A review of Cacciatore et al. 2011; Prolonged weight-shift and altered spinal coordination during sit-to-stand in practitioners of the Alexander technique
Relatively little research has been done on the Alexander Technique. A noteworthy contribution to the science of the Technique has been made by Dr Tim Cacciatore, currently based at University College London, and his associates. Dr Cacciatore was one of the speakers at an on-line symposium on the Technique in May 2020, and a co-author of a recent paper on the science of the Alexander Technique (Cacciatore, Timothy W.; Johnson, Patrick M.; Cohen, Rajal G. (2020) Potential Mechanisms of the Alexander Technique: Toward a Comprehensive Neurophysiological Model, Kinesiology Review, Volume 9, Issue 3, p199-213.)
Here we review a paper published in 2011: Cacciatore, T.W., Gurfinkel, V.S., Horak, F.B., & Day, B.L. (2011) Prolonged weight-shift and altered spinal coordination during sit-to-stand in practitioners of the Alexander technique. Gait & Posture, 34(4), 496–501. In the following review direct quotes from the paper are enclosed in inverted commas.
In this paper the authors compare a selected group of 15 Alexander Teachers with a matched group of 14 control subjects as they move from sitting to standing (sit-to-stand). The balance between the sexes was roughly the same for each group, and according to the authors reflects the sex-balance of American Alexander teachers. The research was carried out at the Neurological Sciences Institute at Oregon Health and Science University.
The paper is divided up, as is conventional, into a number of sections. Much of the Introduction consists of a description of the Alexander Technique. This is essential background information for readers of the paper, many of whom are likely to be unfamiliar with the AT. The emphasis in this description is on the physical effects of the Technique; there is no acknowledgement of the influence of the AT on the mental or psychological state of its practitioners. It could be argued that the physical aspects are what are being measured in this study, and that any psychological aspects of the Technique are irrelevant to its findings. The first sentence of the Introduction is: “The AT is a method to improve habitual postural and movement coordination commonly used by performing artists.” We would agree with this statement as it stands, but suggest that the use of the expression “method to improve” implies that this is the purpose of the AT, which seems to us a rather narrow interpretation.
To quote further: “The emphasis of AT is on axial behavior, the positional and tensional relationships within the neck and trunk, during posture and movement . In particular, AT aims to reduce unnecessary tension and maintain elongation along the spine, referred to as the head-neck-back relationship. Proponents consider this relationship fundamental to any clinical or performance benefit from AT [1,5].” The references here are to two books, Indirect Procedures by Pedro de Alcantara (1997) and Alexander’s third book, The Use of the Self, first published in 1932. It seems to us that these statements are relatively uncontroversial. Alexander referred to the head-neck-back relationship as the “primary control”, and saw it as essential to his technique for improving use through inhibition of habitual responses and the conscious direction of activity.
“Recently, AT has been shown to alter postural tone. This was observed as a reduction in stiffness along the spine and hips in response to slowly applied torsion in unsupported stance.” We are interested in the term “postural tone” used in this paper. It is not always clear what this phrase means, and it is used here without any further explanation. However, there is a description on-line of postural tone by one of the co-authors of this 2011 paper, Victor Gurfinkel; “Postural tone is the steady contraction of muscles that are necessary to hold different parts of the skeleton in proper relation to the various and constantly changing attitudes and postures of the body”. (Gurfinkel V.S. (2009) Postural Muscle Tone. In: Binder M.D., Hirokawa N., Windhorst U. (eds) Encyclopedia of Neuroscience. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-540-29678-2_4711, accessed 18/12/2020). It seems reasonable, therefore, to assume that Cacciatore et al use the term “postural tone” in this sense.
As mentioned above, the authors studied the sit-to-stand procedure in 15 AT teachers and 14 control subjects. Interestingly, the AT teachers were on average a little older, a bit taller and rather heavier than the control subjects, though these differences were not statistically significant.
Cacciatore et al state in the methods (2.4.1) that “STS (sit-to-stand) movement phases were calculated according to Schenkman et al 1990. However, having read the paper referred to, it seems to us that Cacciatore’s team have modified Schenkman’s phase 1 very slightly. As discussed by Cacciatore et al, the flexion-momentum phase (Phase I) began when trunk angle exceeded 5 degrees of the seated value and ended when foot F z > 100% bodyweight (t so). According to Schenkman et al, flexion-momentum phase (phase I), began with initiation of the movement and ended just before the buttocks were lifted from the seat of the chair (lift-off). This suggests that Schenkman’s Phase 1 started and finished earlier in the process than Cacciatore’s. On the other hand, Cacciatore et al have quantified the process more precisely.
