The AT principle of inhibition
is a decision to withhold the habitual response to a stimulus to prevent disruptions to tonic muscular activity, which are automatically triggered by contextual cues. Alexander claimed that the context of engaging in an activity, such as playing an instrument or using a computer, commonly brings out an associated individual, habitual “set” of tonic, preparatory activities or changes in postural readiness that increases tension and interferes with the performance of the action.39,40
Alexander observed that nonmotor stimuli, such as stressful events or interpersonal interactions, also can trigger undesirable changes in tonic muscle activity.39,40
He claimed these triggered changes are a fundamental impediment to controlling tonic muscular activity because of their pervasiveness and their close ties to actions or events, which makes them difficult to change.39,40
Furthermore, Alexander claimed that undesirable changes in tonic muscular activity become worse with compulsiveness to perform an act or achieve an end.39,40
Alexander claimed that performing an activity without attention to inhibition and direction, referred to as “end-gaining,” produces undesirable disruptions of tonic muscular activity.39,40
Inhibition is practiced by first providing a contextual cue to trigger undesirable, habitual changes in tonic muscular activity followed by instructing the person to inhibit these undesirable responses and maintain direction. A teacher guides a person to inhibit by having them dissociate the actual response from the contextual cue. Two strategies used for this are: (1) having the person withhold the entire, immediate response to the cue, to make the person aware of triggered increases in tension and enable a change in response and (2) guiding an unpredictable sequence of actions, to discourage the person from expecting or predicting outcomes based on context. For example, the teacher may provide a contextual cue by asking the person to perform an action, such as standing up from a seated position, which has been reported to commonly evoke an unnecessary tensing of the neck.32
The teacher will ask the person to prevent the initial, impulsive response to stand up (ie, not “end-gain”) and instead maintain directing. The teacher will then guide the person among several different actions, such as leaning backward, actually standing up, or maintaining a seated position, while continually indicating desired tensional relationships through sustained hand contact. In total, this teaching process aims to convey a general ability for inhibition that can be learned and applied across different contexts.38,39,49
Alexander Technique lessons are taught individually and last 30 to 45 minutes. A course of 20 to 25 lessons is thought to convey a basic proficiency in the principles.38,49
In a lesson, an AT teacher selects lesson procedures and instructs, evaluates, and provides feedback to the person. In general, these different aspects are not performed separately, but occur simultaneously and continuously during the lesson. For example, a teacher’s hand contact simultaneously analyzes tensional patterns, makes the person aware of these patterns, guides the directional intentions, and prevents undesired increases in tension.49
Moreover, guiding a person through a movement is evaluative and instructive and provides feedback.
Because inhibition and direction are general principles that can be applied in any activity, they also can be taught in any activity; however, a few standard procedures are most commonly used in a lesson.49
These standard procedures are basic positions and movements that are thought to be most effective for evaluating habitual, tensional patterns; triggering preparatory tensing; and conveying the primary directions. The most commonly used procedure is transitioning between sitting and standing (this is referred to as “chair work”).
In chair work, a teacher guides the person to stand up and sit down, emphasizing inhibition and direction as appropriate. Typically, teachers gently place their hands on people’s heads, necks, or other body segments to evaluate the organization of tonic muscular activity and guide direction along the length of the spine throughout these actions. A teacher may have a person stand up and sit down many times during a lesson and may vary the movement trajectory to alter the demands of the task (eg, by guiding reduced forward trunk inclination at seat liftoff). The aim is not to achieve a particular “ideal” trajectory, but to teach the person to maintain direction throughout a task. The teacher may guide the person to pause or alter the trajectory at any point in mid-movement to convey the desired neutrality and adaptability of equilibrium, claimed to result from inhibition and direction.49
In addition to chair work, a number of other procedures are commonly used during a lesson, such as performing a knee-bend, squat, and rising up onto the toes.49
In addition, most teachers also work with a person lying in a semisupine position (supine, with knees flexed and feet on the floor), which is thought to be an advantageous position while directing tonic muscular activity because the person’s back is supported and balance requirements are minimal. The act of speaking is considered to be a strong trigger of undesired habitual tensing, and teachers often work with people while speaking or singing.38,39,49
A procedure for breaking down the sequence of opening the mouth and vocalizing while maintaining the directions is considered beneficial. Many teachers work with people directly in activities that are important to them or problematic for them, such as playing an instrument or washing dishes. Although offering the advantage of working directly with the activity, this is commonly only done with advanced students because the contextual cues are often considered to be too strong to teach inhibition and direction effectively.
The scientific basis for the AT is not understood; however, the method appears consistent with changing central set. Inhibition and direction both use conscious intentions to alter a preparatory state of postural readiness, thought to affect tonic muscular activity and postural coordination. Similarly, central set is influenced by conscious intention as well as context and, in turn, influences tonic muscular activity and automatic postural coordination.44,46–48,51
Tonic muscular activity has long been hypothesized to closely relate to the state of postural readiness.52–54
More specifically, direction is consistent with changing central set by producing a preparatory state that allows positional changes in segments. Inhibition is consistent with changing central set by changing a person’s sensorimotor expectations and intentions in relation to context.
Although the AT addresses automatic preparation prior to voluntary movements or anticipatory postural adjustments, it is not known whether the AT changes automatic postural responses to external perturbations. If the AT changes automatic postural responses to external perturbations, this would support the ability of the AT to change central set, as opposed to solely changing postural orientation or the trajectory of voluntary movement.
The AT has been claimed to improve different types of musculoskeletal pain, such as LBP and repetitive strain disorders.55
People commonly take lessons especially for alleviating pain; however, the AT is not intended to be therapeutic in that it does not directly address pain. The AT addresses pain indirectly only through teaching the control over tonic muscular activity. An AT teacher does not diagnose the cause of pain, nor does the teacher base lesson procedures or evaluate progress based on pain. However, an AT teacher will inquire about a person’s pain to determine limitations to lesson procedures, which may indirectly shape the teacher’s approach. The AT’s aims are broader than improving pain or even the control over tonic muscular activity and coordination. Alexander taught that learning to control tonic muscular activity through inhibition and direction conveys the close relationship between mental and physical processes, which leads to a specific type of self-awareness and control that can be applied to the whole range of human activities.39,40,50
We were interested in whether the AT alters automatic postural coordination and LBP. The purpose of this case report is to describe how we followed automatic postural coordination and pain before and after AT lessons in a person with long-standing idiopathic LBP.