Alexander Technique Workshop for Stroke Survivors: Observations on its feasibility and efficacy.
David Moore*, Caroline Blackshaw, Lynne Conway
School for F.M. Alexander Studies, North Fitzroy, Australia
* Correspondence to: David Moore, School for F.M. Alexander Studies, 330 St. Georges Rd., Fitzroy North, VIC 3068 Australia. info@alexanderschool.edu.au
Introduction
Strokes happen when the flow of blood and oxygen to the brain is stopped or interrupted and brain cells die. The disabilities that result depend on which area of the brain is damaged[1]. They may include: paralysis and/or problems controlling or coordinating movement (these typically affect one side of the body opposite the side of the brain damaged by stroke); sensory disturbances including pain; problems using or understanding language; problems with thinking and memory; and emotional disturbances. Australians experience more than 56,000 strokes per year – that’s one stroke every nine minutes[2]. More than 475,000 people are living with the effects of stroke.
Rehabilitation starts early and focuses on helping stroke survivors relearn skills that have been lost and regain independence. The recovery rate is generally greatest in the first weeks and months. In Australia stroke rehabilitation occurs in a variety of settings, including in hospital on acute or specialised rehabilitation wards, in the home, or in community outpatient settings. Ongoing support to maintain functioning or achieve small incremental gains may be funded under the National Disability Insurance Scheme (NDIS)[3].
The Alexander Technique, with its emphasis on repatterning movement, is a promising approach for stroke rehabilitation. We know that Alexander himself had a stroke when he was 78 years (in 1947) which partially paralysed his left side, and he was reported to have used the Technique to recover fully. Yet there appears to be nothing published on the effectiveness of the Alexander Technique for stroke disability (no reports were retrieved from a pubmed search) nor is there much anecdotal evidence to support the use of the Alexander Technique in stroke survivors (one youtube video[4] ). An informal survey of Alexander Teachers in Melbourne with many years of teaching experience identified experience with only a handful of stroke survivors.
One of us (CB) has been working with a stroke survivor since September 2018. Lessons began 12 months after the student’s stroke, initially once per week but increasing to twice per week, which provided momentum for ongoing improvement. The student is highly motivated and there has been considerable progress. Her left arm which was strongly spastic is now fully extended and she is much less liable to contract it when doing other activities. It has helped her other therapies be more effective. When doing her exercise program, she had tended to increase the tightness on left side but now uses the thinking strategies of the Alexander technique to prevent this from happening. Her gait is also considerably improved. Lessons are continuing twice a week.
CB was invited to present a short workshop on the Alexander Technique to the Boroondara Stroke Support Group[5], assisted by a third-year trainee from the School for F.M. Alexander Studies. (SOFMAS). Several of the participants were excited with some of the changes they saw or experienced and expressed interest in the Alexander Technique.
DM and CB decided to run a workshop for stroke survivors at The School for F.M. Alexander Studies The program was to run within the training program on four consecutive days with teachers from the Melbourne community invited to assist. This daily format was based on DM’s experience with similar Intensive programs where, with a combination of individual lessons and group work with a general population a rapid change in co-ordination in everyday activities can often be achieved. It would give stroke survivors an opportunity to experience the Alexander Technique, and to discover whether it is of benefit to their recovery or in helping them deal with day to day movement challenges. It would also give Alexander teachers exposure to and experience with a population they don’t normally work with.
This was a small exploratory observational study with the focus on discovery rather than hypothesis testing. We are sharing the observations with the Alexander Technique teaching community with the intention of informing future programs and/or studies of the Alexander Technique with stroke survivors.
Methods
This was an observational study. It was conducted over four consecutive days initially from 10am to 1pm (with 30 minute break, and then shortened by half an hour. The program was only broadly structured prior to commencement with the idea that the content and delivery could be adapted to the participants needs over the four days. We didn’t have prior details on who was attending. The program involved a period of constructive rest to start followed by the introduction of various themes by DM – e.g. body mapping of the functional movement of the leg or arm, with the emphasis on avoiding interference with the primary control. DM then worked with one or two people while the group observed, and this was followed by individual work of Alexander Technique teachers (+/- trainees) with participants on the same theme. In this workshop there would be a ratio of approximately one to one of Alexander Technique teachers (+/- trainees) to participants.
