RESEARCH BMJ: first published as 10.1136/bmj.a884 on 19 August 2008. Downloaded from Randomised controlled trial of Alexander technique lessons, exercise, and massage (ATEAM) for chronic and recurrent back pain Paul Little, professor of primary care research,1 George Lewith, reader,1 Fran Webley, overall trial coordinator and trial manager for Southampton site,1 Maggie Evans, trial manager for Bristol site,4 Angela Beattie, trial manager for Bristol site,4 Karen Middleton, trial data manager,1 Jane Barnett, research nurse,1 Kathleen Ballard, teacher of the Alexander technique,5 Frances Oxford, teacher of the Alexander technique,5 Peter Smith, professor of statistics,3 Lucy Yardley, professor of health psychology,2 Sandra Hollinghurst, health economist,4 Debbie Sharp, professor of primary care4 1Primary Care Group, Community ABSTRACT Trial registration National Research Register Clinical Sciences Division, Objective To determine the effectiveness of lessons in the N0028108728. University of Southampton, Aldermoor Health Centre, Alexander technique, massage therapy, and advice from a Southampton SO16 5ST doctor to take exercise (exercise prescription) along with INTRODUCTION 2School of Psychology, University nurse delivered behavioural counselling for patients with Back pain is a common condition managed in primary of Southampton chronic or recurrent back pain. 3 care and one of the commonest causes of disability in Department of Social Statistics, 12 University of Southampton Design Factorial randomised trial. Western societies. As yet few interventions have been 4Academic Unit of Primary Health Setting 64 general practices in England. proved to substantially help patients with chronic back http://www.bmj.com/ Care, Department of Community Participants 579 patients with chronic or recurrent low pain in the longer term. Based Medicine, University of — back pain; 144 were randomised to normal care, 147 to Supervised exercise classes mainly strengthening Bristol — 5 massage, 144 to six Alexander technique lessons, and and stabilising exercises probably have moderate Society of Teachers of the 3-7 Alexander Technique, London 144 to 24 Alexander technique lessons; half of each of benefit for chronic pain. A trial of advice from a Correspondence to: P Little these groups were randomised to exercise prescription. doctor to take aerobic exercise showed short term [email protected] benefit for acute pain,8 but the evidence of longer term Interventions Normal care (control), six sessions of benefit for chronic or recurrent pain and for exercise on 25 September 2021 by guest. Protected copyright. Cite this as: BMJ 2008;337:a884 massage, six or 24 lessons on the Alexander technique, “prescriptions” is lacking.9 doi:10.1136/bmj.a884 and prescription for exercise from a doctor with nurse Lessons in the Alexander technique offer an delivered behavioural counselling. individualised approach designed to develop lifelong Main outcome measures Roland Morris disability score skills for self care that help people recognise, under- (number of activities impaired by pain) and number of stand, and avoid poor habits affecting postural tone and days in pain. neuromuscular coordination. Lessons involve contin- Results Exercise and lessons in the Alexander technique, uous personalised assessment of the individual patterns but not massage, remained effective at one year of habitual musculoskeletal use when stationary and in (compared with control Roland disability score 8.1: movement; paying particular attention to release of − − massage 0.58, 95% confidence interval 1.94 to 0.77, unwanted head, neck, and spinal muscle tension, − − − − − six lessons 1.40, 2.77 to 0.03, 24 lessons 3.4, 4.76 guided by verbal instruction and hand contact, − − − − to 2.03, and exercise 1.29, 2.25 to 0.34). Exercise allowing decompression of the spine; help and feed- after six lessons achieved 72% of the effect of 24 lessons back from hand contact and verbal instruction to alone (Roland disability score −2.98 and −4.14, improve musculoskeletal use when stationary and in respectively). Number of days with back pain in the past movement; and spending time between lessons prac- four weeks was lower after lessons (compared with control tising and applying the technique (also see appendix on median 21 days: 24 lessons −18, six lessons −10, bmj.com). massage −7) and quality of life improved significantly. No The Alexander technique is thus distinct from significant harms were reported. manipulation,10 back schools,11 and conventional Conclusions One to one lessons in the Alexander physiotherapy.12 Thepracticeandtheoryofthe technique from registered teachers have long term technique, in conjunction with preliminary findings benefits for patients with chronic back