ATEAM Trial

(Reproduced by kind permission of STAT. This material appears on the STAT web-site: see www.stat.org.uk)

Randomized controlled trial of Alexander Technique lessons,
Exercise And Massage (ATEAM) for chronic and recurrent back pain

Significant long-term benefit for low back pain has been demonstrated by a major study published by the British Medical Journal on 20th August 2008 at www.bmj.com.

To summarise: §

• 24 AT lessons proved to be most beneficial

• Six lessons followed by exercise were about 70% as effective as 24 lessons

• Long-term benefits unlikely to be due to placebo effect

• Lessons were one-to-one, provided by experienced STAT teachers

• This was a scientific randomised controlled trial

§ 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.

1. The trial

This research trial compared the long-term benefits of the following groups:

• Six lessons in the Alexander Technique (AT)

• 24 lessons in the AT

• Six sessions of a classical massage

• GP-prescribed aerobic exercise

with a control group which received normal GP care, for NHS patients with significant chronic or recurrent non-specific low back pain.

Half the patients in four groups (Six AT lessons, 24 AT lessons, massage and control) were provided with a GP prescription for taking general aerobic exercise (mainly 30 minutes of brisk walking or the equivalent each day) with practice nurse behavioural counselling. The prescription was given six weeks after patients entered the trial so that exercise followed the six massage sessions and 6 AT lessons, but often overlapped with most lessons for the 24 AT lesson group.

579 patients were recruited from 64 GP practices and 59 Alexander Technique teachers participated in the trial.

2. How were the results/outcomes measured?

Two main outcome measures were used, the principal one being the Roland Morris disability scale. This consists of 28 statements representing the ways that back pain affects a patient's life - the number of statements agreed with in a standard questionnaire is the score. The lower the score, the better is the patient's condition. Functional improvement was assessed by using this scale.

The other main outcome measure was the number of days in pain in the past four weeks. Ten secondary outcome measures were also used.

What were the main results of the trial?

1. The best results were seen in the 24 AT lesson group, with important improvements in function, quality of life and reduction in days in pain. One year after the trial started, the average number of activities limited by low back pain (the RM disability score) had fallen by 42%, and the number of days in pain was only three per month, compared with 21 days in pain in the control group.

2. At three months after the trial started all the intervention groups – six and 24 AT lessons, exercise and massage – showed some significant benefit compared with the normal GP care control group.

3. One year results for Exercise and Massage:

The exercise groups had improved function, with the disability score better at one year than at three months; days in pain were not significantly different from the control group (21 days).

The massage group’s three month improvement in the disability score was not maintained; days in pain (14) were still less than the control group (21 days).

4. Since the effect of massage on the disability score was no longer significant by one year, but the three month beneficial effect of 6 AT lessons was maintained, the authors concluded that the long-term benefits of taking Alexander Technique lessons are unlikely to be due to placebo effects of attention and touch and more likely to be due to active learning of the technique.

5. At one year, a series of six AT lessons followed by GP prescribed aerobic exercise (mainly walking) was about 70% as beneficial as a series of 24 AT lessons alone.

The results show that taking AT lessons can have a long-term beneficial effect, significantly decreasing days in pain and improving the functioning and quality of life of patients.

3. Funding of the trial

The Medical Research Council (MRC) funded the trial (£585,000). The NHS Research and Development Fund contributed an additional £186,000.

The trial was run from Southampton and Bristol University Departments of Primary Care. The trial management team was led by Professor Paul Little (Southampton) and Professor Debbie Sharp (Bristol).

The Alexander Technique component of the trial was taught by STAT teachers. STAT and the interests of the Alexander Technique were represented on the trial management team by Kathleen Ballard and Frances Oxford.

4. Note on lessons in the trial

All Alexander Technique lessons were provided on a one-to-one basis. Teachers had to agree to use both hands-on teaching and adequate verbal explanation. Trial participants were taught and helped to make use of the Alexander Technique to improve muscle tone, coordination, balance, and movement skills, and to recognise and avoid habits that caused or aggravated their pain.

All the Alexander Technique teachers had been teaching for at least three years and were members of STAT, the Society of Teachers of the Alexander Technique.

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