Investigation results

A1 Primary Care group, Community Clinical Sciences Division,
Southampton University, Aldermoor Health Centre,
Southampton SO16 5ST
A2 School of Psychology, University of Southampton
A3 Department of Social Statistics, University of Southampton
A4 Division of Primary Care, Department of Community Based Medicine,
Faculty of Medicine and Dentistry, University of Bristol
A5 Society of Teachers of the Alexander Technique

Correspondence to: P. Little psl3@soton.ac.uk

Accepted: 26. May 2008

ABSRACT

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.

Design Factorial randomised trial.

Setting 64 general practices in England.
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 was randomised to exercise prescription.

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

Main outcome measures Roland Morris disability score (number of activities impaired by pain) and number of days in pain.

Results Exercise and lessons in the Alexander technique, but not massage, remained effective at one year: compared with control Roland disability score 8.1: massage -0.58 (95% confidence interval -1.94 to 0.77), six lessons -1.40 (-2.77 to -0.03), 24 lessons -3.4 (-4.76;-2.03), and exercise -1.29 (-2.25 to -0.34). Exercise after six lessons achieved 72% of the effect of 24 lessons alone (Roland disability score -2.98 and -4.14, respectively). Number of days with back pain in the past four weeks were lower after lessons (compared with control median 21 days: 24 lessons -18, six lessons -10, massage -7) and quality of life improved significantly. No significant harms were reported.

Conclusions One-to-one lessons in the Alexander technique from registered teachers have long term benefits for patients with chronic back pain. Six lessons followed by exercise prescription were nearly as effective as 24 lessons.

II.

Pain Relief through Learning

Major Clinical Trial shows that Alexander Technique lessons give chronic low back pain sufferers long-term benefit

Learning the Alexander Technique helps back pain sufferers
A multicentre clinical trial, funded by the Medical Research Council and the NHS (Research and Development Fund), has shown that Alexander Technique lessons give long-term benefit to chronic low back pain sufferers.

The AT is a taught life-long self-help method that can enable patients with chronic or recurrent non-specific low back pain to reduce number of days in pain and overcome associated incapacity. Experience shows it can also help patients avoid recurrence.

One-to-one Alexander Technique lessons teach an individual how to recognise, understand and avoid pain-producing behaviour related to poor postural and movement habits that interfere with the functioning of postural and motor control systems. Learning and using the Alexander Technique leads to improvements in postural tonus, co-ordination, functioning, mobility and balance - and to significant reduction in non-specific low back pain.

The cost of back pain
Back pain afflicts up to 49% of the UK adult population every year, affects general well-being and quality of life, its overall cost on the NHS, business and the economy being L5 billion a year. Back pain is one of the commonest conditions managed in primary care and one of the commonest causes of disability.

Clinical trial details in brief
579 patients with chronic/recurrent non-specific low back pain were recruited from 64 general practices. They were randomly allocated to four groups: a) a control group receiving normal GP care, b) six (6) classical massage sessions, c) six (6) Alexander Technique lessons and d) twentyfour (24) Alexander Technique lessons. Half of each group received a GP prescription for aerobic exercise with behavioural counselling from a practice nurse.

All trial participants in the Alexander Technique lesson groups were taught by experienced STAT teachers using hand contact together with verbal explanation and advice to educate the participants’ awareness of their postural support and movement patterns.

Two main outcome measures were used, the principal one being the Roland-Morris scale, the ‘industry standard’ outcome measure for back function. It consists of 28 statements representing the ways that back pain affects a patient’s life. It asks people what they are not able to do from a list of daily tasks such as how far a person can walk without pain, whether sleep or appetite is disturbed by back pain and difficulties in getting out of a chair. The number of statements agreed with, is the score. The lower the score, the better is the patient’s condition. The second main outcome measure required patients to record how many days of back pain they had in the last four weeks.
Other outcome measures were also used.

Results
One-to-one Alexander Technique lessons provide significant and important benefit for low back pain patients.

Trial results clearly show that taking one-to-one lessons in the Alexander Technique led to longterm benefits: a reduction in the number of days in pain and significant improvement in function and quality of life.

