The Alexander Technique and the Dancer - Preventive Care
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Assistant Professor, Theatre division, Meadows school of the arts, Southern Methodist University, Dallas, Texas.
To prepare for this lecture, I looked at a lot of literature on dance injury and I found, not much to my suprise, that injury is a pervasive problem for dancers. As dancers we know this; we live it. As doctors for dancers, you need to know this also.
Dancers suffer a documented high incidence of injury which affects their ability to perform and sometimes the continuance of their careers. One representative study that I looked at showed that almost 90% of the dancers in ballet west had suffered a dance related injury at some time in their career. About 62% of these dancers suffered temporary or permanent disability as a result of their injury. A study of the New York city ballet showed that during the season 17% of dancers were not performing on any given day due to injury, which is pretty amazing. Many of the dancers in the companies that I have worked with, which are Rambert, English National Ballet and the Boston Ballet, as well as individual dancers from other companies, have been injured and some of them have been left with chronic disability (I include myself among those).
What kind of injuries are these, and what causes them? In the literature, there seemed to be two kinds of injuries: those caused by traumatic events, such as being dropped by your partner or falling on your head (and these are all things that happen) and those injuries which develop over time with repetitive stress and overuse. We can’t prevent or predict the mishaps which are outside the dancer’s control, so I am not going to deal with that category here. But let’s look at the reasons for that second category, which includes the greatest number of reported injuries.
Justin Howse, who is Consultant Orthopaedic Surgeon for the Royal Ballet School, English Ballet School and the Royal Academy of Dancing writes: "All dance injuries arise from technical faults.” He mentioned this over and over in his book on dance injuries. He is not alone in stating that. Faulty technique comes up repeatedly, both in the literature and in my own experience, as the cause of injury. The dancer is habitually doing something wrong and that leads to injury. Howse calls dance teaching “a form of co-ordination training which develops pre-programmed, automatic multi-muscular patterns” which are called engrams. In other words, a particular configuration of limbs or a sequence of muscular contractions is equated with a particular kinesthetic feeling, doing something in a particular way, which the dancer recreates when she repeats the movement in order to know that she is doing it correctly. These pre-set kinaesthetic programmes allow dancers to perform the movements without having to think their way through them. They go on to automatic (a particular feeling means we are doing our best).
However, and I quote Howse again here, “if inaccuracies are allowed during the development of a technique, this will produce “bad habits”, and these inaccuracies or “bad habits” will themselves become an engram.” The dancers unwittingly may train themselves to perform with a bad habit, so that what feels right may in fact be very wrong. Even minor bad habits, repeated over time, can produce major injuries and the recurrence of injury. What feels comfortable and familiar may in fact not be very good for us to be doing. Body mechanics, which strengthen the functional musculo-skeletal balance, produce a risk of injury and body mechanics which produce musculo-skeletal imbalance and encourage injury. If you are producing imbalance in the body you are going to encourage injury. A faulty technique that is founded on poor body mechanics will predispose the dancer to injury. If you are doing something poorly over and over again, over time the body gives out at its weakest point.
Sometimes, we tend to look at an injury as an isolated incident and to treat an injury without looking at the dancer’s overall functioning. Dr. Jim MacIntyre, who treats dancers at the Orthopaedic Speciality Hospital in Salt Lake City Utah, says “when a dancer presents with an injury, it is easy to assume that the injury has occurred in isolation. However, it is essential to consider that the injury may be secondary to an underlying dysfunction”. So we need to look at the dancer’s habitual co-ordination. Again to quote from MacIntyre: “Ballet demands the performance of complex movements in a precise and controlled fashion. These movements require the action of muscular forces and a series of rigid limb segments joined by mobile linkages commonly referred to as the kinetic chain …Optimum performance requires that all segments of this kenetic chain be appropriately positioned to support the body’s weight and allow for movement. Anything that interferes with normal joint mobility or stability will necessitate compensatory postural and movement changes, which can lead to increased stresses on other sites in the kinetic chain. Once the capacity of the chain to compensate is exceeded, tissue breakdown and injury will occur. This failure may be at the site of the abnormal mobility, however the overt injury can also occur at a site distant to the dysfunction.”
So we come back to technique, to the dancer working in a way that encourages injury. If the way of working interferes with normal joint stability and mobility, then the bones and muscles cannot perform their functions of posture and movement in the way the body is designed to function. The brain will compensate by automatically recruiting other muscles groups that take care of these functions and we develop compensatory kinetic chain dysfunction, which may prove to be the primary cause of injury. MacIntyre found that kinetic chain dysfunction was common to injured ballet dancers and he concluded that kinetic chain dysfunction may be a primary cause of repeated injury.
