Alexander Technique Classes - Multisite
Phase: NA
Conditions: Parkinson's Disease
Sponsor: University of Idaho

 
"Poised for Parkinson's" 
 
Study Protocol for Participation in a Study of Online Alexander Technique Classes  
for People Living with Parkinson's Disease and their Care Partners 
 
Contact information for this study:  
Monika Gross, Executive Director of the Poise Project  
828-254-3102 monika.gross@thepoiseproject.org 
 
Document Date: May 13, 2020 
 
ClinicalTrials.gov NCT04726709 
Principal Investigator: Rajal G. Cohen, rcohen@uidaho.edu 

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4. Research Strategy 
4.1 Significance 
Parkinson’s disease (PD) is the second-most common neurodegenerative disease globally, with a prevalence 
expected to double in the next 20 years to over 12 million cases1. It is thought to disproportionately affect rural 
populations, in part because of demographics and also because of its association with chemicals used in 
farming and found in well water2–4. PD symptoms, including gait impairment, falls, depression, anxiety, and 
chronic pain, are only partially ameliorated by current treatments. These symptoms cause tremendous 
disability and suffering for individuals with PD and their care-partners5,6.   
The care dyad is particularly important in the context of interventions for neurodegenerative disorders such as 
PD. A care partnership involves a bond between the person receiving care and the person providing it. This 
partnership takes place in a psychosocial context built on pillars of trust, equality and shared experience. Care 
provision helps the person with the condition achieve their optimal level of function. The progressive and 
complex nature of Parkinson’s-related syndromes involving motor, psychiatric and cognitive symptoms 
diminishes an individual’s ability to conduct everyday activities and manage self-care. This increases the need 
for a care partner, without whom the rate of admissions to institutional care, as well as the cost of care, would 
increase significantly. However, the impact of a neurodegenerative condition on spousal and other family care 
partner relationships is multifaceted and progressive and includes social, financial, physical, emotional, mental 
and cognitive aspects7,8.  
Rigor of prior research that serves as key support for proposed project. A randomized controlled trial 
found that Alexander technique, a somatic education practice targeting distribution and regulation of postural 
tone, can help PWP manage their motor symptoms. Stallibrass et al. compared Alexander technique to 
massage and found substantial benefits to motor symptoms, depression, and attitudes to self only in the 
Alexander group; benefits were retained at 6 months9,10. These are promising results; however, the traditional 
way of delivering Alexander technique, via one-to-one in-person sessions with a trained Alexander specialist, is 
neither available nor affordable for a large percentage of PWP in the rural Western US. It was previously 
thought that the benefits of Alexander technique depended mostly on manual guidance. However, I have 
shown that even without manual contact, simple Alexander-based instructions can lead to improved balance, 
posture, and mobility, both in PWP and in healthy older adults11,12.Therefore, online group delivery of 
Alexander training may be a way for PWP who do not live in a major urban center to gain greater agency and 
independence in their symptom management. 
We have designed and begun testing an in-person Alexander-based group course for PWP and their care 
partners. In a small controlled study, our Alexander-based group intervention led to objective improvement 
relative to controls in balance (brief BESTest) and coordination (Physical Performance Test). In addition, 75-
100% of care partners reported improvement in their care recipient’s fatigue, anxiety, posture, rigidity, rolling 
over, bradykinesia, vocal volume, self-awareness, balance, and overall confidence in ability to manage living 
with Parkinson’s disease. PWP reported reduced shuffling, freezing, and anxiety; increased upright posture; 
and improved ability to roll over. They also indicated that they learned practical tools for self-management, 
encountered new ideas that they are likely to use in daily life, and would recommend this class to a friend. At 6 
months post-course, most participants reported that they continued to experience benefits from the class and 
to use the things they had learned in their daily life13. 
Transitioning to online instruction is both a logical extension of our long-term research goal of removing 
barriers to access for as many people as possible and a sensible way to proceed during this time of major 
uncertainty about the safety of person-to-person contact.  
How the proposed project will improve scientific knowledge and clinical practice. The proposed project 
will lead to larger, controlled studies, and eventually to the widespread adoption of this unique intervention, 
alongside other PD-specific programs such as Rock Steady Boxing, Dance for PD, and the Parkinson Voice 
Project. From a scientific perspective, evidence that a program targeting postural tone can have widespread 
benefits for the motor system and anxiety would lend support to the continuation of basic research on the 
relation of postural tone to the motor system14–18. From a clinical practice perspective, having this online 

