductions in disability
and fear avoidance (Little et al., 2008). Development of certain
cognitive skills (Laura & Jones, 2020;Williams et al., 2020) can
reduce fear and anxiety (Kinsey et al., 2021;Klein et al., 2014) and
contribute to a greater sense of control over pain, all of which are
strongly correlated with pain reduction (Edwards et al., 2016).
Through AT lessons, the student learns not to fear previously
feared movements (Kinsey et al., 2021); disconfirmation of the
expectation of pain or injury enhances learning that leads to long-
term pain reduction (Kube et al., 2022). For example, achieving a
slow, smooth sit-to-stand movement without lurching provides the
student with the opportunity to reappraise the degree of effort
required and to correct inaccurate predictions of harm when
performing the movement (Vlaeyen & Linton, 2000).
Improved movement performance and increased confidence
(Kinsey et al., 2021) also lead to an increased sense of self-efficacy
(the belief in one’s ability to engage in activities despite pain). Self-
efficacy is strongly correlated with pain reduction and reduced risk
of disability due to pain (Asghari & Nicholas, 2001). Studies on the
AT for neck pain found that increased self-efficacy after AT lessons
was linked to reduced neck pain (Becker et al., 2021;Woodman
et al., 2018).
Attention and Reactivity
There may be other ways in which the AT reduces pain, related to
attention and reactivity. For example, AT teachers often instruct a
student to attend more broadly than to the site of their pain. Aside
from distraction, this manner of intentionally redirecting attention
and expanding awareness is relevant to pain processing (Torta
et al., 2017). Movement coaching methods that direct attention
toward nonprovocative aspects of motion by prioritizing other
senses have been shown to reduce pain (Wand et al., 2023). Brain
imaging shows that diverting attention to cognitive tasks unrelated
to pain activates pain inhibitory systems (Torta et al., 2017). In
general, mindful awareness is associated with lower pain and
reactivity (Wand et al., 2023;Zeidan et al., 2012). Finally, the
AT could reduce heightened pain sensitivity by decreasing overall
reactivity. There is some evidence that the AT improves executive
inhibition (Gross et al., 2022), and this regulation of general
reactivity may act to decrease pain sensitivity (Bjekic et al., 2018).
Other Psychological Effects
Balance confidence is negatively correlated with pain (Stubbs et al.,
2014), as is a sense of safety (Zillig et al., 2023). AT may promote
feelings of safety through improvements in balance (Batson &
Barker, 2008;Cacciatore et al., 2005;Cohen et al., 2020;Cohen &
Hocketstaller, 2023), as well as an increased sense of control
(Kinsey et al., 2021), empowerment, and self-care skills (Glover
et al., 2018;Kinsey et al., 2021;McClean et al., 2015). In essence,
these types of outcomes are hypothesized to reduce overprotection
(Caneiro et al., 2022). Other studies of the AT have found that it
increases psychological well-being, optimism, and confidence.
Furthermore, a mixed methods study found that after AT lessons,
individuals changed their relationship with pain and their pain
management (McClean et al., 2015). All these psychological
factors are known to positively influence pain.
Nonspecific Effects
One of the central features of this individualized interaction is the
use of touch by the teacher. Earlier, we addressed some specific
aspects of AT touch that may contribute to reducing pain. In
addition, touch has many nonspecific effects that are beneficial
for pain. For example, it can suppress pain-related sensory input
(Mancini et al., 2015) while promoting reorganization of body
representations in the brain (Flor et al., 2001), feelings of safety and
relaxation, and a positive therapeutic relationship (Geri et al., 2019;
Jones & Glover, 2014).
There are other likely nonspecific contributors to AT’s re-
ported benefits. For instance, the fact that AT is taught by a highly
trained teacher creates expectations of improvement, which can
improve pain outcomes (Atlas & Wager, 2012;Malfliet et al.,
2019). AT is taught in an individualized manner with importance
placed on an empathetic, caring relationship between teacher and
student. This kind of individualized care has been shown to be
important when addressing persistent pain (Lin et al., 2020;Wernli
et al., 2022), and a therapeutic relationship characterized by
empathy and positive communication enhances outcomes
(Dorflinger et al., 2013;Ferreira et al., 2013). While approach and
content vary widely, a teacher generally provides education on the
principles of AT, including awareness of habitual physical and
mental patterns, whole-body organization, and the psychomotor
processes involved in changing these. Education in and of itself can
be therapeutic (Cook, 2013), particularly when combined with
movement (Wallis & Taylor, 2011). The student is also actively
involved in AT lessons, initially through both the decision to take
lessons even though they are generally not covered by health
insurance and later through engagement in exploration of posture,
movement, and thought processes. While passive approaches in
which something is done to the individual tend to have poorer
outcomes (Covic et al., 2000), active participation that depends on
engagement by the individual has been demonstrated to be benefi-
cial long-term for pain-related improvements (Blyth et al., 2005;
Nicholas et al., 2012).
Future Research
Further research to understand the multisystem mechanisms by
which AT reduces pain will help practitioners optimize pain care
and predict which individuals or subgroups are likely to benefit
from AT. Research on AT is challenging due to heterogeneity of
AT teaching, the inherent difficulty of studying postural mechan-
isms, and difficulties in obtaining funding. Because trials of
participative mind–body therapies such as AT face unique chal-
lenges to avoid bias, measures must be taken to increase the rigor of
studies, including clear protocols, appropriate comparison inter-
ventions to distinguish nonspecific effects and limit confounding
effects, and standardization of reporting (Mehling et al., 2005). We
propose that postural tone and neural excitability are fruitful areas
of investigation into the relationship between AT and pain. We
encourage future researchers to investigate pain-related outcomes
using standardized, validated self-report tools including pressure
point threshold, self-efficacy, fear of movement, anxiety, and
depression; objective tests of proprioceptive acuity; function-
A MODERN PAIN SCIENCE LENS ON ALEXANDER TECHNIQUE 5
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related outcomes such as sleep and sit to stand; and tests of central
nervous system-related mechanisms using conditioned pain mod-
ulation, brain imaging, and laterality judgments.
Conclusion
While there is evidence that Alexander Technique (AT) reduces
pain, the mechanisms by which this occurs are currently not well
understood. However, advances in pain science may shed light
on how AT reduces pain. We have seen that there is little direct
correlation between tissue damage and pain and that pain is the
action of a protective system that includes neural, biological, and
psychological mechanisms. Chronic pain is closely intertwined
with the plasticity of these systems. Modern interventions stem-
ming from the new understandings around pain show increased
efficacy for improving pain and function compared with older
interventions based on a simple biomechanical model. Many of
these new interventions share similarities with AT and are relevant
to the field of kinesiology, with its aim of understanding the
mechanisms underlying movement in relation to pain and active
approach to treatment. They may also have common mechanisms,
such as learning, normalization of sensorimotor function, and
improvement of psychological factors. AT likely has other unique
mechanisms that relate to its pedagogy, including sensorimotor
changes related to normalizing muscle tone, neuronal excitability,
and tissue loading, as well as alterations to body schema and
reducing overall reactivity.
Notes
1. Chronic pain is usually defined as pain lasting longer than 3 months.
Acknowledgments
We are grateful to Dr. Patrick Johnson for his assistance in providing
feedback and helpful comments on drafts of this article. Conflicts of
Interest: Hodges teaches Alexander Technique in private practice and has
received fees for presentations on Alexander Technique and on pain.
Cohen has received honoraria and travel-expense reimbursement for
presenting on pain. Cacciatore has received fees for presentations on the
Alexander Technique and on pain.
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