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A pilot study on the effectiveness of the Alexander Technique for the treatment of knee osteoarthritis (KOAT).

Teacherís report by Peter Bloch mSTAT

First published in STATNews, May 2013; revised March 2014 by the author.


During the period from September 2011 to December 2012, I was the sole AT teacher for a pilot study on the effectiveness of lessons in the AT for knee osteoarthritis (OA) patients. The study was conducted at the School of Health Sciences at Salford University and funded by the BUPA Foundation (a £20,000 award) with further financial support from the University of Salford. The lead researcher was Dr Steven Preece, a longstanding AT pupil and enthusiast who has spent many dauntless years preparing for, and obtaining the funding for, this study. Originally there were to be about 10 pupils, but the early results were so remarkable that both the BUPA Foundation and the University of Salford provided extra funds. In the end I saw 23 pupils for 20 lessons each, 21 of whom were able to complete the course. One pupil dropped out early on and one was too generally infirm to complete the final bio-mechanical testing.

The pupils were recruited through a computerised search of the records of participating local GPs, a letter of invitation, and a brief telephone interview by Dr Preece. Patients had to meet criteria such as established knee OA, age under 70 and the absence of systemic rheumatic diseases. However, because knee OA is generally a disease of advancing years, a disproportionate number of pupils were older and with significant medical histories and co-morbidities. Most had OA in both knees, several of the "dry twig cracking sound on movement" variety. Although it proved surprisingly difficult to attract GP practices to participate in the study, those that did so were very friendly and helpful, even enthusiastic.      

Both before and after the lessons, the pupils filled out detailed self-assessment forms (WOMAC) that included mental state, disability and pain. The WOMAC questionnaire is used in all clinical trials of knee OA which makes it possible to compare the effect of different treatments. Pupils also underwent a battery of bio-mechanical tests.

Giving the lessons

Despite the lack of self-referral and the participation of a number of pupils that I would not normally have encountered in my private practice (for various reasons including socio-economic-educational group, general infirmity, personality and a history of recent serious life crises) I found the experience rewarding, and often surprising in a very positive sense. Indeed, two of the most successful pupils were people who I would not at first have been optimistic about in my private practice, which served to remind me of how hard it is to predict at the outset what use people will be able to make of the skills we teach. One of these pupils was a distinctly grumpy and very disabled elderly man, who arrived with a more pleasant demeanour at each successive lesson until, in the last few, he was positively floating out of the chair and grinning from ear to ear!

What does this study show?

Some of the statistical results that we have so far are very impressive indeed. They are the first evidence that we have of the effectiveness of AT lessons for people with established and mostly longstanding OA. There was an overall 54% reduction in the standard WOMAC clinical scoring system for OA, which includes various measures of disability and pain and a 56% reduction in the pain scores. These results suggest that the AT could outperform all other conservative options for treating knee OA.

In addition, it is interesting to note that the almost linear nature of the dose-response curve (Figure 1) suggests that further lessons would have produced even more benefit.

Figure 1: Dose response curve demonstrating the effect of 10, 15 and 20 AT lessons on WOMAC pain. These date were collected in our pilot study from participants who returned questionnaires at each time point and who completed all 20 AT lessons.

However, it is important to remember that this is a small sample group and that there was no control group. Large-scale trials such as the ATEAM low back pain trial would be required to provide definitive evidence that the AT is an effective treatment for knee OA.

What does this mean for us as AT teachers?

Since this is a very small study, we need to see these figures for what they are -preliminary but exciting data. However, we have been able to provide the first evidence for the effectiveness of AT lessons in addressing the pain and disability of knee OA, a very common and often distressing condition. In addition, we have been able to show the potential of AT lessons for helping people with pain and disability caused by a degenerative disease. Interestingly, the biomechanical data seems to support the idea of the Alexander Technique reducing muscle stiffness across the knee and these results correlated quite well with the degree of reduction in pain. This goes some way towards explaining a mechanism by which the technique works for helping patients with knee osteoarthritis.

What next?

Dr Preece will be writing several papers about the study (one of which has just been presented at the World Congress on Osteoarthritis in Philadelphia) and they will be submitted for publication in due course. What would ideally happen next is the "gold standard" of medical research, a large, randomised, controlled clinical trial. This is a very expensive and complicated undertaking and funding is difficult to obtain. The good news is that the results of this small study make obtaining the necessary funding much more likely. We need to be patient, but already plans are being made and applications submitted for a major research grant.

© Peter Bloch 2013 & 2014


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