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Teaching the Alexander
Technique to People with
Parkinson’s:
Some ideas from my experience
Chloe Stallibrass
Introduction
This paper outlines some activities in lessons and approaches
to teaching that were found to be useful for many or most of
the 29 participants in the Alexander Technique group of a
recent research trial (Stallibrass, Sissons and Chalmers 2002).
My belief is that the principles of the Alexander Technique are
so effective in helping people with Parkinson’s to manage the
main features of their disease that teachers will teach successfully
without prior special knowledge of the disease. However,
there has been a demand to know how we went about it in
the research, and whether there are any generalizations that
might be helpful, and this workshop was given in response to
that interest.
Parkinson’s
There is no known cause of idiopathic Parkinson’s disease in
allopathic medicine. The diagnostic features that are most
obvious to the observer are:
Main diagnostic features of Parkinson’s
• tremor, which commonly appears to begin as cogwheel
tremor in one hand/arm
• rigidity throughout the body, including the neck and the
facial expression muscles
• postural instability
• poverty of movement – smaller, slower and less accurate
movements.
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Other common features of Parkinson’s
The following (except for oily skin) appear to relate to impoverished
movement of particular sets of muscles and the effect
of being heavily ‘pulled down’ in front.
• tiredness/weakness
• depression/apathy
• reduced facial expression
• impaired speech
• impaired swallowing
• dribbling
• pain
• bowel/urinary problems
• oily skin.
There is tremendous variation in symptoms among people
with Parkinson’s. An individual’s symptoms and their level of
disability can also change from lesson to lesson, apparently
unrelated to drug dosage, level of tiredness, etc. Sometimes
Illustration 1. Chloe teaching her father in 1994.
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people are divided into two groups: those with strong rigidity
and little or no tremor, and those with considerable tremor
but less extreme rigidity. You may notice this.
After sitting in one position or lying down for an hour or
two, people with Parkinson’s can be very stiff.
Alexander Technique
I have found learning the Alexander Technique useful for all
four diagnostic symptoms, including tremor. Our research also
found that learning new skills to help manage symptoms in
day-to-day situations often alleviated depression and apathy.
A recently published paper describes the skill retention of the
research sample six months after lessons ended (Stallibrass,
Frank and Wentworth 2005).
Some characteristics of the people who were taught
in the ways described here
They could walk up and down 20 steps and get up from the
floor with the help of furniture (in some cases with great
difficulty); they had reasonable short-term memory and had no
history of hospitalization for depression. The average length of
time since diagnosis by a consultant neurologist was 4.8 years.
Average age was 64 years.
Early lessons
The first lesson
There were three main reasons, why, in the first lesson, we
mainly practised inhibiting and directing during walking and
standing, rather than the more traditional approach of using
sit-to-stand and stand-to-sit. First, for a high proportion of the
sample, arthritis and other painful joint problems made sitting
for any length of time impossible without distraction. Second,
difficulty with walking was of great concern to all participants,
and in most cases of more immediate concern than difficulty
getting out of a chair. Third, it was vital to convince them that
conscious thought can influence balance and movement.
All but a handful of the group knew absolutely nothing
Teaching to People with Parkinson’s ~ Chloe Stallibrass
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about the Alexander Technique before starting the course of
lessons. Most of them at the start were not particularly hopeful
that it could help them. So from the very first lesson we needed
to concentrate on an activity during which the participants
could easily recognize the immediate, beneficial effects of inhibiting
and directing, in order to inspire trust in the method.
The practice rooms were 18 feet long, and changes in walking
performance could easily be felt over that distance.
During the introduction of the head–neck–back relationship,
we used practice in inhibiting starting to walk. While
inhibiting and directing, pupils were asked to consciously
include awareness of the space around themselves, within the
room and even without. We asked them to include in their
conscious awareness the space behind them (to the windows,
or the houses opposite), the space over their heads (to the
ceiling, for instance, perhaps imagining how far away it is in
feet or centimetres), the ground beneath the soles of their feet
and beneath their heels, and the space to the sides of their
upper arms. In most cases there was immediate and marked
improvement in balance and reduced poverty of movement
when they started to walk.
Walking, opening doors and turning
We continued with emphasis on walking, opening doors and
turning. Most falls in the home are the result of turning too
fast, ‘leaving the feet behind’, or tipping forward due to failure
to keep at least one heel on the ground in a confined space.
Working with my father in 1993, I discovered that making
dog-legged progress greatly increased his balance and speed.
So instead of walking by the shortest route from A to B, he
would walk in a series of right angles (Illustration 2).
At every right angle his weight automatically came 100 per
cent back onto one heel, which stimulated all the various uprighting
mechanisms. Making right-angled turns ensured that
his eyes moved around from side to side as he worked out his
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route, and this also had a beneficial effect on his balance.
Illustration 2. From bed to bathroom: dog-legged route and
usual route compared.
To avoid falling when turning in a tight space, we also occasionally
practised becoming familiar with stepping backwards
to start a turn. This avoids the likelihood of letting both heels
come off the ground at once, as stepping forwards to turn
tends to take the weight onto the toes of the leading foot. If
the heel of the back foot starts to come off the ground before
the leading foot is fully on the ground, a fall is quite likely.