pain. Six lessons of changesin posturaltone and its dynamic adaptability followed by exercise prescription were nearly as effective to changes in load and position,13-15 support the as 24 lessons. hypothesis that the technique could potentially reduce BMJ | ONLINE FIRST | bmj.com page 1 of 8 RESEARCH back pain by limiting muscle spasm, strengthening Inclusion and exclusion criteria of patients with back pain BMJ: first published as 10.1136/bmj.a884 on 19 August 2008. Downloaded from postural muscles, improving coordination and flex- in past five years ibility, and decompressing the spine. A small trial, not fully reported, showed promising short term results for Inclusion criteria: to identify those with significant back pain.16 We are not aware of a trial reporting long recurrent pain or chronic pain term results. Presentation in primary care with low back pain more than three months previously (to exclude first Systematic reviews and a recent trial highlighted the episodes) importance of research to assess the effectiveness of holistic therapeutic massage17-19;weparticularly Currently scoring 4 or more on the Roland disability scale wanted to assess massage as it provides no long term educational element, in contrast with lessons in the Current pain for three or more weeks (to exclude Alexander technique. recurrence of short duration) We determined the effectiveness of six or 24 lessons Exclusion criteria in the Alexander technique, massage therapy, and Previous experience of Alexander technique advice from a doctor to take exercise (using an exercise Patients under 18 and over 65 (serious spinal disease prescription) with nurse delivered behavioural coun- more likely) selling for patients with chronic or recurrent back pain. Clinical indicators of serious spinal disease20 Current nerve root pain (below knee in dermatomal METHODS distribution), previous spinal surgery, pending We recruited 64 general practices in the south and west litigation (outcome may be different, groups too small of England in two centres (Southampton and Bristol) to analyse) on the basis of geographical availability of teachers of History of psychosis or major alcohol misuse (difficulty the Alexander technique and massage therapists; 152 completing outcomes) teachers and therapists agreed to participate. Each Perceived inability to walk 100 m (exercise difficult) practice wrote to a random selection of patients who had attended with back pain in the past five years (see box for inclusion criteria, mostly similar to the United patients would be recruited to each trial group or Kingdom back pain exercise and manipulation trial7 informed of the block randomisation. When possible for comparability). Patients were given information each practice was matched to two Alexander technique that there was suggestive preliminary evidence to teachers. http://www.bmj.com/ support each intervention (Alexander technique, massage, and exercise). We recruited patients from 8 Outcome measures July 2002 to 22 July 2004. The first primary outcome measure was disability, measured using the Roland Morris disability ques- Randomisation tionnaire. Patients indicate the number of specified At the baseline appointment, after informed written activities or functions limited by back pain21 22 (for consent had been obtained, participants were rando- example, getting out of the house less often, walking on 25 September 2021 by guest. Protected copyright. mised to one of eight groups by the practice nurse more slowly than usual,not doing usual jobs around the telephoning the central coordinating centre in South- house). The scale is designed for self report and has ampton (table 1 and appendix on bmj.com). A good validation characteristics.23 The second primary statistician had prepared a secure program using outcome measure was number of days in pain during computer generated random numbers so that the the past four weeks24 (a four week period facilitated next allocation could not be guessed. For each practice recall): this is distinct from intensity of pain or contributing 10 patients a block of eight numbers disability.24 25 existed, and two were added from a block that supplied Secondary outcome measures were quality of life, four other practices. Practices were not told how many measured using the short form 36,26 and secondary measures for back pain21: pain and disability using the 24 “ ” 21 Table 1 | Trial groups for patients with chronic or recurrent back pain Von Korff scale and Deyo troublesomeness scale, overall improvement using health transition,23 and fear Intervention No exercise Exercise* avoidance beliefs for physical activity.27 Normal care Group 1 (control) Group 5 For other measures we asked patients to agree or † Therapeutic massage (6 sessions)