Participants were recruited from the Boroondara Stroke Support Group. There were no selection criteria and carers were also free to attend. Participants were provided with an Information Sheet and all consented to take part in the workshop, provide demographic information and a brief medical history and have deidentified data published.
We conducted a semi-structured follow-up telephone interview with each participant to determine whether there had been any change in stroke symptoms, their experience of the workshop and how likely they are to continue with the Alexander Technique and in what format. Feedback was also requested from all Alexander Technique teachers who attended the Workshop on one or more days.
Results
Participants
Five stroke survivors attended. Two attended with their wives who were also their carers and a third attended with his carer who was also a stroke survivor. Three of the participants attended all four days. Two of the participants, who had to travel two hours to attend the course came on days one and three.
All the stroke survivors were male aged between 45 and 65 years. The length of time since the stroke varied considerably from 6 months to 33 years. The two most recent stroke survivors were undergoing intensive rehabilitation aimed at the recovery of functions lost after the stroke (and were the participants who attended with their carers). One participant had ongoing water therapy and exercise sessions. The remaining two had no current therapy. Two of the participants were affected on the right side of the body and three on the left side. Although the severity of disability varied between participants all had some degree of weakness and paralysis in the affected arm and leg and all reported problems with balance and walking. One participant had significant expressive aphasia (difficulty in conveying thoughts through speech). One participant had significant and painful dystonia.
Teachers / trainees
In addition to DM and CB, seven Alexander Technique teachers attended the workshop sessions on one or more days. There were between four and six teachers in attendance on any day. The five trainees of the school also attended the workshop sessions.
The program
The first day started with a group introduction to the Alexander Technique and demonstration of the effect of freeing the neck on ease of movement of the head on the spine. This was followed by 30 – 40 minutes of constructive rest for both stroke survivors and carers with teachers (+/- trainees) working with the participants either on the floor or on a table. After a break this was followed by a group introduction to walking and then individual work of Alexander Technique teachers (+/- trainees) with participants on walking.
For the following three days the program was reduced by about 30 minutes because participants were tired. Each day started with a period of constructive rest for around 30 – 40 minutes followed by the introduction of a theme to the group then participants working individually with teachers (+/- trainees). Topics included walking, raising an arm, getting out of a chair, breathing and from breathing to vocalisation.
How we worked
Improving primary control: Before moving into guiding people through movements of arms, legs or the whole body, it is important to establish the primacy of having a good relationship of the head neck and torso, and of teaching participants to notice and inhibit parasitic movements or contractions which interfere with their overall coordination. For example, in attempts to get out of a chair or wheelchair it is not uncommon for people to put so much contraction and downward pressure through their body in their effort to get up, that they can be unable to do so.
Teaching inhibition: Bringing participants awareness to unnecessary extra tension and a harmful postural set in the initiation of movement and teaching them to stop initiating these postural sets.
Teaching direction: Helping participants to activate a more constructive underlying intention for coordination when going into movement.
Constructive rest: With the aid of a teacher lying in constructive rest was a valuable way of calming body and mind, getting more overall ease through the body and releasing some spasticity.
Body Mapping: We observed some participants used the leg on the affected side without any flexion of the hip, knee, ankle and foot. Re-establishing normal gait can only happen if there is movement in these joints, so in addition to manually guiding people in the movement of these joints it is important for them to have a conceptual idea of the location and function of these joints
Chair work: We observed and then took participants through the process of rising from and sitting onto a chair. It was used to teach them to direct and to catch and inhibit unnecessary muscular effort.
Undoing spasticity: Some of the work we were doing involved manual manipulation to gently undo spasticity in limbs, particularly arms, hands and fingers. This is input which needs to be repeated again and again, while at the same time asking the participant to send directions or intention as best they can to create this undoing.
Teaching movement patterns: As some of the spasticity releases, participants can then begin to move an affected limb. For example, extending an arm or bending a leg. Some manual guidance for those movements can be given when they are in constructive rest. If someone can’t bend a knee when they are not putting weight on it, they are unlikely to be able to do so when upright. Once the movement in this position is available, we can transfer that to more complex activities like walking, reaching, grasping etc. It is important to keep the primary control in mind at all times
What we observed
Constructive rest
The constructive rest periods benefited all stroke survivors. It also made it easy for some participants to get movement in the legs which was not achievable when they were upright, and we used this learning to ask them to bring some of that movement into upright movements. Some participants had difficulty getting onto and up from the floor, and we worked with them on a table, lowered so that they could easily sit on it. Some also needed assistance to on to and up from the table or attempted to get up in a very awkward manner.
