Extensive coverage has today been given to a study that found the Alexander technique – a method of teaching improved posture – is beneficial for easing back pain. The study on the technique involved over 500 people with chronic back pain from general practices across the UK. It found that people who received one-to-one instruction in the Alexander technique, along with exercise, had reduced back pain and improved disability after one year compared to those receiving standard care.
Low back pain is a highly prevalent condition in the UK, with many adults suffering at some point in their lives, some experiencing recurrent problems. It can also be highly disabling, cause significant work loss, and reduced quality of life for the individual. It is now well known that remaining active, rather than bed rest, is the best approach to back pain; however, there has been conflicting evidence about the effectiveness of posture or exercise education. These new findings are likely to promote further research into the benefits and possible limitations of the Alexander technique, the people for whom it would be most suitable, and the best approach to instructing sufferers.
Where did the story come from?
The research was carried out by Professor of Primary Care Research, Paul Little, and colleagues from the School of Psychology at the University of Southampton, the Academic Unit of Primary Care at the University of Bristol and the Society of Teachers of the Alexander Technique. The study was funded by the Medical Research Council. The study was published in the (peer-reviewed) British Medical Journal.
What kind of scientific study was this?
This was a randomised controlled trial designed to examine the effectiveness of the Alexander technique, massage, exercise advice, and behavioural counselling for chronic and recurrent low back pain. The Alexander technique involves assessment of the individual’s normal posture and movements, aiming to release tension from the head, neck and spine, and improve musculoskeletal use when seated and moving.
Sixty-four GP surgeries from the south and west of England were recruited to the study. From each surgery a random selection of patients (aged 18 to 65) with chronic or recurrent back pain were invited to participate. Participants had presented to the surgery with back pain more than three months previously (this criteria excluded acute presentations), were suffering pain for three or more weeks and scored above four on the Roland disability scale. The researchers excluded anyone with potential spinal disease, a previous spinal surgery, nerve root pain in the leg, alcohol abuse, a history of psychosis, unable to walk 100m, or who had previous experience in the Alexander technique.
People from each surgery (total of 579) were randomly allocated to one of eight treatment groups (average 72 in each group). Four of the groups were instructed to do extra exercise (doctor prescription of exercises and nurse-led behavioural counselling) along with one of the following treatments: normal care, six sessions of therapeutic massage, six lessons in the Alexander technique, or 24 lessons in the Alexander technique. The other four groups had the same treatments but with no added exercise.
A total of 152 teachers and therapists were involved in educating and carrying out the techniques. People were assessed by postal questionnaire at start of the study, three months, and one year after they had been allocated a treatment. The main outcome that the researchers examined was disability, assessed using the Roland Morris questionnaire and covering issues such as types of activities limited by pain. They also looked at other outcomes of quality of life and other back pain and disability scales.
What were the results of the study?
Of the 579 people who were allocated a group and completed the questionnaire at the beginning of the study, 80% of the study sample (463) completed the one-year follow-up. When they first enrolled in the study, the characteristics of the participants were similar across all treatment groups and the majority had chronic back pain, experiencing 90 or more days of pain over the past year.
At three months, after exercise had been taken into account, Roland disability score and average number of days with back pain over the past month had significantly decreased in all groups compared to control (massages and 6 or 24 Alexander technique lessons). At one year, 6 or 24 Alexander technique lessons had significantly decreased Roland disability score and average number of days with back pain compared to control, but massage no longer showed significant decrease in disability score. The greatest improvement was seen in the 24-lesson group. Compared to control, exercise, following adjustment for the other techniques, significantly decreased both Roland disability score and average number of days with back pain at three months, but at one year, exercise was only significantly effective on disability score.
When the researchers compared individual groups, they found that the effect of 24 Alexander technique lessons combined with exercise was no different to the effect of 24 Alexander technique lessons alone. Six Alexander technique lessons combined with exercise were 72% as effective as 24 lessons alone without exercise. No adverse effects were reported for the Alexander technique.
What interpretations did the researchers draw from these results?
The researchers conclude that one-to-one instruction in the Alexander technique by registered teachers has long-term benefits in chronic back pain. Six lessons combined with exercise had almost comparable effectiveness to 24 lessons in the Alexander technique.
What does the NHS Knowledge Service make of this study?
This well conducted randomised trial has strengths in that it involved a large number of participants with a sample size large enough to assess meaningful differences in the measured outcomes for each of the different treatments. It also followed the majority of these participants across the one year period. The study demonstrates the effectiveness of the Alexander technique, with and without exercise, in reducing disability score on a recognised scale. A few points to consider:
- Instruction and education in the techniques involved a large number of trained professionals (152) and there may have been minor differences in the treatments given across the sample.
- The fact that the Alexander technique requires education by a registered professional does mean that referral is going to be affected by local care arrangements and resources across the country.
- Although the effectiveness was measured up to one year, longer follow-up would be valuable to assess longer-term outcomes and possible adverse effects.
- Assessments were by postal questionnaire and disability, quality of life and pain are highly subjective measures. How one person views their level of pain and disability is going to be different from another.
- All people in the groups had chronic back pain and fulfilled certain criteria. Many that the researchers contacted initially were not eligible for the study. Importantly, this study has no implications for care of acute low back pain.
Low back pain is a highly prevalent condition in the UK with many adults suffering at some point in their lives, some of whom experience recurrent problems. It can also be highly disabling, cause significant work loss, and reduced quality of life for the individual. It is now well known that remaining active, rather than bed rest, is the best approach to back pain. However, there has been conflicting evidence on the effectiveness of posture or exercise education. These new findings are likely to promote further research into the benefits and possible limitations of the Alexander technique, the people for whom it would be most suitable, and the best approach to instructing sufferers.
Analysis by Bazian
Edited by NHS Website
Links to the headlines
The Guardian, 20 August 2008
The Daily Telegraph, 20 August 2008
BBC News, 20 August 2008
The Times, 20 August 2008
Daily Mail, 20 August 2008
Links to the science
BMJ 2008; 337; a884
Cochrane Database of Systematic Reviews 2005, Issue 3
Cochrane Database of Systematic Reviews 2005, Issue 1
Cochrane Database of Systematic Reviews 2002, Issue 2