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intervention could have potential for reducing the health risks of social isolation for rural PWP and their care 
partners19,20. 
4.2 Innovation 
Our course is an innovative biopsychosocial approach that bridges the gap between exercise approaches like 
dance or fitness classes, psycho-social approaches like support groups and psychotherapy, and informational 
approaches like educational symposiums and meditation classes. It is based on Alexander technique, a non-
exercise somatic education process that accesses the motor system via postural tone, body schema, and 
executive function12,21–25. Once learned, the skills can be applied during any activity. Thus, Alexander principles 
can be applied during PT, OT, SLP, psychotherapy, or exercise sessions, facilitating greater gains through 
increased self-awareness and control of reactions. The skills can also be put into use during normal daily 
activities, without setting time aside to practice or requiring a particular set of movements. This is especially 
beneficial for individuals who can’t (or won’t) exercise. Self-efficacy is not limited by physical fitness. There can 
be personal growth as a human being no matter what physical limitations are imposed by chronic conditions. 
While PD may be out of a person's control, how PWP choose to respond to moment-to-moment stimuli is 
within their control. It follows that with greater agency and control of physical and emotional responses, overall 
confidence and self-esteem will increase, especially for PWP who may be experiencing high levels of despair 
or helplessness. 
The care dyad approach is also innovative. Inclusion of care partners means that if disease progression leads 
to cognitive decline, the care partner’s reminders will help keep PWP active longer. Care partners also learn 
how to give physical assistance with less risk of injury to themselves, and they will gain self-care skills that can 
reduce tensions in what can be very challenging relationships.  
4.3 Approach 
Intervention. Our “Poised for Parkinson’s” course is designed for PWP in early stages of PD and their care 
partners. The targeted impacts for our program are: 1) Practical education of PWP to promote more 
independent self-management of motor symptoms during activities of daily life, with additional non-motor 
symptom benefits; and 2) Practical education of care partners to enable them to facilitate care receivers' 
retention of skills and to help care partners manage their own physical and emotional stress. 
Our study focuses on early stages of PD, when both partners are often experiencing a significant period of 
transition and changing roles that can include negative feelings, depression, diminished well-being, social 
isolation, and loss of autonomy. Our program aims to ease that transition through enhancing partnered 
communication and understanding of one another's experiences through the lens of group interactions with 
other care dyads. 
The course meets twice per week, for two hours per class session, over 8 weeks, for a total of 32 “contact 
hours.” Each class includes some time for participants to connect with each other to review what they learned 
last time, and to share how they have applied the knowledge and what problems they encountered. We have 
piloted using Zoom “breakout rooms” to simulate the smaller breakout groups used in an in-person class, and 
we found them to be effective.    
Participants are taught principles and methods to allow them to attend to unproductive habits of muscle tension 
and to become aware of their ability to make different choices. These practices develop body awareness, 
intentionality, and inhibitory control, which are used to improve the accuracy of the body schema and the 
distribution and regulation of postural tone, leading to cascading benefits through the motor system. 
Research Methods 
Design: We will use a single-group design with a primary focus on course development and feasibility testing. 
We will include 5 dyads, each comprising a PWP and their care partner. Experience suggests that this is an 
ideal group size to create a feeling of cohesion and connection. 
Inclusion criteria: To be included in the proposed study, the PWP needs to be: over 50 years of age; 
diagnosed with PD by neurologist; ambulatory without assistance from another person, a walker, or a 

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wheelchair; cognitively sound enough to follow instructions and retain information; and not at high risk for falls. 
They also need a willing care partner, a good Internet connection, and a decent computer monitor with 
speakers and microphone. Screening will include administration of the Montreal Cognitive Assessment26. 
Participants will be excluded if they score below nineteen, which is the standard cutoff for dementia for white 
non-Hispanic Americans27. Information regarding fall history of the PWP will be collected from the PWP and 
their care partner. If the PWP had any falls in the past 6 months, we will administer the ABC-6 survey and also 
ask the PWP to stand on one leg unassisted. If they cannot stand on one leg for at least five seconds (best of 
three tries)28 AND if they score less than 55 on the ABC-6 (a brief survey of balance confidence that has been 
validated for PWP)29, we will exclude them from the study.    
Recruitment: There are support groups both in Moscow (where the University of Idaho is located) and 
Pullman (8 miles away). We have previously reached out to local PD support groups and found members 
willing to participate in studies. Depending on the status of the pandemic, we can do support group 
presentations either in person or online. Other recruitment strategies we've employed include: announcements 
in regional Parkinson's organizations' monthly email newsletters and social media platforms; announcements 
on The Poise Project website, Facebook page, and Twitter account; emails to the larger PD community from 
email lists; referrals from medical and allied health professionals and fitness trainers; distribution of flyers to 
local community sites, including retirement communities, community organizations, and places of worship; and 
distributing press releases to regional news sources. 
Retention: Our previous courses have had very high retention. In our in-person courses, average course 
attendance was 89% for those who completed the course, and course participants reported they had learned 
practical self-management tools, enjoyed the social interaction of the group setting, and were likely to 
remember and use what they had learned in their daily lives. Retention strategies include: enhancing 
participant engagement in the research process and in the meaning and purpose of study outcomes for the 
larger PD community; specialized training for instructors in group dynamics and bonding; individualized 
instructor attention within the group setting; incremental learning and capacity building through carefully 
designed curriculum; field notes from instructor and follow up supervision and mentoring; access to review 
handouts and videos; and establishing a buddy system to keep participants updated if they miss a class. 
Outcome measures: Our primary outcome measures are class attendance and study retention. Our 
secondary measures include self-reports of symptom management, anonymous course evaluations, and 
objective assessments of balance and motor performance. For our in-person classes, we used the Brief 
BESTest to assess balance30 and the 7-point Physical Performance Test to assess motor performance31. If it is 
safe to travel, we will invite participants to our lab to complete these tests, as well as an instrumented Timed 
Up and Go32. This is a variation on the standard Timed Up and Go that involves standing up from a chair, 
walking 10 meters, turning around, walking back to the starting location, and sitting back down. The 
instrumented version includes wearable inertial sensors (APDM) and automatically computed metrics such as 
step cadence, arm swing, and gait asymmetry. If it is not safe to travel, we will choose a subset of these 
objective measures that can be administered online, with the assistance of the care partner.  
Protocol: Consent. Participants will be sent a copy of the informed consent to read in advance. At the 
screening session, a researcher will go over it with them, answer any questions, and observe them signing the 
form. The form will be returned, either by mail or electronically, before the first testing session. All surveys and 
testing will take place at the same time of day, in the morning when PWP are typically at their best.  
Analysis and interpretation: Class attendance will be compared to attendance at our in-person group 
courses, as well as to other PD-focused courses described in the literature. Study retention will provide 
information about how many participants we will need to recruit in our next study. Qualitative course 
evaluations will be used along with instructor notes and video to improve the course. We will also look at 
balance and motor symptoms, but these will not be subject to inferential statistics due to the small sample size 
and absence of a control group 
Potential pitfalls: Recruitment: If we don’t find enough willing volunteers who qualify for the study in Moscow 
or Pullman, we will expand our recruitment efforts to other towns within an hour’s drive. Scheduling: we will 

