Randomised controlled trial of Alexander technique lessons, exercise, and massage (ATEAM) for chronic and recurrent back pain: economic evaluation
BMJ 2008; 337 doi: https://doi.org/10.1136/bmj.a2656 (Published 11 December 2008) Cite this as: BMJ 2008;337:a2656
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Ashley Grays' cpmments are pertinent in that before referral to
Alexander,
psychological, surgical etc options need to be considered in the types of
syndromes he mentions. However the comments about a control group
suggest a lack of understanding of the purpose of a control group in this
study. The idea is to try to get something close as possible to a placebo
control. Comparison with physiotherapy would be comparing two treatment
modalities: that is not what this study was attempting primarily to do. I
agree
a further study doing just that would be interesting.
He also states that "A good clinician should use postural and
movement
alteration as part of their overall treatment plan". Agreed, but my
experience
of NHS physio referral is that this is rarely if ever done to any
significant
extent. This research would suggest that it may be the major element in
many people's back pain that would benefit from attention.
As GPs we are well used to the nuances and complexities of making
appropriate back pain referral: but it should be borne in mind that the
majority of cases we see are 'mechanical' and I think this research does
give
grounds for considering referring those to an Alexander teacher. The long
term efficacy of physiotherapy or injection in such cases is not
convincing,
and they need to be kept away from surgeons at all costs.
Competing interests:
None declared
Competing interests: No competing interests
Dear Sir/Madam,
Regarding the Alexander technique article, it is good that biomechanical
analysis, movement patterns and strategies to correct any dysfunction
within them are being highlighted. May I point out however that this
concept is nothing new, physiotherapists have been doing it very
successfully for years, and to claim it as a novel technique is
unwarranted.
Secondly may I say that your controls (GP prescribed exercise
and massage) are wholly innappropriate. Of course something that is
supervised, specific and well clinically reasoned will be more effective
than than general massage with no understanding of the underlying
pathology or generic unsupervised nonspecific home exercises. That should
have been obvious from the start.
Lastly, although your cost analysis was
technically very sound it seems folly to me to send patients to
practioners that only have 'one string to their bow'. A good clinician
should use postural and movement alteration as part of their overall
treatment plan (along with other techniques such as manual therapy,
specific supervised exercise therapy, injection therapy, CBT etc..)and not
as the entire treatment plan.
May I suggest that a referral to a
clinician that would utilise all these techniques would be far more cost
effective, and that future research should include the same amount of
physiotherapy sessions as a decent control. I do not want to belittle the
clear effectiveness of biomechanical alteration as a treatment for pain in
individuals where biomechanical dysfunction has been definitively
diagnosed to be the cause of this pain. However I do worry when i read
headlines such as 'Alexander technique PROVEN to be most cost effective in
treating chronic and recurrent low back pain'. I wonder how many Alexander
practioners turn away patients who have chronic complex pain syndrome and
need CBT as a part of their therapy, or have an acute traumatic lumbar
disc prolapse? I urge GPs reading this review to to accept it's
limitations and understand that biomechanical alteration is only one part
of any physical therapy.
Competing interests:
None declared
Competing interests: No competing interests
Quick insight to the Technique
The Alexander Technique is a method for regaining and maintaining
natural
poise. It is a preventative method that has curative value.
In simplicity, it works by engaging the cognitive mind, consciously in
inhibition
and direction.
While there maybe great emphasis placed on body function, an individual is
gaining insight to how they interact and react with their environment.
As a curative method, the Alexander Technique is often taught in tandem
with
therapies such as physical therapy.
To gain insight to the technique, lessons are recommended.
Competing interests:
None declared
Competing interests: No competing interests