Oct 1
2008

British Medical Journal
Published 19 August 2008, doi:10.1136/bmj.a884
Cite this as: BMJ 2008;337:a884
Research
Randomised controlled trial of Alexander technique lessons, exercise, and massage (ATEAM) for chronic and recurrent back pain.

The results of the major back pain study funded by the NHS and MRC* have finally been published online by the prestigious British Medical Journal.  This is a serious scientific paper and should generate a lot of interest from journalists and medics.  One of the things likely to interest them most is that, unlike with conventional treatments, the subjects were still reporting benefits 12 months later. *National Health Service and Medical Research Council – both UK government-funded bodies.

NOTE: This Report can be read in it’s entirety on the web page for the British Medical Journal here. I have extracted only the pertinent sections regarding the Alexander Technique below:

Abstract
Objective To determine the effectiveness of lessons in the Alexander technique, massage therapy, and advice from a doctor to take exercise (exercise prescription) along with nurse delivered behavioural counselling for patients with chronic or recurrent back pain.

Participants 579 patients with chronic or recurrent low back pain; 144 were randomised to normal care, 147 to massage, 144 to six Alexander technique lessons, and 144 to 24 Alexander technique lessons; half of each of these groups were randomised to exercise prescription.

Interventions Normal care (control), six sessions of massage, six or 24 lessons on the Alexander technique, and prescription for exercise from a doctor with nurse delivered behavioural counselling.

Results Exercise and lessons in the Alexander technique, but not massage, remained effective at one year…. Number of days with back pain in the past four weeks was lower after lessons…and quality of life improved significantly.

Conclusions: One to one lessons in the Alexander technique from registered teachers have long term benefits for patients with chronic back pain.

Introduction

Back pain is a common condition managed in primary care and one of the commonest causes of disability in Western societies. As yet few interventions have been proved to substantially help patients with chronic back pain in the longer term. Supervised exercise classes—mainly strengthening and stabilising exercises—probably have moderate benefit for chronic pain. Trial of advice from a doctor to take aerobic exercise showed short term benefit for acute pain but the evidence of longer term benefit for chronic or recurrent pain and for exercise “prescriptions” is lacking.

Lessons in the Alexander technique offer an individualised approach designed to develop lifelong skills for self care that help people recognise, understand, and avoid poor habits affecting postural tone and neuromuscular coordination. Lessons involve continuous personalised assessment of the individual patterns of habitual musculoskeletal use when stationary and in movement; paying particular attention to release of unwanted head, neck, and spinal muscle tension, guided by verbal instruction and hand contact, allowing decompression of the spine; help and feedback from hand contact and verbal instruction to improve musculoskeletal use when stationary and in movement; and spending time between lessons practising and applying the technique.

The Alexander technique is thus distinct from manipulation, back schools, and conventional physiotherapy.  The practice and theory of the technique, in conjunction with preliminary findings of changes in postural tone and its dynamic adaptability to changes in load and position, support the hypothesis that the technique could potentially reduce back pain by limiting muscle spasm, strengthening postural muscles, improving coordination and flexibility, and decompressing the spine. A small trial, not fully reported, showed promising short term results for back pain.  We are not aware of a trial reporting long term results.

Systematic reviews and a recent trial highlighted the importance of research to assess the effectiveness of holistic therapeutic massage we particularly wanted to assess massage as it provides no long term educational element, in contrast with lessons in the Alexander technique. We determined the effectiveness of six or 24 lessons in the Alexander technique, massage therapy, and advice from a doctor to take exercise (using an exercise prescription) with nurse delivered behavioural counselling for patients with chronic or recurrent back pain.

Results

The effect of 24 lessons in the Alexander technique was greater at one year than at three months

Discussion

A series of 24 lessons in the Alexander technique taught by registered teachers provides long term benefits for patients with chronic or recurrent low back pain. Both six lessons in the Alexander technique and general practitioner prescription for aerobic exercise with structured behavioural counselling by a practice nurse were helpful in the long term; classic massage provided short term benefit.

Interventions : Alexander technique lessons Our study shows enduring benefits from lessons … six lessons in the Alexander technique retained effectiveness at one year shows that the long term benefit of Alexander technique lessons is unlikely to result from non-specific placebo effects of attention and touch.

What is already known on this topic

Combined manipulation and physiotherapy-supervised strengthening exercises helps functioning moderately (1-2 activities no longer limited by back pain). Preliminary evidence suggests that massage and lessons in the Alexander technique might help in the short term.

What this study adds

Six sessions of massage, prescription for exercise and nurse counselling, six lessons in the Alexander technique, and 24 lessons helped with back pain and functioning at three months. Lessons in the Alexander technique still had a beneficial effect on pain and functioning after 12 months.