Alexander Technique and Parkinson’s Disease: the research

Both the NHS and Parkinson’s UK recognise that the Alexander Technique (AT) is useful for people living with Parkinson’s Disease (PwP). In fact, there has been over 25 years of research into the benefits of AT in this context.

The first important study was a randomised controlled trial demonstrating that AT had a positive impact on PwP’s everyday activities, their disability and their emotions. More recent research has focused on the mechanisms whereby AT improves balance and mobility among PwP.

You can read about the myriad ways in which AT has helped PwP below, with all references at the end.

Stallibrass (1997)

A small preliminary study was undertaken to test whether AT could be effective in helping PwP manage their disability.

In the study, seven PwP were given an average of 12 AT lessons. Following the lessons, it was found that participants were less depressed; had a more positive body concept; had less difficulty in performing daily activities; and had less difficulty in both fine and gross movement.

Results were statistically significant, and paved the way for the large-scale study which followed.

Stallibrass et al. (2002)

Five years later, a randomised controlled trial – the gold standard of clinical research – was published with the same lead author.

It assigned 93 PwP to three different groups: 1) normal treatment 2) normal treatment + 24 AT lessons and 3) normal treatment + massage.

The research concluded that ‘lessons in the Alexander Technique are likely to lead to sustained benefit for people with Parkinson’s disease’. Findings were that:

• Regarding everyday activities, following the trial, the AT group performed with significantly less difficulty than the other two groups. Even after 6 months, the comparative improvement was maintained.
• Regarding disability, those in the AT group mentioned improvements to aspects such as walking, speech, posture, balance, energy levels, tremor, rigidity and muscle tension.
• Regarding emotions, those in the AT group mentioned being less depressed, stressed and panicked, and more positive, hopeful and self-confident.

The authors gave this explanation of why they thought AT was a useful skill for PwP:

Most people acquire the habit of focusing on the direct control of muscular effort in order to stand, sit and move. The Alexander Technique provides a different mental approach, which appears to facilitate the activity of brainstem mechanisms that control the automatic adjustment of postural support. It leads to less effort in moving, probably due to improved balance and reduced overall tension. Hence its effectiveness for Parkinson’s disease, in which symptoms combine to make movement more of an effort.

Stallibrass et al. (2005)

Stallibrass and colleagues followed up their 2002 paper with another study published in 2005. It looked at whether participants had retained the skills they had learnt six months previously. The key finding was that ‘every participant retained some degree of skill’. In summary,

Each of the pupils in the sample was still using skills they had learnt during Alexander technique lessons six months after the course had ended. The scope of application varied greatly, from application in one activity only (walking, breathing, lying in the semi-supine position) to comprehensive use of the Alexander technique as a way of organising their daily lived experience.

Cohen et al. (2015)

Ten years later, scientists published research on what lay behind some of the findings indicated by the previous studies. In other words, how was AT leading to reductions in disability among PwP?

Twenty PwP took part in this study. They were given two sets of instructions to practise: 1) “Lighten Up” instructions relied on AT principles of reducing excess tension while encouraging length, and 2) “Pull Up” instructions relied on popular concepts of effortful posture correction.

The researchers discovered that only the AT-based “Lighten Up” instructions resulted in:

• reduced postural sway
• reduced axial postural tone
• greater modifiability of tone
• a smoother centre of pressure trajectory during step initiation, possibly indicating greater movement efficiency

The researchers concluded that AT was likely to be enhancing balance and mobility in PwP by ‘facilitating increased upright postural alignment while decreasing rigidity’.

Cohen et al. (2017)

A common Parkinson’s symptom is ‘freezing of gait’. The researchers in this study showed that freezing of gait in PwP was specifically correlated with poor ‘inhibitory control’.

While the study did not investigate AT directly, researchers have hypothesized that there is overlap between the capacity for inhibitory control and the key AT skill of ‘Inhibition’ (see this article). In fact, Rajal Cohen, the lead author of the paper, has even described Parkinson’s Disease as ‘a kind of opposite of Alexander Technique’ (in this video).

Below is a short video demonstrating how PwP can use AT to overcome freezing of gait (courtesy of The Poise Project):

Gross et al. (2020)

A pilot study was conducted into the impact of an in-person AT group course for PwP. The AT experimental group of ten participants showed improvements which were retained at 3-6 months post-course, whereas the control group did not.

