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P Little, University of Southampton, Southampton, UK;
factorial randomised controlled trial. National Research Register N0028108728.
blinded (data entry personnel).*
64 general practices in Southampton and Bristol, UK.
579 patients 18–65 years of age (mean age 45 y, 69% women) who had low back pain for >3 months, Roland Morris disability scores ⩾4, and current pain for ⩾3 weeks. Exclusion criteria were previous experience with the Alexander technique, serious spinal disease, nerve root pain, previous spinal surgery, pending litigation, history of psychosis or alcohol misuse, and perceived inability to walk 100 metres.
24 lessons in the Alexander technique (n = 144), 6 lessons in the Alexander technique (n = 144), 6 sessions of massage (n = 147), or usual care (n = 144). Half of each group was then randomised to doctor prescription for exercise with nurse-delivered behavioural counselling, and the other half was allocated to usual care.
included disability (Roland Morris disability score measuring number of activities affected by pain; 0 = best score, 28 = worst score) and number of days in pain in the past 4 weeks.
Patients allocated to either 6 or 24 Alexander technique lessons had reduced disability and pain compared with control (table). Exercise reduced disability but did not differ from control for pain (table). Massage reduced pain but did not differ from control for disability (table).
The combination of exercise with 6 lessons of the Alexander technique had about three-quarters of the effect of 24 lessons for reduction of disability. However, exercise with 24 lessons of the Alexander technique did not differ from 24 lessons alone.
Alexander technique lessons were effective for chronic or recurrent back pain at 1 year.
Little P, Lewith G, Webley F, et al. Randomised controlled trial of Alexander technique lessons, exercise, and massage (ATEAM) for chronic and recurrent back pain. BMJ 2008;337:a884.
Clinical impact ratings: GP/FP/Primary care 6/7; Surgery—Orthopaedics 5/7
Several treatment approaches have been recommended for back pain. The study by Little et al addresses 1 of these, the Alexander technique. The study design is robust, and the treatment is appropriate. The results are impressive because most patients regained independence and were able to overcome the stigma of their ailment. The technique does not address the causes of back pain, but it is non-pharmacological and therefore prone to fewer adverse reactions than drug treatments. By giving patients a modicum of independence, this technique offers substantial relief and reintroduces patients to an enjoyable and active life. Few other interventions can make this claim. The Alexander technique requires a trained professional for its proper execution, which may add to the expense, but it certainly seems worth the increment if patients are able to return to more satisfactory lives. The technique, in giving prolonged relief, appears to be a major public health advance.
Source of funding: Medical Research Council.