New format for BMJ research articles in print

BMJ 2008; 337 doi: (Published 29 December 2008) Cite this as: BMJ 2008;337:a2946

It’s nearly 10 years since we began abridging original research articles for readers of the print BMJ. Now we’re going a step further, using the advantages of both web and print. The full, open access version of this original article by Hollingshurst and colleagues is published online (doi:10.1136/bmj.a2656), along with our first ever BMJ research video and a podcast. Here are two abridged versions: a BMJ Pico—a new evidence abstract prepared by the authors—and a Short Cuts article written by the BMJ. Which version would you read and use? Which would you prefer if you were the author? Please tell us your views, as readers and researchers, by posting rapid responses to this article.

Pico model—Randomised controlled trial of Alexander technique lessons, exercise, and massage (ATEAM) for chronic and recurrent back pain: economic evaluation

Sandra Hollinghurst,1 Debbie Sharp,1 Kathleen Ballard,3 Jane Barnett,2 Angela Beattie,1 Maggie Evans,1 George Lewith,2 Karen Middleton,2 Frances Oxford,3 Fran Webley,2 Paul Little2

Study question What is the difference in cost effectiveness between long and short courses in the Alexander technique, massage, and a general practitioner’s prescription for exercise for patients with persistent back pain?

Answer An exercise prescription and six lessons in Alexander technique alone were each more than 85% likely to be cost effective at values above £20 000 per quality adjusted life year (QALY), but the Alexander technique performed better than exercise on the full range of outcomes. A combination of six lessons in Alexander technique and exercise was the most effective and cost effective option.

Study design This cost effectiveness analysis compared the cost to the NHS of different interventions with patients’ outcomes (Roland-Morris disability score, days free of pain, and quality adjusted life year (QALY)). Patients’ and societal costs were analysed separately.

Source of effectiveness Interventions were applied in a randomised controlled trial using a 4×2 factorial design (BMJ 2008;337:a884). A short course of six lessons in the Alexander technique, a longer course of 24 lessons, and six sessions of massage were compared with normal care. Half of each group also received a doctor’s prescription for exercise and behavioural counselling from a practice nurse.

Data NHS costs comprised the cost of the intervention, primary care contacts, outpatient appointments, inpatient hospital stays, and medication. Personal costs were those for travel associated with back pain treatment, private treatment and over the counter drugs, prescription charges, loss of earnings, and expenditure on domestic help and care giving. Societal costs were for time taken off work or unpaid activities and use of informal care. Treatment outcomes were derived from routine records and participants’ self completed questionnaires.

Main results Incremental cost to the NHS ranged from £100 (for normal care plus exercise) to £607 (for 24 lessons in the Alexander technique plus exercise) over 12 months. Benefits were additional pain-free days (8-20 per patient, by intervention group), improvements in the ability to perform daily activities (reduction in the disability score of 0.45-4.22 per patient, by group), and a gain in QALY of up to 0.065 per patient, by group. The best value single treatment was normal care plus exercise, at £61 per point reduction in the disability score, £9 per extra pain-free day, and £2847 per QALY gain. The best value dual treatment comprised six lessons of Alexander technique plus exercise, with an additional £64 per point reduction in disability score, £43 per pain-free day, and £5332 per QALY gain.

Results of sensitivity analysis The main areas of uncertainty were adherence to treatment, inpatient stays, and missing data. Complete attendance by patients at all intervention sessions would increase costs by 18%. Excluding inpatient stays reduced overall costs by 4%. Analysis of only those cases with complete data reduced personal costs by 3% and increased the variation in QALY gain across groups.

Limitations of study The missing quality of life data add to uncertainty around the QALY estimates, and the authors emphasise the importance of considering all outcomes when drawing conclusions. Also, the data on lost productivity were incomplete and were not used in the comparative analysis. The study design, as a factorial analysis, creates difficultly in interpreting the economic evaluation, and individual group analysis was therefore used to present the main findings. The payments to teachers and therapists for the interventions may not be generalisable, but, as they were at the upper end of commercial rates, the results are conservative.

Competing interests None declared. All researchers are independent of the funding body, the Medical Research Council.

  • 1Academic Unit of Primary Health Care, University of Bristol, Bristol BS8 2AA

  • 2Primary Care Group, CCS Division, University of Southampton, Aldermoor Health Centre, Southampton SO16 5ST

  • 3Society of Teachers of the Alexander Technique, Linton House, London NW5 1RS

  • Correspondence to: S Hollinghurst [email protected]

  • This article is a summary of a paper that was published on Cite this article as: BMJ 2008;337:a2656

Short Cuts model—Alexander technique and exercise are cost effective options for chronic back pain

  • Hollinghurst et al. Randomised controlled trial of Alexander technique lessons, exercise, and massage (ATEAM) for chronic and recurrent back pain: economic evaluation. BMJ 2008;337:a2656


Chronic low back pain is common, disabling, and expensive for both patients and third party payers. A prescription for home based exercise can help reduce symptoms and improve quality of life. So can a series of lessons in the Alexander technique. But which treatment or combination of treatments represents the best value for money?

Using effectiveness data from a recent randomised controlled trial (BMJ 2008;337:a884), health economists from the UK have calculated that a simple exercise prescription backed up with brief counselling from a primary care nurse costs just £9 for each extra pain-free day per month, or an estimated £2847 for each additional quality adjusted life year. Six lessons in the Alexander technique also looked cost effective, at £13 for each extra pain-free day and £5899 for each extra quality adjusted life year.

More lessons (24 v 6), or the combination of lessons and exercise worked better but cost more in this analysis. Even so, the authors say that first choice for primary care patients should probably be six lessons in Alexander technique followed by an exercise prescription. This combination worked better than exercise alone, worked almost as well as 24 lessons of Alexander technique, and cost the NHS only £43 for each extra pain-free day or £5332 for each extra quality adjusted life year.

  • Alison Tonks associate editor, BMJ [email protected]


Cite this as: BMJ 2008;337:a2946

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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