Walking through doors and down corridors
It is well known that people with Parkinson’s tend to freeze in
corridors and going through doorways. During the night the
effects of the drugs which are administered three or four times
during the day, wears off, and this can make it hard to get out
of bed and go to the bathroom. Fear of freezing or rooting in
the middle of the night when the heating might be turned off
Teaching to People with Parkinson’s ~ Chloe Stallibrass
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and everyone is asleep can increase anxiety levels, and hence
muscular tension and pulling down.
Better not to get stuck in the first place. Again, working with
my father in a domestic setting, I noticed how his eyes would
fix as soon as he thought of having to get through a doorway.
After his eyes fixed, his body fixed. The desire to go forward
pulled him further forward and down. Rooting on approaching
a doorway could be totally avoided if, the moment he thought
of going through it, he looked around the whole doorframe,
side to side and the top (Illustration 3).
Illustration 3. Eye movements on approaching doorway or corridor
and while passing through.
Working in semi-supine
This was much enjoyed by everyone. Some participants spent
much of most lessons on the table.
I found similarity among participants in the pattern of holding
around the chest and upper arms, which I had not come
across in any pupils before. Arm movement, in some cases,
was very restricted to start with. But it was a pleasure to be using
the Alexander Technique and to know that with time the
whole structure would loosen and become more coordinated.
I used the ‘bird’s wing’ analogy to help direct awareness of
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connections from fingers/wing-tips to the very bottom and
top of the back.
Later in the course
Turning over in bed to get up
After several lessons we had usually practised turning over on
the floor to get up. This may seem somewhat early in a course
of lessons for such an apparently complicated movement.
However, turning over in bed to get up (especially in the
night) is particularly difficult for people with Parkinson’s, and
of vital importance to quality of life. It also helps a great deal
in locating the head on the spine and experiencing the power
of allowing the head to lead. We used the model of vertebrates
– cats, horses, tortoises – getting up from their backs.
Illustrations 4 and 5: Cat turning during a fall.
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Breathing
Of course, severe holding in the neck and thorax adversely
affects breathing, swallowing and speaking. We devoted a considerable
proportion of time to breathing, often in semi-supine.
Perhaps the most important aspect of working with breathing
was inhibition. We used ‘games’ to explore inhibition.
Bent arms
We also worked directly on the hands and on turning the
forearms, with directions and inhibition, in such a way that
the whole nervous system was stimulated up the arms.
People with Parkinson’s commonly hold their arms bent,
particularly on the side affected by tremor. A particularly effective
movement for releasing this contraction was devised by
Kathleen Ballard in 1994:
1. While inhibiting and directing, the seated pupil is asked
to let their hand rest on their thigh, with its outer (little
finger) edge on the cloth, and then to move the hand
slowly over the thigh, and from the top of the thigh and
down the outer side to the seat of the chair, constantly
stimulating the outer edge of the hand.
2. Then move the hand on, down the edge of the chair seat,
until the arm is hanging, and leave it there for a while,
(directing, of course). This is very effective in encouraging
the arm to lengthen and straighten.
3. The hand is then rotated, so that the thumb edge is
stimulated as the hand is brought back up to the start
position.
Writing
With some people we worked on writing. The writing of
people with Parkinson’s is distinctive: small, illegible, sloping
upwards on the page towards the right. It can, of course, be
improved by lengthening to the elbow, and all the normal ways
of influencing handwriting. However, if I pulled in my inner
upper arm in the pattern I had noticed in some pupils on the
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table (as mentioned above), my own handwriting instantly
took on the Parkinson’s characteristics. It was impossible to
stop it sloping up to the right, or to prevent the letters from
getting smaller.
If practising writing, it was particularly effective to include
(along with inhibiting and overall directing) attention to
lengthening up the upper inner arm; to lengthening up the
sides of the back from the iliac crests through the armpits,
being sure to include widening across the bottom of the back
(i.e. below the pelvic symphysis), and being aware of the
whole upper limb, like a wing, from the lower back to the
hand, and aware of the connections from the shoulders up
over the head.
Although we rarely applied the Alexander Technique to
other specific fine movements apart from writing, the results
of the trial show that improvement in the performance of
fine hand–eye coordinated movement of the AT group, when
compared to the ‘no extra treatment’ group, was as statistically
significant as the comparative improvement of gross movements
like walking. (Paper in preparation).
Facial expression muscles
Reduced mobility of the facial expression muscles in people
with Parkinson’s impairs communication and makes socializing
more difficult. The following procedure was very effective in
restoring flexibility of the facial expression muscles, and hence
of expressiveness. One woman’s dimple reappeared as her face
recovered its liveliness.
1. The student begins by imagining that the skin of their
face, neck and throat, right into the hairline, is one or
more centimetres deep.
2. Then, beginning under the chin, the student directs for
expansion, slowly working up the face in bands and taking
the attention right across into the hairline at each
stage.