The AT group benefited from significant improvements in posture, as well as self-reported significant improvements in:

• freezing of gait
• anxiety
• dyskinesia

One participant described the effects of the training as follows:

If I clear my mind, go through the steps and get my poise, I can walk across a crowded basement floor without tripping over something. I can pick up an object and carry it.

Gross et al. (2022)

Next, a study was conducted to test whether PwP retained skills they had learnt after participating in an online AT group course.

14 PwP and 12 care partners completed the course. After six months, 6 PwP completed functional assessments, and 8 PwP and 6 care partners completed surveys and interviews. Compared to before taking the course, improvements in the following areas were retained six months later:

• physical performance. Improvements were retained in book-lift, penny-pickup, handwriting, simulated eating, transitions and gait stability.
• self-report of agency. Both PwP and care partners reported improved physical control. Care partners noted improvements in overall agency and emotional control.
• symptom management. PwP and care partners agreed that pain management was even better at 6 months than post-course. PwP reported continued improvement in upright posture, task focus, fine motor, and depression. Care partners reported continued improvement in offperiods, bradykinesia [slowness in movement], shuffling gait, balance, handwriting, vocal volume, swallowing, and fatigue.

The authors of the research concluded:

Alexander technique shows strong potential for long-term symptom-management retention for PWP with increased benefits after 6-7 months in some areas. Large RCTs [Randomised Control Trials] are justified.

Gross et al. (2023)

This pilot study was the first to assess the benefits of AT for the care partners of PwP. Care partners – such as spouses, children, neighbours, and other close connections – often experience emotional stress, loss-of-self (or ‘role engulfment’) and physical injury in their role.

An AT-based in-person course was run in community settings in seven cities in North Carolina (USA); groups met for 90 minutes weekly over 10 weeks.

According to the researchers, the courses were designed to:

• counter care partner isolation;
• allow peer-to-peer learning in a group setting;
• build embodied self-awareness;
• remove economic barriers;
• teach effective use of calm voice and touch to prompt care receivers;
• practise choice-making activities to enhance resilience and agency.

Outcomes were assessed before and after the intervention, and six and 12 months later. Seven of ten measured improvements were maintained at 12 months post-course, these being:

• stroop – conflict
• emotional self-efficacy
• positive affect
• fear
• emotional distress
• mindful awareness
• overall self-efficacy

References

Cohen R., Gurfinkel V., Kwak E., Warden A. & Horak F. (2015) Lighten Up: Specific Postural Instructions Affect Axial Rigidity and Step Initiation in Patients With Parkinson’s Disease. Neurorehabilitation and Neural Repair 29(9), 878-888

Cohen R., Nutt J., and Horak F. (2017) Recovery from Multiple APAs Delays Gait Initiation in Parkinson’s Disease. Front. Hum. Neurosci. 11:60.

Gross, M., Cohen R., Lazaro S., Basye M., Achabal A. & Norcia M. (2020) Poised for Parkinson’s’: Retention of Benefits from Alexander Technique Group Course for People Living with Parkinson’s Disease. Research Poster 1432845. Archives of Physical Medicine and Rehabilitation, 101(12), e149.

Gross, M., Condie, C., Grieb, J. & Cohen, R. (2022) Poised for Parkinson’s: Retention of Benefits 6-7 Months After Alexander Technique Synchronous Online Group Course. Research Poster 2184372. Archives of Physical Medicine and Rehabilitation, 103(12), e150.

Gross, M., Bellingham J., Brisset P. & Cohen R. (2023) ‘Partnering with Poise’: Retention of cognitive, emotional, and physical benefits for care partners of people living with Parkinson’s disease at 6 and 12 months after completion of an in-person Alexander-based group course. 6th World Parkinson Congress, 2023. Barcelona Spain. Abstract #1237.

Stallibrass C. (1997). An evaluation of the Alexander Technique for the management of disability in Parkinson’s disease – a preliminary study. Clinical Rehabilitation 11, 8–12.

Stallibrass, C., Sissons, P., & Chalmers, C. (2002). Randomized controlled trial of the Alexander technique for idiopathic Parkinson’s disease. Clinical Rehabilitation, 16(7), 695–708.

Stallibrass, C., Frank, C., & Wentworth, K. (2005) Retention of skills learnt in Alexander technique lessons: 28 People with idiopathic Parkinson’s disease. Journal of Bodywork and Movement Therapies, 9, 150-157.