This problem goes much deeper than the forms of ballet technique, to very basic properties of posture and movement which are of paramount importance in injury prevention. If you are doing a very challenging activity such as ballet or modern dance, the underpinning of that activity is crucial to support it. This corroborates my own experience as an Alexander Teacher, dancer and former injured dancer. The way of working, over which the dancer has some control, is most often at fault. And in fact, dancers often sense that there is something wrong with what they are doing, but they do not know what it is that is wrong. Certainly, that was true for me when I was injured. So they may attempt to fix the immediate problem by modalities such as acupuncture, massage, therapy, osteopathy, chiropractic, etc. These modalities do alleviate symptoms and they get the dancer back into the studio, but they don’t change the underlying cause of the functional problem, the dancer’s fundamental way of working, the dancer’s fundamental kinetic chain dysfunction, the dancer’s fundamental use of his or her own instrument. Whatever remedial activity they engage in will utilise the same familiar habits of co-ordination which feel right. So we go on wanting to feel right, doing our therapeutic exercises, but we’re not really changing. But to quote Howse: “All forms of treatment are pointless without complete correction of any fault in technique.”
So how do you correct technique? With physical therapy, remedial exercises, with drugs, heat, practising movements to strengthen or stretch or retrain specific muscles? We need to go one step deeper than correctiong technique. Without actually making a change to the basic neuromuscular patterns of co-ordination, nothing has changed. We are just rearranging bad habits and not eliminating them. I cannot stress that enough. I see it over and over again, when you treat injuries by giving someone specific exercises without looking at the overall kinetic chain dysfunction that is going on, it doesn’t solve the problem, the problem recurs, or something else recurs. The Alexander Technique offers a framework to understand this problem and effectively change bad habits. As an Alexander teacher, I call the underlying principle behind faulty technique by the name of poor use. Our fundamental habits of neuromuscular organisation in all our activities either support or interfere with our capacity for co-ordination and I think that that is an important point, our capacity for co-ordination. We can be more or less coordinated depending on how we are using ourselves, how we are organising ourselves. A dancer with poor use is not only performing choreography but is also expending additional, unnecessary energy and misapplied muscular bracing that interferes with the performance of the choreography. This misdirection of muscular effort gets in the way of what the dancer is trying to achieve.
There are within us innate processes which provide for upright support and balance in response to gravity. The force of gravity activates neuromuscular reflexes which tone up our muscles to send us upward and away from gravity. The brain acts below conscious level to keep us balanced upright in space, and to organise our movement in response to our intention to move. It does this by balancing the contractions and release of opposing muscle forces as appropriate for postural stabilization, which supports gesture and movement into space.
When we interfere with this innate support system, we then need to compensate by taking care of postural stabilization by means of dysfunctional tension somewhere else in the body, making efficient co-ordination more difficult. When we brace and constrict ourselves in activity, we interfere with the innate (reflex) tendency to expand upwards in response to gravity. We then need to overcome the faulty effort by stronger muscular effort, to do by force what should happen naturally (the upright balance and poise). We must do this in addition to the activity engaged in, superimposing extra work on ourselves. This, I think, is a principal cause of injury... interfering with the body’s innate support system, and the resulting dysfunctional compensation.
In dancers, misuse is often manifested in undue tension which affects the poise, ease and general readiness for activity. A common problem is muscular overuse and excess tension, which is the result of the dancer’s conception of how much effort is necessary to dance and where that effort needs to be applied. There are great temptations to brace and stiffen in our attempts to support the arms in the proper form and to control the rise and fall of the steps accurately. I think very often it becomes a control issue: to get it ‘just so’. In particular, there is a tendency to overtense and overwork the back and the abdominal muscles, through this central area. Bracing and constricting these muscles interferes with the organisation of muscular co-ordination and ease, and let me add here that bracing and constricting may be masked by the dancer’s talent and may not be noticeable to the untrained observer.
One very common pattern is for the dancer to tighten the abdominals, narrow and shorten the back, arch the lumbar spine and clamp the head back and down on the neck. Holding up and holding in. There is a tendency to brace the back to support the arms and legs, to pull the arms and legs into the torso, which tightens the back, and then tightening the abdominals to control this ingathering of the legs, so there is controlling and pulling at the back and the front. This organisation interferes with the natural support against gravity and consequently freedom of movement, as it is literally holding yourself up in a way that gets in the way of mobility. For example, if you are holding in the hips and the gut, any leg movement at the hip creates a lot of friction and in the long run will cause problems. There is a direct conflict here between free leg movement and holding in the hip joint, literally grating against yourself.