It is important to include bony bits, such as the nose and
brows, and parts that have no name in our language, such as
Teaching to People with Parkinson’s ~ Chloe Stallibrass
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the lower part of the cheeks or under the lower lip. When at
the lips it is helpful to think of the lips from inside the mouth,
and in the shape of an athletics track (mapping the orbicularis
oris), when directing for expansion. The lower lids can be
‘mapped’ as extending a centimetre down the face. With the
eyes, encourage attention to both the nasal and the temporal
sides. The idea of panda-eyes can be helpful.
I use this ‘game’ from time to time with most of my students.
Stress and tension stiffen the facial expression muscles, and
anyone can take ten years off their age by applying directions
in this way. In the research it was mainly practised while lying
on the table, but participants enjoyed the fact that they could
practise anywhere, even while in company. It gave them a
secret agenda.
Eyes
Applying inhibition and direction to the following simple eye
movement changed impassive lids to twitching liveliness, adding
greatly to expressiveness in the face.
The student, in semi-supine, is asked to think of letting their
eyes move from left to right – but, when on the brink of doing
so, to stop, inhibit and direct several times before allowing the
eyes to move.
Part of the directions is to think of the eyes as releasing
from the left corner of each eye, so as to allow movement to
the right as if by unmooring a boat – in contrast to our habit,
which is to think of the eyes being pulled to the right by the
right-hand corners. It is a kind of lengthening into movement
for the eyes. Continue to direct with the focus of attention on
the left side of both eyes.
One participant used to practise on the tube-train, letting
his gaze shift from one of his knees to the other.
Tremor
One in 10–15 participants was not distressed by their obvious
tremor, but most of them were bothered by it, some quite
severely. Commonly used conscious ways to ‘control’ or hide
tremor in the upper limb included putting hands in pockets
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or behind their backs, and putting the moving hand under
the weight of the other hand – even sitting on it. The unconscious
response to tremor was to tighten through the arm (or
leg), beginning in the neck, and this may help account for the
stereotypical posture of people with Parkinson’s, including the
thickened neck and pulling down on the main tremor side.
Our argument was that the Alexander Technique would not
cure tremor, but that it could help manage it.
On the assumption that the unconscious habit of tightening
starts at the top of the neck (close to the basal ganglia), and
applying the principles of the Alexander Technique, I asked
participants to direct imaginary tremor out through the top
of the head in one direction, and out through the fingertips
of the hand with the tremor, in the opposite direction. The
common effect was for the tremor to get momentarily stronger
and then to peter out for an interval from several seconds to a
minute or two, or even considerably longer. Such temporary
relief, we argued, was probably beneficial in reducing the RSI
pain that some experienced in the tightened limb.
Some participants, when directing tremor out through the
top of their heads, showed a slight tremor in the jaw, which
had not been there before. I deduced from these observations
and others, that the unfamiliar feeling of the tremor had been
interpreted as ‘wrong’ and had consequently been blocked
unconsciously by muscular contraction.
The bent-forward posture that is characteristic of Parkinson’s
could also be partly due to tightening unconsciously
around the hip joints to control the tremor through the legs.
Participants could experiment with asking the imaginary
tremor to go out through their head and also through a leg.
Some participants could switch the tremor from an arm to a
leg in this way. In general it helped release the hip joints.
Pain from Parkinson’s is a common but not universal feature.
It sometimes related to the area the participant unconsciously
favoured in tightening against the tremor. Most men
tightened the forearm, and if they had pain, tended to have it
Teaching to People with Parkinson’s ~ Chloe Stallibrass
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there or around the elbow; one tightened in the armpit, and
his pain was between the shoulder blades.
Concluding remarks
People with Parkinson’s may have slow and indistinct speech,
but that is no reflection of their quickness and clarity in other
spheres. Our research shows that they can learn and apply the
Alexander Technique to good effect.
One of the distressing aspects of receiving a diagnosis of
Parkinson’s is the common accompanying stricture that they
can do nothing about it except to keep up exercise. The
Alexander Technique gives them a tool for managing disability,
and enables them to reclaim some of their autonomy by giving
them a means to influence the progress of the disease in terms
of its impact on their daily and social lives. As one person put
it, ‘it’s a godsend’.
References
Stallibrass C., Sissons P. and Chalmers C. (2002) ‘Randomised controlled
trial of the Alexander Technique for idiopathic Parkinson’s
Disease.’ Clinical Rehabilitation 16: 705-718.
Stallibrass C., Frank C. and 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 No. 2 150-157.
Chloe Stallibrass MA (Oxon); PhD (LSE); PG Dip Man (UEL);
Member: Society of Teachers of the Alexander Technique; Associate
Research Fellow, School of Integrated Health, University of Westminster.
Chloe qualified from the Constructive Teaching Centre in
1992. She had previously worked as an economist and policy adviser.
Alongside her teaching activities she has continued her interest in
research. She is interested in new ideas and new research methods
and welcomes collaboration.
Tel. +44 (0)207 483 4830
stallic@wmin.ac.uk
www.Londonalexander.co.uk
Extract from the The Congress Papers - Exploring the
Principles, from the 7th International Congress of the F.
M. Alexander Technique 2004. Published by STAT Books,
2005. Available from STAT Books:
www.stat.org.uk/pages/congresspapers.htm