Phase 2, momentum-transfer, is the same in both papers. However, Schenkman adds the words, “forward momentum of the upper body is transferred to forward and upward momentum of the total body”. It is not clear whether this implies a significant difference from the way in which Cacciatore’s subjects moved from sit-to-stand.
Although Cacciatore et al broadly follow the phases of the sit-to-stand movement described by Schenkman et al, they did not set their subjects up in exactly the same way. Subjects sat on a backless chair, the seat height of which was adjusted to 105% of the subject’s shank length, with the position of the foot adjusted so that the angle at the knee was 85º. Thus the thigh sloped down towards the knee. The feet were brought back behind the knee somewhat. No information is given on the distance or angle between the feet. In Schenkman’s study the seat height was 80% of knee height (i.e. the hip was lower than the knee). This is a considerable difference from the height in the study by Cacciatore. Knee angle is also probably different. Cacciatore describes the angle as being 85 degrees, whereas Schenkman’s knee angle is unspecified but a result of “18 degrees of ankle dorsiflexion, as determined by the angle of the shank with the vertical plane”.
Subjects were asked to stand up as smoothly as possible without using momentum, in their own time, and were recorded 5 times each. They were instructed to “keep their arms crossed in front of the body”. We think this instruction prevents the use of the arms to contribute to upper-body momentum
During the procedure, the force at the foot was measured using a force plate; and the angles at hip and ankle, and flexion of the spine, were measured using kinematics.
The time taken to move from sitting to standing was broadly similar in Alexander teachers and control subjects, at 2.2-2.3 seconds.
Following Schenkman et al, Cacciatore divides the process of sit to stand into phases, as alluded to above:
- flexion-momentum (Phase 1)
- momentum-transfer (Phase 2) and
- extension (Phase 3).
Schenkman’s Phase 4, stabilisation is not studied in this paper.
Phase 1, flexion momentum, is divided by Cacciatore into flexion only and weight transfer; AT teachers were found to spend less time in flexion (but this was not statistically significant), but significantly more time on transferring weight to the feet (p < 0.001). AT teachers transferred weight earlier and more smoothly.
Phase 2, momentum transfer; AT teachers spent significantly less time on momentum transfer than control subjects (p = 0.01). In other words the AT Teachers had a longer weight shift phase (1) and a shorter momentum transfer phase (2).
Phase 3, extension, took roughly the same time in both groups.
Another interesting point is that control subjects were much more likely than AT teachers to reduce the force at the feet as they took themselves forward, before shifting the weight onto the feet (p < 0.01).
There were also significant differences in spinal angles between the controls and AT teachers; basically, there was less movement in the cervical (p < 0.001), thoracic (p < 0.001) and lumbar spine (p < 0.05) in AT teachers than in the control subjects.
It appears, then, that the authors found real and significant differences between the Alexander Technique teachers and their control subjects.
“AT teachers had altered STS phasing, weight-shift and spinal coordination, suggesting they employ a novel strategy for this task.”
“4.1.1. Continuous and sequential STS strategies
AT teachers shifted their weight continuously as the trunk inclined forward, rather than at a more specific trunk angle. To our knowledge this ‘‘continuous strategy’’ for transferring weight has not been reported previously in adults for STS. The continuous strategy indicates that AT teachers simultaneously generate anti-gravity leg-extensor moments while solving the balance problem—bringing the center-of-mass (COM) forward over the feet. In contrast, control subjects have two distinct actions prior to weight-shift: bringing the trunk forward and then shifting weight (Fig. 3B), which we refer to as the ‘‘sequential strategy’’.”
