Alexander technique and Supervised Physiotherapy Exercises in back paiN (ASPEN): a four-group randomised feasibility trial

Abstract

BackgroundThe Alexander technique probably helps back pain but it is unclear whether or not it can be combined with physiotherapy exercise classes, how many lessons are needed and what mechanisms might be involved.ObjectivesTo undertake a feasibility trial of the Alexander technique and supervised exercise classes and perform exploratory biomechanical and neuromuscular physiological marker analyses to better understand mediators of recovery.DesignFeasibility parallel-group randomised controlled trial.SettingGeneral practices in southern England.ParticipantsPatients with recurrent back pain (at least 3 weeks’ duration of a current episode).InterventionsParticipants were allocated by an external randomisation line to four groups: (1) normal care, (2) 10 Alexander technique lessons, (3) 12 physiotherapy exercise classes, (4) Alexander technique lessons plus exercise classes.Main outcome measuresThe feasibility outcomes were recruitment, acceptability and follow-up. The clinical outcomes were the Roland–Morris Disability Questionnaire (RMDQ), days in pain, the Von Korff pain and disability scale, overall improvement, fear of activity, enablement, the Oswestry Disability Index and the Aberdeen pain and function scale. Laboratory-based markers were axial muscle tone and flexibility, electrical activity, muscle tone and mechanical properties of elasticity and stiffness, trunk strength, and proprioception.ResultsIn total, 83 patients consented, 69 were randomised and 56 (81%) were followed up at 6 months. Most patients had long-standing pain (median > 300 days of pain). The RMDQ and other instruments were sensitive to change and the preliminary evidence suggests that the Aberdeen scale could be a useful measure. Study procedures were feasible and three methods of recruitment were successfully piloted. At 6 months the control group had changed little (RMDQ 1 point lower than at baseline) and, compared with the control group, clinically important improvements in RMDQ were seen in all groups, albeit not significant [Alexander technique −3.0, 95% confidence interval (CI) −6.7 to 0.8]; exercise classes −2.9, 95% CI −6.5 to 0.8; combined Alexander technique + exercise classes −2.50, 9% CI −6.20 to 1.19]. Novel biomechanical variables strongly associated with RMDQ score at 6 months were muscle tone (0.94 increase in RMDQ per unit increase in Hz, 95% CI 0.48 to 1.40;p < 0.0001), lumbar proprioception (1.48 increase in RMDQ per degree, 95% CI 0.83 to 2.12;p < 0.0001) and muscle elasticity (−4.86 increase in RMDQ per unit log decrement, 95% CI −0.01 to −9.72;p < 0.05). At 3 months the Alexander technique improved proprioception and exercise classes improved trunk extension strength. At 6 months the Alexander technique improved the timing of multifidus muscle onset and the active straight leg raise test and exercise classes improved multifidus muscle thickness and the ability to contract. The combined effects of the Alexander technique and exercise classes were improvements in muscle tone, elasticity and thickness and contractile ability. These observations provide possible links between intervention, proprioception, muscle tone and elasticity and outcome. In terms of harms, one patient fell in the exercise class group.ConclusionsThe trial is feasible and the interventions may provide clinically important benefits. Exploratory analysis suggests that muscle tone, elasticity and proprioception are strongly associated with improved RMDQ score and are likely to be modified by the interventions.Trial registrationCurrent Controlled Trials ISRCTN51496752.FundingThis project was funded by the Medical Research Council through the Efficacy and Mechanism Evaluation Board.

Non-Invasive Biomarkers of Musculoskeletal Health with High Discriminant Ability for Age and Gender

“…For instance, in the use of Myoton testing of mechanical properties in upper-extremity rehabilitation for stroke patients, muscle stiffness was more responsive to change than tone and elasticity [ 45 ]. Similarly, responsiveness to change of muscle mechanical properties was reported in people with Parkinson’s disease following medication [ 46 ], and brain stimulation [ 47 ], physical treatment for back pain [ 48 ], and following physical activity [ 49 ]. The changes assessed using ultrasound imaging following functional electrical stimulation on muscle structure after stroke have also been reported [ 50 ].…”

Effectiveness of movement and body awareness therapies in patients with fibromyalgia: a systematic review and meta-analysis

“…While Body Awareness Therapies have shown positive outcomes in several pathologies such as cancer 15 in terms of physical, psychological and immune function 16 , quality of life and bone density 17 . European movement approaches such as dance therapy, Feldenkrais and Alexander Technique 18 and integrative dance therapies such as biodance and aquatic biodance have shown efficacy in the rehabilitation programmes for fibromyalgia 19 . Although the effectiveness of body awareness therapies have been assessed by several authors 12,13,20 this updated systematic review and meta-analysis intends to provide a summary of Movement and Body Awareness Therapies in patients Review of Body Awareness Therapies in Fibromyalgia suffering from fibromyalgia and to compare the different approaches in relation to clinical outcomes.…”

Findings from the development and implementation of a novel course consisting of both group and individual Alexander Technique lessons for low back pain

“…Patient participants were also interviewed regarding their experience of the course. Quantitative measures were collected by using similar inclusion criteria to two previous studies that had good data on the natural history,5 7 and where there was a modest improvement in control groups, some provisional comparison could be made.…”

“…5 These mechanisms involve improved coordination of the trunk, head and limbs, and improved motor control of postural muscles, factors which are usually operating poorly in individuals with chronic back pain. [6][7][8][9][10][11] In the ATEAM trial, six lessons resulted in a 1.4 difference compared with usual care in the Roland-Morris Disability Questionnaire (RMDQ), whereas the minimum clinically important difference (MCID) for the RMDQ is of the order of 2-2.5. 5 12 Longer courses of one-on-one lessons in the ATEAM trial were effective (RMDQ −3.4 compared with usual care) but not likely to be as cost-effective as other options that use group environments such as physiotherapy.…”

“…AT aims to correct posture and upright support mechanisms through increasing a person’s awareness of harmful habits of body use, allowing them to consciously move in a different way 5. These mechanisms involve improved coordination of the trunk, head and limbs, and improved motor control of postural muscles, factors which are usually operating poorly in individuals with chronic back pain 6–11. In the ATEAM trial, six lessons resulted in a 1.4 difference compared with usual care in the Roland-Morris Disability Questionnaire (RMDQ), whereas the minimum clinically important difference (MCID) for the RMDQ is of the order of 2–2.5 5 12.…”