Alexander found that the relationship of the head, neck and back was the key to the functioning of the inherent support system. He wrote that a certain use of the head in relation to the neck, and the neck in relation to the torso and other parts of the organism, establishes the best conditions for raising the standard of functioning of the whole. In other words, an appropriate head/neck/back relationship stimulates appropriate co-ordination of the whole. The combination of the release of the head and neck, and consequent lengthening and widening of the back and the positive supporting responses activated by the pressure of the feet on the floor stimulate the expansion and extension of the whole body. When those conditions are maintained, the muscles of the body adapt to support us easily in any movement, as long as we do not interfere with the responses which are designed to keep us easily upright and coordinated.
If we are not interfering with the innate postural support, then the extensor muscles at the back and the flexor muscles at the front provide an appropriate balanced support for upright posture and behavior: the arms will be supported by the elasticity of the back, instead of the tightening of back muscles, so that the arms are coming out of the expansion and lengthening of the back instead of being pulled into the midline in the back. Muscles which previously held the arms and legs into the torso will release as they are not necessary to provide support and instead the intention of the body will lengthen us into the ground. As a result, the upper body will extend up easily and naturally without effort, the back and front will broaden with the head poised lightly on top of the neck. We develop an open, free and expansive carriage as a by-product of improving our choice of neuromuscular organisation. The net result is poise and freedom of movement stemming from appropriate co-ordination. I have seen and experienced this over and over again.
I wrote a paper last year on the Alexander Technique and training contemporary dancers in 18th century dance style. It’s very interesting to look back at some of the manuals from that time: they talk about the poise of the head and the neck and the open expansive carriage, yet you have people trying to do this today and the complexity of the movements are a great stimulus to tighten up. It is so very difficult. What happens, of course, is that excess tightening shortens your stature. The steps are going nicely along, but the carriage has nothing to do with what is described in those books as the open and expansive, free, genteel carriage of the time, and what you find working with Alexander Technique is that when you can get people to be expanding in activity, that carriage is there and then movement is there much more easily. So we get the aesthetics without the strain.
According to my research and my experience, co-ordination which promotes balance and facilitates correct technique reduces the risk of injury. So efficient use is preventive care of the body during activity, not just in advance but as you go along. We become consciously aware of how we do what we do, as we do it. We become consciously aware of our kinetic links so we can make choices about our co-ordination and learn to take better care of ourselves while we are in the process of dancing. It’s not just something you think about before, to get yourself ready, or afterwards, when you have got yourself into trouble, it’s something you think of during, so you take care of yourself while you are actually dancing.
In my experience as a teacher and dancer, dancers find dancing easier and less effortful when they are expanding in activity, instead of contracting in activity and overworking. One individual commented that dancing this way “felt too easy” as he was used to a lot of tension when dancing, he found it disappointing that dancing did not feel like a lot of work! Which raised an interesting question: the basic conservatism of the dancers, who want to stick to what they have done all those years, because they know that it works: there is a resistance to change. However, we know that eliminating excess neuromuscular signaling reduces internal interference and internal stress. So, the experience of dancing can be simpler and clearer, and the body actually feels lighter. Dancers report that they tire less easily and that challenging physical skills are easier. When our organisation of voluntary activity is not in conflict with involuntary activity controlling our balance, we can just dance, we don’t have to do all that other stuff, we can just do the dancing, and you have within your grasp the two lovely, fragile perishable things which Martha Graham speaks of in the wonderful film “The Dancer’s World”: spontaneity and simplicity, being alive to the moment and doing literally and simply the movement and not interfering.
I believe that the Alexander Technique can play a significant role in the rehabilitation programme of injured dancers. Dr. MacIntyre writes that: “All too often, medical personnel entrusted with the care of dancers focus solely on the injured site without considering what is happening at other sites in the kinetic chain. This oversight is compounded when the physician or therapist is satisfied with discovering simply what injury has occurred, rather than investigating why the injury occurred”. I have seen dancers conscientiously and enthusiastically practising their physical therapy exercises with a great deal of misapplied effort. They are effectively reinforcing poor body mechanics while strengthening specific weak muscles.
Rehabilitation without an improvement in general use is merely a re-arrangement of old habits. We must consider the whole system, we must change the basic manner of co-ordination in order to prevent a recurrence of the functional injury. The Alexander Technique empowers the dancer to change bad habits by learning to control basic use of themselves and thereby to establish a good foundation on which to build technique. You have to start by building that foundation and then going on to the technique, rather than dealing with the more superficial level of technique.