Lessons are tailored to people’s individual needs and capabilities and applied to daily activities. They include attending to head poise and lengthening of the spine while moving from sitting to standing, walking, bending and lifting, part of the lesson taking place with the person lying supine on a table with the head supported, knees bent and feet on the table.

The principles of the Alexander Technique are explained and related to the individual’s particular circumstances. The aim is that people should develop sufficient skill and understanding to continue applying the AT in daily life on their own, so reducing episodes of back pain and ultimately avoiding them. Occasional refresher lessons are advisable.

One of the factors in non-specific low back pain is thought to be abnormal muscle tone with harmful uncoordinated tension of longitudinal and diagonal muscles along the spine and elsewhere, leading to shortening of the spine and compression of vertebrae and discs. When these problems are present, Alexander lessons are likely to help by facilitating the reduction of tension or spasm in over-tightened muscles, encouraging lengthening of the spine and the relief of abnormal pressure on discs and other structures.

In summary, individuals are helped to recognize self-damaging habits that cause or aggravate their pain, and to avoid them. It may take a number of lessons for individuals to learn how to prevent these learnt ‘automatic’ responses that interfere with normal tone and coordination, and before they begin to stand, sit and move in a better way.

For sustainable benefit around 25 individual lessons lasting 30-40 minutes are normally recommended. People are usually asked to remove shoes but otherwise remain fully clothed.

Of the approaches tested, lessons in the Alexander Technique provided the most benefit. The research reveals that following 24 Alexander Technique lessons, the average number of activities limited by low back pain had fallen by 42%, and the number of days in pain had decreased from 21 to 3 days per month one year after the trial started.

Since the effect of massage on activities was no longer significant by one year, but the effect of Alexander Technique lessons was maintained, the trial authors concluded that the long-term benefits of taking Alexander Technique lessons are unlikely to be due to placebo effects of attention and touch and more likely to be due to active learning of the Technique.
Significantly, a series of 6 Alexander Technique lessons followed by GP-prescribed general exercise was about 70% as beneficial as 24 Alexander Technique lessons alone. There were no adverse effects recorded in the trial by any of the 288 participants in the AT groups that together received a total of over 2,400 AT lessons.

"If it weren't for the Alexander Technique, I would not be living an independent life now, as my back would have prevented this."

Female Alexander Technique Pupil
Retired, 63 (STAT Survey 2006)

Alexander lessons
In a lesson the teacher first finds out if something the person is doing is causing their problem and then teaches them to stop doing it. This is achieved by teaching the person the Alexander Technique and how to make use of it to overcome the problem.

The teacher uses gentle hands-on contact together with verbal explanation to help people learn to attend to head poise and lengthening of the spine in a way that facilitates normal postural tone and coordination and brings relief from back pain. At the same time, poor habits that adversely affect back muscle tone and coordination and involve shortening of the spine are identified and tactfully brought to the person’s attention. Frequent assistance and constructive feedback are given to help the person prevent the intrusion of unwanted self-damaging habit and to make better use of their back muscles.

The Alexander lesson effect
During lessons people find they can sit, stand and move with less effort and strain, experiencing less pain. Afterwards they frequently feel taller, freer and more securely balanced. The benefits of AT lessons are maintained when individuals continue to practise what they have learned.

“Each year for many years, I was having to take two or three days off work several times in the year when I badly strained my neck/shoulder muscles, resulting in incapacitation. Since starting Alexander Technique lessons, I have experienced very little problem.”

Male Alexander Technique Pupil
Civil Servant (STAT Pupil Survey 2006)

Qualified registered teachers
All STAT qualified teachers undergo a three year approved teacher training course. They carry professional indemnity insurance and abide by a code of professional conduct. STAT keeps a register of qualified teachers who are entitled to use the initials MSTAT after their name.

Contacts for further Information

Questions on the ATEAM clinical trial:
Contact Professor Paul Little Primary Medical Care Group, Community Clinical Sciences Division, University of Southampton, Aldermoor Health Centre, Aldermoor Close, SO16 5ST.
Tel: 02380 240162 email: p.little@soton.ac.uk

For further information about the Alexander Technique and to find a local teacher:
www.stat.org.uk

For Additional information Contact, Ilia Daoussi, STAT, Linton House, 39-51
Highgate Road, NW5 1RS. Tel: 0207 482 5135 email: ilia@stat.org.uk