Chair work
The chair work was an effective way of teaching the participants to use both legs equally, learning to direct their head and torso in a way which effectively brings the weight over both feet when moving into standing and back into sitting. All participants improved their ability to get out of a chair and to sit down again with greater ease over the course of the workshop.
Walking
A common walking pattern after a stoke is for the whole of the affected leg to be moved as one piece, so for those for whom this was a problem we worked with helping the participant to map the joints required for a smother movement, and to begin to bring movement to those joints without interfering with the overall coordination.
One participant could bend both knees and lower his body in space a little (movement of hip, knees and ankle). From lying down we guided him through lifting his right leg while bending the knee. But once he went into walking the leg would tend to move as a single unit and needed to be manually guided to bend his knee in the movement. The improvement at the end of four days was only slight for him.
Arm movements.
One participant could with minimal assistance rotate his affected arm out sideways, but in taking the arm forward, in a movement like shaking hands he lifted his whole shoulder girdle and the whole side of his body. We worked on bringing his attention to this, guiding him manually through the movement, while asking him to inhibit this excess movement, which he could do successfully when guided. He was beginning to do less of this excess movement by the end of the program, but it was still quite marked.
Another participant could raise his right arm a little above 90 degrees above his shoulder but then he activated inappropriate compensatory movements of the shoulder girdle and torso to raise the arm higher. We looked at various ways of gaining a little more mobility in the shoulder girdle to allow for movement which would not interfere with his Primary Control
Participant feedback
Four of the five participants provided feedback in a follow-up phone interview 1-2 weeks after the workshop finished. When asked directly if there had been a change in stroke symptoms only one of the participants responded there had been an ongoing change, noting better balance and steadier walking with bigger steps. These changes had been noted by his regular physiotherapist. Two of the participants who said there had been no change in symptoms noted other changes, better co-ordination and ease in getting up from a chair in one case and managing stairs better and more independent temperament in the other case. One participant did not find the Alexander Technique of benefit and did not see that it had a place in his rehabilitation program. The other three participants all learned something of benefit, liked the format, length, content and working with a range of teachers (gave them different experiences). All three would recommend the Alexander Technique to other stroke survivors. Two participants are keen to pursue the Alexander Technique in a group setting.
Teacher feedback
A number of general themes emerged from the teacher feedback.
The principles of the Alexander Technique (accurate body mapping, working with the whole self, inhibition and direction) are as applicable to stroke survivors as to anyone else and are an effective way of helping them manage their symptoms.
One teacher was concerned that "We do need to be clear about what we are doing and how the Alexander Technique principles support but do not replace therapeutic modalities such as physiotherapy, speech therapy etc. When working with students who have significant disability we need to guard against end-gaining."
Constructive rest provides an effective way to calm mind and body and relieve tension and stress and provides a basis to take these changes into upright activities. Some participants were only comfortable in constructive rest for a relatively short period of time so there needs to be flexibility in scheduling in future workshops.
Although there were advantages to the loosely structured evolving nature of the teaching, a pre-specified teaching program with teachers working under the leadership of one teacher may benefit learning with this participant group.
Although all teachers were able to work effectively with participants as they found them, a future program would benefit from collecting and sharing the participant history prior to the workshop start.
Teachers were able to work effectively with participants without prior special knowledge of stroke disability. But it is likely teachers would have benefited from some background information about stroke disability, potential challenges of working with stroke survivors and the various stages of rehabilitation.
Some teachers felt uncomfortable moving people onto and off the tables and requested some prior training in this and in managing fall risks for future programs. (In the workshop they did call for assistance from more experienced teachers.
There were advantages and disadvantages of having participants exposed to different teachers. A variety of teaching styles and approaches versus potential confusion. Some teachers would thought a pre-specified teaching program with teachers working under the leadership of one teacher would provide a cohesive approach.
The workshop provided a sense of community for both teachers and participants. It was particularly valuable for teachers to experience working with stroke survivors and to see how other teachers worked with them. CB reported that she has used many observations as inspiration in working with her current stroke student.
Discussion
This small workshop had a number of positive benefits in exploring the role of the Alexander Technique in stroke survivors.