How do you achieve good use? The Alexander Technique is not a therapy or manipulation, it’s education. It’s about learning to consciously choose your own self-organisation. How can the Alexander Technique help the dancer change a deeply-ingrained habit of poor organisation? The habit is a stereotyped response to a particular stimulus, so preventing the customary response to the stimulus is the essential first step to breaking a habit. A nerve can either transmit a signal, which is excitation, or not transmit a signal, which is inhibition. It can’t do both at the same time. You have to first stop firing messages along the familiar wrong pathways before you can send them down the right ones; the neurophysiological term that Alexander used for stopping neuromuscular messages from following their habitual pre-set automatic patterns is inhibition. We have to prevent the automatic response to stimulus, which allows us to choose an appropriate response instead of the habitual one. Once the automatic response is inhibited, we can mentally direct the neuromuscular system to make the right response of postural reflexes, eliciting natural springiness in response to gravity. The we go ahead with my activity. Direction is a process of directive thinking, of projecting orders to the whole system which organise conditions stimulating good use.
Alexander developed a methodology for changing habits of use. The Alexander Technique teacher helps the student to learn both inhibition, the refusal to indulge in old habits, and direction, conscious choice of good use. In fact, the Alexander Technique focuses on the head/neck and back relationship as the primary control for reinstating the natural co-ordination affecting greater ease and economy of movement. Alexander found that neither words nor exercises were sufficient to stimulate change. His method involves individualised, hands-on work, with a teacher guiding the student in the direction of improved use through the integration of the head/neck/back relationship. They work together, the student mentally prevents the old habits and mentally projects the directions for the use while the teacher, through hands-on guidance, helps bring about the conditions associated with those directions. The teacher helps the student experience improved use in response to projected thought and the student gradually develops the skill to inhibit and direct without the teacher’s help. The student is increasingly able to monitor his own use during activity, that is the dancer develops the skill to take care of himself while dancing. So he can use the Alexander Technique as conscious preventive care during activity.
I recommend a course of individualised lessons outside of dance class as a foundation for technique. I feel that this work has an important role to play both in the rehabilitation and re-education of injured dancers, and in primary education of the student. Certainly, if a dancer learns good habits at the beginning, many potential problems can be avoided. This is a real problem, because a lot of dance training is not very tuned in to ‘use’ and a lot of problems are established early on.
As a dance and Alexander Technique teacher, I am particularly interested in helping dancers to acquire the skill to apply the principles of the Alexander Technique to dancing. I have found that a combination of private lessons in the Alexander Technique and dance classes works well, and I should stress again that I am not dealing with learners but mostly professionals or pre-professionals. I teach individual lessons for the dancers and as the students progress in their skills of improved use, we begin to work with dance movement in the classes. In addition, I come into dance classes with particular teachers teaching, teachers who are sympathetic to this work and understand what’s going on, and I assist the dancers to prevent inappropriate habits while they are taking class. I give them guidance with my touch and words, reminding them to attend to their use while they are engaged in taking class. This has proved very successful as a practical bridge between the private lessons and the dancer working unaided in class or rehearsal. I have to say when I do this, I only work with dance teachers whose work I find to be ‘friendly’. I’ve had the experience of working in class with a teacher who was telling someone completely the opposite to what I was doing. She was telling the students to pull up and tighten and I was helping them to release and lengthen. It just works better if you are saying the same thing!
To sum up: the Alexander Technique teaches the individual the skill to eliminate inappropriate habits of use and to organise oneself in a way that facilitates co-ordination. If the head and neck are in a situation of dynamic balance and poise, and the back is expanding and lengthening, there is a resulting poise of the head, freedom of the neck, openness of the chest and steadiness of the back to facilitate dancing. This organisation is not the result of exercise or relaxation, but of consciously learning to change old habits, or exchange old habits of tension and compression for new ones of expansion and ease. In order to reduce the risk of re-injury, we have got to go deeper than rehabilitative exercises: we must eliminate the predisposing conditions of use which lead to injury. We must change the basic organisation of posture and movement.
We must empower the dancer to take care of his or her own conditions of use. The dancer whether professional or not, whether injured or healthy, must learn to take care of herself. The Alexander Technique offers the dancer preventive care during activity, by learning how to prevent interfering habits and how to choose instead a conscious self-organisation which promotes co-ordination and reduces the risk of injury and re-injury.
Phyllis Richmond teaches at Meadows School of the Arts, Southern Methodist University, Dallas, Texas
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