Intended for healthcare professionals


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

BMJ 2008; 337 doi: (Published 11 December 2008) Cite this as: BMJ 2008;337:a2656
  1. Sandra Hollinghurst, senior lecturer in health economics1,
  2. Debbie Sharp, professor of primary health care1,
  3. Kathleen Ballard, Alexander technique teacher3,
  4. Jane Barnett, research nurse2,
  5. Angela Beattie, trial manager1,
  6. Maggie Evans, trial manager1,
  7. George Lewith, reader2,
  8. Karen Middleton, data manager2,
  9. Frances Oxford, Alexander technique teacher3,
  10. Fran Webley, trial coordinator2,
  11. Paul Little, professor of primary care research2
  1. 1Academic Unit of Primary Health Care, University of Bristol, Bristol BS8 2AA
  2. 2Primary Care Group, CCS Division, University of Southampton, Aldermoor Health Centre, Southampton SO16 5ST
  3. 3Society of Teachers of the Alexander Technique, Linton House, London NW5 1RS
  1. Correspondence to: S Hollinghurst s.p.hollinghurst{at}
  • Accepted 5 October 2008


Objective An economic evaluation of therapeutic massage, exercise, and lessons in the Alexander technique for treating persistent back pain.

Design Cost consequences study and cost effectiveness analysis at 12 month follow-up of a factorial randomised controlled trial.

Participants 579 patients with chronic or recurrent low back pain recruited from primary care.

Interventions Normal care (control), massage, and six or 24 lessons in the Alexander technique. Half of each group were randomised to a prescription for exercise from a doctor plus behavioural counselling from a nurse.

Main outcome measures Costs to the NHS and to participants. Comparison of costs with Roland-Morris disability score (number of activities impaired by pain), days in pain, and quality adjusted life years (QALYs). Comparison of NHS costs with QALY gain, using incremental cost effectiveness ratios and cost effectiveness acceptability curves.

Results Intervention costs ranged from £30 for exercise prescription to £596 for 24 lessons in Alexander technique plus exercise. Cost of health services ranged from £50 for 24 lessons in Alexander technique to £124 for exercise. Incremental cost effectiveness analysis of single therapies showed that exercise offered best value (£61 per point on disability score, £9 per additional pain-free day, £2847 per QALY gain). For two-stage therapy, six lessons in Alexander technique combined with exercise was the best value (additional £64 per point on disability score, £43 per additional pain-free day, £5332 per QALY gain).

Conclusions An exercise prescription and six lessons in Alexander technique alone were both more than 85% likely to be cost effective at values above £20 000 per QALY, but the Alexander technique performed better than exercise on the full range of outcomes. A combination of six lessons in Alexander technique lessons followed by exercise was the most effective and cost effective option.

How does the Alexander Technique work? What are the authors findings about the clinical and cost effectiveness of the treatment? Watch this video to find out (12 mins).


  • Contributors: Jackie Brown designed the economic evaluation and Alan Montgomery and Tim Peters gave statistical advice. PL and GL had the original idea for the study, and DS and FO had been working on a parallel protocol; the protocol was developed by all the authors. PL and DS were the principal investigators, and FW coordinated the trial on a day-to-day basis. KM, JB, and AB managed the data. The analysis was carried out by SH, with all authors contributing to the interpretation of the results. SH wrote the paper, with comments and contributions from all authors, who all approved the final version. SH is guarantor for the paper.

  • Funding: The study was funded by the Medical Research Council (ISRCTN 26416991 (2000-2005)). All researchers are independent of the funding body.

  • Competing interests: None declared.

  • Ethical approval: The Southwest Multicentre Research Ethics Committee (2000 MREC: 01/06/54).

  • Provenance and peer review: Not commissioned; externally peer reviewed.

  • Accepted 5 October 2008

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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