It demonstrated that stroke survivors can use the Alexander Technique principles to manage at least some of their symptoms and day to day movement challenges. Teaching inhibition ie getting participants to notice and inhibit parasitic movements or contractions which interfere with their overall coordination, appears to be particularly promising. This may differentiate the Alexander Technique from other approaches to stroke rehabilitation. The program over four consecutive day appeared to reinforce learning that may not have occurred so quickly with less frequent sessions.
It provided a collegial framework for both teachers and participants. Participants found value in and enjoyed the interactions with different teachers. Teachers gained experience with a group of potential students which none had worked with before and gained further insight from watching others work.
It created visibility of the Alexander Technique for stroke survivors and their carers as a potentially useful approach to recovering function. The coordinator of the Boroondara Stroke Support Group attended the final session and expressed interest in running group workshops of the Alexander Technique in 2020. Interested Alexander Technique teachers could consider contacting other stroke survivor support groups[6].
The workshop was necessarily limited in scope. We have not been able to determine whether the changes observed in participants were sustained. We are not yet sure what results people will get working by themselves in constructive rest. We have not been able to determine the degree of change that is possible with a longer period of lessons; whether it would lead to sustained changes in walking and lifting arms in those participants with significant disability; whether constant repatterning would lead to increased mobility of paralysed limbs. We were not able to assess the extent to which cognitive dysfunction will compromise learning and retaining Alexander Technique skills. Some stroke survivors may have poor executive functioning, may be easily distracted and lack concentration, and may have memory problems.
Important questions include whether the Alexander Technique can contribute to the full recovery of function or is it primarily to allow stroke survivors to move with greater ease and coordination within the constraints of their permanent disabilities? Whether the Alexander Technique has a role in supporting therapeutic modalities such as physiotherapy, water therapy or speech therapy in the early rehabilitation phase.
There is also the question of funding Alexander Technique lessons for stroke survivors. Early stroke rehabilitation occurs in established rehabilitation centres according to evidence-based protocols[7] and is funded through state based health services. Stroke survivors would have to self-fund Alexander Technique lessons during this phase. Stroke survivors who have moved on from early rehabilitation but remain with substantial disability should have access to discretionary funding under the NDIS. (CB's stroke student gets funding from the NDIS for lessons.)
There are additional ways to build on this workshop. An Alexander Technique for stroke survivors Special Interest Group could be established (possibly affiliated with AUSTAT) to facilitate sharing information and experience. Ultimately a project similar to the POISE Project for Alexander Technique in Parkinson’s Disease[8] may be feasible for Alexander Technique in stroke survivors.
The future
We intend to follow up the invitation from the Bundoora Stroke Support Group to establish a program with them. And we are offering a short introduction to the Alexander technique in February 2020. We will also explore options for funding for individuals through the NDIS.
While many people have mild strokes from which they ultimately recover, there is a large cohort who experience either residual or significant ongoing disability. Anecdotal evidence suggests that significant return to function is possible to some stroke survivors, but that considerable and quite intensive work is required for this to happen. (4) (9) As Doidge points out any type of neuroplastic change requires consistent and conscious work over a considerable period of time. (10) And we know that Alexander would teach people only if they would commit to daily lessons over a number of weeks in order to change their underlying postural and movement habits.
The Alexander Technique brings a special perspective to recovering function. Narrowly focused attention to recovering specific movements can leave out a wider focus on overall coordination, bringing in unnecessary extra tightening, thereby limiting the possibility for a larger and more holistic improvement. This wider focus on the overall coordination in the hallmark of Alexander technique practice.
Contributors
Sincere thanks to all those who contributed to the workshop:
The Alexander Technique teachers who attended on one or more days and provided feedback: Caroline Blackshaw, Anne Carroll, Cathy Dowden, Susannah Keebler, Alex Lepikhin, Teresa Mears, Bronwyn Munro, Jenny Thirtle.
The SOFMAS trainees who attended: Lynne Conway, Helene Goldberg, Pemra Kahraman, Maeve McKeown, Georgia Shine.
And most of all the five stroke survivors and two carers who gave up time and traveled long distances to participate with grace and good will in this exploratory program.
[9] 9 - Farrell, B - Pat and Roald Hutchinson, UK, 1970 – (a book which includes an account of Patricia Neal’s recovery from a devastating stroke.)
[10]- Doidge, N - Brain the Changes Itself – Scribe Publications, Melbourne, 2010
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