Intended for healthcare professionals


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

BMJ 2008; 337 doi: (Published 19 August 2008) Cite this as: BMJ 2008;337:a884
  1. Paul Little, professor of primary care research1,
  2. George Lewith, reader1,
  3. Fran Webley, overall trial coordinator and trial manager for Southampton site1,
  4. Maggie Evans, trial manager for Bristol site4,
  5. Angela Beattie, trial manager for Bristol site4,
  6. Karen Middleton, trial data manager1,
  7. Jane Barnett, research nurse1,
  8. Kathleen Ballard, teacher of the Alexander technique5,
  9. Frances Oxford, teacher of the Alexander technique5,
  10. Peter Smith, professor of statistics3,
  11. Lucy Yardley, professor of health psychology2,
  12. Sandra Hollinghurst, health economist4,
  13. Debbie Sharp, professor of primary care4
  1. 1Primary Care Group, Community Clinical Sciences Division, University of Southampton, Aldermoor Health Centre, Southampton SO16 5ST
  2. 2School of Psychology, University of Southampton
  3. 3Department of Social Statistics, University of Southampton
  4. 4Academic Unit of Primary Health Care, Department of Community Based Medicine, University of Bristol
  5. 5Society of Teachers of the Alexander Technique, London
  1. Correspondence to: P Little psl3{at}
  • Accepted 26 May 2008


Objective To determine the effectiveness of lessons in the Alexander technique, massage therapy, and advice from a doctor to take exercise (exercise prescription) along with nurse delivered behavioural counselling for patients with chronic or recurrent back pain.

Design Factorial randomised trial.

Setting 64 general practices in England.

Participants 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.

Interventions Normal care (control), six sessions of massage, six or 24 lessons on the Alexander technique, and prescription for exercise from a doctor with nurse delivered behavioural counselling.

Main outcome measures Roland Morris disability score (number of activities impaired by pain) and number of days in pain.

Results Exercise and lessons in the Alexander technique, but not massage, remained effective at one year (compared with control Roland disability score 8.1: massage −0.58, 95% confidence interval −1.94 to 0.77, six lessons −1.40, −2.77 to −0.03, 24 lessons −3.4, −4.76 to −2.03, and exercise −1.29, −2.25 to −0.34). Exercise after six lessons achieved 72% of the effect of 24 lessons alone (Roland disability score −2.98 and −4.14, respectively). Number of days with back pain in the past four weeks was lower after lessons (compared with control median 21 days: 24 lessons −18, six lessons −10, massage −7) and quality of life improved significantly. No significant harms were reported.

Conclusions One to one lessons in the Alexander technique from registered teachers have long term benefits for patients with chronic back pain. Six lessons followed by exercise prescription were nearly as effective as 24 lessons.

Trial registration National Research Register N0028108728.

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).


  • We thank the patients, practices, general practitioners, practice nurses, teachers, and therapists for their time and effort; Carolyn Nicholls, who helped develop the Alexander technique teachers’ record forms and organised the pilot of the trial; Andy Fagg, who helped develop the massage intervention; and the trial steering committee (chairman Martin Underwood) for their help throughout the trial.

  • Contributors: PL and GL had the original idea for this protocol; DS and FO had been working on a parallel protocol. The protocol was developed by all the authors. PL led the grant application in conjunction with DS, GL, and PS (principal investigators). FW coordinated the trial on a day to day basis supervised by PL and helped by JB and KM, and managed the Southampton site. KM managed the database, supervised by PS. ME and AB managed the Bristol site on a day to day basis, supervised by DS. KB and FO coordinated the development of the Alexander technique intervention and monitoring. LY coordinated the development of the exercise prescription intervention and monitoring. All authors contributed to regular meetings on trial management. PL and PS did the analysis, which was discussed by all authors. PL wrote the paper, and all authors contributed to revisions of the paper. PL is guarantor for the paper.

  • Funding: This work was supported by the Medical Research Council [grant number G0001104]. The Medical Research Council was independent of the running, analysis, and interpretation of the trial. GL’s post is supported by the Rufford Maurice Laing Foundation.

  • Competing interests: None declared.

  • Ethical approval: South west multicentre research ethics committee (reference 01/6/54).

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

  • Accepted 26 May 2008

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

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