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have three different possible times of day that we could offer the class, to maximize our ability to find 
participants who can do it. This flexibility is made possible by the absence of a need to reserve a teaching 
space. Technical problems: If the Internet connection is not as good as anticipated for some of the participants, 
they can switch to using telephone for audio and only streaming video live. PD is a neurodegenerative disease, 
so balance and motor symptoms may not improve even if the course is successful. Sometimes slower disease 
progression and decline is the best one can hope for. However, this will not affect our primary outcomes. 
4.3.1 Intent to yield key preliminary data to facilitate an extramural grant application. The knowledge 
gained from this study will facilitate the subsequent generation of a large-scale grant submission. The PI 
recently had a conversation with an NIH program officer who suggested that we consider following this study 
with an R34 and then an R01. The R34 is a three-year medium-sized planning grant that would allow us to 
establish a full research team and develop the data management tools necessary to be fully prepared to 
submit a competitive R01. NIH has a keen interest in and has announced funding opportunities for studies to 
identify best practices to deliver remote symptom-management courses. For instance, PAR-20-154 solicits 
investigator-initiated clinical trials (R01) of complementary and integrative interventions delivered remotely. 
4.3.2 Interim milestones. The Poise Project (TPP) will take the lead on content development and revision, 
using the PI’s expertise and background as needed. TPP will develop the course manual and training 
materials, train the instructor, and supervise the delivery of the course. TPP has previously done all these 
steps for several different in-person courses according to specified timelines. The PI will be responsible for 
recruiting, screening and testing participants, analyzing data, disseminating the results, and writing subsequent 
grant(s). 
4.3.3 Project timeline (The Poise Project in red, Mind in Movement Lab in blue; TPP & MML in purple) 
 
 
 
 
 
 
 
 
 
 
 
 
 
During the course of this project, we plan to submit for publication the results of our recent study testing in-
person Alexander courses for PWP/care partner dyads. We will also continue conversation with our NCCIH 
program officer contact and initiate conversations with NCMRR and NIA program officers to discuss next steps, 
such as whether it would be wise to apply for an R01 next or to apply for an intermediate mechanism such as 
R34 (described above in 4.3.2). Such an application could potentially be generated in summer 2021, 
depending on the results of the proposed work. For this extramural proposal, we will work with MW CTR-IN’s 
appointed biostatistician at the U of I on the project’s study design and analysis strategy. 
Impact. “Poised for Parkinson's” has great potential as an impactful, scalable, sustainable, and measurable 
program. This innovative, dyad-centered, Alexander technique-based approach to the care of individuals with 
Parkinson’s disease has the capacity to significantly improve management of several refractory PD symptoms. 
 
Sept-Oct 
Nov-Dec 
Jan-Feb 
Mar-Apr 
May-Jun 
Aim 1  
Develop Content  
 
 
 
 
 
Develop Training Materials  
 
 
 
 
Train Instructor 
 
 
 
 
 
Aim 2 
Recruit, Screen, & Pretest 
 
 
 
 
 
Deliver Course 
 
 
 
 
 
Posttest 
 
 
 
 
 
Aim 3 
Analyze Data 
 
 
 
 
 
Create & Present Poster  
 
 
 
 
 
Revise Course