The results show clear, and statistically significant, differences in sit-to-stand between Alexander Technique teachers and matched control subjects. In this paper two distinct strategies for getting out of the chair are recognised, sequential, as employed by control subjects, and continuous, as employed by Alexander teachers. Note, however, that both strategies involve bringing the weight forward by flexion at the hip and increasing dorsiflexion at the ankle. This is clearly what the Alexander Technique teachers selected for this trial did. This procedure, involving flexion at the hips until the head is over the feet prior to lift-off, is perhaps dictated by the instruction to get out of the chair without using momentum. Not all schools for training AT teachers, however, adopt this strategy. Members of PAAT send the head up to the full height above the feet by the shortest possible route; this procedure involves some coming forward from the hips, but not the flexion to take the head over the feet described by Cacciatore. It is debatable whether the phases as described in detail by Schenkman (1990) and Cacciatore (2011) apply to this procedure for moving from sit-to-stand, as it seems that transfer of weight and upward and forward momentum, to achieve full standing height, are simultaneous. We believe this procedure for rising from a chair can be traced back to Alexander himself, and was taught by his principal assistant Walter Carrington, who took over Alexander’s practice and training school. (A video of Walter Carrington teaching is available on Youtube; https://www.youtube.com/watch?v=gFgbp6WveFg, accessed 08/01/2021).
Therefore, although we accept that this paper shows a real difference in the way some Alexander Technique teachers move from sit to stand, compared with people who have not been trained in the Technique, we would not accept that the way described is the most efficient way of rising from a chair.
In discussing differences in flexion of the spine, Cacciatore writes: “Another possibility is that AT teachers’ heightened dynamic tone modulation acts to precisely counteract the changing axial loads during STS. This would require a change in sign so that it resists spinal movement rather than yielding to it. In support of this possibility, AT procedures practice both resistance and compliance [1 – the reference is to de Alcantara].
“….. the AT head–neck–back relationship might generally serve to transfer trunk momentum and work performed on the trunk to the limbs. It is notable that the primary movements in AT (knee bends, squats, lunges, stand-to-sit, as well as STS—the so-called procedures of mechanical advantage ) all involve flexing leg joints while they provide antigravity support. Thus, transferring mechanical energy to these joints to drive eccentric contractions may be a fundamental principle of AT.”
These are interesting points. Cacciatore is suggesting the carrying out of these “procedures” in Alexander technique training may account for some of the differences in results between the subjects and the teachers. Alexander does not use the term procedures of mechanical advantage, although it is clear that his Technique involves carrying out procedures in mechanically optimal ways. In his first book, Man’s Supreme Inheritance Alexander makes a number of references to mechanical advantage, and particularly to “positions of mechanical advantage”. The premise is that these positions (which should be dynamic and not static) facilitate the carrying out of a procedure efficiently and effectively. Directions for the neck to be free, the head to be freely poised, and for the back to lengthen and widen are fundamental to the application of the Alexander Technique, both at rest and during activity. These directions, and the relationship between the neck, head and back, are maintained while carrying out other movements.
In the last paragraph of his Discussion, Cacciatore suggests that the continuous strategy may help people with impaired mobility rise from the chair. We have no experience of this, as the strategy that the Alexander teachers in his study used is not the same as ours. However, having said that, it is necessary to come forward from the hips to bring the head over the feet in getting out of a low arm-chair or sofa. In this instance, coming forward from the hips makes sit-to-stand easier.
“We found that AT teachers raise themselves from a chair with altered movement coordination compared to matched control subjects. In particular, AT teachers had a prolonged weight-shift duration, shorter momentum transfer phase and reduced spinal movement resulting in continuous weight shift onto the feet as they inclined the trunk forwards. We hypothesize that decreased leg stiffness and increased power transmission through the spine enable this continuous STS strategy. Future studies are necessary to understand whether features of AT STS coordination are beneficial, from a performance or clinical standpoint, and whether they generalize to other motor behaviors, particularly those not explicitly practiced in AT.”
It seems to us that this paper is a starting point in the investigation of the sit-to-stand movement. The finding that AT teachers employed a continuous strategy (rather than the sequential strategy of the control subjects) for getting out of the chair is interesting, and a basis for further studies. However, as discussed above, we do not believe that Cacciatore’s findings apply to all teachers of the Alexander Technique, nor that the procedure he describes is the most efficient way of moving from a sitting to a standing position.
Alexander F M 1910, Man’s Supreme Inheritance, Mouritz edition 1996
Alexander F M 1932, The use of the self, Gollancz edition 1985
de Alcantara, P 1997, Indirect Procedures Oxford, Clarendon Press
Gurfinkel V.S. (2009) Postural Muscle Tone. In: Binder M.D., Hirokawa N., Windhorst U. (eds) Encyclopedia of Neuroscience. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-540-29678-2_4711,
Schenkman M, Berger R A, Riley P O, Mann R W, Hodge W A 1990, Whole body movements when rising to standing from sitting. Phys Ther 1990; 70 (10) 638-51