Randomised controlled trial of Alexander technique lessons, exercise, and massage (ATEAM) for chronic and recurrent back pain

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. 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 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. 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 to -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 was 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. Trial registration National Research Register N0028108728.

Methodological issues in pragmatic trials of complex interventions in primary care

“…Conversely, using a 'credible' control or comparison intervention can help control for the known non-specific effects of complex interventions, ensure that the trial results are not simply explained by regression to the mean, natural history of the complaint or attention from a health professional, but provide an underestimate of the total effect of the intervention. More than one control group can be useful to tease out some of these issues, 7 but equally it can be very difficult to separate fully the specific and non-specific effects of an intervention. 8 Performance bias is a particular issue since an integral component of complex interventions is frequently patient-practitioner interaction or the 'therapeutic relationship'.…”

How do we define the condition ‘recurrent low back pain’? A systematic review

“…A comprehensive list of these explicit definitions is given in Table 1. Only three definitions were used by more than one study; one definition was shared by three studies [16,17,37], a second definition was shared by two studies [13,18], and a third definition was shared by two studies [31,43].…”

“…Some definitions were more general in nature, defining frequency as ''multiple spells over the past year'' [14] or ''repeated pain episodes over the past year'' [16,17]. Other definitions of frequency were related to seeking care; e.g., ''at least one previous outpatient visit for low back pain over past year'' [22] or ''previous presentation to primary care with low back pain within the last 3 months'' [18].…”

“…These features included specifying the number of previous episodes of LBP (e.g., ''at least 10 times'' [39]), the duration of pain (e.g., a recurrent episode must last for ''C2 consecutive days with low back pain'' [19]), the severity of pain (e.g., ''low back pain affecting physical capacity to work and resulting in sick leave'' [29]), and the pain course (e.g., ''report regular or prolonged pain at two consecutive interviews'' [51]). These features were used in 4 [13,18,39,47] [27]). von Korff's recommended definition for recurrent LBP [2] was used by only 3 of 36 studies (giving explicit definitions) [16,17,37] published since his 1994 paper.…”

“…This means that following an episode of low back pain it is likely that a patient will have further episodes of pain [3] causing suffering for the patient and time loss from work. A number of treatments have been developed to reduce the risk of recurrent low back pain (recurrent LBP) [4][5][6][7][8][9][10][11] with clinical trials conducted to evaluate how effective treatments are in patients with recurrent LBP [12][13][14][15][16][17][18][19].…”